Nanda Nursing Diagnosis

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 Assessment for Hyperemesis Gravidarum Activity / rest Systolic blood pressure decreases, pulse rate increased by more than 100 times per minute. Ego Integrity Interpersonal family conflicts, economic difficulties, changes in perception about the conditions, unplanned pregnancies. Elimination Changes in consistency; defecation, increased frequency of urination Urinalysis: increased concentration of urine. Food / fluid Excessive nausea and vomiting (4-8 weeks), epigastric pain, weight loss ...

Nursing Care Plan for Prostatectomy Prostatectomy A prostatectomy is the surgical removal of all or part of the prostate gland. Abnormalities of the prostate, such as a tumour, or if the gland itself becomes enlarged for any reason, can restrict the normal fassessment Nursing Assessment for Prostatectomy Subjective data: Patients complain of pain at the incision. Patients said they could not have sex. Patients are always asking about the action taken. Objective Data: There is the incision Tachycardia Restlessness Blood pressure increases Facial expressions of fear Installed catheterlow of urine along the urethra. Nursing Diagnosis for Prostatectomy Acute Pain related to muscle spasm spincter Goal : After treatment, patients were able to adequately maintain a degree of comfort. Expected outcomes: Verbally patient expresses pain diminished or disappeared. Patients can rest easy. Nursing Intervention for Prostatectomy Assess pain, note the location, intensity (scale 0-10) Monitor and r...

Knowledge Deficit : About the Disease Process Definition: The absence or lack of cognitive information in connection with a specific topic. Defining characteristics: verbalization of problems, inaccuracies follow instructions, inappropriate behavior. Related factors: cognitive limitations, interpretations of misinformation, lack of desire to seek information, not knowing the sources of information. NOC: Kowlwdge: disease process Kowledge: health behavior Results Criteria: Patients and families express an understanding of the disease, condition, prognosis and treatment programs Patients and families are able to perform the procedure correctly explained Patients and families are able to explain again what was described nurse / other health team NIC: Teaching: Disease Process Give your assessment of the level of knowledge about the patient's specific disease process Describe the pathophysiology of the disease and how it relates to anatomy and physiology, in a proper way. Describe the...

Acute Pain Definition: An unpleasant sensory and emotional experience arising in an actual or potential tissue damage or describe the damage (International Association of Pain Study): a sudden attack or low in intensity from mild to severe which can be anticipated by the end of a predictable and with a duration less than 6 months . Defining Characteristics : Report of verbal or non verbal The fact of the observation Antalgic position to avoid pain Movement to protect Cautious behavior Face masks Sleep disturbances (eyes glazed, looking tired, difficult or chaotic motion, grinning) Focused on self- Focus narrowed (decreased perception of time, the damage is thought process, decreased interaction with people and the environment) Behavior distraction, for example: roads, meet other people and / or activities, repetitive activities) Autonomic Response (such as diaphoresis, changes in blood pressure, changes in breathing, pulse and dilated pupils) Changes in muscle tone, autonomic (probably...

Nursing Care Plan for Bartholinitis Bartholinitis an inflammatory condition of one or both Bartholin's glands, caused by bacterial infection. Usually the causative microorganism is a species of Streptococcus, Staphylococcus, or Escherichia coli , or a strain of gonococcus . The condition is characterized by swelling of one or both glands, pain, and development of an abscess in the infected gland. A fistula may develop from the gland to the vagina, anus, or perineum. Treatment includes local application of heat, often by soaking in hot water; antibiotics; or, if necessary, incision of the gland and drainage of the purulent material or excision of the entire gland and its duct. Nursing Assessment Nursing Care Plan for Bartholinitis Changes in skin color Edema Fluid in the gland Pain Lump on vaginal lips The smell of the fluid Cleanliness of the body The number and color of urine Nursing Diagnosis Nursing Care Plan for Bartholinitis Self-care deficit related to limitation of motion...

