Nursing Diagnosis Intervention

Nursing Diagnosis and Nursing Intervention

Social Isolation related to Schizophrenia

Nursing Care Plan for Schizophrenia

Nursing Diagnosis : Social Isolation
related to :
  • lack of confidence to others.
  • freaking out.
  • regression to earlier developmental stages.
  • delusions.
  • difficult to interact with others in the past.
  • weak ego development.
  • repression of fear.

Defining characteristics:
  • Alone in the room.
  • Not communicate, withdraw, do not make eye contact (mutism, autism).
  • Sad, flat affect.
  • Attention and actions that are inconsistent with developmental age.
  • Thinking about things according to his own thoughts, actions are repetitive and meaningless.
  • Approaching nurses to interact, but then refused to respond to the nurse to self-acceptance.
  • Expressing feelings of rejection or loneliness to others.


General Purpose:
  • The patient can voluntarily spend time with other patients and nurses in the group's activities.

Special purpose:
  • The patient already included in the activity therapy was accompanied by a nurse to believe in one week.

Expected outcomes:
  • The patient may demonstrate a desire to socialize with other people.
  • The patient can follow the group activity without prompting.
  • The patient did approach the interaction with others in a way that is appropriate / acceptable.


1. Show the acceptance by conducting frequent contacts, but brief.
Acceptance of others will improve the patient's self-esteem and facilitates a sense of trust in others.

2. Show a positive reinforcement to the patient.
Make the patient feel that would be a useful.

3. Accompany the patient to show support for group activities that may be the case that scary or difficult for the patient.
The presence of someone who believed would provide a sense of security to the patient.

4. Honest and keep all appointments.
Honesty and a sense of need raises a trusting relationship.

5. Orient the patient at the time, people, places, as needed.

6. Be careful with the touch. Let the patient got an extra room and the opportunity to leave the room if the patient becomes so anxiety.
The patients who suspect may be receptive to touch as a body language that suggests the threat.

7. Give the drugs, according the patient's treatment program. Monitor the effectiveness and side effects of drugs.
Medications help to reduce the symptoms of psychosis in a person, thus facilitating interaction with other people.

8. Discuss with the patient signs of increased anxiety and techniques to cut response. (Eg, relaxation exercises, "stop thinking").
Maladaptive behavior such as withdrawing and suspicious manifested during an increase in anxiety.

9. Give recognition and appreciation without prompting the patient can interact with others.
Reinforcement will increase the patient's self-esteem and encourage the repetition of such behavior.

Disturbed Sensory Perception (visual) related to Glaucoma

Nursing Care Plan for Glaucoma

Glaucoma is a group of eye disorders characterized by increased intraocular pressure. (Barbara C. Long, 2000: 262)

Glaucoma is an eye condition that is usually caused by an abnormal increase in intraocular pressure (up to more than 20 mmHg). (Elizabeth J.Corwin, 2009: 382)


Glaucoma is divided into; primary glaucoma, secondary, and congenital.

1. Primary Glaucoma

In primary glaucoma has no known cause, obtained form:
  • Closed angle glaucoma, acute congestive glaucoma.
  • Open angle glaucoma, chronic simple glaucoma.

2. Secondary Glaucoma

Secondary glaucoma occurs as a result of other diseases in the eye, caused by:
a. Lens aberration.
  • Luxation.
  • Swelling (intumescent).
  • Phacolytic.
b. abnormalities of the uvea
  • Uveitis.
  • Tumors.
c. Trauma
  • Bleeding in the anterior chamber. (Hyphema).
  • Perforation of the cornea and iris prolapse, which caused leucoma adherent.
d. Surgery
  • Anterior chamber are not quickly formed after cataract surgery.
e. Other causes of secondary glaucoma
  • Rubeosis iridis (due to central retinal vein thrombosis).
  • Excessive use of topical corticosteroids.

3. Congenital glaucoma
  • Primary congenital glaucoma or infantile glaucoma. (Buftalmos, hidroftalmos).
  • Glaucoma concerned with other congenital abnormalities.

