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1. Ineffective airway Airway must be given the first attention as based on
clearance related to the rule of ABC, which stands for Airway, Breathing
retained secretions in the and Circulation. Addressing the problem will give
bronchotracheal tree 2° patent airway to the client. Oxygenation is a vital
pneumonia need for every cell, if there is any problem related to
it, it could easily affect the functioning of the
individual. Retained secretions can cause blockage
Classification: Actual Problem of airway, which will further cause difficulty of
breathing (Berman, et al, 2016).
2. Hyperthermia related to This is the next priority because the increase in the
increased metabolic rate body temperature is just in response to the disease
experienced by the body. However, many
complications may arise if it was left untreated.
Hyperthermia may result to fluid loss, hemodynamic
alterations, serum enzyme abnormalities and other
symptoms of variable severity. It can also cause
neurologic symptoms including nausea, confusion,
Classification: Actual Problem disorientation, apathy, delirium, stupor or coma
(Progress in Brain Research, page153).
3. Risk for decreased cardiac The patient has hypertension and the
output related to vasoconstriction itself may lead to decreased
increased afterload cardiac output. If it happens, all of the vital organs
(vasoconstriction) will suffer. It is a priority since there is inefficient
pumping of the heart. This is the 4th priority since the
nature of the problem is potential, meaning it can
Classification: Potential
be prevented.
4. Risk for unstable blood The patient has Type 2 DM, so the problem is her
glucose related to blood glucose level. It is a priority since if the patient
impaired insulin secretion had her blood glucose less than 80, hypoglycaemia
will occur, if it is too high, hyperglycemia will occur
which both problems leads to different
complications like ketoacidosis. This is the 5th priority
Classification: Potential because it is a risk, thus it can be prevented.