Nursing Care Plan for Pleura Effusion Autor : Read More from NCP-Blog Pleural effusion A pleural effusion is an accumulation of fluid between the layers of tissue that line the lungs and chest cavity. Causes Your body produces pleural fluid in small amounts to lubricate the surfaces of the pleura, the thin tissue that lines the chest cavity and surrounds the lungs. A pleural effusion is an abnormal, excessive collection of this fluid. Two different types of effusions can develop: * Transudative pleural effusions are caused by fluid leaking into the pleural space. This is caused by elevated pressure in, or low protein content in, the blood vessels. Congestive heart failure is the most common cause. * Exudative effusions usually result from leaky blood vessels caused by inflammation (irritation and swelling) of the pleura. This is often caused by lung disease. Examples include lung cancer, lung infections such as tuberculosis and pneumonia, drug reactions, and asbestosis. Symptoms * Che...

Rheumatoid Arthritis (RA) Rheumatoid Arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of the tissue around the joints, as well as in other organs in the body. Autoimmune diseases are illnesses that occur when the body's tissues are mistakenly attacked by their own immune system. The immune system contains a complex organization of cells and antibodies designed normally to "seek and destroy" invaders of the body, particularly infections. Patients with autoimmune diseases have antibodies in their blood that target their own body tissues, where they can be associated with inflammation. Because it can affect multiple other organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease. While rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience long periods without symptoms. However, rh...

Nursing Care Plan for Pneumonia Pneumonia Pneumonia is an infection of one or both lungs which is usually caused by bacteria, viruses, or fungi. Prior to the discovery of antibiotics, one-third of all people who developed pneumonia subsequently died from the infection. Currently, over 3 million people develop pneumonia each year in the United States. Over a half a million of these people are admitted to a hospital for treatment. Although most of these people recover, approximately 5% will die from pneumonia. Pneumonia is the sixth leading cause of death in the United States. Symptoms and Signs Most people who develop pneumonia initially have symptoms of a cold (upper respiratory infection, for example, sneezing, sore throat, cough), which are then followed by a high fever (sometimes as high as 104 F), shaking chills, and a cough with sputum production. The sputum is usually discolored and sometimes bloody. Depending on the location of the infection, certain symptoms are more likely to...

Nursing Diagnosis for Risk for Deficient Fluid Volume Risk for Deficient Fluid Volume Definition : The decrease intravascular fluid, interstitial, and / or intrasellular. This leads to dehydration, loss of fluids with sodium expenditure. Characteristics : Weakness Thirst Decreased skin turgor / tongue Mucous membrane / dry skin Increased pulse rate, decreased blood pressure, decrease in volume / pulse pressure Completion of decreased venous Changes in the mental position The concentration of urine increased Increased body temperature Elevated hematocrit Weight loss immediately (except on third spacing) Related Factors : Loss of active fluid volume Failure of regulatory mechanisms NOC : Fluid balance Hydration Nutritional Status: Food and Fluid Intake Results Criteria : Maintain urine output in accordance with age and body weight, urine specific gravity normal, normal HT Blood pressure, pulse, body temperature within normal limits There are no signs of dehydration, good skin turgor,...

Sepsis is a condition in which the body is fighting a severe infection that has spread via the bloodstream. If a patient becomes "septic," they will likely have low blood pressure leading to poor circulation and lack of perfusion of vital tissues and organs. This condition is termed "shock." This condition can develop either as a result of the body's own defense system or from toxic substances made by the infecting agent (such as a bacteria, virus, or fungus). Causes Many different microbes can cause sepsis. Although bacteria are most commonly the cause, viruses and fungi can also cause sepsis. Infections in the lungs (pneumonia), bladder and kidneys (urinary tract infections), skin (cellulitis), abdomen (such as appendicitis), and other areas (such as meningitis) can spread and lead to sepsis. Infections that develop after surgery can also lead to sepsis. Source : emedicinehealth.com NCP - Nursing Care Plan for Sepsis Nursing Assessment The main c...

Definition Cholelithiasis : Is the presence of gallstones in the gallbladder. Causes : The follow list shows some of the possible medical causes of Cholelithiasis that are listed by the Diseases Database : * Sickle cell disease * Somatostatinoma * Clofibrate * Erythropoietic protoporphyria * Hypercalcaemia * Combined oral contraceptive pill * Hereditary spherocytosis * Somatostatin * Cystic fibrosis * Haemoglobin E disease * Haemolytic anaemia * Lanreotide Source: Diseases Database Clinical Manifestation Patients with bile duct stones often have symptoms of chronic and acute. Acute symptoms * Signs: o right epigastric pain and spasm o Business tangible inspiration in the upper right kwadran o enlarged and gall bladder pain o mild jaundice * Symptoms: o pain (colic gall) that persist o Nausea and vomiting o febrile (38.5 ° ° C) Chronic symptoms * Signs: o Normally invisible image on the abdomen o Sometimes there is pain in the upper right kwadran * Symptoms: o pain (colic gall), Venue: ...

