Nursing Diagnosis and Nursing Intervention

Goals of Postural Drainage

Goals of Postural Drainage
Postural drainage (bronchial drainage) is a means of mobilizing secretions in one or more lung segments to the central airways by placing the patient in various positions so that gravity assists in the drainage process. When secretions are moved to the larger airways, they are then cleared by coughing or Endotracheal suctioning. Postural drainage therapy also includes the use of manual techniques, such as percussion and vibration, as well as voluntary coughing.
1. Positions are based on the anatomy of the lungs and the tracheobronchial tree.
2. The patient may be positioned on a.
Bronchial Drainage
  • Postural drainage table that can be elevated at one end.
  • Tilt table.
  • Reinforced padded table with a lift.
  • Hospital bed.
  • A small child can be positioned on the therapist’s lap.
Goals of Postural Drainage
1. Prevent accumulation of secretions in patients at risk for pulmonary complications. This may include:
  • Patients with pulmonary diseases that are associated with increased production or viscosity of mucus, such as chronic bronchitis and cystic fibrosis.
  • Patients who are on prolonged bed rest.
  • Post surgical patients who have received general anesthesia and who may have painful incisions that restrict deep breathing and coughing postoperatively.
  • Any patient who is on a ventilator if they are stable enough to tolerate the treatment.
2. Remove secretions already accumulated in the lungs of:
  • Patients with acute or chronic lung disease, such as pneumonia, Atelectasis, acute lung infections, and COPD.
  • Patients who are generally very weak or are elderly.
  • Patients with artificial airways. To drain the middle and lower portions of your lungs, you should be positioned with your chest above your head. Possible techniques to achieve this position are:
    • If a hospital bed is available, put in Trendelenburg position (head lower than feet)
    • Place 3-5 wood blocks, that are 2 inches by 4 inches, in a stack that is 5 inches high, under the foot of a regular bed. Blocks should have indentations or a 1 inch rim on top so that the bed does not slip
    • Stack 18-20 inches of pillow under hips.
    • Place on a tilt table, with head lower than feet.
    • Lower head and chest over the side of the bed.
       To drain the upper portions of your lungs, you should be in a sitting position at about a 45 degree angle.
       When you are in the proper postural drainage position, change your position per the following sequence:
    • Turn side to side
    • Lay on stomach
    • Lay on back
    Remain in each position approximately five to ten minutes. Use suction or assisted cough before changing position to insure removal of any secretions drained while in that position. Postural draining is usually taught by your physical therapist.
    Inspiratory Muscle Trainer is a device to assist in building inspiratory muscle strength. The device should be used daily as part of your daily routine to keep lungs healthy.
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How is Low Blood Pressure Treated ?

Low blood pressure in healthy subjects without symptoms or organ damage needs no treatment. However, all patients with symptoms possibly due to low blood pressure should be evaluated by a doctor. (Patients who have had a major drop in blood pressure from their usual levels even without the development of symptoms also should be evaluated.) The doctor needs to identify the cause of the low blood pressure because treatment will depend on the cause. For example, if a medication is causing the low blood pressure, the dose of medication may have to be reduced or the medication stopped, though only after consulting the doctor. Self-adjustment of medication should not be done.

Dehydration is treated with fluids and minerals (electrolytes). Mild dehydration without nausea and vomiting can be treated with oral fluids and electrolytes. Moderate to severe dehydration usually is treated in the hospital or emergency room with intravenous fluids and electrolytes.

Blood loss can be treated with intravenous fluids and blood transfusions. Continuous and severe bleeding needs to be treated immediately.

Septic shock is an emergency and is treated with intravenous fluids and antibiotics.

Blood pressure medications or diuretics are adjusted, changed, or stopped by the doctor if they are causing low blood pressure symptoms.

Bradycardia may be due to a medication. The doctor may reduce, change or stop the medication. Bradycardia due to sick sinus syndrome or heart block is treated with an implantable pacemaker.

Tachycardia is treated depending on the nature of the tachycardia. Atrial fibrillation can be treated with oral medications, electrical cardioversion, or a catheterization procedure called pulmonary vein isolation. Ventricular tachycardia can be controlled with medications or with an implantable defibrillator.

Pulmonary embolism and deep vein thrombosis is treated with blood thinners, intravenous initially with heparin, and oral warfarin (Coumadin) later.

Pericardial fluid can be removed by a procedure called pericardiocentesis.

Postural hypotension can be treated by increasing water and salt intake*, increasing intake of caffeinated beverages because caffeine constricts blood vessels, using compression stockings to compress the leg veins and reduce the pooling of blood in the leg veins, and in some patients, the use of a medication called midodrine (ProAmatine). The problem with ProAmatine is that while it increases blood pressure in the upright position, the supine blood pressure may become too high, thus increasing the risk of strokes. Mayo Clinic researchers found that a medication used to treat muscle weakness in Myasthenia gravis called pyridostigmine (Mestinon) increases upright blood pressure but not supine blood pressure. Mestinon, an anticholinesterase medication, works on the autonomic nervous system, especially when a person is standing up. Side effects include minor abdominal cramping or increased frequency of bowel movements. *Note: Increasing salt intake can lead to heart failure in patients with existing heart disease and should not be undertaken without consulting a doctor.

