Nanda Nursing Diagnosis

Nursing Diagnosis and Interventions for Neonatal Sepsis Sepsis is a syndrome characterized by clinical signs and symptoms of severe infection that can progress toward septicemia and septic shock. (Doenges, 1999) While neonatal sepsis is a severe infection that affects neonates with systemic symptoms and there are bacteria in the blood. Neonatal sepsis course of the disease can take place quickly so often not monitored, without adequate treatment babies can die within 24 to 48 hours. (Surasmi, 2003). Nursing Diagnosis and Interventions for Neonatal Sepsis Hyperthermia related to damage control temperature, secondary to infection or inflammation. Expected outcomes: The body temperature within normal limits. Pulse and breathing frequency within normal limits. Intervention and Rationale: 1. Monitoring of vital signs every two hours and monitor skin color. R /: Changes in vital signs that would significantly affect the regulatory processes or metabolism in the body. 2. Observation of seizu...

Nursing Care Plan for Blepharitis Blepharitis or better known as inflammation of the eyelids is one of the eye diseases to watch out for. The disease is caused by the oil glands at the base of the lashes were damaged, causing itching in the eyelids, irritation, even to inflammation. If this is allowed then it would be blepharitis. Although blepharitis does not cause permanent damage to the eye, but very disturbing activities of our vision. Symptoms of Blefarits as follows: The eyelids are often greasy. Itch on the eyelids. Burned in the eye. Eyes look red. Frequent watery eyes. Eye swelling of the eyelids. Eyelash gross waking. Very sensitive to light. Have peeling skin around the eyes. Eyelashes fall out. Eyelashes abnormal and irregular direction. Main causes of the occurrence of blepharitis (inflammation of the eyelids) Infected by the bacteria. Glands damaged eye. Dandruff of the scalp to eyebrows. Rosacea. Allergic to something eg eye drops, eye lens. Nursing Diagnosis and Interve...

Nursing Care Plan for Bronchiectasis Bronchiectasis is a chronic dilatation of the bronchi and bronchioles that may be caused by various conditions, including lung infections and bronchial obstruction; foreign body aspiration, vomit, and objects from the upper respiratory tract; and the pressure due to a tumor, blood vessels dilated and enlarged lymph nodes (Brunner & Suddart, 2002). According Suyono (2001) etiology of bronchiectasis are: 1. Infection Bronchiectasis often occur after a child suffering from pneumonia who frequently relapse and long lasting. Pneumonia is generally a pertussis or influenza complications suffered during the child, pulmonary tuberculosis, and so on. 2. Abnormalities hereditary or congenital abnormalities In this case bronchiectasis occurs in the womb. Genetic factors or growth factors and fetal development plays an important role. Usually has the characteristics on almost all branches of the bronchi in the lungs one or two. Usually accompanied by other ...

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 Diagnosis for Schizophrenia : Risk for Self or Other- Directed Violence Goal: The patient can control violent behavior, with the following criteria: Bright face, smiling. Want to get acquainted and there is eye contact. Willing to tell the feeling. Telling cause irritation / anger. Can identify signs of violent behavior. Can identify, form of violence that is done. Can be identified as a result of violent behavior. Able to practice taught how to control anger. Able to engage in group activity therapy. Can taking medication with minimal assistance. Clients can continue the relationship in accordance with the responsibilities of the role. Interventions Client Intervention Perform a trusting relationship. Identify the causes of violent behavior. Identify the signs and symptoms of violent behavior. Identification form of violence that is ever done. Identification due to violent behavior. Teach how to control violent behavior, among others: Physically (relaxation, activities and spo...

Nursing Care Plan for Schizophrenia, Nursing Diagnosis : Disturbed Sensory Perception Schizophrenia is a disease that affects the brain and cause thoughts, perceptions, emotions, movement, strange and disturbed behavior (Videbeck, 2008). Nursing Diagnosis : Disturbed Sensory Perception hearing / vision related to: freaking out withdraw strss heavy, threatening the weak ego. Defining characteristics: talking and laughing themselves behave like listening to something (tilt the head to one side as if someone was listening to something). stop talking in the midst of a sentence to listen to something. disorientation low concentrations rapidly changing minds chaos groove mind response is not appropriate. Expected outcomes: Patients can be admitted that the hallucinations occur during extreme anxiety increased. Patients can say signs of increased anxiety and use certain techniques to break the anxiety. Planning: General purpose : Patients are able to define and examine the reality, reducing ...

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...

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...

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 Cesarean Section Nursing Diagnosis : Risk for Injury related to biochemical function or regulation, the effects of anesthesia, tissue trauma. Goal: Demonstrate behaviors to reduce risk factors and / or self-protection. Free from complications. Itervention: 1. Review the prenatal and intra prenatal record, the factors of clients in complications. Rationale: The presence of risk factors such as fatigue miometrial, excessive uterine distension, slow oxytocin stimulation, or thrombophlebitis a prenatal, allowing clients more susceptible to post-operative complications. 2. Monitor blood pressure, pulse and temperature. Note the skin is cold, wet, weak pulse and subtle, changes in behavior, delayed capillary refill, or cyanosis. Rationale: High blood pressure can indicate the occurrence or continuation of hypertension. Hypotension and tachycardia may indicate dehydration and hypovolemia but may not occur until the circulating blood volume has been decreased to 35% - 50...

