What is the most priority nursing diagnosis?

The planning stage of the nursing process will require the nurse to use decision-making and problem-solving skills in designing a plan of care for each patient. During planning, priorities are set due to multiple nursing diagnoses assigned including a variety of proposed interventions. Planning is a category of nursing behaviors in which client-centered goals and expected outcomes are specifically chosen to resolve the client's problem and achieve the goals and outcomes (Potter & Perry, 2005). Priority setting involves ranking nursing diagnoses in order of importance. With prioritizing, the nurse can attend to the client's most important needs and organize ongoing care activities. 

Priorities are classified as high, intermediate, or low.

• High-priority nursing diagnoses are those that if untreated, could result in harm to the client. In many cases, these diagnoses protect basic needs of safety, adequate oxygenation, and comfort. Example: Risk for other-directed violence, impaired gas exchange, acute pain, risk for ineffective airway clearance.
• Intermediate priority nursing diagnoses involve non-emergent, non-life threatening needs of the client. Example: Ineffective peripheral tissue perfusion in a post-operative patient can place the client at risk for post-operative venous stasis and DVT, therefore maintaining normal circulation to the lower extremities becomes an immediate priority.
• Low priority diagnoses are client needs that may not be directly related to a specific illness or prognosis but may affect the client's future well-being. Many focus on the long-term health care needs of the client. Example, the post-operative client will be discharged after surgery and will be required to manage the wound and nutritional needs at home (Potter & Perry, 2005). Example: Deficit knowledge is an important diagnosis but must be considered a low priority when issues such as pain management and patent airway are a major concern with the client.

After identifying nursing diagnoses for the client, the nurse must determine what the best approach to address and resolve the problem. Goals and expected outcomes are established to guide the plan of care. These are specific statements of client behavior or physiological responses that a nurses uses to resolve a problem (Potter & Perry, 2005). A client-centered goal is a specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function (Potter & Perry, 2005). An example of a client-centered goal is: "Client will perform self-care hygiene independently", "Client will remain free of infection", "Client will accept body image alteration".


There are two types of goals: short-term goals and long-term goals



Short-term goals are objectives that are expected to be achieved within a short time frame, usually less than a week. Short-term goals are applicable for the immediate care plan due to shorter hospital stays (Potter & Perry, 2005). For instance if the nursing diagnosis acute pain related to the tissue trauma of a surgical incision is utilized, a short-term goal would be "Client will achieve comfort within 24 hours postoperatively"(Potter & Perry, 2005).


Long-term goals are objectives expected to be achieved over a longer time frame, usually over weeks or months. Long-term goals are more appropriate for after discharge, especially from acute care settings. These goals are more appropriate for those clients in home care settings and "adapting to chronic illnesses who reside in long-term care facilities and for those clients in rehabilitation, mental health, ambulatory care, and community nursing settings (Carpenito, 1997 as cited in Potter & Perry, 2005).
For instance if the nursing diagnosis deficient knowledge regarding postoperative home care related to inexperience is utilized, a long-term goal may be "Client will adhere to postoperative activity restrictions for one month (Potter & Perry, 2005).
The nurse must realize that long-term goals are essential to continuity of care. Failure to do so may hinder the client's success to recovery. 



Read Chapter 17, pages 318-338 for more on the planning phase.

The purpose of this study was to identify high frequency-treatment priority nursing diagnoses in critical care nursing using survey research methods. Through a mailed survey the prevalence of 135 nursing diagnoses from the NANDA Diagnostic Taxonomy and other diagnoses was rated by a national, random sample of 678 critical care nurses. Six important diagnostic areas were: sleep-rest, activity, nutritional-metabolic, cognitive-perceptual, self-perception (mood state), and health management (risk) patterns. Twenty diagnoses were rated as nearly always or frequently present in their practice by 70% or more of the nurses. Findings can be used to focus clinical studies of the highly prevalent diagnoses.

