Nanda Nursing Diagnosis

Nursing Diagnosis Risk for infection - NCP Impetigo Nursing Diagnosis Risk for Infection related to decreased immune system, malnutrition, inflammation, and invasive procedures. Expected outcomes are: Clients are free from signs and symptoms of infection. Showed the ability to prevent infection. Demonstrate healthy behavior. Describe the process of transmission of the disease, factors that influence transmission. Nursing Interventions - Nursing Care Plan for Impetigo : Monitor for signs and symptoms of infection. Monitor susceptibility to infection. Limit the visitor when necessary. Instruct patient visitors to wash their hands during a visit and after leaving the patient. Maintain aseptic environment during ongoing treatment. Give skin care in the area epidema. Inspection of skin and mucous membrane of the redness, heat. Inspection of the condition of the wound. Give antibiotic therapy if necessary. Teach how to avoid infection.

Nursing Diagnosis of Knowledge Deficit - Nursing Care Plan for Impetigo  Nursing Diagnosis: Knowledge Deficit : the disease, prognosis and treatment needs. Patients showed an understanding of disease processes and treatment procedures, with the expected outcomes: the patient can explain the status of the disease, treatment, care understand that done. Nursing Interventions ; Teach About the Disease: Determine the level of knowledge of patients and families related to disease processes. Describe the pathophysiology of the disease and connect with the anatomy and physiology. Describe the signs and symptoms of the disease. Describe the disease process. Identification of possible causes. Provide information about the patient's condition. Provide information about the diagnostic measures. Describe the rationality of therapy / treatment given. Describe complications. Talk about lifestyle changes in patients who may be required. Discuss treatment options. Take time to explore a second opin

Nursing Care Plan for Impetigo - Nursing Diagnosis and Interventions : Impaired Skin Integrity Nursing Diagnosis: Impaired Skin Integrity related to lesions and mechanical injury (scratching the itchy skin) Expected outcomes are: A good skin integrity can be maintained (sensation, elasticity, temperature) No injuries or lesions on the skin. Able to protect skin and keep skin moist and natural treatments. Good tissue perfusion. Nursing Interventions: 1. Instruct the patient to use, loose clothing. Rational: a loose shirt, shirt will reduce friction on the skin lesions. 2. Cut nails and keep the client's hand hygiene. Rational: the nail that will reduce the short and avoid scratching the impetigo lesion severity. 3. Keep clean skin, to keep them clean and dry. Rational: the skin clean and dry, will reduce the spread or proliferation of bacteria. 4. Monitor skin color, the existence of redness. Rational: to know the progression of the disease and the effectiveness of actions taken. 5

Nursing Interventions Risk for Decreased Cardiac Output in Hypertension Nursing Diagnosis: Risk for Decreased Cardiac Output - Nursing Care Plan for Hypertension Risk for Decreased Cardiac Output related to vasoconstriction Expected outcomes are: Clients participating in activities that lower blood pressure / load cardiac work, maintaining blood pressure within an acceptable range of individuals, showing stable norms and cardiac frequency in the normal range. Nursing Intervention: 1. Observation of blood pressure (the ratio of pressure to give an overview more complete, the involvement / field of vascular problems). 2. Note the presence, quality of the central and peripheral pulsation (throbbing carotid, jugular, radial and femoral probably observed / palpation. 3. Auscultation of heart and breath sounds tone. (S4 commonly heard in patients with severe hypertension due to atrial hypertrophy, the development of S3 showed ventricular hypertrophy and malfunction, the presence of crackles

Nursing Interventions for Hyperemesis Gravidarum 1. Assess for signs of dehydration Rational: improve fluid balance, and maintain a homeostatic mechanism, is the basis for the mother and fetus to maintain balance. 2. Assess vital signs Rational: temperature, pulse rate increased and decreased BP are signs of dehydration and hypovolemia. 3. Give parenteral fluids: electrolytes, glucose and vitamins according to program Rational: This fluid will provide or meet the needs of the body's acid-base balance, electrolytes and hypoavitaminosis. 4. Provide nutrition in small but frequent portions. Rational: feeding gradually or slowly may help. 5. Monitor the provision of fluids and food in 24 hours as well as expenditures and recorded fluid intake. Rational: the provision of fluids and electrolytes is a way to deal with persistent vomiting, this recording will be able to assess the balance of electrolytes are given, while the number of how many calories can already be given. 6. Review of ed