Postprandial hypotension refers to low blood pressure occurring after meals. Ibuprofen (Motrin) or indomethacin (Indocin) may be beneficial.

Vasovagal Syncope can be treated with several types of drugs such as beta blockers [for example, propanolol (Inderal, Inderal LA)], selective serotonin reuptake inhibitors [fluoxetine (Prozac), escitalopram oxalate (Lexapro), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), fluvoxamine (Luvox)], fludrocortisone (Florinef) (a drug that prevents dehydration by causing the kidney(s) to retaining water). A pacemaker can also be helpful when a patient fails drug therapy.

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Signs and symptoms of Low Blood Pressure

When the blood pressure is not sufficient to deliver enough blood to the organs of the body, the organs do not work properly and may be permanently damaged. For example, if insufficient blood flows to the brain, brain cells do not receive enough oxygen and nutrients, and a person can feel lightheaded, dizzy, or even faint.

Going from a sitting or lying position to a standing position often brings out symptoms of low blood pressure. This occurs because standing causes blood to "settle" in the veins of the lower body, and this can lower the blood pressure. If the blood pressure is already low, standing can make the low pressure worse, to the point of causing symptoms. The development of lightheadedness, dizziness, or fainting upon standing caused by low blood pressure is called orthostatic hypotension. Normal individuals are able to compensate rapidly for the low pressure created by standing with the responses discussed previously and do not develop orthostatic hypotension.

When there is insufficient blood pressure to deliver blood to the coronary arteries (the arteries that supply blood to the heart's muscle), a person can develop chest pain (a symptom of angina) or even a heart attack.

When insufficient blood is delivered to the kidneys, the kidneys fail to eliminate wastes from the body, for example, urea and creatinine, and an increase in their levels in the blood occur (for example, elevations of blood urea nitrogen or BUN and serum creatinine, respectively).

Shock is a life-threatening condition where persistently low blood pressure causes organs such as kidney(s), liver, heart, lung, and brain to fail rapidly.

Treatment for Deep Vein Thrombosis

What is the treatment for deep vein thrombosis?

Superficial Thrombophlebitis
Treatment for superficial blood clots is symptomatic with:
  • warm compresses,
  • leg compression, and
  • an anti-inflammatory medications such as ibuprofen.
If the thrombophlebitis occurs near the groin where the superficial and deep systems join together, there is potential that the thrombus could extend into the deep venous system. These patients may require anticoagulation or blood thinning therapy (see below).
Deep venous thromboses
Deep venous thromboses that occur below the knee tend not to embolize (break loose). They may be observed with serial ultrasounds to make certain they are not extending above the knee. At the same time, the cause of the deep vein thrombosis may need to be addressed.
The treatment for deep venous thrombosis above the knee is anticoagulation, unless a contraindication exists. Contraindications include recent major surgery (since anticoagulation would thin all the blood in the body, not just that in the leg, leading to significant bleeding issues), or abnormal reactions when previously exposed to blood thinner medications.
Anticoagulation prevents further growth of the blood clot and prevents it from forming an embolus that can travel to the lung.
Anticoagulation is a two step process. Warfarin (Coumadin) is the drug of choice for anti-coagulation. It is begun immediately, but unfortunately it may take a week or more for the blood to be appropriately thinned. Therefore, low molecular weight heparin [enoxaparin (Lovenox)] is administered at the same time. It thins the blood via a different mechanism and is used as a bridge therapy until the warfarin has reached its therapeutic level. Enoxaparin injections can be given on an outpatient basis.
For those patients who have contraindications to the use of enoxaparin (for example, kidney failure does not allow the drug to be metabolized), intravenous heparin can be used as the first step. This requires admission to the hospital.
The dosage of warfarin is monitored by blood tests measuring the prothrombin time or INR (international normalized ratio). For an uncomplicated deep vein thrombosis, the recommended length of therapy with warfarin is three to six months.
Some patients may have contraindications for warfarin therapy, for example a patient with bleeding in the brain, major trauma, or recent significant surgery. An alternative may be to place a filter in the inferior vena cava (the major vein that collects blood from both legs) to prevent emboli from reaching the heart and lungs. These filters may be effective but also may be the source of new clot formation.
Surgery is a rare option in treating large deep venous thrombosis of the leg in patients who cannot take blood thinners or who have developed recurrent blood clots while on anti-coagulant medications. The surgery is usually accompanied by placing an IVC (inferior vena cava) filter to prevent future clots from embolizing to the lung.
Phlegmasia Cerulea Dolens describes a situation in which a blood clot forms in the iliac vein of the pelvis and the femoral vein of the leg, obstructing almost all blood return and compromising blood supply to the leg. In this case surgery may be considered to remove the clot, but the patient will also require anti-coagulant medications.


Fluid Volume Excess Nursing Diagnosis and Interventions

Nursing Diagnosis - Interventions for Fluid Volume Excess

Nursing Diagnosis Fluid Volume Excess

Excess fluid volume related to decreased glomerular filtration rate (decrease in cardiac output) and the retention of sodium / water.

Characterized by:
Orthopnea, S3 heart sound, oliguria, edema, weight gain, hypertension, respiratory distress, abnormal heart sounds.

Objectives / evaluation criteria:
Clients will be demonstrating the stable fluid volume with the balance of inputs and expenditures, breath sounds clean / clear, vital signs within an acceptable range, stable weight and no edema, fluid restriction expressed understanding of the individual.

