Prioritizing nursing dx

What is the best way to prioritize nursing dx? I am working on a care plan and I have several nursing dx from the physiological mode and it's not as cut and dried as I'd thought it would be when it comes to prioritizing them. Maybe I'm reading into it too much. Anyway, if you can give me some suggestions, I'd appreciate it. Thanks.

What is the most important and/or life-threatening thing for your patient. For example if they are cardiac-what is their resp status(ie CHF-full of fluid, SOB?), or pain level, perfusion issues(IE MI's with mycardium damage). If they are say immobilized for some reason, then complications of immobility(ie:

decreased perfusion-hence increased chance of PE, thromophlebitis; skin care issues-again poor circulation, decubiti; decreased dietary intake, psycho-social issues-ICU pychosis, lack of stimulation, need foe assistance with ADL's. Look for the most obvious things first, think what your instructor is going to be looking for, think what you would need or be concerned about in that same situation with the current knowledge you have now. Don't read too much into it, it will make you nuts in the end. In my facility care plans are done by the computer when you input pt dx and the computer documentation is build around addressing what needs to be for that pt. It will get after you get out of school, just always look at the obvious first.

flaerman

Generally, follow your A B C's and Maslow's Hierarchy of Needs.

http://web.utk.edu/~gwynne/maslow.HTM

http://chiron.valdosta.edu/whuitt/col/regsys/maslow.html

Here is a guide for the nursing process that we use at our school

(warning: check with your instructors before using this, to make sure this is in accordance with what they want)

Nursing Process

I: ASSESSMENT - should be relevant to that particular nursing diagnosis, not just a collection of data.

A: Subjective- symptoms apparent only to the person affected. Including sensations, feelings, values, beliefs, attitudes, and perceptions of personal health status. In quotes from the patient or patient's family. Example- "My head feels like it is coming off my shoulders." Patient's wife states that patient is complaining of "pain in his head".

B: Objective- signs that are detectable by an observer or can be measured or tested against a standard. Can be seen, heard, felt, or smelled.

II: ANALYSIS (Nursing Diagnosis)

A: Must be NANDA approved.

B: Three-part statement:

P- problem (diagnostic label)

E- etiology R/T may not use a medical diagnosis except for "secondary to". Senior level may use more than 1 etiology, but freshmen should stick to 1.

S-signs and symptoms AEB

C: Two-part statement used with R/F diagnosis

D: Types of nursing Diagnosis

1. Actual- a problem that is present at the time of the assessment. Based on the presence of signs and symptoms

2. Risk- clinical judgment that a problem does not exist, but the presence of risk factors indicate that a problem is likely to develop unless the nurse intervenes. Any diagnosis may be R/F

3. Wellness- one indicating a healthy response of a client who desires a higher level of wellness.

4. Syndrome- a diagnosis associated with a cluster of other diagnoses. Only 8.

III: PLANNING

A: Set priorities- based on Maslow's Hierarchy of Needs

B: Establish a goal- goal should be a "mirror" reflection of the Nursing Diagnosis (turning it around), one goal for each etiology in the Nursing Diagnosis

1. Short Term- usually within a week

2. Long Term-greater than 1 week

C: Components:

1. Subject-noun. The client, or patient, patient's family

2. Verb- an action the client is to perform. Use verbs that denote directly observable behaviors.

3. Conditions or Modifiers- explains circumstances under which the behavior is to be performed(the what, when, how, or where).

4. Criteria- the standard by which performance is evaluated and at what level.

D: NOC- designed to cross-reference with NANDA nursing diagnoses in the back. -Then select a "suggested outcome." Indicators can be used as specific outcomes to be individualized to your patient.

IV: IMPLEMENTATION

A: Should be 4 interventions for each diagnosis. Each order should include a rationale. Sources should be sited at the bottom.

B: Writing Nursing Orders

1. Subject- the student nurse will... (may be placed at the top of the page if all interventions are for the student nurse.)

2. Verb- should be an action verb and very precise. If you are using several interventions that use the verb "teach" you should probably be using the "Deficient Knowledge" diagnosis.

3. Content area-the what, and the where of the order.

4. Time element- When, how long, or how often the nursing action is to occur.

C: NIC- Interventions are much broader than we expect the student's to be. Book has a cross-reference with NANDA diagnoses. Then you select a "suggested nursing intervention for problem resolution". The activities listed are useful to formulate interventions.

V: EVALUATION

Compare assessment data gathered during evaluation phase to desired outcomes (NOC indicators)

A: Options:

1. Goal met- the patient's response was the same as the desired outcome

2. Goal partially met-either a short-term goal was achieved but the long term was not, or the desired outcome was only partially attained

3. Goal not met

4. Unable to evaluate- since the student may not be there at the time the goal needs to be evaluated. The student must include what criteria that they would have looked for.

List Of Verbs For Use In The Client Goal, Client Objectives And Nursing Orders

Client Goal:

The following verbs are broad indicators of client performance:

Explore, increase, decrease, obtain, maintain, develop, accept, improve, cope, plan, express, experience, resume, share, eliminate, reduce, regain, restore, attain, prevent, establish, ideal, replace, display

Client Objectives and Nursing Orders:

The following measurable verbs reflect client actions that are seen or heard:

Rest, walk, move, assess, monitor, turn, ambulate, assist, perform, offer, inspect, apply, practice, cough,

deep breathe, drink, eat, observe, expectorate, position, demonstrate, wash, exercise, stand, sit, avoid, write, measure, record, change, irrigate, suction, verbalize, communicate, state, describe, teach, instruct, report, consult, discuss, explain, identify, respond, list, relate, listen, refer

Non-Specific Verbs:

AVOID using in client goal, client objectives, and nursing orders:

Encourage, know, employ, understand, indicate, enable, provide, facilitate, let, permit, keep, use, allow, engages, learn, limit, have, be, get, ensure, prepare, introduce, put, do

Here is a site with CURRENT NANDA-approved nursing diagnoses:

http://www1.us.elsevierhealth.com/MERLIN/Ackley/NDH/Constructor/index.cfm