NCP for Epilepsy Epilepsy Epilepsy is a brain disorder that causes people to have recurring seizures. The seizures happen when clusters of nerve cells, or neurons, in the brain send out the wrong signals. People may have strange sensations and emotions or behave strangely. They may have violent muscle spasms or lose consciousness. Epilepsy has many possible causes, including illness, brain injury and abnormal brain development. In many cases, the cause is unknown. Doctors use brain scans and other tests to diagnose epilepsy. It is important to start treatment right away. There is no cure for epilepsy, but medicines can control seizures for most people. When medicines are not working well, surgery or implanted devices such as vagus nerve stimulators may help. Special diets can help some children with epilepsy. NIH: National Institute of Neurological Disorders and Stroke Nursing Diagnosis High risk of ineffective airway, breathing patterns related to damage the perception Nur...

NCP - Nursing Care Plan for Hepatitis Hepatitis Hepatitis is an inflammation of the liver, most commonly caused by a viral infection. There are five main hepatitis viruses, referred to as types A, B, C, D and E. Hepatitis A and E are typically caused by ingestion of contaminated food or water. Hepatitis B, C and D usually occur as a result of parenteral contact with infected body fluids (e.g. from blood transfusions or invasive medical procedures using contaminated equipment). Hepatitis B is also transmitted by sexual contact. The symptoms of hepatitis include jaundice (yellowing of the skin and eyes), dark urine, extreme fatigue, nausea, vomiting and abdominal pain. www.who.int Nursing Assessment for Hepatitis Activity Weakness Fatigue Depression Circulation Bradycardia (hiperbilirubin weight) Sclera jaundice on the skin, mucous membranes Elimination Dark urine Diarrhea Stool color clay Food and Fluids Anorexia Weight loss Nausea and vomiting Increased edema Ascites Neuro ...

NURSING DIAGNOSIS: Ineffective individual coping related to: depression, fear, anxiety, and ongoing grieving associated with the diagnosis of AIDS and poor prognosis; need for permanent change in lifestyle associated with impaired immune system functioning and potential for disease transmission to others; uncertainty of disease course and feelings of powerlessness over course of disease; need for disclosure of diagnosis with possibility of subsequent rejection and/or distancing by others and loss of employment and health benefits; guilt associated with past behavior (if it was a factor in contracting HIV) and/or possibility of having transmitted HIV to others; lack of personal resources to deal with disability and premature death associated with youth (a significant number of clients are in their twenties or thirties and are not developmentally prepared to acknowledge and cope with disability and their own mortality); multiple losses (e.g. death of close friends with AIDS; loss of norm...

Nursing Care Plans for Anxiety A nursing care plan for Anxiety is used when a patient feels a vague, uneasy or discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual), a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat. Related factors for Anxiety : Anesthesia Invasive/noninvasive procedure Interpersonal conflicts Anticipated/actual pain Loss of significant other Threat to self-concept

Nursing Care Plan for Activity Intolerance A nursing care plan for Activity Intolerance is used when a patient has insufficient physiological or psychological energy to endure or complete required or desired daily activities Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. Activity intolerance may also be related to factors such as obesity, malnourishment, side effects of medications, or emotional states such as depression or lack of confidence to exert one’s self. Nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient to maintain a satisfactory lifestyle. Related to: Generalized weakness / Fatigue Malnourishment Chronic disease Stressors Insufficient sleep or rest periods Prolonged immobility/bed rest Depression Lack of motivation Imbalance of oxygen supply and demand Pain As evidenced by: Verbal report of fatigue or weakness Inability to begin or...

Nursing Care Plans for Pain (Chronic/Acute) Nursing Care Plans for pain can be used for patients having unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain). Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in elderly patients, where cognitive impairment and sensory-perceptual deficits are more common. *Acute pain – duration of less than 6 months *Chronic pain – duration of greater than 6 months RELATED FACTORS: Acute: Musculoskeletal disorder Trauma Pressur...