Prioritizing Nursing Diagnoses

[KrCmommy522, BSN, RN]

Hello! I am doing med-surg right now.Last week we did our first care plan for that course and it asked us to list the diagnoses in order of priority. The other care plans we have done for our other clinicals didn't have us do that. So I was looking into it. I know you are supposed to do it by Maslow's hierarchy. But I am having trouble with prioritizing the physiologic needs. I know you start with ABCs - airway, breath, circulation. But what about after that. I am having trouble figuring out past the ABCs, what would be priority. For example, my pt last week the nursing diagnoses I used were (and this is the order of priority I used):

- Impaired tissue integrity r/t impaired physical mobility secondary to mechanical factors

- Acute pain r/t surgical procedure

- Stress urinary incontinence r/t degenerative changes in the pelvic muscles and the supporting structures connected elderly.

- Impaired physical mobility r/t sedentary lifestyle

- Risk for infection r/t inadequate primary defenses (broken skin)

In my NUR 250 class my professor always said that risk diagnoses come after actual diagnoses. However, when my professor graded my care plan she said she would think risk for infection would be paramount.

Can anyone help me with prioritizing the physiologic needs? Again, I understand that diagnoses r/t airway come first, breathing second, and circulation third. But what about the other physiologic needs? Tomorrow I go to clinicals again, so I will be doing my care plans for those patients and would like to know how to prioritize the diagnoses better.

Thanks!

[sailornurse]

What were you taught about pain in relation to the ABCs'?

[Summer Days]

Think of it this way, out of those ndx you have listed, what is likely to kill the pt first and fast? Using this, you can quickly rule out acute pain, stress incontinence, and impaired mobility. Now the other two, what is the pt likely to die from NOW?

[KrCmommy522, BSN, RN]

Nothing yet?

[KrCmommy522, BSN, RN]

Risk for infection. So that would be first. How would you prioritize after that?

[nursej22, MSN, RN]

Will pain kill you? No

Will impaired mobility kill you? Maybe, eventually, but people live with this...

Will impaired skin kill you? Hmmmmm......could it lead to infection?

Stress urinary incontinence? People live with this...

[PyridiumP]

Not true that risk dx are always after actual ones. Risk can b more importnt than some actual like risk of serious bleeding is worse than nausea KWIM? My 1st post so xcuse any errors.

[KrCmommy522, BSN, RN]

Ok I think I'm starting to get it now. Ok my pt this time is a 55 yo woman with C-diff. She has a Hx of seizures. Her potassium is 2.8 and her calcium is 7.7. So I am making her diagnoses:

Risk for ineffective airway clearance r/t accumulation of secretions during seizure

Risk for Decreased Cardiac Tissue Perfusion r/t possible dysrhythmia from electrolyte imbalance

Risk for Electrolyte Imbalance r/t loss of electrolytes through diarrhea

Risk for Impaired Skin Integrity r/t increased moisture

Imbalanced nutrition: Less than body requirements r/t seizure disorder AMB pt states she is unable to cook because she shakes,” reported intake less than RDA, and aversion to eating.

Risk for Injury r/t uncontrolled movements during seizure

I listed them in order of priority (I think) - the first one has to do with airway so that's first, then the second has to do with circulation so I put that second, an electrolyte imbalance can kill the pt faster than any of the rest can so I put that 3rd, impaired skin integrity I think would be 4th, then imbalanced nutrition, and risk for injury is last because it's safety. Is that right? I hope so!!

[nursej22, MSN, RN]

Has she actually been seizing? And what kind? Many people with a history of seizures are well controlled, and unless they are grand mal, she is not necessarily at risk for airway compromise. do you have a anticonvulsant drug level lab?

She actually has an electrolyte imbalance, hypokalemia, hypocalcemia. And I am guessing a fluid imbalance, so this is not a risk for.

I like the cardiac output dx, but what interventions will you use?

Skin Integrity, good choice.

Imbalanced nutrition, okay, but not so sure about the reported shaking, are you sure this is seizure activity? But if intake is decreased, and with an infection, people are generally in a hyper metabolic state, so need more intake. Again, what interventions?

[KrCmommy522, BSN, RN]

Oh yes! She had a seizure when I was in there with her and it scared the crap out of me!! She didn't have seizure precautions on so when she started seizing her head started to hit the side of the bed. So I went over to her and I put the pillow there to protect her bed and I hit the alarm and said she was seizing so they'd send the nurse. It was a grand mal seizure (tonic-clonic). She was clear liquid diet the day before and NPO since midnight because she was supposed to have a fecal transplant surgery. However, she didn't complete her bowel prep and since her potassium was so low they moved the surgery to the next day and were going to try to get her potassium up before then. But since she was NPO she hadn't had her anticonvulsant meds. But afterwards she was given her meds. I don't have the anticonvulsant drug level lab though.

I know she isn't at risk for an electrolyte imbalance because she already has one but the only NANDA diagnosis was At risk for electrolyte imbalance. There wasn't one for electrolyte imbalance. I assume because that's a medical diagnosis? But I didn't want to make up my own lol so I just used at risk for? She didn't seem to be dehydrated in any way so I don't think she has a fluid imbalance. She was getting fluids so I think that replaced what she lost, but her potassium and calcium was still low.

For the cardiac output I would assess for symptoms of hypoperfusion like chest discomfort, tightness, crushing, squeezing; back, neck, jaw, shoulder, or arm discomfort or numbness; SOB; diaphoresis; dizziness; etc. Administer O2 as ordered and continuously monitor pulse ox. Perform a 12-lead ECG as ordered.

The imbalanced nutrition, what she described as her meals when she is at home was horrible nutritionally wise. She only eats things she doesn't have to cook and the reason for this she said was "I can't cook because my hands and arms shake all the time." Which they do. I'm not sure if it's seizure activity or because of the seizures she's had?

Even if they aren't all right for my pt, are they in the correct order? Aside from knowing if they are right for my pt I would like to know if I am understanding how to prioritize the diagnoses

[nursej22, MSN, RN]

Your explanation makes the picture much clearer. Yes, airway clearance, in this client, would be priority, then cardiac. You might be able to justify risk for deficient fluid volume deficit r/t diarrhea, if present, or restricted po intake. Either way you are going to monitor i&O, and daily weights.

Good job!

[Summer Days]

Here is my thought:

1. Risk for ineffective airway clearance

2. Electrolyte Imbalance r/t K of 2.2 and Ca of 7.7

3. Risk for injury

4. Risk for decreased cardiac perfusion

The supporting data for imbalanced nutrition does not make sense. You need more concrete reasons to support imbalanced nutrition less than body requirements.