4. Absolute Glaucoma
  • Final state of a glaucoma, ie with total blindness and eye pain.
(Sidarta Ilyas, 2002: 240-241)

Clinical Manifestations
  1. Pain in the eye and surrounding areas (orbital, head, teeth, ears).
  2. View of foggy, Seeing rainbows around lights.
  3. Nausea, vomiting, sweating.
  4. Red eye, conjunctival hyperemia, and ciliary.
  5. Decreased visual acuity.
  6. Corneal edema.
  7. Shallow anterior chamber (may not be found in open-angle glaucoma).
  8. Pupil wide oval, no reflex to light.
  9. IOP increases.
(Anas Tamsuri, 2010: 74-75)

Nursing Diagnosis : Disturbed Sensory Perception (visual) related to decrease in visual acuity and clarity of vision.

  • Stated vision blurred, indistinct, decreased vision area.
  • Decreased visual field examination.
  • Decreased ability to identify the environment (objects, people, places)
The client reported a greater ability to process visual stimuli and communicate the visual changes.

Expected outcomes:
  • The client identifies the factors that affect visual function.
  • The client identifies and shows patterns of alternatives to improve the visual stimuli reception.

Interventions :

1.Assess the client's visual acuity.
2. Approach the clients of the healthy side.
3. Identification of alternatives to optimize the stimulus source.
4. Adjust the environment to optimize vision:
  • Orient the client to the ward.
  • Place the tool that is often used near a client or on the sides of the eyes healthier.
  • Provide sufficient lighting.
  • Put in place a fixed tool.
  • Avoid glare.
5. Encourage the use of alternative acceptable environmental stimuli: auditory, tactile.

Rationale :

1. Identify the client visual capabilities.
2. Provide sensory stimulation, reducing the sense of isolation / alienation.
3. Giving sight accuracy and maintenance.
4. Improving the ability of sensory perception.
5. Improving the ability of response to environmental stimuli.

Knowledge Deficit related to Diabetic Foot Ulcers

Nursing Care Plan for Diabetic Foot Ulcers

Nursing Diagnosis : Knowledge Deficit about the disease process, diet, care, and treatment related to a lack of information.

Goal: The patient receive clear and accurate information about the disease.

Expected outcomes:
  • The patient know about the disease, diet, care and treatment and may explain the return if asked.
  • The patient can perform self-care based on the knowledge acquired.


1. Assess the level of knowledge of the patient / family about the disease of diabetes and gangrene.
Rationale: To provide information to patients / families, nurses need to know the extent to which information or knowledge that is known to the patient / family.

2. Assess the patient's educational background.
Rationale: In order for nurses to provide explanations by using words and phrases that can understand the patient as the patient's level of education.

3. Explain the process of disease, diet, care and treatment in patients with language and words that are easy to understand.
Rationale: In order information can be received easily and precisely so as to avoid misunderstandings.

4. Explain the procedure to be performed, the benefits to the patient and the patient engage in it.
Rationale: With the explanations and participate directly in the action taken, the patient will be more cooperative and reduced anxiety.

5. Use pictures to give an explanation (if there is / possible).
Rational: images may help to remember the explanation has been given.

Ineffective Tissue perfusion related to Diabetic Foot Ulcers

Nursing Care Plan for Diabetic Foot Ulcers

Ulcers are open sores on the skin or mucous membrane surface and the ulcer is extensive tissue death and accompanied invasive saprophyte bacteria. The existence of the saprophyte bacteria cause ulcers smelling, diabetic ulcers is also one of the symptoms and the clinical course of the disease diabetes mellitus with peripheral neuropathy. (Andyagreeni, 2010).

Diabetic ulcers are chronic complications of diabetes mellitus as a major cause of morbidity, mortality and disability in patients with diabetes. High LDL levels play an important role for the occurrence of diabetic ulcers through the formation of atherosclerotic plaque in the walls of blood vessels, (zaidah 2005).

Diabetic foot ulcers are the complications associated with morbidity from diabetes mellitus. Diabetic foot ulcers are serious complications due to diabetes. (Andyagreeni, 2010).

Nursing Care Plan for Diabetic Foot Ulcers

Nursing Diagnosis : Ineffective Tissue perfusion related to weakening / decrease in blood flow to the area of gangrene due to obstruction of blood vessels.