Nursing Diagnosis for Hyperemesis Gravidarum Hyperemesis Gravidarum Hyperemesis gravidarum (HG) is a severe form of morning sickness, with "unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids." Hyperemesis is considered a rare complication of pregnancy but, because nausea and vomiting during pregnancy exist on a continuum, there is often not a good diagnosis between common morning sickness and hyperemesis. Estimates of the percentage of pregnant women afflicted range from 0.3% to 2.0% Nursing Diagnosis for Hyperemesis Gravidarum 1. Fluid and electrolyte imbalances related to excessive vomiting or lack of fluid intake. 2. Imbalanced Nutrition Less Than Body Requirements related to nausea, vomiting or lack of nutritional intake. 3. Anxiety related to hyperemesis influence on the health of the fetus. 4. Knowledge deficit related to lack of information about the treatment of hyperemesis. 5. Sleep pattern disturbance r

Nursing Care Plan for Hyperemesis Gravidarum : Nursing Assessment for Hyperemesis Gravidarum 1. Main complaint: Severe vomiting Nausea, vomiting in the morning and after meals Epigastric pain Feeling thirsty No appetite Vomiting of food / liquid acid 2. Predisposing factors Maternal age <20 years Multiple gestation Obesity Trophoblastic Disease 3. Physical Examination Metabolic acidosis is characterized by headache, disorientation Tachycardia, hypotension, vertigo Conjunctival jaundice Impaired consciousness, delirium Signs of dehydration: Dry skin, mucous membranes dry lips Slow return of skin turgor Sunken eyelids Weight loss Increase in body temperature Oliguria, ketonuria Concentrated urine Laboratory data: Proteinuria Ketonuria Urobilinogen Decreased levels of potassium, sodium, chloride, and protein Decreased levels of vitamin Increased Hb and Ht Nursing Diagnosis for Hyperemesis Gravidarum

Nursing Assessment for Epilepsy - ABCDE Airway In the ictal phase, the client usually found clenched his teeth so that obstruct the airway, the client bite the tongue, mouth foaming, and the postictal phase, usually found injury to the tongue and gums due to the bite. Breathing In the ictal phase, the client breathing down / speed, increased mucus secretion, and skin was pale even cyanosis. In phase posiktal, clients have apnea. Circulation In the ictal phase pulse and cyanosis increase, the client usually unconscious. Disability Clients can be realized or not depends on the type of attacks or characteristics of epilepsy suffered. Usually the patient was confused, and do not remember the incident when the seizures. Exposure Client's clothing was opened to thoracic examination, whether there are additional injuries due to seizures. Nursing Diagnosis for Epilepsy Nursing Diagnosis and Interventions Risk for Injury - Seizures

Social isolation related to low self-esteem Objectives: Clients can build a trusting relationship. Clients can positively identify the capabilities they have. Clients can assess the capability of being used. Clients can (set) to plan activities in accordance with the capabilities. Clients can perform activities according to the condition of pain and ability. Clients can take advantage of existing support systems. Nursing Interventions: Construct a trusting relationship with therapeutic communication: Therapeutic greet. Introduce yourself. Explain the purpose of interaction. Create a calm environment. Create a clear contract. Stay on time. Discuss the capability and the positive aspects of the client owned. Every meeting with clients avoid from giving negative ratings. Polar realistic praise. Discuss with the client the ability to still be used for ill. Discuss with the client capabilities that can be shown to the user. Plan activities with clients who may be continued every day accordi

