Nanda Nursing Diagnosis

Definition : Decreased intravascular, interstitial, and or intracellular fluid. Related Factors : Active fluid volume loss; failure of regulatory mechanisms Deficient Fluid volume Characteristics : Decreased urine output, increased urine concentration, weakness, sudden weight loss, decreased venous filling, increased body temperature, decreased pulse volume or pressure, change in mental state, elevated hematocrit, decreased skin or tongue turgor; dry skin/mucous membranes, thirst, increased pulse rate, decreased blood pressure. Deficient Fluid volume Outcomes Maintains urine output more than 1300 ml/day (or at least 30 ml/hr) Maintains normal blood pressure, pulse, and body temperature Maintains elastic skin turgor; moist tongue and mucous membranes; and orientation to person, place, time Explains measures that can be taken to treat or prevent fluid volume loss Describes symptoms that indicate the need to consult with health care provider NOC Outcomes (Nursing Outcomes Classif...

Definition: Passage of loose, unformed stools Related Factors: Psychological High stress levels and anxiety Situational Alcohol abuse, toxins, laxative abuse, radiation, tube feedings , adverse effects of medications, contaminants, travel Physiological Inflammation, malabsorption, infectious processes, irritation, parasites As evidenced by Major: Loose liquid stools and/or: Frequency Minor: Urgency Cramping/abdominal pain Hyperactive bowel sounds Increase of fluidity or volume of stools Outcomes Defecates formed, soft stool every day to every third day Maintains a rectal area free of irritation States relief from cramping and less or no diarrhea Explains cause of diarrhea and rationale for treatment Maintains good skin turgor and weight at usual level Contains stool appropriately (if previously incontinent) Nursing Interventions Nursing Care Plan for Diarrhea Assess abdomen for distention, bowel sounds, pain. Identify factors that contribute to diarrhea. Record color, odor, amount a...

Definition: A decrease in a person's normal frequency of defecation, accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool Defining Characteristics: Change in bowel pattern; bright red blood with stool; presence of soft paste-like stool in rectum; distended abdomen; dark, black, or tarry stool; increased abdominal pressure; percussed abdominal dullness; pain with defecation; decreased volume of stool; straining with defecation; decreased frequency; dry, hard, formed stool; palpable rectal mass; feeling of rectal fullness or pressure; abdominal pain; unable to pass stool; anorexia; headache ; change in abdominal growing (borborygmi); indigestion; atypical presentation in older adults (e.g., change in mental status, urinary incontinence, unexplained falls, elevated body temperature); severe flatus; generalized fatigue; hypoactive or hyperactive bowel sounds; palpable abdominal mass; abdominal tenderness with or without palpable muscle ...

Nursing Care Plan for Stroke A stroke, previously known medically as a cerebrovascular accident (CVA), is the rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a haemorrhage (leakage of blood). As a result, the affected area of the brain is unable to function, which might result in an inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field. A stroke is a medical emergency and can cause permanent neurological damage, complications, and death. It is the leading cause of adult disability in the United States and Europe and the second leading cause of death worldwide. Risk factors for stroke include old age, hypertension (high blood pressure), previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, cigarette smoking ...

NCP for Anemia Nursing Care Plan for Anemia Anemia Anemia is a medical condition in which the red blood cell count or hemoglobin is less than normal. The normal level of hemoglobin is generally different in males and females. For men, anemia is typically defined as hemoglobin level of less than 13.5 gram/100ml and in women as hemoglobin of less than 12.0 gram/100ml. These definitions may vary slightly depending on the source and the laboratory reference used. Anemia Symptoms Clinical symptoms that appear to reflect dysfunction of various systems in the body such as decrease in physical performance, impaired neurologic (nerve), which is manifested in changes in behavior, anorexia (emaciated body), and abnormal cognitive development in children. Often, too, growth abnormality, epithelial dysfunction, and reduced gastric acidity. An easy way to know anemia with 5 signs : weak, tired, lethargic, tired, negligent. If it appears five of these symptoms , we can be sure a person has anemia....

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...