PRIORITY diagnosis

[alaskalala]

Our weekly care plans ask for our top three nursing diagnoses. Out of the three, we are asked to choose the PRIORITY dx (and give a care plan for it), and to provide a rationale for why this particular dx is our top choice.

I can come up with loads of dxs for my patients. So I usually think to myself: what could kill this person now, this shift, or soon? If one of them fits the bill, that's my priority. I go down the ABC's, and if they are all good, up Maslow's hierarchy. Easy.

If nothing will kill them soon, then I get fuzzy. And sort of look at all my dx's and let the one that "seems" most urgent grab me. Maybe I'm even letting which one is the easiest or quickest to fix grab me. I'm not sure.

I'm flummoxed when it comes to writing the rationale for my choice. Since I choose the "it'll kill you quicker" ones by a process of elimination, my rationale doesn't sound like a "rationale."

In my head, my rationale sounds like this: "No airway problem, breathing...breathing problem -- stop -- priority dx," or "No airway, breathing, circulation problems, moving on to Maslow, physiologic needs...fluid problem -- stop -- priority dx."

For the "it won't kill you any time soon, but it certainly sucks" ones, I really don't know how to justify my choice. "This one's easy/quick to fix so let's just knock it off your long list of sucky things," or "This one's not so sucky now, but let's begin to tackle it so it doesn't turn into an 'it'll kill you' one."

I like to keep things simple, but I'm feeling like maybe I need more ways to look at, and more clarity, on WHY or HOW I choose the priority dx.

I don't know how to phrase my question here anymore precisely, than to say: I feel like something's missing.

Maybe I'm looking at this whole thing the wrong way. I feel like I'm looking at the negative side, i.e., imagining the worst-case scenario for my patient and trying to avoid that. Should I be imagining their best-case scenario, their "ultimate" goal, would that help?

I wonder if my fear about missing something important (as an inexperienced nursing student) is skewing or narrowing my view, and if I should begin to incorporate another, broader, perspective on care.

Right now, I could sure use a better rationale than, "well, er, um, everything else that's more important is O.K., and everything else that's less important is, um...less important?"

Any thoughts would be most welcome.

[Jules A, MSN]

If you give a few examples we can help you prioritize them.

[Daytonite, BSN, RN]

i think i know what you're getting at. the abcs (airway, breathing and circulation) are certainly a top priority. many instructors have students prioritize by maslow's hierarchy of needs. i'm posting it for you. the abcs are incorporated into the very first entry. i always have always classified pain as a comfort need. however, i have been finding that some instructors feel that this is a top priority item and want it placed at the top of the nursing diagnoses. i do not understand their rationale for doing this. if your instructors are among the ones doing this, i can only suggest that you have a sit down in their offices and try to get their thinking and rationale on this because it is not where maslow classifies it.

1. physiological needs (in the following order)
   • the need for oxygen and to breathe [the brain gets top priority for oxygen, then the oxgenation of the heart followed by oxygenation of the lung tissue itself, breathing problems come next, then heart and circulation problems--this is based upon how fast these organs die or fail based upon the lack of oxygen and their function.]
     
   • the need for food and water
     
   • the need to eliminate and dispose of bodily wastes
     
   • the need to control body temperature
     
   • the need to move
     
   • the need for rest
     
   • the need for comfort

[*]safety and security needs (in the following order)

• safety from physiological threat
  
• safety from psychological threat
  
• protection
  
• continuity
  
• stability
  
• lack of danger

[*]love and belonging needs

• affiliation
  
• affection
  
• intimacy
  
• support
  
• reassurance

[*]self-esteem needs

• sense of self-worth
  
• self-respect
  
• independence
  
• dignity
  
• privacy
  
• self-reliance

[*]self-actualization

• recognition and realization of potential
  
• growth
  
• health
  
• autonomy

[alaskalala]

Thanks, Jules, for the offer to help prioritize. I usually do o.k. there. It's providing a rationale for my choice that hangs me up.

And thanks, Daytonite, for the expanded Maslow. I like how the ABC's are incorporated. And I've never seen a prioritization of oxygenation by organ before, LOVE IT. Not intuitive for me, I would have thought just the opposite, lungs first, then heart, then brain. But time to loss of function wasn't something I took into consideration, makes perfect sense.

Yes, as a matter of fact, my instructors do seem to make pain a priority diagnosis, and I am not clear on why.

If the air isn't going in and out, or the blood's not going round and round, your pain takes a backseat to my mind.

And if a patient's pain is such that it's interfering with something of a higher order (i.e., it's making them hyperventilate), then I don't see why my priority dx wouldn't be: ineffective breathing pattern r/t pain AEB hyperventilation, with an intervention to provide pain meds. Yes, they're tied together, but effective breathing is more critical than comfort.

The intervention (pain meds) is the same as if my dx was acute pain, but I'd be wrong, priority dx-wise, at school.

Ah, well, mine is not to question why, mine is to figure out the rules and play ball. I just wish the rules were consistent and written down somewhere. "But they are," you say. Unfortunately, sticking to NANDA and Maslow is not encouraged in the program. We are encouraged to make these up, so as to exercise critical thinking, so as to be more client-specific.

With the exception of pain, I usually get the priority dx right.

However, the rationale I'm to write should explain WHY I choose one dx as the priority over another dx.

I like structure. I'd like to be able to follow the Maslow's, in order, and give that as my rationale. Something like, "according to Maslow, the need for oxygen and to breath is a higher priority than comfort."

But that ain't workin' for my instructors. They want something else. What? Beats me. I just started doing these in September, so it's all fairly new to me.

I think I'm going to go online and get ten or twenty case scenarios, pick a priority dx and write a rationale for my choice, and take the whole works to an instructor for feedback. This one care plan, once a week thing, is just not enough feedback to learn the rules.

Thanks again to both of you.

[Daytonite, BSN, RN]

Yes, as a matter of fact, my instructors do seem to make pain a priority diagnosis, and I am not clear on why.

If the air isn't going in and out, or the blood's not going round and round, your pain takes a backseat to my mind.

Makes perfect sense to me too. This is why I think you need to have a sit down with them and get them to spill the beans and give their rationale on this. The only thing I can come up with is related to the actual treatment that is being given. If we're giving more pain shots than, let's say, concentrating on the circulation to their leg so they don't get a DVT or a skin ulcer heals, then I guess maybe there's another rationale in play I don't know about. But, it still doesn't make sense to me.