In caring for an immobile client, which nursing diagnosis is highest priority?

In caring for an immobile client, which nursing diagnosis is highest priority?

• A. Risk for constipation
• B. Self-care deficit
• C. Impaired gas exchange
• D. Impaired skin integrity

Answer: (C)

Preserving breathing and oxygen delivery takes priority, especially in an immobile client. Immobility can lead to shallow breaths, reduced chest expansion, and pooling of secretions, which raise the risk of atelectasis and pneumonia. When gas exchange is impaired, tissues and organs don’t receive enough oxygen, and this can rapidly become life-threatening, making impaired gas exchange the highest-priority concern. Constipation, self-care deficits, and skin integrity are important to address, but they do not pose the same immediate threat to life as problems with breathing. To support the highest-priority need, monitor respiratory rate and effort, oxygen saturation, and breath sounds; encourage deep breathing and coughing, use incentive spirometry, and ensure regular turning and airway clearance as tolerated.

Preserving breathing and oxygen delivery takes priority, especially in an immobile client. Immobility can lead to shallow breaths, reduced chest expansion, and pooling of secretions, which raise the risk of atelectasis and pneumonia. When gas exchange is impaired, tissues and organs don’t receive enough oxygen, and this can rapidly become life-threatening, making impaired gas exchange the highest-priority concern.

Constipation, self-care deficits, and skin integrity are important to address, but they do not pose the same immediate threat to life as problems with breathing. To support the highest-priority need, monitor respiratory rate and effort, oxygen saturation, and breath sounds; encourage deep breathing and coughing, use incentive spirometry, and ensure regular turning and airway clearance as tolerated.