Nursing Interventions Volume Excess Fluid:
Monitor urine output, record the number and color of the time in which diuresis occurs.
Rational: Spending a little and concentrated urine may be due to decreased renal perfusion. Supine position so that helps diuresis of urine may be increased during bed rest.

Monitor / calculate the balance of income and expenditure for 24 hours.
Rational: diuretic therapy may be caused by a sudden loss of fluid / redundant (hypovolaemia), although edema / ascites is still there.

Keep sitting or bed rest with semifowler position during the acute phase.
Rationale: The position is increasing kidney filtration thus improving diuresis.

Monitor blood pressure and CVP (if any).
Rational: Hypertension and increased CVP indicates fluid overload and may indicate an increase in pulmonary congestion, heart failure.

Assess bowel sounds. Record complaints of anorexia, nausea, abdominal distension and constipation.
Rational: visceral congestion can interfere with the function of gastric / intestinal tract.

Administration of drugs as indicated (collaboration)
Consult with the dietitian.
Rational: to provide an acceptable diet that meets client needs calories in sodium restriction.

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Nursing Diagnosis for Liver Abscess - Nursing Interventions for Liver Abscess

Nursing Diagnosis for Liver Abscess - Nursing Interventions for Liver Abscess

Liver abscess is a relatively uncommon but life-threatening disorder that occurs when bacteria or protozoa destroy hepatic tissue. The damage produces a cavity, which fills with infectious organisms, liquefied hepatic cells, and leukocytes. Necrotic tissue then walls off the cavity from the rest of the liver.
A liver abscess occurs when bacteria or protozoa destroy hepatic tissue, producing a cavity, which fills with infectious organisms, liquefied liver cells, and leukocytes. Necrotic tissue then walls off the cavity from the rest of the liver. Liver abscess carries a mortality of 10% to 20%, despite treatment. Liver abscess affects both sexes and all age-groups, although it's slightly more prevalent in hospitalized children (because of a high rate of immunosuppression) and in females (most commonly those between ages 40 and 60).

Nursing Diagnosis for Liver Abscess
  1. Impaired Liver Function
  2. Acute pain
  3. Deficient knowledge (diagnosis and treatment)
  4. Imbalanced nutrition: Less than body requirements
  5. Risk for impaired skin integrity
  6. Risk for infection

Nursing Interventions for Liver Abscess

1. Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient. Analgesic Administration: Use of pharmacologic agents to reduce or eliminate pain. Environmental Management: Comfort: Manipulation of the patient’s surroundings for promotion of optimal comfort

2. Teaching: Individual Planning, implementation, and evaluation of a teaching about Liver abscess. Learning Facilitation: Promoting the ability to process and comprehend information. Learning Readiness Enhancement: Improving the ability and willingness to receive information.

3. Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids. Weight Gain Assistance: Facilitating gain of body weight

4. Skin Surveillance: Collection and analysis of patient data to maintain skin and mucous membrane integrity. Pressure Management: Minimizing pressure to body parts. Pressure Ulcer Prevention: Prevention of pressure ulcers for a patient at high risk for developing them

5. Infection Protection, Infection Control, Surveillance: Prevention and early detection of infection in a patient at risk. Minimizing the acquisition and transmission of infectious agents. Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making.

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Pulmonary Tuberculosis Nanda Nursing Diagnosis

Pulmonary tuberculosis (TB) is a highly contagious disease caused by a bacteria known as Mycobacterium tuberculosis. TB generally affects the lungs, but it also can invade other organs of the body, like the brain, kidneys and lymphatic system.

TB is spread through coughing, sneezing, and spitting. Only a small amount of inhaled germs are needed to become infected, however prolonged exposure to someone else who has TB is the easiest way to get the disease. Those who have a weakened immune system are even more at risk.

Many people who are infected with TB have few or no symptoms at all, at least in the beginning. Some people develop symptoms slowly, over time, and pay little attention to them until the disease has reached the advanced stages. When symptoms do appear, they generally include:
  • fatigue
  • loss of appetite and weight loss
  • cough with purulent and/or bloody sputum
  • night sweats
  • low-grade fever that occurs mostly in the afternoon
  • lethargy
Pulmonary Tuberculosis Nursing Diagnosis - NANDA

a. Ineffective airway clearance

related to viscous secretions or blood secretions, weakness, poor cough effort, edema, tracheal / pharyngeal.

b. Impaired Gas Exchange

related to the reduced effectiveness of the surface of the lung, atelectasis, alveolar capillary membrane damage, thick secretions, bronchial edema.

c. Imbalanced Nutrition: Less Than Body Requirements

related to fatigue, frequent coughing, the sputum production, dyspnea, anorexia, decreased financial capabilities.

d. Acute pain

related to lung inflammation, persistent cough.

e. Hyperthermia

related to active inflammatory process.

f. Intolerance Activity

related to the imbalance between supply and oxygen demand.

g. Knowledge Deficit : about conditions, treatments, prevention

associated with no one to explain, the interpretation is wrong, the information obtained is incomplete / inaccurate, lack of knowledge / cognitive

h. Risk for the spread of infection / re-infection activity related to inadequate primary defenses, decreased ciliary function / static secretions, tissue damage caused by the spread of infection, malnutrition, environmental contamination, lack of information about the bacterial infection.