Nursing Diagnosis for CHF - Congestive Heart Failure 1 Decreased Cardiac Output related to changes in left ventricular contractility, rhythm frequency changes, electrical conduction 2. Ineffective Tissue Perfusion related to decrease in cardiac output tissue hypoxemia, acidosis and, the possibility of thrombus or emboli. 3. Ineffective Airway Clearance related to decrease in lung volume, hepatomegaly, splenomegaly 4. Activity Intolerance related to imbalance between myocardial oxygen supply and demand of the body, the ischemic / necrotic myocardial tissue 5. Excess Fluid Volume related to Systemic fluid overload, interstitial fluid permeation in the systemic secondary to decreased cardiac output, right heart failure 6. Imbalanced Nutrition: Less Than Body Requirements related to anorexia, dyspnoea, nausea, vomiting, side effects of drugs, sputum production 7. Sleep pattern disturbance related to paroxysmal nocturnal disease, hospitalization, crowded 8. Anxiety related to fear of death,

Nursing Assessment for Congestive Heart Failure 1. Activity / rest Symptoms: fatigue / tiredness throughout the day, insomnia, chest pain with activity, dyspnea at rest. Symptoms: Anxiety, mental status changes such as lethargy, changes in vital signs of activity. 2. Circulation Symptoms: history of hypertension, acute myocardial infak, previous episodes of Chronic Heart Failure , heart disease, cardiac surgery, endocarditis, anemia, septic shock, swelling in the legs, feet, abdomen. Signs: blood pressure; may be low (pump failure), pulse pressure; may be narrow, heart rhythm; dysrhythmias, cardiac frequency; Tachycardia, apical pulse; PMI may spread and change in an inferior position to the left, heart murmurs; S3 (gallops) is diagnostic, S4 may, occur, S1 and S2 may be weakened, systolic and diastolic murmur, Color: blue, pale gray, cyanotic, nail backs; pale or cyanotic with a filling, capillary slow, Liver; enlargement / can be palpated, breath sounds ; crackles, rhonchi, edema; ma

Diagnostic Examination for CHF 1. Thoracic X-ray: may reveal an enlarged heart, edema or pleural effusion which confirmed the diagnosis of CHF. 2. ECG: reveals tachycardia, ventricular hypertrophy and ischemia, an echocardiogram. 3. Laboratory examination: includes electrolytes, serum sodium levels revealed a low blood hemodilution that results from the presence of excess water retention, potassium, sodium, chloride, urea and blood sugar. 4. Sonogram (echocardiogram) to indicate the dimensions of ventricular enlargement, changes in the function / structure of the valve or area decreased ventricular contractility. 5. Cardiac catheterization: an indication of abnormal pressure and helps to distinguish right and left heart failure and valvular stenosis or insufficiency. Also assess patency of coronary arteries. Contrast agent is injected into the ventricles show abnormal size and ejection fraction / change in contractility. 6. Ultrasonography (USG): get an overview of free fluid in the ab

Constipation / Diarrhea related to Anemia Nursing Diagnosis: Constipation / Diarrhea related to a reduction in dietary inputs, changes in digestion, the side effects of oral therapy. Signs : frequency change characteristics and the amount of feces nausea / vomiting anorexia sudden abdominal pain impaired bowel sounds. Expected outcomes are: normal bowel function behavioral changes necessary to live as the cause. Nursing Intervention: Observation of color, consistency, frequency, amount. Auscultation of bowel sounds Supervise the input / output Encourage input 2500-3000 ml Consult with a nutritionist: high-fiber diet Give an enema as indicated Give anti-diarrheal medications as indicated.

