Nanda Nursing Diagnosis

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...

Knowledge Deficit    Definition: Absence or deficiency of cognitive information related to a specific topic. Defining Characteristics: verbalization of the problem, inaccurate follow-through instructions, inaccurate performance of tests, 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 NOC: Kowlwdge: disease process Kowledge: Health behavior Expected Outcomes: Patients and families agree on diseases, conditions, prognosis and treatment programs Patients and families are able to perform the correct procedure Patients and families are able to explain what the nurse or other health team explains NIC: Teaching: Disease Process Give about the level of patient knowledge about the specific disease process. Explain the pathophysiology of the disease and how it relates to an...

Nursing Care Plan for Morbid Obesity Obesity is defined as having excess fat in the body. Obesity increases the risk of other diseases, such as diabetes and high blood pressure. Doctors use the BMI (body mass index), which is based on weight and height to determine whether you suffer from obesity. Extreme obesity or severe obesity known as morbid obesity. Morbid obesity is a condition where a person has a BMI over 40 or more. Symptoms associated with obesity include: Hard to sleep. Snoring. Stop breathing for a while suddenly during sleep. Back pain or joint. Excessive sweating. Always feel hot. Rash or infection of the skin folds. Difficulty breathing. Often sleepy and tired. Depression. There are genetic and hormonal influences on body weight. The most fundamental thing is that obesity occurs when the body receives more calories rather than burn it. Calories are then accumulate and become fat. Obesity is usually the result of a combination of the following factors: Not physically act...

Trigeminal Neuralgia Neuralgia is a stabbing pain that arises occasionally, but short and heavy, which occurs along the distribution of a nerve. Trigeminal neuralgia (NT) is neuralgia on the trigeminal nerve (fifth cranial nerve) that is responsible for sensation in the face. Trigeminal neuralgia (facial pain) is characterized by brief episodes of strong facial pain, stabbing, and like electricity. According to Dr. Dito Anurogo, Trigeminal Neuralgia is a complaint of pain attacks one side of the face are repeated. Called trigeminal neuralgia, because facial pain occurs in one or more nerves than the three branches of Trigeminal nerve. This large nerve located in the brain and carries sensation from the face to the brain. The pain is caused by a disturbance in Trigeminal nerve function in accordance with the regional distribution of innervation of one branch of the trigeminal nerve caused by a variety of causes. Etilogy trigeminal neuralgia is still not fully understood. There is one th...

Nursing Diagnosis for Dehydration Fluid volume deficit related to excessive output, less intake. Risk for ineffective tissue perfusion related to decreased blood flow. Risk for impaired skin integrity related to decreased skin turgor. Activity intolerance related to physical weakness. Risk for Decreased cardiac output related to a decrease in systemic vascular resistance. Nursing Care Plan for Dehydration Nursing Interventions for Dehydration 1. Fluid volume deficit related to excessive output, less intake. Goal: adequate fluid volume so that fluid volume deficiency can be overcome. Expected outcomes: Maintain fluid balance. Vital signs (pulse = 80-100 beats / min, temperature = 36-37oC) Capillary refill less than 3 seconds. Akral warm. Urine output: 1-2 cc / kg body weight / hour. Intervention: Monitor vital signs, capillary refill, the status of the mucous membranes. Discuss strategies to stop vomiting and use of laxatives / diuretics. Identification of a plan to increase the optima...

Risk for Infection related to the invasion of microorganisms in the body Goal : after the act of nursing for 3x24 hours of infection did not occur. Expected outcomes: Patients will show a careful hand-washing techniques. Patients will be free of the nosocomial infection during hospitalization. Patients will demonstrate knowledge of the risk factors associated with infection and appropriate precautions to prevent infection. Intervention - Risk for Infection : 1. Monitor for signs and symptoms of infection. R /: To determine whether there is an infectious process. 2. Monitor laboratory results, Monitor the patient's temperature. R /: Leukocyte increased and increased body temperature is not expected, a sign of infection. 3. Use antiseptic technique when taking action to clients. R /: Prevent cross-infection. 4. Emphasize the need to wash hands regularly / thoroughly before and when handling food, after toileting. R /: Many viruses such as cytomegalovirus (CMV) can be excreted in th...

