Alright I have come up with a few nursing diagnosis for my case study patient and I really would like some input on my prioritization of them.
Backround: 44yr female with ventricular bleed went into a coma. Drain inserted and ventricles were no longer compressed. It seems the bleeding was contained in the ventricles only (phew!) She is now neurologically stable (No more bleeding) The after affects are why she is still in the hospital. She is in the ICU for weaning from the vent then onto a SNF for future care. For her case study I had to choose two systems that I would focus on. Since her medical hx contains hypertension I chose caridac and she also has aspiration pneumonia so I chose respiratory. I Only need three dx's per system so a total of six. Do you think the prioritization is in a good order or would you move them around?
My list are as follows:
1. Ventilator weaning response, dysfunctional related to muscle weakness/fatigue, inability to control respiratory muscles and immobility as evidenced by inability to maintain respiration rate of 12-20 breaths/minutes when PEEP setting is lowered.
2. Impaired Gas exchange related to Ventilation-perfusion imbalance; alveolar-capillary membrane changes as evidenced by dyspnea; abnormal arterial blood gas levels; restlessness; tachycardia; abnormal rate, rhythm, depth of breathing; diaphoresis
3. Airway clearance, Ineffective related to obstructed airway as evidenced by retained secretions and presence of artificial airway (tracheostomy)
4. Decreased Cardiac output related to altered afterload as evidenced by variations in blood pressure readings and decreased renal perfusion/urine output.
5. Excess Fluid volume related to Compromised regulatory mechanism and excess fluid intake as evidenced by abnormal breath sounds (crackles); pulmonary congestion; pleural effusion; intake exceeds output; blood pressure changes; oliguria; altered electrolytes; edema.
6. Ineffective Tissue perfusion: renal related to decreased cardiac output as evidenced by decreased urine output
What do you think? ANY HELP IS SOOOO APPRECIATED!!!