Nursing Diagnosis and Nursing Intervention


Risk for Ineffective Airway Clearance - Goiter

Risk for ineffective airway clearance related to obstruction of the trachea, swelling, bleeding and laryngeal spasms

characterized by:
  • Subjective data: pain swallowing, painful wound.
  • Objective data: breathing fast and deep, there is a discharge / thick mucus in the throat, dyspnoe, stridor, cyanosis.
Goal to be achieved, according to the criteria of the results:
Maintaining a patent airway to prevent aspiration.

Plan of action / intervention:

1.) Monitor respiratory frequency, depth and breath work.
Rational:
Breathing normally sometimes quickly, but development of respiratory distress is indicative of tracheal compression due to edema or hemorrhage.

2.) Auscultation of breath sounds, record a voice Rhonchi.
Rational:
Rhonchi is indicative of obstruction laryngeal spasm that require rapid evaluation and intervention.

3.) Assess presence of dyspnea, stridor, and cyanosis. Note the sound quality.
Rational:
Indicators of tracheal obstruction / laryngeal spasm requiring immediate evaluation and intervention.

4.) Alert patients to avoid binding on the neck, supporting the head with a pillow.
Rational:
Decrease the likelihood of stress on the injured area for surgery.

5.) Assist in the change of position, deep breathing exercises and cough effectively or as indicated.
Rational:
Maintaining the cleanliness of the airway and evaluation. But the cough is not recommended and can cause severe pain, but it was necessary to clear the airway.

6.) Perform suctioning the mouth and trachea as indicated, note the color and characteristics of the sputum.
Rational:
Edema or pain can impair a patient's ability to issue and clear the airway itself.

7.) Perform reassessment of the regular cast, especially in the posterior.
Rational:
If there is bleeding, bandage the anterior part may seem dry because of blood deposited / collected in region-dependent.

8.) Investigate difficulty swallowing, accumulation of oral secretions.
Rational:
Is indicative of edema / hemorrhage frozen tissue surrounding the area of ​​operation.

9.) Maintain equipment near the patient's tracheostomy.
Rational:
Affected airway can create life-threatening emergency that requires action.

10.) Bone Surgery
Rational:
It might be very necessary for splicing / repair blood vessel bleeding continuously.

Activity Intolerance - Pneumonia

Activity Intolerance Nursing Diagnosis and Interventions - Pneumonia

Activity Intolerance related to imbalance between oxygen supply and demand, general weakness.

Goal: Report / show increased tolerance to activity.

Expected outcomes: No dipsnea, excessive weakness and vital signs within normal ranges.

Interventions:
a). Evaluate the client's response to the activity.
b). Provide quiet environment and limit visitors during the acute phase as indicated.
c). Explain the importance of rest in the treatment plan and the need to balance activity and rest
d). Help clients choose a comfortable position weeks to rest / sleep
e). Help the client care activities as needed.

Nursing Interventions Deficient Fluid and Electrolyte Volume - DHF

Nursing Diagnosis Care Plan for DHF: Deficient Fluid and Electrolyte Volume related to increased capillary permebilitas, bleeding

Goal: After nursing actions, balanced electrolyte fluid volume

Expected outcomes:
  • Showed improved fluid balance, evidenced by adequate urine output with normal specific gravity.
  • Vital signs are stable.
  • Moist mucous membranes, good turgor and capillary refill quickly.
Nursing Intervention for DHF: Deficient Fluid and Electrolyte Volume:

1. Monitor vital signs: compare with previous results.
Rationale: Changes in blood pressure and pulse can be used for a rough estimate blood loss.

2. Note the individual patient's physiological response to hemorrhage such mental changes, weakness, restlessness, anxiety, pallor, increased temperature and sweating.
Rational: symptomatology can be useful in measuring the weight / length episodes of bleeding, worsening of symptoms can indicate bleeding or inadequate understanding of the fluid.

3. Measure CVP when there
Rationale: Shows the circulating volume and cardiac responses to hemorrhage and fluid replacement, for example, CVP between 5 and 20 cm H2O showed adequate volume.

4. Supervise the input and output, and relationship to changes in weight, measuring blood loss / fluid through vomiting and defecation.

5. Maintain accurate records subtotal fluid / blood during replacement therapy.
Rationale: Potential excess fluid transfusion up, especially when the extra volume of blood transfusions given before.

6. Maintain bed rest: prevents vomiting and defecation current voltage.
Rationale: Activities / vomiting increased intra-abdominal pressure and can trigger bleeding continued.

7. Observations of secondary hemorrhage, such as nose / gum bleeding continuously from the area of ​​injection.
Rationale: Loss / inadequate replacement clotting factors can trigger the occurrence of KID.

8. Give fluid / blood as indicated.
Rationale: Fluid replacement depends on the degree of hypovolemia and length of bleeding.

9. Full of fresh blood / red cell packaging
Rational: full of fresh blood indicated for acute bleeding (with shock), due to deficiency of blood clotting factors deposits.

10. Fresh frozen plasma (FFP) and / or platelets
Rational: coagulation factors / components decimation by 2 mechanisms: loss of bleeding and clotting.

11. Record intake and output
Rationale: Measuring inputs and expenditures can see fluid volume deficit occurs.

12. Check the hemoglobin, hematocrit, platelets every 4-6 hours
Rational: Seeing bleeding conditions change.

Nursing Management for Diarrhea

Nursing Management for Diarrhea

Diarrhea is often caused an extraordinary event, such as the number of cholera patients a lot in a short time. But with the management of diarrhea fast, precise and quality, mortality can be reduced to a minimum.

Problem Formulation
  1. What Definition of Diarrhea?
  2. What Etiology of Diarrhea?
  3. How Pathophysiology of Diarrhea?
  4. What Are the Clinical Symptoms of Diarrhea?
  5. What are the Complications of Diarrhea?
  6. How Nursing Care Plan of Diarrhea?
Purpose
  1. Knowing the Definition of Diarrhea.
  2. Knowing the etiology of diarrhea.
  3. Knowing the pathophysiology of diarrhea.
  4. Know the Clinical Symptoms Diarrhea.
  5. Knowing the Complications of diarrhea.
  6. Knowing Nursing diarrhea.

Nursing Diagnosis

Nursing Diagnosis

NANDA NURSING DIAGNOSIS

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