RN DX prioritization....Help Needed

  1. 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!!!
    Last edit by 2007_RN on Oct 1, '06 : Reason: Spelling error
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    About 2007_RN

    Joined: Jun '05; Posts: 27
    too many!!!


  3. by   Daytonite
    Looks good. Looks like you did your homework on ventilators.
  4. by   2007_RN
    Thanks!!! Do you think the prioritization is in order or would you choose to put them in a different order?
  5. by   Daytonite
    It looked OK to me. I did look at the order you had placed them in. At first I thought #5 and #6 should be switched, but then I was looking at the symptoms. I think the pulmonary symptoms that go along with #5 trump the urinary problems in #6, so I think they are OK as you listed them.
  6. by   2007_RN
    Thankyou!!!! I will write the carplan now and leave these puppies alone.

    Take care of you!

  7. by   IbPOTSyNurse
    I have a pt admitted for interstitial pneumonia, and has anemia- low H&H and metastatic cancer of unknown origin, he has low prealbumin, protein malnutrition, hyponatremia, crackles in RLL, inspiratory wheezes in RUL, LUL, and LLL. He is on 12L O2 NC and has a O2 sat of 90-93%.

    I have some nursing dx's thought of but not sure about the r/t part and which ones to use and in which order I need 3.
    impaired gas exchange - What is the r/t part that I should include ?
    Ineffective airway clearance- What is the r/t?
    imbalanced nutrition less than body requirements- What is the r/t part? the man has a normal bmi but has protein malnutrition!
    deficient knowledge r/t ? aeb pt asking why he is on steroids,
    activity intolerance r/t ?
    Chronic pain is r/t chronic disease process okay? he has met Ca in his bones- high WBC, low RBC, low H&Hbarely low Na+, and slightly high glucose- non fasting.

    Can I use infection as a nursing dx or only risk for infection?
    Any help would be greatly appreciated!