Imbalanced Nutrition: Less Than Body Requirements - Anemia Nursing Diagnosis and Interventions Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements Signs: weight loss, oral mucosal changes, loss of muscle tone Expected outcomes are: weight gain / stable with normal laboratory values​​, no sign of malnutrition. Nursing Intervention: Observation and record food intake Measure weight every day Observation of nausea / vomiting, flatulence and other symptoms Give and good oral hygiene aids Give your dessert is diluted when the oral mucosa injury Monitor lab results: Hb / HMT, protein, iron, B12, folic acid and serum electrolytes Give the drug as interuksi: vitamins, minerals, oral iron Give soft diet, low in fiber, did not stimulate. Source : http://nanda-nursing-care-plan.blogspot.com/2012/07/imbalanced-nutrition-less-than-body_14.html

Activity Intolerance - Nursing Diagnosis and Intervention for Anemia Nursing Diagnosis: Activity Intolerance Symptoms: weakness, plenty of rest, palpitations, tachycardia, increased BP, dyspnea. Expected outcomes are: increase in activity tolerance; pulse, respiration and blood pressure normal. Nursing Intervention : Assess the ability to perform the task, record the presence of fatigue and difficulty performing tasks Assess the running balance disorders and muscle weakness Monitor vital signs during and after activity Change position slowly, monitor for dizziness Give assistance activity / ambulation if necessary Encourage to stop activity when palpitations, chest pain, shortness of breath, weakness and dizziness.

Impaired Social Interaction related to Self-concept Disturbance Goal: Shows the appearance of a role Indicate the involvement of social Expected outcomes are: Social interaction skills: the use of effective social interaction behavior. Social engagement: social interaction of individuals who are with other people, groups. Nursing Interventions: Increase socialization. Assess the interaction patterns among patients with other people. Rational: To improve patient interactions with others. To determine the pattern of patient interaction with others.

Nursing Diagnosis: Urinary incontinence related to pelvic muscle degenerative Goal: Showed urinary continence. Adequacy of time to reach a small room between urgency and urinary output. Underwear stays dry all day Able to urinate on their own. Expected outcomes are: Urinary continence. Maintain the frequency of urination over 2 hours. Nursing Interventions Urinary Incontinence: Perform pelvic floor muscle exercises Perform treatment of urinary incontinence Identification of the multifactorial causes of incontinence Rational: Muscle strengthening volunteer pubotogsigeal with repeated contractions. To improve urinary continence and to maintain intregitas perineal skin. To find out the cause of urinary incontinence.

Nursing Care Plan for Risk for Social Isolation - Nursing Diagnosis for Risk for Social Isolation Risk factors may include, changes in health conditions, changes in physical appearance or sexual perception of social behavior is unacceptable, inadequate resources and or the fear of losing their personal resources. Desired outcomes / evaluation criteria: Identification of a stable support system. Use of resources for appropriate help. Reveal an increase in self-esteem. Nursing Interventions Risk for Social Isolation: 1. Determine the client's response to the conditions, feelings about self, concerns or worries about the other person's response, his ability to control the situation, and a sense of hope. Rational: How to receive individual and relate to the situation will help determine treatment plans and interventions. 2. Assess the coping mechanisms and methods of dealing with the problems of life previously. Rational: Assessing reveals successful techniques that can be used in

Nursing Interventions for Hepatitis B Setting energy use to treat or prevent fatigue and optimize function. Regular physical exercise to maintain fitness and health. Anxiety reduction and minimize anxiety, fear or anxiety associated with unknown source or anticipated danger. Teaching people about the disease, diagnosis and treatment. Facilitation of Learning: Promoting the ability to process and understand information. Increased Readiness Learning: Improving the ability and willingness to receive information. Infection Protection: Prevention and early detection of infection in patients at risk. Infection Control, Minimizing the acquisition and transmission of infectious agents. Supervision: purposeful and ongoing acquisition. Surveillance and safety. purposeful and ongoing collection and analysis of information about the client and the environment to be used in promoting and maintaining client safety. Analysis of potential risk factors, determining the health r

 Hepatitis B Hepatitis B is a viral infection that attacks the liver and can cause both acute and chronic disease. The virus is transmitted through contact with the blood or other body fluids of an infected person. Two billion people worldwide have been infected with the virus and about 600 000 people die every year due to the consequences of hepatitis B. The hepatitis B virus is 50 to 100 times more infectious than HIV. Hepatitis B is an important occupational hazard for health workers. Hepatitis B is preventable with the currently available safe and effective vaccine. Most people do not experience any symptoms during the acute infection phase. However, some people have acute illness with symptoms that last several weeks, including yellowing of the skin and eyes (jaundice), dark urine, extreme fatigue, nausea, vomiting and abdominal pain. In some people, the hepatitis B virus can also cause a chronic liver infection that can later develop into cirrhosis of the liver or liver cancer.