Risk for Activity Intolerance related to physical weakness Activity Intolerance is a decrease in physiological capacity to maintain activity to the level desired or required. Defining Characteristics: Major : Change the client's physiological response to the activity undertaken. Respiratory: dyspnea (breathing frequency increased exaggeration). Shortness of breath (decrease frequency). Pulse: weak, declining, excessive increase, the increase in the rhythm, failed to return to the level before the activity after 3 minutes. Blood pressure: failed to increase the activity, an increase in diastolic over 15 mmHg. Minor: fatigue ,  weakness,  cyanosis or pale,  mental chaotic,  vertigo Subjective Data: weakness fatigue dyspnea lack of sleep Objective Data : Assess the strength and balance, the evaluation of an individual's ability to: Changing positions himself on the bed. Ambulation. Doing ADL (activity daily living) or daily activities. Assess for the presence of: pale...

Nursing Care Plan for Acute Lymphoblastic Leukemia Acute lymphoblastic leukemia is an acute form of leukemia, which are classified according to the cell that is more in the bone marrow, which is the form lymphoblasts. In case of leukemia occurred abnormal leukocyte cell proliferation, malignant, often accompanied by other forms of leukocytes than normal, excessive amounts, and can cause anemia, thrombocytopenia, and ends with death. Causes of Acute lymphoblastic leukemia is unknown, but it is possible because of the interaction of a number of factors: neoplasia infection radiation descent chemicals gene mutations Clinical manifestations Anemia: tiredness, lethargy, dizziness, tightness, chest pain. Anorexia. Bone and joint pain (bone marrow infiltration). Fever, sweating (hypermetabolism symptoms). Mouth infections, upper and lower respiratory tract, cellulitis, or sepsis. Skin bleeding (petechiae, ecchymosis atraumatic), bleeding gums, hematuria, gastrointestinal bleeding, brain hemor...

Nursing Care Plan for Cataracts Cataract is the medical term for each state turbidity occurs in the eye lens that can occur as a result of hydration (adding liquid lens), the lens protein denaturation, or can also be a result of both. Usually on both eyes and walked progressive. Cataracts cause the patient can not see clearly because of the cloudy lens is difficult light reaches the retina and will produce a blurred shadow on the retina. The number and shape of the eye lens opacities in each may vary. Causes of Cataracts Aging (Senile Cataracts): Most cataracts occur due to degenerative process or the age of a person. The average age of a cataract is at age 60 years and older. Trauma: Eye injury can be informed of all ages such as a hard blow, puncture objects, clipped, high heat, and chemicals can damage the eye and the lens is called cataract traumatic circumstances. Other eye diseases (uveitis) Systemic disease (Diabetes Mellitus). Congenital defects. Cataract is diagnosed mainly b...

Nursing Care Plan for Endocarditis NURSING DIAGNOSIS 1. Acute pain related to systemic effects of infection. Interventions : Independent Assess the complaint of chest pain. Pay attention to nonverbal cues of discomfort. Provide a quiet environment and comfort measures, such as: changes in position, back rub, use a warm compress / cold. Give proper entertainment activities. Collaboration Give medications as indicated. Give O2 supplementation as indicated. Rationale : Chest pain may and may not accompany the presence or absence of ischemia depends endocarditis. This action can reduce the patient's physical and emotional discomfort. Redirecting attention, provide distraction in the level of individual activities. Can relieve pain, decrease the inflammatory response. Maximize the availability of O2 to reduce the workload of the heart and prevent ischemia. 2. Risk for decreased cardiac output related to disorders of the heart valves and the endothelium. Interventions : Independent Mon...

Maslow's hierarchy of needs can be the basis for the nurse to make a priority nursing diagnosis. Maslow's hierarchy of five levels are: Biological and Physiological needs. Safety needs. Love and belongingness needs. Esteem needs. Self-Actualization needs. Physiological needs is a top priority and must be met before the needs of the higher level. Example of Maslow's hierarchy of needs : 1. Biological and Physiological needs : Respiration (circulation, temperature),  Hydration (avoiding pain, break or mobilization),  Nutrition (elimination, skin care),  Sey. 2. Safety needs. Environment free from danger. Stable living conditions. Regulations and laws in society. Free from threats. Clothes. Protection of the. Free from infection. Free from fear. 3. Love and belongingness needs. Affection. Seyyuality. Affiliates in the group. Relationship friends, family, community. 4. Esteem needs. Get respect from colleagues. The development of a sense of competence. Feelings of self-respec...

