Nursing Problems Identified Imbalanced Nutrition: less than body requirements

Cues

Rank 1

Justification This problem does not affect airway, breathing and circulation, but affects the physiologic needs of human. It is not life threatening but important because the effects of this problem may disturb other function eventually. This was prioritized first because the pain is already tolerated. Nurse and client have sufficient resources to solve this problem. In order to achieve the Maslows hierarchy of needs, an individual must be capable of doing things without alteration or pain. This is an actual problem because pain causes changes to the clients homeostasis and can affect the treatment and cooperation of the patient. This must be addressed first before proceeding to other problems. Pain is considered as sixth vital sign and needs an immediate intervention. All actual problems are highly prioritized than potential problems. Nurse and client have sufficient resources to solve this problem. This is not life threatening and does not need

Acute Pain related to distention of intestinal tissues by inflammation.

Activity Intolerance related to pain

Subjective: ayaw nya maglakad-

lakad dahil masakit daw yung tyan nya Objective: Pain scale of 5/10

Impaired skin integrity related to surgery (appendectomy)

Objective: Surgical incision Pain in the incision site

Risk for infection Objective: related to the surgical Surgical incision incision

risk for constipation related to decreased activity

Subjective: ayaw nya maglakadlakad dahil masakit daw yung tyan nya Objective: Frequent lying on bed Pain scale of 5/10

immediate attention. However, it can affect the bodys normal functioning. For a person to achieve the Maslows hierarchy of needs, an individual must be capable of doing things. This is an actual problem but it is not life threatening. Interventions needed to address this problem are to prevent further impairment to the clients current condition. Any break in the skin can readily serve as a portal of entry putting the individual at risk for potential infections. It does not require immediate attention compared to other prioritized problems. This is not an actual problem at the moment but it may move to another level if left unchecked. Infection can lead to serious problems or complication and need to be prioritized than risk for constipation. It is last prioritized because based on the types of nursing diagnosis, patients health is at risk and may likely happen.