Nanda Nursing Diagnosis

Impaired verbal communication is defined as decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols. Related to : Physiologic conditions Alteration of central nervous system Impaired neurologic development or dysfunction Disturbance in attachment/bonding with the parent/caregiver Characterized by : Language delay or total absence of language Immature grammatic structure; pronoun reversal; inability to name objects Stereotyped or repetitive use of language (echolalia, idiosyncratic words, inappropriate high-pitched squealing/giggling, repetitive phrases, sing-song speech quality) Lack of response to communication attempts by others Outcome : Communicate in words/gestures that are understood by others Interventions and Rationales Use one-on-one interactions to engage the client in nonverbal play. R/: The nurse enters the client’s world in a nonthreatening interaction to form a trusting relationship. Recognize subtle cues indicating the client is

Pleural effusion Pleural effusion is excess fluid that accumulates in the pleura, the fluid-filled space that surrounds the lungs. Excessive amounts of such fluid can impair breathing by limiting the expansion of the lungs during respiration. Etiology of Pleural Effusion Various causes of pleural effusion are: Neoplasms, such as bronchogenic and metastatic neoplasms. Cardiovascular, such as congestive heart failure, pulmonary embolus and pericarditis. Diseases of the abdomen, such as pancreatitis, ascites, abscess and Meigs syndrome. Infections caused by bacteria, viruses, fungi, and parasites microbacterial. Trauma Other causes such as systemic lupus erythematosus, rheumatoid arthritis, nephrotic sindroms and uremia. Signs and Symptoms of Pleural Effusion Cough Dyspnea varies Complaints of chest pain (pleuritic pain) In severe effusions occur protrusion intercostal space. Chest movement was reduced and delayed on the part of the experience effusion. Percussion dims above pleural eff

Pulmonary embolism (PE) A pulmonary embolism is a sudden blockage in a lung artery. The cause is usually a blood clot in the leg called a deep vein thrombosis that breaks loose and travels through the bloodstream to the lung. Pulmonary embolism is a serious condition that can cause Permanent damage to the affected lung Low oxygen levels in your blood Damage to other organs in your body from not getting enough oxygen If a clot is large, or if there are many clots, pulmonary embolism can cause death. Signs and Symptoms dyspnoea - suddenly and there is at 90% of cases pleuritic chest pain haemoptisis fainting tachycardia more than 100/menit tachipnoe more than 20/menit fever Threat Signs of Life: Symptoms of Pulmonary embolism: severe dyspnea chest pain increased venous pressure there is evidence of right heart failure hypotension shock Assessment for Pulmonary Embolism Assessment of the ABCD approach Airway Assess and maintain airway Perform head tilt, chin lift if necessary Use this too