In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of establishing priorities in order to:

• Apply knowledge of pathophysiology when establishing priorities for interventions with multiple clients
• Prioritize the delivery of client care
• Evaluate the plan of care for multiple clients and revise plan of care as needed

Actual needs and problems take priority over wellness, possible risk and health promotion problems and short term acute patient care needs and problems typically take priority over longer term chronic needs.

Applying a Knowledge of Pathophysiology When Establishing Priorities for Interventions with Multiple Clients

As previously mentioned with the "Integrated Process related to the Nursing Process", priorities are established using a number of methods and frameworks including the ABCs, Maslow's Hierarchy of Needs and the ABCs/MAAUAR method. Knowledge of these frameworks and an in-depth knowledge about pathophysiology facilitate the proper establishment of priorities relating to the interventions that are then provided to individual clients and groups of clients with diverse needs of varying acuity and differing priorities.

The ABCs identifies the airway, breathing and cardiovascular status of the patient as the highest of all priorities in that sequential order.

Maslow's Hierarchy of Needs identifies the physiological or biological needs, including the ABCs, the safety/psychological/emotional needs, the need for love and belonging, the needs for self-esteem and the esteem by others and the self-actualization needs in that order of priority.

Some examples of each of these needs according to Abraham Maslow's Hierarchy of Needs are:

Physical and Biological Needs

• Some physical needs include the need for the ABCs of airway, breathing and cardiovascular function, nutrition, sleep, fluids, hygiene and elimination.

Safety and Psychological Needs

• The psychological or emotional, safety, and security needs include needs like low level stress and anxiety, emotional support, comfort, environmental and medical safety and emotional and physical security.

Love and Belonging

• The love and belonging needs reflect the person's innate need for love, belonging and the acceptance of others including a group.

Self Esteem and Esteem by Others

• All people have a need to be recognized and respected as a valued person by themselves and by others. People have a need self-worth and self-esteem and they need the esteem of others.

Self Actualization

• Self-actualization needs motivate the person to reach their highest level of ability and potential.

The ABCs / MAAUAR method, which was previously detailed, places the ABCs as the highest and greatest priorities which are then followed with the 2nd and 3rd priority level needs.

The 2nd priority needs include MAAUAR which is mental status, acute pain, acute impaired urinary elimination, unresolved and unaddressed needs, abnormal diagnostic test results, and risks. The 3rd level priorities include all concerns and problems addressed with the 2nd level priority needs.

Prioritizing the Delivery of Client Care

The delivery of client care is prioritized as just discussed above.

In addition to prioritizing and reprioritizing, the nurse should also have a plan of action to effectively manage their time; they should avoid unnecessary interruptions, time wasters and helping others when this helping others could potentially jeopardize their own priorities of care.

Evaluating the Plans of Care for Multiple Clients and Revising the Plan of Care as Needed

In addition to providing guidance and direction in terms of nursing care delivery, plans of care, including nursing care plans and other systems like a critical pathway, provide the mechanism with which the outcomes of the care can be measured and evaluated.

Appropriate and effective client care is dependent on the accuracy and appropriateness of the client's plan of care. For this reason, reasessments and updating and revising a plan of care as based on the client's current status is necessary.

RELATED NCLEX-RN MANAGEMENT OF CARE CONTENT:

SEE - Management of Care Practice Test Questions

Alene Burke RN, MSN is a nationally recognized nursing educator. She began her work career as an elementary school teacher in New York City and later attended Queensborough Community College for her associate degree in nursing. She worked as a registered nurse in the critical care area of a local community hospital and, at this time, she was committed to become a nursing educator. She got her bachelor’s of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. She graduated Summa Cum Laude from Adelphi with a double masters degree in both Nursing Education and Nursing Administration and immediately began the PhD in nursing coursework at the same university. She has authored hundreds of courses for healthcare professionals including nurses, she serves as a nurse consultant for healthcare facilities and private corporations, she is also an approved provider of continuing education for nurses and other disciplines and has also served as a member of the American Nurses Association’s task force on competency and education for the nursing team members.

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