Question

Please list 4 nursing diagnoses in the order of priority for the following: 86 y/o male admitted on 9/9. NKDA/NKA. Presents with large L. periorbital hematoma and L. forehead laceration R/T a fall at home on cement. PMH: Hx A-Fib on warfarin, stage IV CKD, IDDM, HTN & stasis dermatitis.

Answer 1

Nursing diagnosis should be prioritized base on the immediate treatment needed for the patient.

The four nursing diagnosis according to the priority includes

1. Acute pain related to the presence of periorbital hematoma and forehead laceration as evidenced by patient verbalization of pain.

2.Impaired skin integrity related to the presence of the wound as evidence by periorbital hematoma and forehead laceration.

3.Impaired visual perception related to the presence of periorbital hematoma as evidence by the large swelling in the orbital area.

4. Risk of fall related to loss of muscle strength and weakness.