NCP Nursing Diagnosis: Ineffective airway clearance

Nursing Diagnosis: Ineffective airway clearanceNOC Outcomes (Nursing Outcomes Classification)Suggested NOC Labels * Respiratory Status: Airway PatencyNIC Interventions (Nursing Interventions Classification)Suggested NIC Labels * Cough Enhancement * Airway Management * Airway SuctioningNANDA Definition: Inability to clear secretions or obstructions from the respiratory tract to

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Nursing Care Plan for Dehydration

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Dehydration Definition Dehydration is a condition in which a person who is not fasting experiencing or at risk of dehydration vascular, interstitial or intra-vascular (Sell Lynda Carpenito, 2000: 139). Classification Classification of dehydration by Donna D. Ignatavicus there are 3 types: a. Isotonic dehydration Isotonic dehydration is lost water followed by the electrolyte so that the density remained normal, then this type of dehydration is usually not result in ECF fluid move to the ICF. b. Hypotonic dehydration Hypotonic dehydration is the loss of solvent from the ECF exceeds fluid loss, resulting in blood vessels become more concentrated. ECF osmotic pressure decreases, resulting in fluid moves from the ECF to ICF. Vascular volume also decreased, as well as cell swelling occurs. c. Hypertonic dehydration Hypertonic dehydration is ECF fluid loss exceeds the solvent is non-osmotic dehydration ECF decreased, resulting in fluid moves from ICF to ECF. Etiology Various causes dehydratio...
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NCP Post Traumatic Stress Disorder

DSM-IV 309.81 Posttraumatic stress disorder (specify acute, chronic, or delayed onset) 308.3 Acute stress disorder An anxiety disorder resulting from exposure to a traumatic event in which the individual has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death/serious injury or a threat to the physical integrity of the self or others. The
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Nursing Diagnosis - Hypothermia : Definition, Related Factors, Outcomes and Interventions

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Hypothermia: Definition : Body temperature below the normal range Defining Characteristics : body temperature below normal range, cool, pale skin, dizziness, hypertension, increased heart rate, lack of coordination, piloerection, shivering, slow capillary refill Related Factors : alcohol and drug use, decreased metabolic rate, exposure to cold environment, extreme evaporative heat loss from skin, illness, inability to shiver, inadequate nutrition, poor clothing, medications, trauma NOC: Thermoregulation Thermoregulation: neonate Expected Outcomes: Body temperature in the normal range Pulse and respiratory rate are in the normal range NIC: Temperature Regulation Monitor temperature at least every 2 hours. Plan temperature monitoring continuously. Blood pressure monitor, pulse, and respiratory rate. Monitor skin color and temperature. Monitor signs of hyperthermia and hypothermia. Increase intake of fluids and nutrients. Cover the patient to prevent loss of body warmth. Teach patients ho...
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