OTHER SUPPORTING
NURSING DIAGNOSIS
Impaired Airway Clearance
related to accumulation of
secretions in tracheobronchial
tree
Impaired cerebral tissue
perfusion related to
mechanical reduction of
arterial blood flow
Impaired peripheral tissue
perfusion related to
mechanical reduction of
arterial blood flow
JUSTIFICATION
THEORIES
According to ABC’s Airway is According to actual and
the 1st priority, because airway potential problem we must
obstruction is an emergency. It treat the actual problem first.
causes hypoxia which risk the And in my patient Airway
damage to other organs such clearance should be treated
as brain, heart and kidneys. first since this aggravates the
other problems for example is
the Impaired cerebral
perfusion, how would we give
oxygenation in the brain if the
airway is not patent.
According to ABC’s Breathing Acute vs. Chronic Problem
is the 2rd priority, the states that , we must
exchange of oxygen in order to prioritized the new diagnosis,
supply oxygen to the brain to that is why this nursing
perform well. diagnosis is prioritized as 3rd
because we need to address
first the Development of
Pneumonia since the pt.
developed some level of
adaptation with the illness.
According to ABC’s Breathing Acute vs. Chronic Problem
is the 3rd priority, the exchange states that , we must
of oxygen in order to supply prioritized the new diagnosis,
oxygen to the body that is why this nursing
diagnosis is prioritized as 4th
because we need to address
first the perfusion in the
ADVANTAGE
If we will be prioritizing this
problem, the patient will be
able to expectorate secretions
thus having a patent airway,
which will help in improving
ventilation, thus it will also
help to resolve the 2nd
problem. Which is cerebral
tissue perfusion, because
oxygen is needed to tissue
perfusion in the brain. In order
to supply enough oxygen to
the brain the airway needs to
be patent.
This is the 3rd priority since
the pt. diagnosis is CVA ,
when the there is a good
oxygen perfusion on lungs and
then it will be delivered to the
brain which will be helping
other problems such as the 4th
and 6th.
This is the 3rd priority since
upon receiving the perfusion
needed in peripheral tissues,
this will help the muscle and
tissue to function well, and
will help in mobility and
activities of the patient.
DISADVANTAGE
If we will not be prioritizing
this problem, the client might
be in respiratory distress,
which will aggravate the other
problems.
Once this is not resolved, the
part of the brain that does not
receive oxygen might lost its
function which is significant to
improve the motor and sensory
perception of the patient.
If there is no peripheral tissue
perfusion , tissues or muscles
in extremities doesn’t have
oxygen which means they will
get easily tired when moving
thus the pt. mobility will be
compromised.

Impaired mobility related to
neuromuscular impairment
Impaired swallowing related to hierarchy to priority. In the
neuromuscular impairment
Activity intolerance related to
generalized weakness
According to maslow’s
hierarchy of need, safety and
comfort is 2nd level on the
hierarchy to priority. In the
case of the patient this
diagnosis causes risk for injury
in the patient such as fall.
Thus, this is the 4th priority.
According to maslow’s
hierarchy of need, safety and
comfort is 2nd level on the
case of the patient this
diagnosis causes risk for injury
in the patient such as
aspiration.
According to maslow’s
hierarchy of need, safety and
comfort is 2nd level on the
hierarchy to priority. In the
case of the patient this
diagnosis causes risk for injury
in the patient such as fall.
cerebral tissue before the
peripheral.
Trend vs. Isolation Finding
says that recognizing
deterioration is a key.
Trend vs. Isolation Finding
says that recognizing
deterioration is a key.
Trend vs. Isolation Finding
says that recognizing
deterioration is a key.
4th priority because impaired
mobility is the first thing to
focus on before focusing on 5th
and 6th problems. By resolving
this problem this 6th and 7th
problem will be easier to
manage.
Prioritize as 5th because
impaired swallowing might
give a risk of Decreased fluid
volume, and Imbalance
nutrional status: less than body
requirements.
6th priority because helping the
pt. in improving ADL’s will
give the patient motivation to
continue and improve and
participate in ADL gradually.
When there is an impaired
mobility, patient will be in a
high risk of injury, and patient
might develop other
complications.
If this will not be resolved the
pt. will be in NGT thus, there
will be an Imbalanced
nutrition less than body
requirements.
If pt will be having an activity
intolerance, pt. will not be
living again in her normal
routines which is
compromised.