Nursing Diagnosis and Nursing Interventions for Hirschsprung's Disease

Nursing Diagnosis and Nursing Interventions for Hirschsprung's Disease

Nursing Care Plan for Hirschsprung's Disease

Hirschsprung's Disease Nursing Care Plan

Hirschsprung’s Disease

Hirschsprung's disease is a blockage of the large intestine due to improper muscle movement in the bowel. It is a congenital condition, which means it is present from birth.


Symptoms that may be present in newborns and infants include:

  • Difficulty with bowel movements
  • Failure to pass meconium shortly after birth
  • Failure to pass a first stool within 24 - 48 hours after birth
  • Infrequent but explosive stools
  • Jaundice
  • Poor feeding
  • Poor weight gain
  • Vomiting
  • Watery diarrhea (in the newborn)

Symptoms in older children :
  • Constipation that gradually gets worse
  • Fecal impaction
  • Malnutrition
  • Slow growth
  • Swollen belly
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Nursing Care Plan for Hirschsprung's Disease

Nursing Assessment
  1. The main complaint
    Obstipation is the main sign and in newborn infants. What is often found is a slow exit meconium (more than 24 hours after birth), flatulence and vomiting green. Other symptoms are vomiting and diarrhea.
  2. History of present illness
    Is a congenital disorder that is a functional bowel obstruction. Total obstruction at birth with vomiting, abdominal distension and absence of meconium evacuation. Babies often experience constipation, vomiting and dehydration. Mild symptoms of constipation for several weeks or months, followed by acute intestinal obstruction. But there is also a mild constipation, enterocolitis with diarrhea, abdominal distension, and fever. Fetid diarrhea may occur.
  3. History of previous illnesses
    No previous illnesses that affect the occurrence of Hirschsprung's disease.
  4. Family health history
    No family who suffer from this disease descended to his son.
  5. Immunization
  6. History of growth and development of children
  7. Nutrition
  8. Physical examination
    • Respiratory system
      Shortness of breath, respiratory distress
    • Digestive system
      Generally obstipation. Abdominal bloating / abdominal strain, vomiting green. In older children there are chronic diarrhea. In the plug anus finger will feel the pins and on time withdrawn will be followed by the release of air and meconium or feces spraying.
    • Genitourinarius system
    • Locomotor system / musculoskeletal
      Impaired sense of comfort

Nursing Diagnosis and Nursing Interventions for Hirschsprung's Disease

Deficient Knowledge Nursing Diagnosis Interventions

Nursing Diagnosis for Deficient Knowledge

Absence or deficiency of cognitive information related to a specific topic

Verbalization of the problem; inaccurate follow-through of instruction; inaccurate performance of test; 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

  • Knowledge of: Diet
  • Disease Process
  • Energy Conservation
  • Health Behaviors
  • Health Resources
  • Infection Control
  • Medication
  • Personal Safety
  • Prescribed Activity
  • Substance Use Control
  • Treatment Procedure(s)
  • Treatment Regimen

Client Outcomes

  • Explains disease state, recognizes need for medications, understands treatments
  • Explains how to incorporate new health regimen into lifestyle
  • States an ability to deal with health situation and remain in control of life
  • Demonstrates how to perform procedure(s) satisfactorily
  • Lists resources that can be used for more information or support after discharge


  • Teaching: Disease Process
  • Teaching: Individual
  • Teaching: Infant Care
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Fatigue Nursing Diagnosis - NIC NOC

Nursing Diagnosis for Fatigue

Definition: Fatigue An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at usual level

Characteristics: Inability to restore energy even after sleep; lack of energy or inability to maintain usual level of physical activity; increase in rest requirements; tired; inability to maintain usual routines; verbalization of an unremitting and overwhelming lack of energy; lethargic or listless; perceived need for additional energy to accomplish routine tasks; increase in physical complaints; compromised concentration; disinterest in surroundings, introspection; decreased performance; compromised libido; drowsy; feelings of guilt for not keeping up with responsibilities

Related Factors:
Boring lifestyle; stress; anxiety; depression
Humidity; lights; noise; temperature
Negative life events; occupation
Sleep deprivation; pregnancy; poor physical condition; disease states (cancer, HIV, multiple sclerosis); increased physical exertion; malnutrition; anemia

NOC Outcomes (Nursing Outcomes Classification)
• Endurance
• Concentration
• Energy Conservation
• Nutritional Status: Energy

Client Outcomes
Verbalizes increased energy and improved well-being
Explains energy conservation plan to offset fatigue

NIC Interventions (Nursing Interventions Classification)
Energy Management

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Activity Intolerance Nursing Diagnosis NIC NOC

Nursing Diagnosis for Activity Intolerance

NANDA Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities

Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in elderly patients with a history of orthopedic, cardiopulmonary, diabetic, or pulmonary- related problems. The aging process itself causes reduction in muscle strength and function, which can impair the ability to maintain activity. Activity intolerance may also be related to factors such as obesity, malnourishment, side effects of medications (e.g., Beta-blockers), or emotional states such as depression or lack of confidence to exert one's self. Nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient to maintain a satisfactory lifestyle.