Goal: maintain peripheral circulation remained normal.

Expected outcomes:
  • Palpable peripheral pulses were strong and regular.
  • The color of the skin around the wound; not pale / cyanosis.
  • The skin around the wound felt warm.
  • Edema does not occur and the wound is not getting worse.
  • Sensory and motor improves.


1. Instruct the patient to mobilize.
Rational: the mobilization improves blood circulation.

2. Teach about the factors that can increase blood flow: Elevate the patient's leg is slightly lower than the heart (elevation position at rest), avoid crossing legs, avoid tight bandage, avoid the use of cushions, behind the knees and so on.
Rational: increase blood flow back so there is no edema.

3. Teach about the modification of risk factors such as:
Avoid high-cholesterol diet, relaxation techniques, stop smoking, and drug use vasoconstriction.
Rational: high cholesterol can accelerate the onset of atherosclerosis, smoking can cause vasoconstriction of blood vessels, relaxation to reduce the effects of stress.

4. Cooperation with other health care team in the delivery of vasodilators, checks blood sugar regularly and oxygen therapy.
Rational: vasodilator administration will increase the dilation of blood vessels and tissue perfusion can be improved, while the regular blood sugar checks can track the progress and state of the patient.

Acute Pain related to Cellulitis

Nursing Care Plan for Cellulitis

Cellulitis is an infection by Staphylococcus, Streptococcus, or by both of them in the deepest layers of the skin. Bacteria can enter the body through the other parts of the skin of a cut, scratch, or bite. Usually if the skin is infected, affected only the top layer and will disappear on their own with proper care. But in cellulitis, skin tissue becomes infected parts in red, hot, inflamed and painful. Cellulitis usually occurs on the face and lower legs.

While according to Neville, Oral and Maxillofacial Pathology, explains that the term cellulitis used an oedematous deployment of acute inflammation on the surface of the soft tissues and is diffuse. Cellulitis can occur in all places where there is soft tissue and loose connective tissue, especially on the face and neck, because usually in the area of defense against infection is less than perfect.

The main causes of facial cellulitis is Staphylococcus aureus and Streptococcus b- hemolyticus, whereas Staphylococcus epidermidis is a normal inhabitant of the skin and rarely fight infections. Pyoderma predisposing factor is the lack of hygiene, immune deficiencies, and other diseases have been found in the skin.

Cellulitis are not contagious, usually begins as a small, inflamed, pain, swelling, heat, and redness of the skin. When the milking area began to spread, the child will feel pain and discomfort, fever, and can be accompanied by chills and sweating. Swollen lymph nodes in the folds are sometimes found on the nearby skin infections.

Nursing Diagnosis and Interventions :

Acute Pain related to local inflammatory response of subcutaneous tissue.

Goal : The client expressed pain decreased after nursing care.

Expected outcomes :
  • Stable pain scale (0-3).
  • Showed no pain / controlled.
  • Looks relaxed, able to sleep / rest and participate in activities according to ability.
  • Following the recommended pharmacological program.

Intervention :

1. Observation pain scale (0-10), the characteristics of pain, and pain location.
Rational : assist in determining the need for pain management, and program effectiveness.

2. Let the patient take a comfortable position and increase bed rest as indicated.
Rational : to limit the pain.

3. Give a gentle massage.
Rational : increase relaxation / reduce muscle tension.

4. Encourage the use of stress management techniques, such as progressive relaxation, therapeutic touch, biofeedback, visualization, guidance imagination, self hypnosis, and breath control.
Rational : increase relaxation, gives a sense of control, and may improve coping skills.


5. Give the medicine before the activity / exercise is planned, according to the instructions.
Rational : increase relaxation, reduce muscle tension / spasm, easy to participate in therapy.

6. Apply ice or a cold pack if necessary.
Rational : the cold can relieve pain and swelling during the acute period.

Risk for Fluid Volume Deficit related to Low Birth Weight

Nursing Care Plan for Low Birth Weight

Nursing Diagnosis : Risk for Fluid Volume Deficit age and extreme weight, excessive fluid loss (thin skin), less fat layer, immature kidney / failure to concentrate urine.

