Nanda Nursing Diagnosis

Knowledge, deficient regarding condition, treatment program, self-care, and discharge needs related to lack of exposure and information, misinterpretation of information and unfamiliarity with information resources. Deficient Knowledge Definition: Absence or deficiency of cognitive information related to a specific topic Defining Characteristics: Verbalization of the problem; inaccurate follow-through of instruction; inaccurate performance of test; inappropriate or exaggerated behaviors (e.g., hysterical, hostile, agitated, apathetic) Related Factors: Lack of exposure lack of recall information misinterpretation cognitive limitation lack of interest in learning unfamiliarity with information resources Nursing Interventions Nursing Care Plan for Deficient Knowledge 1. Assess ability to learn or perform desired health-related care. Rational : Cognitive impairments need to be identified so an appropriate teaching plan can be designed. 2. Determine client’s learning style especially if cli...

Nursing Care Plan for Appendicitis Post Operative Definition of Appendicitis a. Appendicitis is a minor surgical diseases most often occur. Although appendicitis can occur at any age, but most often in young adults. Before the antibiotic era, the high mortality of this disease (Sylvia A. Price, 1994). b. Acute appendicitis is the inflammation spreads to the surface of the parietal peritoneum the pain persists, more powerful and gain weight when moving. (Barbara C. Long, 1996) c. Acute appendicitis is the most common cause of acute inflammation in the lower right quadrant abdominal cavity, the most common cause for emergency abdominal surgery (Brunner and Suddarth, 2001). Clinical Manifestations of Appendicitis a. The main complaint of appendicitis: pain. Abdominal pain lasting more than 6 hours must be taken into consideration. The pain is caused by the blockage of the appendix and its the same as the pain caused by intestinal obstruction. At first intermittent pain such as colic, beca...

Urethritis, Cystitis, and Acute Pyelonephritis Acute pyelonephritis usually results from ascending bladder infection. Acute pyelonephritis can also occur through hematogenous infection. Infection can occur in one or both kidneys. Chronic pyelonephritis may occur due to repeated infections, and are usually found in individuals who develop stones, obstruction, or vesicoureteric reflux. Cystitis (bladder inflammation) are most commonly caused by the spread of infection from the urethra. This can be caused by the backflow of urine from the urethra into the bladder (reflux urtrovesikal), fecal contamination, the use of catheters. Urethritis an inflammation usually is an infection that spreads up to be classified as general or mongonoreal. Gonococcal urethritis caused by niesseria gonorhoeae and is transmitted through sexual contact. Nongonoreal urethritis; urethritis is not related to niesseria gonorhoeae usually caused by chlamydia urelytikum frakomatik or plasma urea. Pyelonephritis (u...

Nursing Diagnosis for Anemia: Ineffective Tissue Perfusion related to the decrease in the cellular components required for the delivery of oxygen / nutrients to the cells. Objectives: increased tissue perfusion. Expected outcomes are: - indicates inadequate perfusion, such as stable vital signs. Ineffective Tissue Perfusion Nursing Interventions for Anemia Independent 1. Monitor vital signs assess capillary refill, color of skin / mucous membranes, nail beds. Rational: provides information about the degree / adequacy of tissue perfusion and help determine the need for intervention. 2. Elevate head of bed as tolerated. Rational: increase lung expansion and maximize oxygenation for cellular needs. Note: if there is hypotension contraindicated. 3. Monitor respiratory effort; auscultation of breath sounds adventisius note sounds. Rational: dyspnea, gurgling menununjukkan heart problems due to strain the old heart / cardiac output increased compensation. 4. Investigate complaints of chest ...

Nursing Assessment for Appendicitis - Nursing Care Plan (NCP) for Appendicitis Assessment according to Wong (2003), Doenges (1999), Catzel (1995), Betz (2002), among others: A. Interview Get a thorough medical history, especially regarding: The main complaint: the client will get a pain around the epigastrium radiating to the lower right abdomen. Complaints arising under the right abdominal pain may be a few hours later after the pain in the center or in the epigastrium felt in some time ago. Nature of the complaints of persistent pain is felt, may be lost or there is pain in a long time. Complaints which usually accompanies a client complaining of nausea and vomiting, loss of heat. Past medical history: usually associated with health problems the client is now asked of the parents. Diet, eating foods low in fiber. Elimination habits. 2. Physical examination General condition: the client looks sick mild / moderate / severe. Circulation: tachycardia. Respiratory: Tachypnea, shallow brea...

Nursing Diagnosis for Anemia Anemia is a decrease in number of red blood cells (RBCs) or less than the normal quantity of hemoglobin in the blood. However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin deficiency. Causes of Anemia Except for the acute form, anemia is a result of systemic toxemia and acidosis-a condition of poisons, toxins and accumulated waste products floating in the blood - and lymph-streams, and of enervation or lowered nerve-tone. There is either an accumulation of these injurious substances due to failure of eliminative organs to handle a normal amount of such products, or they are produced in such considerable quantities that even normal organs, eliminating a normal amount or more than a normal amount of eliminations can not remove them rapidly enough. They have the effect of poisoning the organs that make the blood cells, which pr...

Nursing Diagnosis Risk for Infection Nursing Care Plan Definition: At increased risk for being invaded by pathogenic organisms Related Factors: See Risk Factors. Risk Factors: Invasive procedures; insufficient knowledge regarding avoidance of exposure to pathogens; trauma; tissue destruction and increased environmental exposure; rupture of amniotic membranes; pharmaceutical agents (e.g., immunosuppressants); malnutrition; increased environmental exposure to pathogens; immunosuppression; inadequate acquired immunity; inadequate secondary defenses (e.g., decreased hemoglobin, leukopenia, suppressed inflammatory response); inadequate primary defenses (e.g., broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids, change in pH secretions, altered peristalsis); chronic disease. NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Immune Status Knowledge: Infection Control Risk Control Risk Detection NIC Interventions (Nursing Interventions Classifi...

Chronic obstructive pulmonary disease ( COPD ) is one of the most common lung diseases. It generally defines the conditions which consist of regular difficulty in expelling or exhaling air from the lungs. There are two major forms of COPD: chronic bronchitis and emphysema. Chronic bronchitis consists of a long term cough with mucus. Emphysema is a gradual destruction of the lungs. Most people who have COPD have a combination of these forms because smoking is a major cause of both of them. There are a few signs of COPD that a healthcare worker may detect although they can be seen in other diseases. Some people have COPD and have none of these signs. Common signs are : tachypnea, a rapid breathing rate wheezing sounds or crackles in the lungs heard through a stethoscope breathing out taking a longer time than breathing in enlargement of the chest, particularly the front-to-back distance (hyperaeration) active use of muscles in the neck to help with breathing breathing through pursed li...

Nursing Care Plan for Pneumonia Nursing Diagnosis for Pneumonia  Nursing Interventions for Pneumonia Pneumonia is an illness that affects one or both lungs and that used to be one of the main causes of death 2 centuries ago. It is caused by microorganisms that attack the tissue from the lungs, causing it to inflammate and leading to a severe condition if the infection is not treated in time. Viral pneumonia is very common form of pneumonia affecting children, teenagers and the elderly. It can sometimes be mistaken for either the flu or a cold. Viral pneumonia presents the following symptoms: inflammation of the throat, productive or non-productive cough, a swelling in the lymph nodes, chest discomfort during breathing, mild to severe headache and a generalized feeling of fatigue. The cough may or may not produce varying amounts of mucus. You may also experience a mild fever and chills. Pneumonia 1. Impaired Gas Exchange 2. Ineffective Breathing Pattern 3. Risk for Infection related...