List of prioritization

Ineffective Cerebral Tissue Perfusion Related

to: Interruption of blood flow: occlusive
disorder, hemorrhage; cerebral vasospasm,
cerebral edema-

rationale
Decrease in oxygen resulting in failure to
nourish tissues at the capillary level

Impaired Physical Mobility Related to:

Neuromuscular involvement: weakness,
paresthesia; flaccid/hypotonic paralysis
(initially); spastic paralysis-

Alteration in mobility may be a temporary or

more permanent problem. Most disease and
rehabilitative states involve some degree of
immobility, as seen in strokes, leg fracture,
trauma, morbid obesity, multiple sclerosis,
and others. With the longer life expectancy for
most Americans, the incidence of disease and
disability continues to grow. And with shorter
hospital stays, patients are being transferred
to rehabilitation facilities or sent home for
physical therapy in the home environment.

Mobility is also related to body changes from

aging. Loss of muscle mass, reduction in
muscle strength and function, joints becoming
stiffer and less mobile, and gait changes
affecting balance can significantly
compromise the mobility of elder patients.

Mobility is paramount if elder patients are to

maintain any independent living. Restricted
movement affects the performance of most
activities of daily living (ADLs). Elderly
patients are also at increased risk for the
complications of immobility. Nursing goals are
to maintain functional ability, prevent
additional impairment of physical activity, and
ensure a safe environment.

 Impaired Verbal Communication related

to:Impaired cerebral circulation;
neuromuscular impairment, loss of facial/oral
muscle tone/control; generalized
weakness/fatigue-

Self-Care Deficit Related to Neuromuscular

impairment, decreased strength and
endurance, loss of muscle
control/coordination-

Communication is a multifaceted kinetic, reciprocal

process. Communication may be impaired for any
number of reasons but rarely are all avenues for
communication compromised at one time. The task
for the nurse, whether encountering the patient in
the hospital or in the community, becomes
recognizing when communication has become
ineffective and then using strategies to improve
transmission of information
The nurse may encounter the patient with a
self-care deficit in the hospital or in the
community. The deficit may be the result of
transient limitations such as those one might
experience while recuperating from surgery or
the result of progressive deterioration that
erodes the individual's ability or willingness to
perform the activities required to care for
themselves.

 Knowledge Deficit Related to: Lack of

exposure; unfamiliarity with information
resources

Risk for Impaired Swallowing Related to:

Neuromuscular/perceptual impairment

Knowledge deficit is a lack of cognitive

information or psychomotor skills required for
health recovery, maintenance, or health
promotion.
- acute and chronic conditions can place
patients at risk for aspiration. Acute
conditions, such as postanesthesia effects
from surgery or diagnostic tests, occur
predominantly in the acute care setting.
Chronic conditions, including altered
consciousness from head injury, spinal cord
injury, neuromuscular weakness, hemiplegia
and dysphagia from stroke, use of tube
feedings for nutrition, endotracheal intubation,
or mechanical ventilation may be encountered
in the home, rehabilitative, or hospital
settings. Elderly and cognitively impaired
patients are at high risk. Aspiration is a
common cause of death in comatose patients.

 Disturbed Sensory Perception related to:

Altered sensory reception, transmission,
integration (neurological trauma or deficit)-

Ineffective Coping Related to situational

crises, vulnerability, cognitive perceptual
changes

Change in the amount or patterning of

incoming stimuli accompanied by a
diminished, exaggerated, distorted, or
impaired response to such stimuli

For most persons, everyday life includes its

share of stressors and demands, ranging from
family, work, and professional role
responsibilities to major life events such as
divorce, illness, and the death of loved ones.
How one responds to such stressors depends
on their coping resources. Such resources can
include optimistic beliefs, social support
networks, personal health and energy,
problem-solving skills, and material resources.
Sociocultural and religious factors may
influence how people view and handle their

problems. Some cultures may prefer privacy

and avoid sharing their fears in public, even to
health care providers. As resources become
limited and problems become more acute, this
strategy may prove ineffective. Vulnerable
populations such as the elderly, those in
adverse socioeconomic situations, those with
complex medical problems such as substance
abuse, or those who find themselves suddenly
physically challenged may not have the
resources or skills to cope with their acute or
chronic stressors.