Nursing Diagnosis and Nursing Interventions : Imbalanced Nutrition: Less Than Body Requirements of Gastritis Gastritis is a common name for all kinds of inflammation of the inner lining of the stomach, which is known as the mucosa. It is characterized by severe stomach ailments like cramps in the stomach, diarrhea and constipation and even blood with the stools. Symptoms of Gastritis 1. Upper abdominal pain or dyspepsia 2. Nausea 3. Vomiting 4. Belching 5. Acid reflux 6. Bloating 7. Indigestion 8. Loss of appetite 9. Bad breath 10. Feeling of fullness in upper abdomen 11. Concentrated burning sensation in upper abdomen 12. Passing of blood in stool 13. Blood vomiting 14. Passing black, tarry stool. Nursing Diagnosis for Gastritis : Imbalanced Nutrition: Less Than Body Requirements related to the lack of food intake. Goal: After the patient's nutritional needs of nursing actions are met. Expected outcomes are: General condition is quite Good skin turgor Increased weight Difficulty

Nursing Diagnosis : Acute Pain - NCP Gastritis Gastritis is basically an erosion of the stomach lining, which can occur suddenly due to certain factors or happen gradually over a longer period of time. Inflammation or irritation of the lining of the stomach is also a form of gastritis. Gastritis can occur in adults and in children, which when left untreated can give rise to other gastrointestinal problems. There can be a number of different causes that give rise to gastritis. An infection caused by Helicobacter pylori (H. pylori) or other bacteria and viruses living in the mucous lining of the stomach could be one of the causes. A back flow of bile from the bile tract into the stomach, which is known as bile reflux could give rise to gastritis. Pernicious anemia, which is the stomach's inability to properly digest vitamin B12 could be another cause. Acute Pain Definition : Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in ter

Pathophysiology of Osteomyelitis Staphylococcus aureus is the cause of 70-80 percent of bone infection. Other pathogenic organisms commonly found in osteomyelitis include: Proteus , Pseudomonas and E.coli . There is an increased incidence of penicillin-resistant infections, nosocomial, gram negative and anaerobic. Onset of osteomyelitis after orthopedic surgery can occur within the first 3 months (acute fulminant stage I) and is often associated with accumulation of hematoma or superficial infection. Late onset infection (stage 2) occurred between 4 and 24 months after surgery. Osteomyelitis long onset (stage 3) is usually due to haematogenous spread and occurred 2 years or more after surgery. Initial response to infection is one of inflammation, increased Vascularization and edema. After 2 or 3 days, thrombosis in blood vessels occurs in the area, resulting in ischemia with bone necrosis associated with an increased and can spread to soft tissue or joints in the vicinity, unless the

Nursing Management of Diabetic Ulcers Diabetic ulcers are sores, or pain that occurs at the foot of the person who has suffered from diabetes mellitus. Meanwhile, according to Askandar (2001) Diabetic Ulcers are sores on the feet of red-black and foul smelling due to the blockage that occurred in medium or large vessels in the legs. The cause of diabetic ulcers Diabetic ulcers occur because of complications of diabetes mellitus called sensory neuropathy. People with diabetes also have poor blood circulation, thereby causing injury to the toe easily or toes which can lead to ulcer / gangrene. Diabetic ulcer wound care Dressing and wound control and help protect the wound from further damage. Keep the circulation in the legs with active passive movement. Control blood sugar levels. If necessary, collaboration with medical debridement for action. Prevention to avoid diabetic ulcers For patients with diabetes mellitus are at risk for diabetic ulcers should consult immediately to health car