Nursing Diagnosis for Activity Intolerance

Activity intolerance (a condition where individuals have physiological energy insufficiency) related to immobilization, physical weakness, imbalance of oxygen supply with demand.

NOC: The patient showed tolerance to the activity


Therapeutic activity
Energy management
Cardiac care

Assessment in patients with CHF

Assessment in patients with CHF

Congestive heart failure (CHF) is generally classified as systolic or diastolic heart failure and becomes progressively more common with increasing age.

Systolic heart failure: The pumping action of the heart is reduced or weakened. A common clinical measurement is the ejection fraction (EF). The ejection fraction is a calculation of how much blood is ejected out of the left ventricle (stroke volume), divided by the maximum volume remaining in the left ventricle at the end of diastole or relaxation phase. A normal ejection fraction is greater than 50%. Systolic heart failure has a decreased ejection fraction of less than 50%.

Diastolic heart failure: The heart can contract normally but is stiff, or less compliant, when it is relaxing and filling with blood. This impedes blood filling into the heart and produces backup into the lungs and CHF symptoms. Diastolic heart failure is more common in patients older than 75 years, especially in women with high blood pressure. In diastolic heart failure, the ejection fraction is normal.

Heart failure affects 1% of people aged 50 years, about 5% of those aged 75 years or older, and 25% of those aged 85 years or older.
Heart failure is the most common reason for Medicare patients to be admitted to the hospital.
As the number of elderly people continues to rise, the number of people diagnosed with this condition will continue to increase.

Nursing Assessment for Congestive Heart Failure (CHF)

1. Activity / rest
Symptoms: Fatigue / tiredness throughout the day, insomnia, chest pain with activity, dyspnea at rest.
Signs: Restlessness, changes in mental status such as: lethargy, changes in vital signs of activity.

2. Circulation
Symptoms: history of hypertension, new myocardial infarction / acute, previous episodes of congestive heart failure, heart disease, cardiac surgery, endocarditis, anemia, septic shock, swelling in the legs, feet, abdomen.
Signs: blood pressure may be low (pump failure), pulse pressure; may be narrow, heart rhythm; dysrhythmias, cardiac frequency; Tachycardia,

3. Ego integrity
Symptoms: Anxiety, worry and fear. Stress related to illness / financial keperihatinan (work / cost of medical care)
Signs: A variety of behavioral manifestations, such as: anxiety, anger, fear and irritability.

4. Elimination
Symptoms: Decreased urination, dark colored urine, nighttime urination (nocturia), diarrhea / constipation.

5. Food / fluid
Symptoms: Loss of appetite, nausea / vomiting, significant weight gain, swelling of the lower extremities, clothes / shoes felt tight, high-salt diet / food that has been processed and the use of diuretics.
Signs: rapid weight gain and abdominal distension (ascites) and edema (general, dependent, stress and pitting).

6. Hygiene
Symptoms: Fatigue / weakness, fatigue during Self-care activities.
Signs: Appearances indicate neglect of personal care.

7. Neuro Sensory
Symptoms: weakness, dizziness, fainting episodes.
Symptoms: Lethargy, tangled thought, oriented, behavior changes and irritability.

8. Pain / Leisure
Symptoms: Chest pain, acute or chronic angina, right upper abdominal pain and muscle pain.
Signs: No quiet, restless, the focus narrows danperilaku protect themselves.

9. Breathing
Symptoms: Dyspnea on exertion, while sitting or sleeping with several pillows, cough with / without the formation of sputum, history of chronic disease, use of rescue breathing.
Signs: Respiratory: tachypnea, shallow breathing, use of accessory respiratory muscles. Cough: Dry / loud / non-productive or persistent cough may be with / without pemebentukan sputum. Sputum; Perhaps blood Flushed, pink / frothy (pulmonary edema). Breath sounds; may not be heard. Mental function; may decrease, anxiety, lethargy. Skin color; Pallor and cyanosis.

10. Security
Symptoms: Changes in mental function, kehilangankekuatan / muscle tone, skin abrasions.

11. Social interaction
Symptoms: Decreased participation in social activities are wont to do.

12. Learning / teaching
Symptoms: use / forgot to use cardiac drugs, such as: calcium channel blockers.
Signs: Evidence of the lack of success to improve.

Nursing Assessment Nursing Care Plan for Congestive Heart Failure (CHF)

Asthma Nursing Assessment

Asthma Nursing Assessment

Nursing Assessment for Asthma

Nursing Care Plan Nursing Assessment for Nursing Assessment for Asthma

Asthma is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm.

Symptoms include wheezing, coughing, chest tightness, and shortness of breath.

Asthma is clinically classified according to the frequency of symptoms, forced expiratory volume in 1 second (FEV1), and peak expiratory flow rate. Asthma may also be classified as atopic (extrinsic) or non-atopic (intrinsic).

Nursing Assessment for Asthma

Assessment of nursing in asthma patients, as follows:

Past medical history:

Assess personal or family history of previous lung disease.
Assess history of allergic reaction or sensitivity to the substances / environmental factors.
 Assess patient's employment history.


The inability to perform activities because of difficulty breathing.
The decline in the ability / improvement needs help doing daily activities.
Sleep in a sitting position higher.