Goal: liquid fulfilled

Expected outcomes:
  • Free of signs of dehydration.
  • Shows the weight gain of 20-30 grams / day.

Interventions :

  • Compare the input and output of urine, every shift and balance each periodic cumulative 24 hours.
  • Monitor the specific gravity of each finished urinating or every 2-4 hours to inspire urine from diapers when the baby can not stand the reservoir bag urine.
  • Evaluation of skin turgor, mucous membranes, and the state of the anterior fontanelle.
  • Monitor blood pressure, pulse, and mean arterial pressure (TAR).
  • Monitor laboratory examination in accordance with the indications; Ht.
  • Give parenteral infusion.
  • Give a blood transfusion.

Rationale :
  • Output should be 1-3 ml / kg / h, while the need for fluid therapy is approximately 80-100 ml / kg / day on the first day, increased to 120-140 ml / kg / day on the third day postpartum. Blood sampling for tests lead to decreased levels of hemoglobin / hematocrit.
  • Although renal immaturity and inconvenience to concentrate urine, usually resulting in a low specific gravity in preterm infants (range normal1,006-1,013). Low levels indicates excessive fluid volume and content of greater than 1.013 indicates the inability of fluid intake and dehydration.
  • Loss or minimal fluid shifts can quickly lead to dehydration, visible by poor skin turgor, dry mucous membranes, and sunken fontanelle.
  • Losing 25% of blood volume resulting in shock, with TAR 25 mmHg indicates hypotension.
  • Dehydration increases hematocrit levels 45-53% above normal serum potassium.
  • Hypoglycemia can occur due to loss through diarrhea or vomiting nasogastric tube.
  • The replacement of body fluids increase the volume of blood, helps restore vasoconstriction due to hypoxia, acidosis, and right-to-left shunt through the PDA, and has helped in reducing complications necrotizing enterocolitis, and bronchopulmonary dysplasia.
  • It may be necessary to maintain the levels of hematocrit / hemoglobin optimal and replace blood loss.

Ineffective Breathing Pattern related to Low Birth Weight

Ineffective Breathing Pattern related to Low Birth Weight
Nursing Care Plan for Low Birth Weight

Nursing Diagnosis :  Ineffective Breathing Pattern

According Manuaba (2002) since 1961 WHO replace the term premature with low birth weight (LBW) as they realized that not all babies born weighing less than 2500 grams at birth is not premature baby, then according Pantiawati (2009), LBW is a baby with birth weight less than 2500 grams. Meanwhile, according Proverawati (2010) LBW is babies born weighing less than 2500 grams regardless of pregnancy, in line with the opinions Prawiroharjo (2011) LBW is newborn birth weight less than 2500 (up to 2499 grams).

According Proverawati (2010), Clinical / LBW Infants characteristics:
  • Weight less than 2500 grams.
  • Length of less than 45 cm.
  • Chest circumference less than 30 cm.
  • Head circumference less than 33 cm.
  • Thin subcutaneous fat tissue or less.
  • Gestational age less than 37 weeks.
  • Larger heads.
  • Transparent thin skin, lanugo hair a lot, less fat.
  • Cartilage earlobe, rudimentary growth.
  • Weak hypotonic muscle is a muscle that is no active movement of the arms and elbows.
  • Irregular breathing can occur apnea.
  • Extremities: abduction of the thigh, the knee / leg flexion-straight, heel shiny, smooth soles.
  • Head is not able to erect, yet nerve function or ineffective and weak tears.
  • Breathing 40-50 times / min and pulse 100-140 beats / min.

Nursing Diagnosis for Low Birth Weight : Ineffective breathing pattern related to the immaturity of the respiratory center, the limitations of muscle growth or decline in muscle weakness and metabolic imbalance.

Goal: Patterns breath back effectively.

Expected outcomes:
Neonates will maintain periodic breathing patterns.
Pink mucous membranes.

Nursing Interventions :

Assess the frequency and pattern of breathing, note the presence of apnea and cardiac frequency changes.
Suction the airway as needed.
Place the baby in the abdomen or supine position with a rolled diaper under the shoulder to produce hyperextension.
Review the history of the mother to drugs that would aggravate respiratory depression in infants.

