PRIORITIZATION OF NURSING PROBLEMS
NURSING DIAGNOSIS
1. Ineffective airway
clearance related to
retained secretions in the
bronchotracheal tree 2°
pneumonia
Classification: Actual Problem
2. Hyperthermia related to
increased metabolic rate
Classification: Actual Problem
3. Risk for decreased cardiac
output related to
increased afterload
(vasoconstriction)
Classification: Potential
Problem
4. Risk for unstable blood
glucose related to
impaired insulin secretion
Classification: Potential
Problem
JUSTIFICATION
Airway must be given the first attention as based on
the rule of ABC, which stands for Airway, Breathing
and Circulation. Addressing the problem will give
patent airway to the client. Oxygenation is a vital
need for every cell, if there is any problem related to
it, it could easily affect the functioning of the
individual. Retained secretions can cause blockage
of airway, which will further cause difficulty of
breathing (Berman, et al, 2016).
This is the next priority because the increase in the
body temperature is just in response to the disease
experienced by the body. However, many
complications may arise if it was left untreated.
Hyperthermia may result to fluid loss, hemodynamic
alterations, serum enzyme abnormalities and other
symptoms of variable severity. It can also cause
neurologic symptoms including nausea, confusion,
disorientation, apathy, delirium, stupor or coma
(Progress in Brain Research, page153).
The patient has hypertension and the
vasoconstriction itself may lead to decreased
cardiac output. If it happens, all of the vital organs
will suffer. It is a priority since there is inefficient
pumping of the heart. This is the 4th priority since the
nature of the problem is potential, meaning it can
be prevented.
The patient has Type 2 DM, so the problem is her
blood glucose level. It is a priority since if the patient
had her blood glucose less than 80, hypoglycaemia
will occur, if it is too high, hyperglycemia will occur
which both problems leads to different
complications like ketoacidosis. This is the 5th priority
because it is a risk, thus it can be prevented.