Case No.
Nursing Diagnosis Rank Justification according to ABC or Maslow’s
Cues
1. Decreased Cardiac This has been a prioritized problem because decreased
Output related to cardiac output may lead to reduced blood flow to the
altered heart rate as brain and other vital organs which falls under the
evidenced by category of physiological needs in Maslow’s
tachycardia and Hierarchy of Needs.
decreased blood
pressure Low Cardiac Output is a clinical condition that is
caused by a transient decrease in systemic perfusion
Objective: secondary to myocardial dysfunction. The outcome is
History of an imbalance between oxygen delivery and oxygen
rheumatic fever consumption at the cellular level. The condition has
PR:130 bpm clinical features of fatigue, hypotension, tachycardia,
BP: 90/40mmHg raised jugular venous pressure, and hypoxemia that
arises from the inability of the heart to generate
enough cardiac output.
1
Cardiac function is also related to the ABC nursing
priority and falls under the C, for circulation. Because
the ABCs should be the highest priority, this diagnosis
was prioritized first.
References
Burke, A., 2019. Establishing Priorities: NCLEX-RN.
[online] Registerednursing.org. Available at:
<https://www.registerednursing.org/nclex/establishing-
priorities/> [Accessed 31 March 2020].
Masse, L., Antonacci, M. (2015) Low cardiac output:
Identification and Management. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/16344207
Michigan Medicine University of Michigan. (2020).
Heart Failure: Compensation by the Heart and Body.
Retrieved from https://www.uofmhealth.org/health-
library/aa86963
2. Deficient Knowledge This has been a prioritized problem because lack of
related to lack of cognitive information and ability needed for health
exposure as evidenced preservation, or health promotion is vital for the
by development of pregnant patient together with the fetus. It falls under
preventable the category of safety and security needs in Maslow’s
complication Hierarchy of Needs.
2
Objective: Deficient knowledge is characterized by inappropriate
Developed actions that affect one’s health and incorrect task
gestational performance. It is associated with unfamiliarity with
diabetes information resources, lack of exposure. Having low
Had two level of literacy results to less awareness about health
previous promotion and the management of a disease that brings
hospital visits higher rates of hospitalization for inadequate level of
for literacy.
hyperglycemia
Current blood Reference:
serum is Blackwell, W. (2017). Nursing Diagnoses Definition
207mg/dl and Classification 2015-2017 10th Edition page 257
Mcleod, S. (2020, March 20). Maslow's Hierarchy of
Needs. Retrieved March 27, 2020, from
https://www.simplypsychology.org/maslow.htm
Risk for Impaired This is a risk diagnosis; therefore, it is not of top
Maternal-Fetal Dyad priority. On the other hand, this diagnosis still falls
related to impaired into the physiological needs of the mother and child
glucose metabolism because the mother’s hormonal function could pose a
(gestational diabetes) threat to the development of her child.
Objective Cues: Gestational diabetes is characterized by a high blood
Developed sugar concentration during the pregnancy. It can cause
gestational serious birth defects to the brain and heart, and
diabetes increased birth weight if it develops in the latter half of
Had two the pregnancy. A large baby often creates labor and
previous delivery complications so it is important that the
hospital visits diabetes is diagnosed and treated early.
for
hyperglycemia Reference
Current blood
serum is Birthinjuryinfo.org, 2020. Pregnancy Complications.
207mg/dl [online] birthinjuryinfo.org. Available at:
Fetal heart rate <https://www.birthinjuryinfo.org/Pregnancy-
is 180 bpm Complications/index.html#G> [Accessed 31 March
2020].
4. Risk for unstable This has been a prioritized problem because
blood glucose level vulnerability to variation in blood glucose levels from
related to insufficient the normal range may compromise the health of the
diabetes management, client.
insufficient knowledge
of disease management The diagnosis deals with the hormonal function of the
endocrine and pancreas so therefore, it falls under the
Objective: safety and security needs under Maslow's Hierarchy of
Serum blood glucose Needs. Needs at this level must be met imperatively in
level of 207 mg/dl order to move on to the other needs of the client.
Gestational diabetes is diabetes diagnosed for the first
time during pregnancy (gestation). Like other types of
diabetes, gestational diabetes affects how your cells
use sugar (glucose). Gestational diabetes causes high
blood sugar that can affect your pregnancy and your
baby's health.
Reference:
Mayo Foundation for Medical Education and Research
(MFMER). (2020, February 27). Gestational diabetes.
Retrieved March 27, 2020, from
https://www.mayoclinic.org/diseases-
conditions/gestational-diabetes/symptoms-causes/syc-
2035533
Mcleod, S. (2020, March 20). Maslow's Hierarchy of
Needs. Retrieved March 27, 2020, from
https://www.simplypsychology.org/maslow.htm