Monitor laboratory tests as indicated.
Give oxygen as indicated.
Give medications as indicated.

Rationale :

Help in distinguishing normal breathing rotation period of true apnea attacks, especially common in the 30th week of gestation.
Eliminate mucus that clogs the airways.
This position facilitates breathing and decrease episodes of apnea, especially if found any hypoxia, metabolic acidosis or hypercapnia.
Magnesium sulfate and narcotics suppress the respiratory center and CNS activity.
Hypoxia, metabolic acidosis, hypercapnia, hypoglycemia, hypocalcemia and sepsis aggravate apnea attacks.
Improvement of oxygen and carbon dioxide levels can improve respiratory function.

Nursing Interventions for Bone Cancer

Definition of bone cancer is cancer that occurs in the bone. Bone cancer can occur in any bone in the body, such as cancer of the spine, etc., but most often affects the arm and leg bones. There are several types of bone cancer. Some types of bone cancer occurs primarily in children, while others affect mostly adults.

Symptoms of Bone Cancer

Characteristic feature of bone cancer or bone cancer symptoms include:
  • Bone pain.
  • Swelling and pain near the affected area.
  • Fracture.
  • Fatigue.
  • Weight loss is not desired.

Types of Bone Cancer

Bone cancer is divided into separate types based on the type of cell where the cancer started. The most common type of bone cancer include:
  • Osteosarcoma. Osteosarcoma begins on bone cells. Osteosarcoma occurs most often in children and young adults.
  • Chondrosarcoma. Chondrosarcoma begins in the cartilage cells are normally found in the bone ends. Chondrosarcoma most commonly affects older adults.
  • Ewing's Sarcoma. It is not clear where ewing sarcoma begins. Ewing's sarcoma is believed that to begin in nerve tissue in the bone. Ewing's sarcoma occurs most often in children and young adults.

Nursing Interventions for Bone Cancer

1). Pain management
Psychological pain management techniques (deep breath relaxation techniques, visualization, and guided imagery) and pharmacological (providing analgesic).

2). Teach effective coping mechanisms
Motivation clients and families to express their feelings, and give moral support and encourage families to consult a psychologist or clergy.

3). Provide adequate nutrition
Decreased appetite, nausea, vomiting often occur as a side effect of chemotherapy and radiation, so it should be given adequate nutrition. Antiemetic and relaxation techniques can reduce gastrointestinal reactions. Parenteral nutrition can be carried out in accordance with the indications of the doctor.

4). Health education
Patients and families are given health education on the likelihood of complications, treatment programs, and wound care techniques at home (Smeltzer. 2001: 2350).

5) If necessary; traction, Traction Treatment Principles
  • Provide comfort measures (eg frequently change position, back massage) and therapeutic activity.
  • Give the drug as an indication of examples; analgesic muscle relaxant.
  • Give local heating as indicated.
  • Give strength in early bandage / replacement in accordance with the indications, use aseptic technique correctly.
  • Keep linen remains dry, free of wrinkles.
  • Encourage the client to use loose cotton clothing.
  • Encourage the client to use stress management, for example: guided imagery, deep breathing.
  • Assess the degree of immobilization produced.
  • Identification signs or symptoms that require medical evaluation, eg edema, erythema.

Risk for Hypovolemic Shock, Risk for Metabolic Acidosis and Self-care Deficit

Nursing Diagnosis : Risk for Hypovolemic Shock related to continuous bleeding.

Goal :
  • Shock does not occur during the treatment period.
Expected Outcomes:
  • Not decreased consciousness.
  • Vital signs within normal limits.
  • Good skin turgor.
  • Good peripheral perfusion (acral warm, dry and red).
  • Fluid balance in the body.

Nursing Interventions :
1. Encourage the patient to drink more.
R /: Increased fluid intake, may increase intravascular volume, which can increase tissue perfusion.

2. Observation of vital signs every 4 hours.
R /: Changes in vital signs can be an early indicator of dehydration.

3. Observation of the signs of dehydration.
R /: Dehydration is the beginning of the syock if dehydration is not in good hands.

