PROBLEM PRIORITIZATION

Nursing diagnosis Ran Justification

Impaired tissue integrity related to mass
recurrence in the right frontotemporal area
of the head secondary to S/P craniectomy
Subjective cues:
Dati kasi, bukol lang yan na maliit.
Inoperahan, tinanggal. Tapos ilang buwan lang,
tumubo ulit. Masmalaki pa. Inoperahan ulit.
As verbalized by the patients SO
k
1 Wounds should be treated as a priority
diagnosis, especially when it is an open wound,
because wounds so puts patient at risk for
infection and could have further breakdown and
complication, if not monitored properly.
Reference: Medical-Surgical Nursing, by
Smeltzer and Bare p. 944

Objective cues:
(+) Depression on right frontotemporal
area of the head
(+) Wound dressing at right
frontotemporal area, soaked
(+) pain, 5/10

Vital Signs:
BP: 110/70
PR: 84
RR: 20
Temp: 36 C
Medications:
Methylprednisolone 1 tab OD 6 PM
Meropenem 500mg TIV q8
Tramadol 50mg 1 tab q6 RTC
Levoflaxacin 750 mg/tab OD x 14
Celecoxib 200 mg/cap RTC after meals

Ineffective airway clearance related to 2 Airway must be given the first attention as
excessive mucus as evidenced by crackle based on the rule of ABC which is Airway,
sounds in the lungs upon ausculatation Breathing and Circulation. In addition,
secondary to presumed PTB difficulty of breathing can cause anxiety to the
client that is why, immediate attention must be
Objective cues: done. Addressing the problem to proper health
(-) dyspnea care provider will give patent airway to the
(+) crackles, both lung fields client. Oxygenation is a vital need for every
(+) yellow nasal secretions cell, if there are any problems related to it can
easily affect the functioning of the individual.
Vital Signs:
BP: 110/70 Reference: Fundamentals of Nursing 8th ed.
PR: 84 by Kozier and erbs p. 1299
RR: 20
 Temp: 36 C

Medications:
NAC 600, 600 mg/tab in a half glass of
water OD
Ipratropium salbutamol (DUAVENT)

Acute pain related inflammatory process 3 Pain should be a prioritized problem next to
evidenced by reports of pain. airway, breathing and circulation, because pain
can affect the treatment and cooperation of the
Subjective: patient. Pain can also adhere his difficulty of
Mejo kumikirot-kirot paminsan minsan, pero breathing, especially when patient is in
kaya naman. respiratory distress. It also limits his
As verbalized by the client movements, which could lead to another
problem and slows down his recovery
Objective:
Pain scale 5/10 Reference: Merck Manuals Professional
(+) facial grimace Edition, by Kathryn Colby, MD, PhD

Medications:
Methylprednisolone 1 tab OD 6 PM
Tramadol 50mg 1 tab q6 RTC