Nursing Interventions in Accordance with The Type of Nursing Diagnosis 1. Actual Nursing Diagnosis: Reduce or eliminate the factors that cause or are associated with the problem. Improving well-being for the better. Monitor the status. 2. Risk Nursing Diagnosis Reduce or eliminate the risk factors. Prevent the problem. Monitor events. 3. Possible Nursing Diagnosis: Collect additional data to confirm the diagnosis. Collaborative problem: Monitor the status change. Managing change in status with the provision of nursing and medical interventions. Evaluating the response. Nursing diagnosis can be solved or prevented by primary nursing intervention. Collaborative problem solved with nursing and medical interventions. For interventions nursing diagnoses, labels or related factors can use the diagnosis given to the client. Example: anxiety related to cancer diagnosis. Nursing interventions, the client will: Reduce anxiety: improved disclosure of feelings about cancer, cancer in the family du...

Functional Urinary Incontinence (1986, 1998) according to Diagnosis NANDA, NIC NOC Interventions, Nursing A. Definition The inability of individuals who typically continent to reach the toilet in time to avoid unintentional urine output. B. Defining characteristics Being able to empty the bladder completely. The length of time needed to reach the toilet longer than the time between the felt urge to urinate and urinate uncontrollably. Passing urine before reaching the toilet. Possibility incontinence only in the morning. Feeling the urge to urinate. C. Related factors Changes in environmental factors. Impaired cognition. Visual impairment. Neuromuscular limitations. Psychological factors. Weakness. D. Suggestions Usage Nothing E. Alternative diagnoses suggested Urinary incontinence: overflow. Urinary incontinence: reflex. Urinary incontinence: stress. Urinary incontinence: the total. Urinary incontinence: urgency. Self-care deficit, elimination. Urinary elimination, interruption. Urina...

Nursing Care Plan for Anthrax Anthrax is an infectious disease caused by Bacillus anthracis. The disease is a zoonosis particularly grazing animals such as sheep, goats, and cattle. Humans infected with this disease when endospores enter the body through skin abrasions or wounds, inhalation or contaminated food. Naturally humans can become infected if it comes in contact with anthrax-infected animals or animal products contaminated with anthrax germs. Although rare, transmission through insect bites can also occur. Aerosol spore dispersal through potential use in warfare and bioterrorism. Cutaneous anthrax is the most common infection, and is characterized by skin lesions localized with eschar (necrotic ulcers) non-pitting edema central surrounded. Inhalation anthrax is characterized by hemorrhagic mediastinitis, progressive systemic infection, and resulted in a high mortality rate. Gastrointestinal anthrax is rare and is associated with high mortality. 8 Nursing Diagnosis for Anthrax ...

Nursing Care Plan for Asthma : Functional Health Patterns - Nursing Diagnosis 1. Health Perception – Health Management Pattern Clients complain of shortness of breath, coughing, mucus difficult out. Complain easily tired and dizzy. Drug usage data. Clients know / do not know the cause of the attack. 2. Nutritional – Metabolic Pattern Nausea, vomiting, no appetite. Shows signs of dehydration, dry mucous membranes. Cyanosis, a lot of sweat. 3. Elimination Pattern 4. Activity – Exercise Pattern Activity is limited because of wheezing and shortness of breath. Smoking habits. Cough and mucus that is difficult to remove. Use of accessory muscles during inspiration. 5. Cognitive – Perceptual Pattern The extent to which the client's knowledge about the disease. The ability to overcome the problem. The weakening process of thinking. 6. Sleep – Rest Pattern Lack of sleep complaints. Tired from the attack of shortness of breath and cough. 7. Self-perception – Self-concept Pattern Clients like...

