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Prioritizing Nursing Diagnosis

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I have to develop a care plan, and I've only been in nursing school for 4 weeks, so we haven't even gone over these hardly at all. My patient is 92 yrs old, presents with temp of 103, BP 140/90, Pulse 114, Resp 30, labored breathing. Diarrhea for the past 3 days. What is the first priority? I'm thinking either "ineffective breathing pattern" or "impaired gas exchange" because of vital signs and labored breathing. But I know he's probably dehydrated too. Which is #1 nursing diagnosis? Or am I totally off base? Thanks for your help!

Always utilize Maslow's Hierarchy of Needs when prioritizing nursing diagnoses. It will help you determine which interventions are most important. You are right in thinking that impaired breathing is very high up on the list, physiologic needs are always first.. followed immediately by pain relief and then other needs may be met.

Thank you:) That's what I was thinking

Wave Watcher

Specializes in Community Health/School Nursing. Has 7 years experience.

Airway/breathing/circulation is ALWAYS FIRST. That would be your ABC's.

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Hi! Welcome to AN! The largest online nursing community!

What care plan resource do you have? First......you are falling into the same hole that trips most new students. You find your diagnosis and then try to retrofit the patient into the diagnosis. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

  1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
  2. Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
  3. Planning (write measurable goals/outcomes and nursing interventions)
  4. Implementation (initiate the care plan)
  5. Evaluation (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

So....

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arkrunnergirl I have to develop a care plan, and I've only been in nursing school for 4 weeks, so we haven't even gone over these hardly at all. My patient is 92 yrs old, presents with temp of 103, BP 140/90, Pulse 114, Resp 30, labored breathing. Diarrhea for the past 3 days. What is the first priority? I'm thinking either "ineffective breathing pattern" or "impaired gas exchange" because of vital signs and labored breathing. But I know he's probably dehydrated too. Which is #1 nursing diagnosis? Or am I totally off base? Thanks for your help!

You have some assessment data. Is the patient confused? What was her O2 sat? Maybe her increased respiratory rate was from the temp and not hypoxia. What is her hydration status? Were her mucous membranes moist? What was her urinary output? What labs were done? Did the CXR show anything? How was her skin turgor? Did she have any other co-morbidities? Was she diabetic? HTN? On diuretics? Is she alert? Did she live alone? Did she live a home?

Tell me about HER...What did she say? How did she feel? Was she alert?

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

A nursing diagnosis statement by GrnTea

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A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. "

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological." "Surgery" counts for a physical injury-- after all, it's only expensive trauma

Each NANDA is accompanied by specific information to apply to the patient. You must have at least ONE criteria in order to apply that diagnosis.

NANDA defines ineffective breathing pattern as: Inspiration and/or expiration that does not provide adequate ventilation.

Defining characteristics: Alterations in depth of breathing; altered chest excursion; assumption of three-point position; bradypnea; decreased expiratory pressure; decreased inspiratory pressure; decreased minute ventilation; decreased vital capacity; dyspnea; increased anterior-posterior diameter; nasal flaring; orthopnea; prolonged expiration phase; pursed-lip breathing; tachypnea; use of accessory muscles to breathe.

Related to/as evidenced by: Anxiety; body position; bony deformity; chest wall deformity; cognitive impairment; fatigue; hyperventilation; hypoventilation syndrome; musculoskeletal impairment; neurological immaturity; neuromuscular dysfunction; obesity; pain; perception impairment; respiratory muscle fatigue; spinal cord injury

You also thought of impaired gas exchange: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane

Defining characteristics: Abnormal arterial blood gases; abnormal arterial pH; abnormal breathing (e.g., rate, rhythm, depth); abnormal skin color (e.g., pale, dusky); confusion; cyanosis; decreased carbon dioxide; diaphoresis; dyspnea; headache upon awakening; hypercapnia; hypoxemia; hypoxia; irritability; nasal flaring; restlessness, somnolence; tachycardia; visual disturbances

related to/as evidenced by: Ventilation-perfusion imbalance; alveolar-capillary membrane changes

What evidence do you have that her gs exchange was not normal at the capillary bed? Were ABG's done? Did the CXR show pneumonia? Does she have COPD?

Reference Ackley: Nursing Diagnosis Handbook, 10th Edition

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Prioritization can be decided by Maslows Hierarchy of needs. maslow's hierarchy of needs - enotes.com virginia henderson's need theory

Maslow’s hierarchy of needs is a based on the theory that one level of needs must be met before moving on to the next step.

  • self-actualization – e.g. morality, creativity, problem solving.
  • esteem – e.g. confidence, self-esteem, achievement, respect.
  • belongingness – e.g. love, friendship, intimacy, family.
  • safety – e.g. security of environment, employment, resources, health, property.
  • physiological – e.g. air, food, water, sex, sleep, other factors towards homeostasis.

SO basically it is...ABC...airway breathing circulation. If they aren't breathing they aren't leaving. But is the brathing what is the most dangerus to your patient right now? They have a temp of 103. What is the fluid status? When did she urinate? IS she alert?

Tell me about her.

RookieRoo

Specializes in Critical care.

Not my thread- but I wanted to say, Esme, you rock. You're so helpful, I get a lot out of reading the feedback you leave for other posters. Thanks a lot!

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

You're welcome! any time ;)

mrsboots87

Specializes in Neuro, Telemetry. Has 6 years experience.

One thing that will help will be to always keep in mind that we do not base our careplans solely off of the patients medical diagnoses and recent vitals. We diagnose their whole person and their response to their disease process and then intervene. This patient has an infection of some sort ( I think anyway based on the vitals you gave), your job is to diagnose how they are responding to that infection. With that high resp rate, what do their lungs sound like? They have diarhea, what does their abdomen sound like? Also, how does their skin look in the rectal and perineal area? Smells? What is their mental status? These are some things we can diagnose and intervene on. Gl and as always Esme has given some great careplan advice. That same advice is what has turned my careplanning around in the right direction.

Seriously Esme12. I have been lurking on AN for a few years, just started my prerequisites to hopefully get into next year's program and I'm already scheming of ways of making you my online tutor somehow. Do you do this? You totally should. I would pay. I think everyone on AN would lol.

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

AspiringNurseMW said:
Seriously Esme12. I have been lurking on AN for a few years, just started my prerequisites to hopefully get into next year's program and I'm already scheming of ways of making you my online tutor somehow. Do you do this? You totally should. I would pay. I think everyone on AN would LOL.

I am right here...everyday ((HUGS)) My payment is helping the next generation become the very best they can be so I have the best nurses caring for me ...LOL

Always remember...pay it forward.