A patient is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this patient's care, which of the following nursing diagnoses should the nurse prioritize?
A) Ineffective Tissue Perfusion Related to Bowel Ischemia
B) Imbalanced Nutrition: Less Than Body Requirements Related to Impaired Absorption
C) Anxiety Related to Bowel Obstruction and Subsequent Hospitalization
D) Impaired Skin Integrity Related to Bowel Obstruction
Ans: A
Feedback:
When the bowel is completely obstructed, the possibility of strangulation and tissue necrosis (i.e., tissue death) warrants surgical intervention. As such, this immediate physiologic need is a nursing priority. Nutritional support and management of anxiety are necessary, but bowel ischemia is a more immediate threat. Skin integrity is not threatened.
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