Dipsnea at rest or in response to activity or exercise.
Breath worsened when the patient lay supine in bed.
Using the breathing aids drug, for example: raising the shoulders, widen the nose.
The existence of wheezing breath sounds.
The recurrent coughing.


There is an increasing blood pressure.
There is an increasing frequency of heart.
The color of skin or mucous membranes normal / gray / cyanosis.
Flushing or sweating.

Integrity ego:

Sensitive stimulation

Nutrient intake:

Inability to eat due to respiratory distress.
Weight loss due to anorexia.

Social relations:

The limited physical mobility.
Hard talk
The existence of dependence on others.


Decrease in libido

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Acute Pain - Chronic Pain Nursing Diagnosis

There are many things that can cause a person pain and different people have different tolerances for types of pain. Someone with a low tolerance may find many things very painful. Someone with a higher tolerance may be able to withstand these things.

There is the pain of a headache and there are many kinds of headaches that produce vaious degrees and quality of pain. There is organ pain when something is wrong inside and muscle pain when they are pushed beyond the norm either by exercise or emergency. Pain can be mild and a mere annoyance, or brutal and debilitating.

Acute pain is a pain that is recent, a sudden onset of pain, something that has been caused by an accident, a fall, an injury, or something of that nature. Acute pain is usually quite strong and ranges from a sharp nerve pain or shooting pain, to a very strong ache. It can be made worse by certain movements and may restrict you from doing things.

These are some of the obvious things that cause instant pain but sometimes acute pain seems to appear out of nowhere. For example, the sudden onset of lower back pain or neck spasms.

Generally the majority of acute pain conditions are caused by muscle spasms. Sure they may feel like they are incredibly painful because when muscles spasm they can also entrap and irritate nerves. Acute pain conditions are generally easy to treat and do not leave any residual problems. Massage therapy is the treatment used to alleviate muscular problems. Remedial massage acts by stimulating the muscles that are in spasm so they release. By stimulating the right muscles the body will then correct itself, releasing the muscle spasms and bringing your body back to normal.

Nursing Diagnosis for Pain – Acute

Acute Pain is Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months
Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in elderly patients, where cognitive impairment and sensory-perceptual deficits are more common.

Nursing Diagnosis for Pain – Chronic

Chronic Pain is Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of intensity from mild to severe; constant or recurring without an anticipated or predictable end and a duration of greater than 6 months.
Chronic pain may be classified as chronic malignant pain or chronic nonmalignant pain. In the former, the pain is associated with a specific cause such as cancer. With chronic nonmalignant pain the original tissue injury is not progressive or has been healed. Identifying an organic cause for this type of chronic pain is more difficult.

Nursing Diagnosisi Nursing Care Plan for Pain

Acute Pain - Pyelonephritis Nursing Care Plan

Acute pyelonephritis is a potentially organ- and/or life-threatening infection that characteristically causes scarring of the kidney. An episode of acute pyelonephritis may lead to significant renal damage; kidney failure; abscess formation (eg, nephric, perinephric); sepsis; or sepsis syndrome, septic shock, and multiorgan system failure.

Acute pyelonephritis is complex, and there is no consistent set of signs and symptoms that is both sensitive and specific for the diagnosis. Therefore, clinicians must maintain a high index of suspicion.

In contrast to the plethora of data available for the treatment of cystitis, less substantial data are available regarding the appropriate antibiotic choice or duration of therapy for acute pyelonephritis. An additional cause for concern is the growing resistance of uropathogens to standard agents. Nevertheless, useful recommendations can be made. (emedicine)

Nursing Care Plan for Pyelonephritis

Nursing Diagnosis for Pyelonephritis : Acute Pain related to inflammation and infection of the urethra, bladder and other urinary tract structures.

Evaluation criteria: no pain when urinating, no pain on percussion of the pelvis.

Nursing Interventions and Rational for Pyelonephritis


1. Monitor urine output to changes in color, odor and voiding pattern, input and output every 8 hours and monitor the results of repeated urinalysis.
Rational: To identify indications of progress or deviations from expected results.

2. Record the location, duration, intensity scale (1-10) the spread of pain.
Rational: To help evaluate the obstroksi and cause pain.

3. Provide comfort measures, such as back massage, environment, rest, sleep.
Rational: Increase relaxation, reduce muscle tension.

4. Help or encourage the use of focused relaxation breathing.
Rational: Helps to redirect attention and for muscle relaxation.

5. Give perianal care.
Rational: To prevent contamination of the urethra.

6. If mounted catheter, catheter care provided 2 times per day.
Rational: The catheter provides a way for bacteria to enter the bladder and up into the urinary tract.


1. Consul doctor if: previous urine yellow, ivory, yellow urine, dark orange, hazy or cloudy. Micturition pattern changes, frequent urination in small amounts, feeling the urge to urinate. Persistent pain or increasing pain.
Rational: These findings could signal further tissue damage and needs extensive examination.

2. Give analgesics as needed and evaluate its success.
Rational: Analgesic block the path of pain, thereby reducing pain.

3. Giving antibiotics. Create a variety of drink preparations, including fresh water. Provision of water to 2400 ml / day.
Rational: As a result of urine output makes it easy to urinate often and help flush urinary tract.

