Nursing Diagnosis Prioritization
NURSING CARE PLAN PRIORITIZATION
Ineffective Breathing
Pattern related to
Pulmonary congestion
Ineffective airway
clearance r/t airway spasm
Excess Fluid Volume
related to decreased urine
output and retention of
sodium and water.
Imbalanced Nutrition: Less
than Body requirements
related to nausea and
dietary restrictions
Rationale
High Priority Ineffective breathing pattern related to pulmonary
congestion is marked highest priority since cellular
respiration is important to provide required oxygen for the
cells and to expel out the toxic carbon dioxide out of the
cells. Cells require oxygen to transform nutrients into fresh
energy. An insufficient supply of oxygen to meet the
body’s energy demands would result in a reduction of
cellular functioning. Extended periods of oxygen
deprivation can and will cause death. Airway must be given
the first attention as based on the rule of ABC which is Airway,
Breathing and Circulation. In addition, difficulty
of breathing can cause anxiety to the client that is why,
immediate attention must be done.
High Priority Ineffective airway clearance related to airway spasm is
also marked as a high priority to attend to because it can be
very life threatening if not intervened immediately by the
health care team.
Addressing the problem to proper health care provider will
give patent airway to the client and will greatly affect the
breathing pattern..
The airway spasm causes obstruction of normal air flow
during breathing, especially when exhaling. Such
obstruction limits the oxygen available for gas exchange
between the lungs and the rest of the body. The long
smooth muscles of the airways may constrict due to the
spasms, further narrowing these airways. The airway
spasms result in respiratory distress with labored
breathing, reduced blood oxygen exchange, and oxygen
deprived muscles. Oxygenation is a vital need for every
cell, if there are any problems related to it can easily affect
the functioning of the individual. Airway spasms can cause blockage of
airway which will cause further difficulty of breathing
(Fundamentals of Nursing 8th ed by Kozier and erb’s p. 1299)
Medium Priority Excess fluid volume should be corrected since there is a
disruption in the body’s homeostasis. When the
circulating volume is excessive and more than the heart
can effectively cope with, fluid overload will occur. This
results in heart failure.
Medium Priority This is not a life-threatening condition but it could be, if it
persists. As the other medical conditions are being treated,
67
the clients’ nutrition is also monitored and strictly
followed. Given a medium priority, we want to resolve it
to prevent it from exacerbating.