XV.

Nursing Care Plans

A. Prioritization of Problems

a.1. List of Problems

We have classified our nursing difficulties into the lowest level of the pyramid,
which is the physiological demands, in line with Maslow's hierarchy of needs, which is a
five-tier model of human needs. These are necessary for survival, and impairments in
one's body's structure and function might hamper one's capacity to meet these needs. As a
result, nursing interventions that focus on these issues are critical to preventing further
deterioration of one's body and the worsening of a disease.
1. Acute Pain
2. Hyperthermia
3. Impaired Gas Exchange
4. Ineffective Tissue Perfusion
5. Risk for fluid volume excess

a.2. Basis for Prioritization

NURSING DIAGNOSES JUSTIFICATION
1. Acute Pain Prioritization begins with determining immediate threats to
life as part of the initial assessment and is based on the ABC
pneumonic.Pain Management falls under the physiological
needs category of Maslow’s hierarchy of needs such as
breathing and pain management as a top priority. According
to Maslow’s Hierarchy of Needs, once a client has
established an appropriate airway, breathing, and circulation,
the next aspects that should be prioritized are safety and
infection. As a result, pain is prioritized first because it is the
most pressing concern.

2. Hyperthermia The second priority should be the hyperthermia or elevated

body temperature because it is correlated with the acute
pain. Due to infection and inflammation, our body produces
pyrogens ( group of chemically diverse substances that
cause fever ) which signals the hypothalamus to increase the
body’s set point temperature, leading to a fever.

3. Impaired Gas Exchange According to Maslow’s Hierarchy of Needs, impaired

gas exchange should be the next prioritization. In ABC
pneumonic, the airway and breathing will be the first
priority since patient is on oxygen support and his
oxygen saturation decreases.
4. Ineffective Tissue Perfusion
5. Risk for fluid volume excess
The fourth priority would be the ineffective tissue perfusion.
Due to the vasoconstriction of the blood vessels leading to
pancreas. In pancreatitis, the inflammation, swelling and the
damage of the pancreatic tissue might lead to compromised
of the blood vessels. This will create an abnormality of the
blood supply and the oxygen supply of the patient.
The risk of fluid volume overload will be the last priority. In
severe pancreatitis situations, the inflammation can spread to
neighboring tissues and organs, resulting in regional edema.
This might alter the body's regular fluid balance. In
conclusion, pancreatitis can predispose people to fluid
volume excess due to the complicated interaction of
inflammation, edema, and therapeutic measures such as
fluid replacement.