Source :

Uterine Fibroids - Nursing Interventions Acute Pain

A uterine fibroid is a leiomyoma (benign (non-cancerous) tumor from smooth muscle tissue) that originates from the smooth muscle layer (myometrium) of the uterus. Fibroids are often multiple and if the uterus contains too many leiomyomata to count, it is referred to as diffuse uterine leiomyomatosis. The malignant version of a fibroid is extremely uncommon and termed a leiomyosarcoma.

Other common names are uterine leiomyoma,myoma, fibromyoma, fibroleiomyoma.

Fibroids are the most common benign tumors in females and typically found during the middle and later reproductive years. While most fibroids are asymptomatic, they can grow and cause heavy and painful menstruation, painful sexual intercourse, and urinary frequency and urgency. Some fibroids may interfere with pregnancy although this appears to be very rare. (wikipedia)

Nursing Diagnosis Acute Pain related to inflammation due to the addition of mass in the uterus
  • Pain can be reduced or lost
Expected outcomes are:
  • Pain scale (1-10) = 1-3.
  • Respiration = 16-24 beats / minute.
  • Pulse  = 60 -100 beats / min.
  • Expression showed no signs of pain and seemed to relax.
1. Observation of a pain scale (1-10)
Rational: Observation of a pain scale is necessary for us to know the level of pain experienced by the client so that we can provide appropriate interventions for clients.
2. Find the area, location, and intensity of pain
Rational: To determine the location of pain, pain in the abdomen may indicate the likelihood of complications
3. Give a sitting position while hugging a pillow or a position in the sense of comfort by the client
Rational: It can provide comfort to the client.
4. Give instruction in relaxation techniques and deep breathing techniques
Rational: relaxation and deep breathing techniques to increase comfort and reduce the level of pain experienced by the client
5. Encourage clients to use a warm compress
Rational: Warm compresses can increase vasodilation of blood vessels at the site of pain so that pain can be reduced.
6. Collaboration in the delivery of analgesics and antiemetics, as indicated when necessary.
Rational: The provision of analgesia is necessary if the client is a pain scale of 7-10, this analgesic increase relaxation, decrease attention to pain, and control the adverse action.
7. Provide information about the use of analgesics that are prescribed or not prescribed
Rational: The specific instructions about the use of drugs, increasing awareness of safe use and side effects.
8. Evaluation of vital signs.
Rational: To determine the condition of clients after the intervention so that it can be done to determine further action.

Fatigue Nursing Interventions - Activity Intolerance

Activity intolerance related to fatigue

Definition: Insufficient physiological or psychological energy to continue or complete the requested activity or daily activities.

Defining characteristics:

Verbal report of fatigue or weakness.
Abnormal response of blood pressure or pulse of activity
ECG changes indicating ischemia or arrhythmia
Presence of dyspnea or discomfort on exertion.

Related factors:

Bed rest or immobilization Baring
Overall weakness
Imbalance between oxygen suplei needs
Lifestyle is maintained.


Energy conservation
Self Care: ADLs

Expected Result:
Participate in physical activity without an accompanying increase in blood pressure, pulse and respiration
Able to perform daily activities (ADLs) independently


Energy Management

Observation of client restrictions in activities
Encourage the child to express feelings of limitations
Assess the factors that cause fatigue
Monitor nutrition and adequate sources of energy
Monitor the patient's physical and emotional exhaustion are excessive
Monitor cardiovascular response to activity
Monitor sleep patterns and duration of sleep / rest patients

Activity Therapy

Collaborate with the Medical Rehabilitation Workers dalammerencanakan progran appropriate therapy.
Help clients to identify activities that can be done
Helps to choose activities consistent with the ability yangsesuai physical, psychological and social
Helps to identify and obtain resources needed for the desired activity
Mendpatkan auxiliary aids for activities such as wheelchairs, crick
Bantu untu identify a preferred activity
Help clients to exercise their free time schedule
Help the patient / family to identify deficiencies in the activity
Provide positive reinforcement for active move
Help the patient to develop self-motivation and reinforcement
Monitor physical response, EMOI, social and spiritual

Source :

Nursing Intervention for Diabetes Mellitus - Deficient Fluid volume

Nursing Intervention - Deficient Fluid volume for Diabetes Mellitus
1.Monitor orthostatic blood pressure changes.
Rational : Hypovolemia may be manifested by hypotension and tachycardia.
2.Assess peripheral pulses, capillary refill, skin turgor, and mucous membrane.
Rational : Indicators of level of dehydration, adequacy of circulating volume.
3.Monitor respiratory pattern like Kussmaul’s respirations and acetone breath.
Rational : Lungs remove carbonic acid through respirations, producing a compensatory respiratory alkalosis for ketoacidosis.
4. Monitor input and output. Note urine specific gravity.
Rational : Provides ongoing estimate of volume replacement needs, kidney function, and effectiveness of therapy.
5. Promote comfortable environment. Cover patient with light sheets.
Rational : Avoids overheating, which could promote further fluid loss.
6. Monitor temperature, skin color and moisture.
Rational : Fever, chills, and diaphoresis are common with infectious process; fever with flushed, dry skin may reflect dehydration.

6 Nursing Diagnosis - Care Plan for Dengue Fever

6 Nursing Diagnosis for Dengue Fever - Care Plan for Dengue Fever
Dengue haemorrhagic fever (DHF) is a disease caused by dengue virus of a virus belonging to arbovirus and entered into the patient's body through the bite of a mosquito "Aedes aegypty" (Christantie Efendy, 1995).

