Question

Mr. Jones is an 84-year-old male admitted for fever, dehydration, and pneumonia. Place the following nursing diagnoses in order of priority.

Risk for impaired skin integrity related to fever, age, and illness.

Altered tissue perfusion related to impaired gas exchange and inadequate fluid volume as evidenced by CRT > 4 sec.

Acute pain related to pulmonary consolidation as evidenced by patient report of pain at 7 out of 10.

Impaired gas exchange related to pulmonary consolidation as evidenced by the need for oxygen at 4L/NC to maintain sats >90%.

A) 2, 4, 3, 1
B) 3, 4, 2, 1
C) 1, 3, 2, 4
D) 4, 2, 3, 1

Answer 1

The correct order of priority for the nursing diagnoses in this case is impaired gas exchange, altered tissue perfusion, acute pain, and risk for impaired skin integrity.

Step-by-step explanation:

The correct order of priority for the given nursing diagnoses is:

1. Impaired gas exchange related to pulmonary consolidation as evidenced by the need for oxygen at 4L/NC to maintain sats >90%.
2. Altered tissue perfusion related to impaired gas exchange and inadequate fluid volume as evidenced by CRT > 4 sec.
3. Acute pain related to pulmonary consolidation as evidenced by patient report of pain at 7 out of 10.
4. Risk for impaired skin integrity related to fever, age, and illness.

To prioritize the nursing diagnoses, we consider the potential risks to the patient's health and well-being. In this case, impaired gas exchange is the most urgent issue as indicated by the need for supplemental oxygen to maintain adequate oxygen saturation levels. Altered tissue perfusion is the next priority, as it is related to impaired gas exchange and inadequate fluid volume. Acute pain is an important issue to address but can be managed after addressing the gas exchange and tissue perfusion problems. Lastly, the risk for impaired skin integrity, while still important, is considered a lower priority compared to the others.