Nursing Diagnosis for Plan Tuberculosis (TB) : Ineffective airway clearance related to the accumulation of purulent secretions in the airway. Goal: Airway clearance back effectively. Nursing Interventions: Assess respiratory function, for example; breath sounds, speed and rhythm. Give the patient semi-Fowler's position or high Fowler effectively assist the patient to cough and deep breathing exercises. Maintain fluid intake at least 2500 ml / day, except, contra indications. Collaboration for the administration of drugs according to indications, mucolytic drugs. Rational: Decreased breath sounds may indicate atelectasis, crackles, wheezing showed accumulation of secretions inability to clean the airway. The position helps maximize lung expansion and lower respiratory effort. High input of fluids helps to thin the secretions, making it easily removed. Mucolytic agents decrease the viscosity and adhesion of lung secretions for easy cleaning. Nursing Diagnosis for Plan Tuberculosis (...

Nursing Care Plan for Prostate Cancer -  Assessment and 6 Nursing Diagnosis Definition Prostate cancer is the development of cancer in the prostate, a gland in the male reproductive system. Etiology As with other malignant tumors, the etiology of prostate cancer is not known precisely. There is a link with inflammation or hormones. Nearly 75% of prostate cancers are found in the posterior part of the medial lobe, and almost entirely from parts close to the hoop. There is the opinion noted that there are three times more likely the case because there is a history of the father or grandfather of prostate cancer. Prostate carcinoma is a malignant tumor that is often found in older men (50% of all malignant tumors of men) aged over 50 years and will rise sharply at the age of 80 years. Signs and Symptoms The onset of signs and symptoms usually after an advanced stage that is the enlargement of the prostate, because at the beginning of a difficult palpable in touche rectal examination. ...

Nursing Diagnosis and Interventions for Bronchopneumonia - 1. Ineffective airway clearance related to accumulation of secretions. Goal: Airway clearance back effectively. Outcomes: secretions can come out. Interventions: Monitor respiratory status every 2 hours, assess the increase in respiratory and abnormal breath sounds. Do suction as indicated. Give oxygen therapy every 6 hours. Create an environment / convenient so patients can sleep. Give a comfortable position for the patient. Monitor blood gas analysis to assess respiratory status. Perform chest percussion. Provide sputum for culture / sensitivity test. 2. Impaired gas exchange related to changes in alveolar capillaries. Goal: back to normal gas exchange. Outcomes: The client showed improved ventilation, gas exchange and oxygenation optimally adequately. Interventions: Observation of level of consciousness, respiratory status, signs cianosis. Give appropriate sleeping position fowler / semi-Fowler. Give oxygen according to th...

Nursing Care Plan for Bronchopneumonia Definition Bronchopneumonia is an inflammation of the lungs that affects one or more lobes of the lungs characterized by patches of infiltrates (Whalley and Wong, 1996). Bronchopneumonia is the frequency of pulmonary complications, long productive cough, signs and symptoms usually increased temperature, increased pulse rate, increased respiration (Suzanne G. Bare, 1993). Bronchopneumonia also called lobularis pneumonia, is inflammation of the lungs caused by bacteria, viruses, mold and foreign objects (Sylvia Anderson, 1994). Etiology Bacteria : Diplococcus Pneumoniae, Pneumococcus, Streptococcus Haemolyticus Aureus, Haemophilus Influenzae, Bacillus Friedlander, Mycobacterium Tuberculosis. Virus : Respiratory syncytial virus, influenza virus, citomegalic virus. Fungi : Histoplasma capsulatum, Cryptococcus Nepromas, Blastomyces Dermatitidis, Coccidioides Immitis, Aspergillus Sp, Candida Albicans, Mycoplasma Pneumonia. Foreign body aspiration: Facto...

Nursing Care Plan for Encephalitis Definition Encephalitis is an infection of the CNS caused by a virus or other microorganism that non-purulent. Encephalitis is an infection of the brain tissue by a variety of microorganisms. Encefalopati terminology that was used for the same symptoms, no signs of infection are now no longer in use. (Abdoerrachman, et al, 1985). Etiology A wide variety of organisms can cause encephalitis, such as bacteria, protozoa, worms, fungi, spirokaeta, and viruses. The most common cause is a virus. Infection can occur due to virus attacks the brain directly or acute inflammatory reaction due to systemic infection or previous vaccination. Encephalitis can also be caused by the direct invasion of the cerebrospinal fluid during a lumbar puncture. Various types of viruses can cause encephalitis, despite similar clinical symptoms. According to the type of virus and its epidemiology, known to a wide variety of viral encephalitis. Signs and Symptoms The clinical sympt...