Dengue haemorrhagic fever (DHF) is a disease found in children and adults with primary symptoms of fever, muscle aches and joint pain accompanied by rash or without a rash. DHF is classified as a type of virus arbo virus and entered into the patient's body through the bite of a mosquito "Aedes aegypty" (female) (Seoparman, 1990).

Signs and Symptoms of Dengue Haemorrhagic Fever (DHF)

High fever for 5-7 days
Nausea, vomiting, no appetite, diarrhea, constipation.
Bleeding, especially bleeding under the skin, ptechie, echymosis, hematoma.
Epistaxis, hematemisis, melena, hematuri.
Sore muscles, joints, abdomen, and heartburn.
Swelling around the eyes.
Enlarged liver, spleen, and lymph nodes.
Signs of shock (cyanosis, clammy skin, decreased blood pressure, anxiety, capillary refill of more than two seconds, fast and weak pulse.)

Complication of Dengue Haemorrhagic Fever

The complication of dengue fever include:

Extensive bleeding.
Shock or shock.
Effuse pleural
Impairment of consciousness.

Classification of Dengue Haemorrhagic Fever

a. Degree I:
Fever accompanied by other clinical symptoms or spontaneous bleeding, positive tourniquet test, thrombocytopenia and Hemo concentration.

b. Degree II:
Clinical manifestations of degree I with the manifestation of spontaneous bleeding under the skin like petekhie, hematoma and bleeding from other places.

c. Degree III:
Clinical manifestations of degree II, coupled with the circulation system failure was found manifestation in the form of a rapid and weak pulse, hypotension with moist skin, cold and anxious patients.

d. Degree IV:
Clinical manifestations in patients with degree III coupled with a heavy shock was found manifestations with marked tension was measured and no palpable pulse.

Nursing Assessment Nursing Care Plan for Dengue Fever
  • Review the basic data, the need for bio-psycho-social-spiritual patients from various sources (patients, families, medical records and other health team members).
  • Identify potential sources and available to meet patient needs.
  • Review the history of nursing.
  • Assess the increase in body temperature, signs of bleeding, nausea, vomiting, no appetite, heartburn, sore muscles and joints, signs of shock (rapid and weak pulse, hypotension, cold and moist skin, especially on the extremities, cyanosis , restlessness, decreased consciousness).

6 Nursing Diagnosis for Dengue Fever - Care Plan for Dengue Fever
  1. Hypovolemic shock related to hemorrhage
  2. Imbalanced Nutrition: Less than body requirements related to nausea, vomiting, no appetite.
  3. Increased body temperature related to the process of dengue virus infection.
  4. Risk for bleeding related to thrombocytopenia.
  5. Deficient Fluid Volume related to increased capillary permeability, bleeding, vomiting and fever.
  6. Deficient Knowledge: about the disease process related to a lack of information.

Nursing Intervention and Rational for Asthma

Nursing Intervention and Rational for Asthma

a. Auscultation of breath sounds, record the presence of breath sounds, such as: wheezing, ronkhi.

Rationale: Some degree of bronchial spasms occur with airway obstruction. Faint breath sounds with expiratory wheezing (empysema), there is no breathing function (severe asthma).

b. Review / monitor the frequency of recorded respiratory inspiration and expiration ratio.

Rational: Tachypnea is usually present in some degree and can be found at the reception during strest / presence of acute infectious process. Respiratory frequency can be slowed down and elongated than the expiration of inspiration.

c. Assess the patient to a safe position, such as: elevation head is not sitting on the backrest.

Rational: Elevation head is not easier for respiratory function by using gravity.

d. Observation of the characteristic cough, persistent, hacking cough, wet. Auxiliary measures to improve the effectiveness of cough effort.

Rational: cough may persist but are not effective, especially on elderly clients, acute pain / weakness.

e. Give warm water.

Rational: the use of warm fluids can decrease bronchial spasms.

f. Collaboration drugs as indicated.

Spiriva bronchodilator 1 × 1 (inhalation).

Rational: Freeing spasm of the airway, wheezing and mucus production.

Nursing Care Plan for COPD


Anaemia is a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient to meet physiologic needs, which vary by age, sex, altitude, smoking, and pregnancy status.

The word anemia is taken from a Greek word meaning lack of blood as hemoglobin deficiency prevails in the blood. Hemoglobin present inside the red blood cells normally carries oxygen from lungs to the tissues and anemia causes hypoxia in organs.

Anemia can be mild, moderate, or severe, and this condition can be caused by many different factors. In this condition your body does not have an adequate number of red blood cells present, and if the condition is severe it can lead to serious complications or even be fatal in some cases.

Anemia signs and symptoms are:
1. Paleness
2. Headache
3. Irritability

Symptoms of more severe iron deficiency anaemia include:
1. Dyspnea
2. Rapid heartbeat
3. Brittle hair and nails

Nursing Diagnosis for Anemia

1. Ineffective Tissue Perfusion related to decrease in the cellular components required for the delivery of oxygen / nutrients to the cells.

2. Fatigue related to an imbalance between oxygen supply (delivery) and demand.

3. Risk for infection related to inadequate secondary defenses.

4. Anxiety related to change in health status.
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