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Prioritized List of Nursing Process

DATE NURSING PROBLEMS CUES JUSTIFICATION

IDENTIFIED
07/16/10 Risk for Deficient Fluid Volume: A risk diagnosis is This is an example
risk factors may include loss of not evidenced by of risk nursing
fluid through abnormal routes signs and diagnosis which is
(chest tube drainage) and symptoms as the not yet present in
medically restricted intake problem has not the client but there
occurred; rather. are presence of risk
factors. No
Objective: interventions are
• The client needed at present,
has chest tube except for continued
drainage. assessment and
• The client reassurance so it is
is in NPO the least prioritized
temporarily soft problem.
diet
07/16/10 Impaired Tissue Integrity related Objective: This problem is an
to surgery (Explore Laparotomy) • The client was actual problem since
as manifested by destroyed stabbed by it is already present
tissue unknown on the client but the
assailant client doesn’t have
• Destroyed any concerns about
tissue this. The resources
• The client needed are not
undergone readily available and
Explore not easily accesible
Laparotomy (surgery)
07/16/10 Acute pain related to interruption Subjective: This problem is an
in skin and tissue layer brought • Client rated the actual problem
about by therapeutic intervention pain that he is because it is already
(chest tube drainage insertion) experiencing as present at the time
10 (1-without of nursing
pain and 10- assessment which
intense pain) needs immediate
• The pain he is action. This is also
experiencing the client’s primary
prevents him concern. Resources
from doing his such as manpower
activities of and medications are
daily living and readily available.
his usual
routines.
• He usually
 stays in bed to
reduce the pain
that he is
experiencing.
Objective:
• Grimace
• The client’s
hand is always
on the painful
part (guarding
behavior)
• Restlessne
ss
• Positioning
to avoid pain