Nursing Diagnosis for Cesarean Section : Acute pain related to surgical trauma, anesthesia, hormonal effects, distended bladder / abdomen. Goal: Identify and use interventions to treat pain / discomfort appropriately. Reveal a reduction in pain. Relaxed able to sleep / rest. Intervention: 1. Determine the characteristics and location of discomfort. Pay attention to verbal and non-verbal cues such as grimacing, stiffness, and limited movement or protect. Rationale: The client may not be verbally reported pain and discomfort directly. Distinguish specific characteristics of pain and postoperative pain helps distinguish from complications. 2. Evaluation of blood pressure and pulse, note the change in behavior change. Rationale: Pain can cause restlessness and increased blood pressure and pulse. 3. Change the position of the client, reduce harmful stimuli, and give a back rub. Encourage the use of breathing techniques, relaxation and distraction. Rationale: muscle relaxes and distracts fr...

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 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...

Nursing Care Plan for Pain Pain is the most common reason a person seek medical assistance. Pain occurs with the disease process, diagnostic examination and treatment process. Pain is very annoying and difficult many people. Nurses can not see and feel the pain experienced by the client, because pain is subjective (between one individual to another individual is different in addressing the pain). Nurses provide nursing care to clients in a variety of situations and circumstances, which provide interventions to improve comfort. According to some theories of nursing, comfort is a basic requirement that the client is the purpose of nursing care. The statement was supported by Kolcaba who said that comfort is a state of fulfillment of basic human needs have. Definition According to the International Association for the Study of Pain (IASP), pain is a subjective sensory and emotional obtained unpleasant associated with actual or potential tissue damage or described the condition of the occu...

Nursing Care Plan for Hirschsprung's Disease Assessment of Hirschsprung's Disease 1. Activity / rest Symptoms: Malaise, changing patterns of rest / sleep associated with pain, limitations. 2. Ego Integrity Symptoms: Anxiety, fear, feelings of helplessness parents. 3. Elimination Symptoms: Constipation can be accompanied by diarrhea. Symptoms: Abdominal distension progressively, until the thin abdominal wall veins visible, peristaltic activity can be observed. 4. Food / fluid Symptoms: Anorexia, nausea, vomiting, weight loss. Signs: Decrease subcutan fat / muscle mass, weakness, a sign of malnutrition and growth failure. 5. Pain / comfort Symptoms: Abdominal pain. Signs: Facial expressions grimacing, moaning / crying, behavioral distraction, abdominal tenderness / distension. 6. Extension / learning Parent questions related to the disease, care and treatment of children. Patient's discharge plan: Requires assistance / demonstration how irrigation and colostomy care, the abil...

Nursing Care Plan for Abdominal Tumor DEFINITIONS Abdominal tumor is a solid mass with different thickness, which may wrap around large blood vessels and ureter. In the pathology of this disorder is easy to peel and can extend to retroperitonium, ureteral obstruction may occur or the inferior vena cava. Mass of fibrotic tissue that surround and define the structure in the wrapper but not invaded. CAUSES The immediate cause of the tumor is actually not known, but there are some results of the study showed that: Excess nutrients, especially fat. The end result of metabolic and bacterial. Constipation. Infections, trauma, hypersensitivity to the drug. SIGNS AND SYMPTOMS Pain Anorexia, nausea, lethargy Weight loss Bleeding Enlargement of the existing organ tumors DIAGNOSTIC TEST Digital rectal test X - ray Sigmoidoscope Fiber optic scope plexible Ultra sonography Nursing Diagnosis and Interventions for Abdominal Tumor 1. Chronic Pain related to an emphasis on retroperitoneal organs, Chara...

Cystic fibrosis (CF) is an inherited disease of the mucus glands and sweat . Cystic fibrosis (CF) affects mostly the lungs, pancreas, liver, intestines, sinuses, and sex organs. Normally , mucus is watery / runny. Maintaining the layers of certain organs moist and prevents drying out or getting infected. But in CF, an abnormal gene causes mucus to become thick and sticky. Mucus formed in the lungs and block the airways. It makes it easier for bacteria to grow and leads to repeated lung infections are serious. Over time, these infections can cause serious damage to the lungs. Thick and sticky mucus can also block tubes, or ducts of the pancreas. As a result, the digestive enzymes produced by the pancreas is not able to reach the small intestine. These enzymes help break down food. Without them, the intestines can not absorb fats and proteins fully. As a result: Nutrients leave the body unused, and can become malnourished. Stools become very large. May not get enough vitamins A, D, E, an...