Nursing diagnoses are the second step in the nursing process, following assessment. After all the available data is evaluated, the nurse writes one or more diagnoses that identify existing or potential health problems. When a patient has more than one diagnosis, the nurse must decide which problem or possible threat is most important. Priority concerns are those that will either halt or hinder progress or will negatively affect the overall functioning of the patient.
Rule number one: if it can kill or further deteriorate the condition of the patient, it is a priority diagnosis. Everyone needs to breathe and have a heartbeat to survive. Ineffective airway clearance is a priority diagnosis because it hinders the patient's ability to breathe. Decreased cardiac output is also a high priority because it means an insufficient amount of blood is being pumped through the body to support the metabolic needs. Elderly patients are especially at risk for decreased cardiac output because their heart ventricles are less compliant.
Ensuring the safety of the patient is another top priority. There are many safety concerns to evaluate. A patient experiencing dizziness is at a risk for falls and should be monitored when ambulating. Impaired skin integrity can lead to bed sores, which can lead to infection. These issues need to be addressed before a self-hygiene deficit or deficient knowledge diagnosis. It is highly unlikely that not taking a bath can injure or kill a patient. However, falling while walking to the bathroom or acquiring an infection can.
Pain affects the entire body. It can increase heart rate and blood pressure, alter mood and cause stress and anxiety. Until the pain is managed, it will be difficult to proceed with other lower priority nursing interventions. For example, a patient recently had knee surgery and is cleared to start ambulating. He is also being discharged soon and needs to understand care instructions. But his knee is still causing him a great deal of pain. He is not interested in trying to walk, he doesn't want to hear his instructions, he just wants to stop hurting. Everything else comes to a halt until that pain reaches a manageable level.
Actual vs. Risk
In nursing, there are actual and risk diagnoses. An actual diagnosis means the health concern is already present. A risk diagnosis means the nurse has reason to believe the concern is imminent. Generally speaking, the actual problem should take priority over the risk, unless the risk can cause injury or death. In some cases, taking care of the actual concern can decrease the likelihood of the risk. For example, anxiety takes precedence over risk for impaired parent/infant/child attachment if the anxiety is the root of the risk. However, a risk for suicide takes priority over constipation because the imminent threat will cause more harm than the present problem.
Every patient and situation is unique and needs to be evaluated from that perspective. When creating a care plan, look at the diagnoses and determine which health concerns can cause the most damage. If it can cause injury or death, it needs to be addressed first. If it can hinder further goals, it needs to come first. If it can prevent additional problems, it is a priority. There may be cases where there are no major problems or risks. In those cases, prioritize based on what will help the patient reach her fullest health potential.