Nanda Nursing Diagnosis

Nursing Diagnosis : Fear r/t invasive procedure, hospitalization, unfriendly experience. Fear Definition Response to perceived threat that is consciously recognized as a danger Defining characteristics: Panic Terror Avoidance or attack behavior Impulsive Pulse, respiration, systolic BP increases Anorexia Nauseous vomit Pale Stimulus as a threat Tired Tense muscles Sweat increases Uproar Tension increases Express fear Cry Protest Escape Outcomes : Fear Control The client : Don't attack or avoid scary sources. Use relaxation techniques to reduce fear. Able to control the response. Does not run away. Duration of fear decreases. Cooperative when done care and treatment. Anxiety Control The client : Adequate sleep. There is no physical manifestations. There is no behavioral manifestations. Want to interact socially. Interventions : Coping Enhancement Assess the patient's fearful response: objective and subjective data. Explain to the client / family about the disease process. Expla...

Nursing Care Plan for Diarrhea Nursing Diagnosis : Deficient Fluid Volume related to input decreases, loss of active fluid volume, failure in the regulatory mechanism Defining Characteristics: Weakness Thirsty Decreased skin turgor Mucous membrane / dry skin Pulse increases, blood pressure decreases, pulse pressure decreases Decreased capillary filling Change in mental status Decreased urine output Increased urine concentration Increased body temperature Hematocrit increases Sudden weight loss. Goal After implementation, fluid and electrolyte requirements are adequate, with the following criteria: Hydration Adequate skin hydration Blood pressure is within normal limits The pulse is palpable Moist mucous membrane Normal skin turgor Stable weight and within normal limits Eyelid - not concave Fontanela - not concave Normal urine output No fever There is no very thirst There is no short breaths Fluid Balance Normal blood pressure Palpable peripheral pulse There is no orthostatic hypotensi...

Assessment History: Data collected by nurses from clients with possible appendicitis include: age, sey, surgical history, and other medical history, oral / rectal barium administration, history of diit especially fibrous foods. a. Subjective Data Before surgery • Navel area pain radiates to the lower right abdomen • Nausea, vomiting, bloating • No appetite, fever • The right leg cannot be straightened • Diarrhea or constipation After surgery • Pain in the surgery area • Weak • Thirst • Nausea, bloating • Dizzy b. Objective data Before surgery • Tenderness at McBurney point • Muscle spasm • Tachycardia, tachypnea • Pale, nervous • Bowel noise is reduced or absent • Fever 38 - 38.5 degrees C After surgery • There are surgical wounds in the right lower quadrant of the abdomen • Attached infusion • There is a drain / gastric pipe • Reduced bowel sounds • Dry oral mucous membranes Laboratory examination • Leukocytes: 10,000 - 18,000 / mm3 • Netrophils increase by 75% • Increased WBC up to 2...

Nursing Care Plan for Diverticular Disease 1. Nursing Diagnosis : Constipation NOC 1. Bowel elimination 2. Hydration Outcomes: 1. Maintain soft stool every 1-3 days. 2. Free from discomfort and constipation. 3. Identify indicators to prevent constipation. 4. Soft and shaped feces. NIC 1. Constipation / Impaction Management 2. Monitor signs and symptoms of constipation. 3. Monitor bowel sounds. 4. Monitor stool (frequency, consistency and volume) 5. Explain the etiology and rationalization of the action against the patient. 6. Identify factors that cause constipation. 7. Support fluid intake. 8. Collaborate for laxatives. 9. Monitor for signs and symptoms of impaction. 10. Monitor bowel movements, including consistency of frequency, shape, volume, and color. 11. Consult with the doctor about the decrease / increase in frequency of bowel sounds. 12. Monitor for signs of intestinal rupture / peritonitis. 13. Describe the etiology of the problem and thoughts for the patient's actions. ...

Nursing Care Plan for Rheumatoid Arthritis Rheumatoid arthritis is a chronic autoimmune disorder that causes inflammation of the joints (Lemone & Burke, 2001: 1248). Nursing Diagnosis for Rheumatoid Arthritis : Body image disturbance related to changes in the ability to perform common tasks, increased use of energy, mobility imbalance. Expected outcomes: Expressing increased confidence in the ability to cope with illness, changes in lifestyle, and possible limitations. Develop a realistic plan for the future. Nursing Interventions: Encourage disclosure about the problem of disease processes, hope for the future. Discuss the meaning of the loss / change in patient / significant other. Ascertain how the patient's personal views on the functioning of everyday lifestyle. Discuss the patient's perception of how the people closest to accept limitations. Acknowledge and accept the feelings of the bereaved, hostile, dependence Consider withdrawing behavior, or deny the use of too...

Nursing Care Plan for Schizophrenia Nursing Diagnosis : Ineffective Individual Coping related to: Inability to trust others. Freaking Out. Sensitivity (vulnerability) someone. Low self-esteem. Examples of negative feelings. Pressing fear. Inadequate support systems. Ego less developed. Possibility heriditer factor. Family system dysfunction. Defining characteristics: Abnormalities in social participation. Inability to fulfill basic needs. The use of self-defense mechanism is not appropriate. Planning General purpose: The patient can use adaptive coping, as evidenced by a lack of compatibility between the interaction and the desire to participate in society. Specific purpose: The patient will develop a sense of trust in others, The patient is not easy to panic. The patient can control the fear and low self-esteem. Expected outcomes: The patient can assess the situation realistically passage and no action projection feelings in that environment. The patient can recognize and clarify the ...

Nursing Care Plan for Dementia Dementia is a decline in intellectual functioning which leads to loss of social independence. (William F. Ganong, 2010) Nursing Diagnosis for Dementia : Altered Thought Processes related to physiological changes (irreversible neuronal degeneration), characterized by: loss of memory, loss of concentration, not able to interpret the stimulation and assess reality accurately. Goal: The client is able to recognize a change in thinking. with outcomes: Able to demonstrate the cognitive ability to undergo the consequences of stressful events on the emotions and thoughts of suicide. Able to develop strategies to overcome negative self assumption. Being able to recognize behavior and the causes. Interventions : Develop a supportive environment and client-nurse relationships are therapeutic. Maintain a pleasant and quiet environment. Face-to-face when talking to clients. Call the client with the name. Use a rather low voice and speak slowly on the client. Rationa...