Priority Nursing DX

Posted
by m_corbelli m_corbelli (New) New

Yesterday in clinical I had two patients assigned to me. One was an 88 yo w/ asthma that was admitted through the ED in resp distress. One was a 70 yo man w/ schizophrenia that was admitted for agitation and fighting w/ the other men in his group home. The 88 yo was to be d/c that day and was waiting only for the Dr.s orders. The 70 yo was ready to go home for weeks but was waiting for placement in a group facility. On both, v/s were normal and head to toe assessment revealed no abnormal findings. During post-conference I was asked "what is your priority nursing dx?" Honestly, I was stumped. What do we look for when a patient is assymptomatic?

Well, your first patient would be 88 yo w/asthma. Even healthy people can have some risks for the diseases due to their life style. Asthma is a chronic disease so these patients will always have some dx. For example priority dx could be Ineffective airway clearance r/t tracheobronchial narrowing. Other dx can be ineffective coping r/t situational crisis, impaired home maintenance r/t deficient knowledge regarding control of environmental triggers, activity intolerance r/t fatigue.

Esme12, ASN, BSN, RN

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

If you consider their ages......I'd also include safety and a biggie as well.

Maybe it would help if you think of this patient as someone close to you a parent or grandparent.

What comes to mind why an 80yr.old with asthma might be in the ED in respiratory distress?

For me I would think knowledge deficient, poor health maintenance, or memory impaired, does he know what to avoid that triggers his asthma, does he recognize early signs of an asthma attack, what medication is he on and does he know what to use when, does he know how and when to use his rescue inhaler.

NANDA DIAGNOSIS:

risk for Ineffective Airway clearance r/t tracheobronchial narrowing, as "Karolyte" stated above.

risk for Ineffective Health Maintenance r/t deficient knowledge regarding physical triggers, medications, or treatment of early warning signs.

risk for Ineffective Therapeutic Regimen Management

When I was in nursing school often I felt stumped too when the instructor asked questions. In hindsight, I felt I needed to give a very intellectual sounding answer or a word for word Nanda nursing diagnosis. Now, honestly, I think if I had said risk of his airway constricting, or risk of future asthma attacks, something that would have told my instructor I understood this patient's "priority diagnosis" would involve the "A" of ABC's Airway, Breathing, and Circulation I would have been fine with those answers. I quess it all depends on how strict your instructor is.

For the Schizophrenic patient

disturbed, Thought Processes, is the first thing that comes to mind but for your patient who had been fighting I would prioritize Violence or Injury.

risk for self- and other-directed Violence r/t lack of trust, panic, hallucinations, delusional thinking

risk for injury

These are some other possible nursing diagnosis for schizophrenia but not ones that I could spout off in post conference without having looked at a list of nursing diagnosis ahead of time.

Social interaction impaired

risk for, relocation stress syndrome

disturbed personal identity

ineffective community coping

Best of Luck

Thanks all. I only had to write up one of the two so I took the asthmatic. For my write up I went with Maslow's. 1. Physiologic-Ineffective airway clearance, 2. Safety- Risk for falls, and 3. Self esteem-Knowledge deficit. Instructor is very strict. I'm in my second week of second semester so I am just getting my feet under me.