prioritizing nursing diagnosis

[srg4784]

I'm having trouble this week prioritizing my diagnosis b/c I have a pt. that has sooooo much going on. Here's the scenario. 67 y.o. pt. admitted for tracheal stenosis and resp. distress. A trach was put in on 10/13. Abnormal labs are:

WBC 18.3 (H) infection

RBC 3.52 (L) anemia, malnutrition (decreased 02 carrying capacity)

MCH 32.2 (H)

K 2.6 (L) risk for dysrrhytmias

PLT 493 (H)

Pre-albumin 11.0 (L) malnutriton, inflammation

PO2 79 (L) bronchospasms, mucus plugs

HBG 11.3 (L) anemia, bleeding, diet deficiency

HCT 32.2 (L) anemia, bleeding, diet deficiency

BUN 6 (L)

Ca 8.2 (L) risk for dysrrhythmias

PTT 39 (H)

There were no antibiotics ordered for this pt. No bronchodilators. These two factors amaze me since the trach site is red, inflammed and smelled. This pt. also had a craniotomy earlier in the month with burr holes to remove a subdural hematoma. We only get to pick three diagnosis and here's the list I've come up with but I'm having trouble narrowing it down to 3. The pt. is in restraints due to violence to staff (hitting, kicking) and had been for the past 24 hrs.

Ineffective breathing pattern

Impaired gas exchange

Imbalanced nut. less than

Anxiety

Noncompliance

Risk for Ineffective airway clearance ( i put risk b/c the pt. stats were normal on my DOC and non productive cough, I only had to suction once b/c nothing was coming back up)

Risk for aspiration

Risk for deficient fluid volume

Risk for injury

I hate choosing only three b/c all of them rly are important. I know I'm going to do risk for ineffective airway clearance I think that is a priority eventhough its only risk for. My instructors mom died from aspiration (she had a trach) due to being layed down after a tube feeding ( I know, crazy!!!) so the pt is at risk for it since the pt. is receiving parenternal nutrition. Also imbalanced nutrition and impaired gas exchange. But the low K and low Ca is a problem, a big problem too. AHHHHHHH!!!! I need some guidance.

[Daytonite, BSN, RN]

forget the "risk for" diagnoses. they are anticipated problems (non-existent) and your patient already has a load of real problems that you need to address. you can cover everything in the first three diagnoses you listed:

• ineffective breathing pattern
  
• impaired gas exchange
  
• imbalanced nut. less than

if the patient has a tracheostomy and is being suctioned why can't you use ineffective airway clearance? have you looked at a nursing diagnosis reference book and the defining characteristics of this diagnosis? [color=#3366ff]ineffective airway clearance i would be very surprised to find that your patient doesn't already have some of the symptoms of this nursing diagnosis. i'd dump the ineffective breathing pattern in favor of using impaired gas exchange. the imbalanced nutrition: less than body requirements is going to cover you for the parenteral nutrition the patient is getting. the hypocalcemia is only a priority problem for you to address if the patient has a malabsorption or renal failure problem and then you can address it under the nursing diagnosis of imbalanced nutrition: less than body requirements. hypokalemia is a problem of the heart, not the nutritional status. you have to decide if the heart is more of a problem than the patient's nutrition. decreased cardiac output is the nursing diagnosis used for hypokalemia because it causes arrhythmias.

i'm curious as to why you are not addressing the patient's craniotomy and neuro status and not using ineffective tissue perfusion: cerebral.

based on the information you gave, i think your diagnoses, in priority order should be:

1. impaired gas exchange
   
2. ineffective airway clearance
   
3. imbalanced nutrition: less than body requirements

[srg4784]

Daytonite, as always...thanks for your insight. I didn't address the craniotomy b/c it was so long ago. Although her LOC was decreased (it was before the craniotomy as well) this is why I didnt address it. I too was thinking ineffective airway clearance ( i put risk for b/c her stats were normal during my care but I see what your saying, it is an actual) & imbalanced nutrition......I wanted to address the cardiac issue but everyone Ive asked has said that both the imbalance nutrition or cardiac was not important as some others. That's why I hate prioritizing, it's so confusing. I think the cardiac issue is one of thetop because of the level of K, the pt. is at risk for cardiac arrest so that's important! The nutrition is also important, I wish I could pick four instead of three but I can't so there ya go.

[Daytonite, BSN, RN]

Go with actual problems then that came out of your assessment. Only address the low level of potassium if it is causing arrhythmias now. Potential arrhythmias cannot be a concern if you are restricted to only 3 nursing diagnoses. That is not to say that it is a serious concern. They're treating the low potassium anyway, aren't they? Go with what you already assessed as the actual problems.