Priority Nursing Diagnosis

[Mmessenger]

Having trouble determining what my priority diagnosis is on patients. Pt is a 4 month old, admitted with fever 102.2, HR 150, RR 62, BP 95/65, SAO2 85%. Woke up gasping for air and was blue, admitted Bronchoiolitis and Flu A positive. History of Down's syndrome and Tetraology of Fallot. His temp is now 98.8, with stable vital signs, On fluids D5 1/4 NS w 20 mEq/L @23 ml/hr. The only abnormal result is glucose 198. Chest x-ray indicates infiltrates in right lower lobe.

I think my priority is Impaired Gas Exchange but I think it is related to the Broncholitis. But you also have the Tetraology of Fallot factoring into the impaired gas exchange. Since the disease is treated with surgery I would think my priority is to take care of the Broncholitis.

But I also think Ineffective Airway cleareance.

My other thoughts are:

Ineffective thermoregulation

Risk for imbalanced fluid volume

Imbalanced Nutrition: less than body requirements

I usually don't get these right. Any help is appreciated.

[Assailants]

It's always ABCs so I'd pick the nursing dx related to airway, breathing, or circulation.

[NCRNMDM, ASN, RN]

Always go by what will kill your patient first. That sounds kind of harsh, but when you are prioritizing think about it and it will help you. In this situation, the respiratory issues will kill your patient before anything else. Impaired gas exchange is a good diagnosis, but what data do you have to back that up? Is the patient's saturation currently low? Is the patient having difficulty breathing, gasping for breath, or otherwise in respiratory distress? While you can write that the impaired gas exchange is secondary to broncholitis, you cannot write that it is related to it. Your related to information can never be a medical diagnosis. You could write something like impaired gas exchange r/t swelling and mucous buildup in the bronchioles secondary to broncholitis AEB patient's oxygen saturation 85%, abnormal blood gas results, and tachypnea.

After impaired gas exchange, I feel like ineffective airway clearance is your next diagnosis. After that you should probably use ineffective thermoregulation, then imbalanced nutrition, and then risk for imbalanced fluid volume. Remember, always list your risk for diagnoses last. Also keep in mind that you have to have evidence to back up all of your nursing diagnoses. Do a thorough assessment prior to formulating any possible diagnoses in your head (unless you are very experienced and very comfortable with the world of nursing diagnoses). Don't jump to conclusions, and don't try to come up with any diagnoses prior to your assessment.

[nurseprnRN, BSN, RN]

his sats are gonna be low because of his tetralogy of fallot, so anything that decreases his oxygenation is orders of magnitude worse than it would be for someone else. a spo2 of 85% is a lot worse than an pao2 of 85 torr (look up the reason why or come back and ask me if you can't figure it out). gas exchange in this kiddo is therefore a very big deal, and you can do what you can about the bronchiolitis. good spot.

i don't see any evidence for ineffective thermoregulation. you're supposed to spike a temp if you have an infection. that's effective thermoregulation, . you want to make sure it's not too high, though, because increased fever increases heart workload, and he's already a little shy on that department. think about something like increased metabolic and oxygen demands c fever...