4. Observation of fluid intake and output.
R /: adequate fluid intake can compensate for excessive discharge.

5. Collaboration in:
  • Intravenous fluids or transfusion.
  • Giving coagulant and uterotonic.
  • CVP custom installation.
  • Examination of the plasma density.

Nursing Diagnosis : Risk for Metabolic Acidosis related to a decrease in the amount of blood in the capillaries.

Goal :
Metabolic acidosis did not occur during the treatment period,

Expected Outcomes:
  • The results of blood gas analysis within normal limits.
  • Vital signs within normal limits.
Nursing Interventions :
1. Observation vital signs within normal limits.
R /: Changes in vital signs is an early sign of detection of acidosis.

2. Encourage and motivate patients to drink sweet.
R /: Reducing protein breakdown and excessive fat to meet metabolic needs.

3. Collaboration in:
  • BGA inspection.
  • Intravenous fluids.

Nursing Diagnosis : Self-care Deficit related to physical weakness

Goal :
During the treatment period of daily activity needs are met.

Nursing Interventions :
1. Explain to the patient about the importance of maintaining personal hygiene.
R /: Adequate knowledge enables clients cooperatively towards the maintenance action performed.

2. Assist the client in meeting the nutritional needs (food and drink).
R /: Weakness of the body requires that the client needs with the help of others.

3. Assist the client in meeting the needs of personal hygiene.
R /: Weakness of the body that occur can lead to inability to meet the needs of personal hygiene.

4. Observation fulfillment daily activities.
R / Increased ability fulfillment of daily needs may reflect reduced body weakness.

Hyperthermia and Acute Pain related to Dengue Fever Hemorrhagic (DHF)

Hyperthermia and Acute Pain related to Dengue Fever Hemorrhagic (DHF)
Hyperthermia r/t Dengue Fever Hemorrhagic (DHF)
Nursing Diagnosis : Hyperthermia related to disease process (viremia)

Goal :
Patient 's body temperature can be reduced.

Outcome :
  • Comfortable body condition.
  • Temperature 36,80C-37,50C.
  • Blood pressure : 120/80 mmHg.
  • Respiration : 16-24 x / mnt.
  • Pulse : 60-100 x / mnt.

Intervention :
  • Assess the onset of fever.
  • Observation of vital signs (temperature, pulse, blood pressure, respiration) every 3 hours.
  • Instruct the patient to drink (2.5 liters / 24 hours).
  • Give warm compresses.
  • Suggest to not wear thick blankets and clothing.
  • Give intravenous fluid therapy and medications as ordered.

Rationale :
  • To identify patterns of fever.
  • Vital Signs is a reference to determine the patient's general condition.
  • The increase in body temperature results in increased evaporation body so it needs to be balanced with a high fluid intake.
  • With vasodilation can increase evaporation which accelerates the decline in body temperature.
  • Clothing thin body helps reduce evaporation.
  • Fluid administration is very important for patients with a high temperature.

Nursing Diagnosis : Acute Pain related to pathological disease process.

Goal :
Patient's pain can be reduced and disappeared.

Outcomes :
  • The patient said that the pain was reduced / lost.
  • The pain was on a scale of 0-3.
  • Blood pressure : 120/80 mmHg.
  • Temperature : 36,80C-37,50C.
  • Respiration : 16-24 x / mnt.
  • Pulse : 60-100 x / mnt.

Intervention :
  • Observation of the patient's level of pain (scale, frequency, duration).
  • Provide a quiet and comfortable environment and comfort measures.
  • Give proper entertainment activities.
  • Involve families in nursing care.
  • Teach the patient relaxation techniques.
  • Collaboration with physicians to analgesic drug delivery.

Rationale :
  • Indicates the need for intervention and also the signs of the development / resolution of complications.
  • A comfortable environment will help the process of relaxation.
  • Refocused attention ; improve the ability to cope with pain.
  • Family will help the healing process by training the patient relaxation.
  • Relaxation pain will move to other things.
  • Provide pain relief.
Copyright © Nursing Diagnosis Intervention. All rights reserved. Template by CB | Published By Kaizen Template | GWFL | KThemes