Nursing Diagnosis and Nursing Intervention

Risk for Fluid Volume Deficit related to Vomiting

Risk for Fluid Volume Deficit related to Vomiting
Vomiting is defined as the discharge of the contents of the stomach up into the mouth by force. Vomiting can be an attempt removing toxins from the gastrointestinal tract such as diarrhea, lower gastrointestinal tract.

Vomiting can be caused by many things such as the following:

  • Congenital abnormalities
  • Infection of the digestive tract
  • Feeding the wrong way
  • Poisoned

Complications of vomiting are as follows :
  • Dehydration or alkalosis, due to loss of body fluid / electrolyte
  • Ketosis from not eating and drinking
  • Acidosis caused a sustained ketosis can be a shock even to seizures
  • Abdominal muscle tension, conjunctival hemorrhage, esophageal rupture, aspirations, caused by severe vomiting.

Persistent vomiting can lead to complications of dehydration, electrolyte disturbances, rips Mallory Wiess, aspiration of gastric fluid.

Nursing Diagnosis for Vomiting

Risk for Fluid Volume Deficit related to the feeling of nausea and vomiting

Goal: Maintain the balance of fluid volume.

Outcomes: The client does not nausea and vomiting.

1. Monitor vital signs.
Rationale: An early indicator of hypovolemia.

2. Monitor intake and output and urine concentration.
Rationale: Decreased urine output and concentration will improve the sensitivity / sediment as one impression of dehydration and require increased fluids.

3. Give fluid little by little but often.
Rationale: To minimize the loss of fluids.

4. The risk of infection associated with an inadequate immune, characterized by: body temperature above normal. Increased respiratory rate.

Source :

Nursing Interventions for Encephalitis : Ineffective Tissue Perfusion

Nursing Diagnosis: Ineffective Tissue Perfusion related to increased intracranial pressure.


  • Patient's neurological status returned to the state before the illness.
  • Increased patient awareness and sensory function.

  • Vital signs within normal limits.
  • Reduced headache pain.
  • Increased awareness.
  • No signs or loss of increased intracranial pressure.


1. Total bedrest patients, with supine sleeping position without a pillow.
Rationale: Changes in inta-cranial pressure will be able to mislead the risk for brain herniation.

2. Monitor signs of neurological status with GCS.
Rational: It can reduce further brain damage.

3. Monitor vital signs such as blood pressure, pulse, temperature, respiration and caution in systolic hypertension.
Rational: In normal circumstances autoregulation maintains a state of altered systemic blood pressure fluctuation. Autoregulation failure will cause a cerebral vascular damage can be manifested by an increase followed by a decrease in systolic and diastolic pressure. While the increase in temperature can describe the course of infection.

4. Monitor intake and output
Rational: Hyperthermia can lead to increased IWL and increase the risk of dehydration, especially in patients who are not aware, and nausea were lower intake by mouth

5. Help the patient to limit vomiting, coughing. Instruct the patient to exhale when moving or turning in bed.
Rationale: Activity vomiting or coughing can increase intracranial and intra-abdominal pressure. Exhale when moving or changing position can protect themselves from the effects of Valsalva.

6. Give fluids per infusion with strict attention.
Rationale: Minimize the burden of vascular and fluctuations in intracranial pressure, fluid and fluid vetriksi can reduce cerebral edema.

7. Monitor blood gas analysis of oxygen delivery when needed.
Rational: The possibility of acidosis is accompanied by the release of oxygen at the cellular level may lead to the occurrence of cerebral ischemic.

8. Provide appropriate therapy such as physician advice: Steroids, Aminofel, Antibiotics
Rational Therapy given to decrease capillary permeability.
Lowering of cerebral edema
Lowered metabolic cells / consumption and seizures.

Source :

Nursing Diagnosis : Imbalanced Nutrition related to Hyperemesis Gravidarum

Nursing Care Plan for Hyperemesis Gravidarum - Nursing Diagnosis : Imbalanced Nutrition: less than body requirements

Hyperemesis Gravidarum

Nausea and vomiting (emesis gravidarum) is a natural phenomenon and is often caught in the first trimester of pregnancy. Nausea usually occurs in the morning, but can arise at any time and at night. These symptoms occur approximately 6 weeks after the first day of the last menstrual period and lasts for approximately 10 weeks. Nausea and vomiting occur in 60-80% primi gravida and 40-60% multi gravida. One in every thousand pregnancies, these symptoms become more severe.

Nausea is largely attributable because of increased levels of estrogen and HCG (Human Chorionic Gonadrotropin) in serum. Physiological effect of the hormone increase is not clear, probably because the central nervous system or the gastric emptying of the stomach is reduced. In general, women can adapt to this situation, though symptoms of severe nausea and vomiting that can last up to 4 months. Daily work was interrupted, and the general condition became worse. This condition is called hyperemesis gravidarum. Complaints of symptoms and physiological changes determine the severity of the disease. (Prawirohardjo, 2002)

Hyperemesis gravidarum is defined as excessive vomiting or uncontrolled during pregnancy, which causes dehydration, electrolyte imbalance, or nutritional deficiencies, and weight loss. The incidence of this condition is approximately 3.5 per 1000 births. Although most cases of missing and disappeared over time, one out of every 1,000 pregnant women will undergo hospitalization. Hyperemesis gravidarum usually disappear on their own (self-limiting), but healing is slow and frequent relapses are common. The condition often occurs among primigravida women and tends to recur in subsequent pregnancies. (Lowdermilk, 2004).

Nursing Diagnosis for Hyperemesis Gravidarum : Imbalanced Nutrition: less than body requirements related to excessive frequency of nausea and vomiting.

Read More :

Nursing Interventions for Apendicitis

Appendicitis is an inflammation of the appendix, a sac that no such additional functions located in the inferior and cecum. The most common cause of appendicitis is obstruction of the lumen by fecal eventually damage erode supply and mucosal blood flow, causing inflammation (Wilson & gold man, 1989).

Appendicitis is caused by blockage of the lumen of the appendix by fecalit, foreign objects, because there are previous inflammation. The obstruction causes mucus-producing mucosa, having the dam. However, the elasticity of the walls of the appendix has limitations that cause intra-luminal pressure. The increased pressure will inhibit the flow of lymph which will cause edema and ulceration of the mucosa, this occurs when the local acute appendicitis is characterized by the presence of pain.

Appendix unknown function, is part of the cecum. Inflammation of the appendix may occur by the presence of mucosal ulceration or obstruction of the lumen wall (usually by fecalit / hardened feces). Penymbatan spending mucus resulting in adhesions, and inhibition of bloodstream infections. Of hypoxia, resulting gangreng or rupture within 24-36 hours. If this process continues around the walls of organs appendix adhesions will occur that will cause an abscess (chronic). If the infection process is very fast will cause peritonitis.

Perforation signs include increased pain, muscle spasm right lower quadrant abdominal wall with a sign that generalized peritonitis or abscess localized, ileus, fever, malaise, leukocytosis increasingly clear. When perforation with generalized peritonitis or abscess formation has occurred since the increment clients outsmart come, the diagnosis can be established with certainty.

If peritonitis occurs, specific therapy is surgery performed to close the perforation origin. While the other acts as a support: Fowler position bed rest in the medium, the installation of NGT, fasting, correction fluids and electrolytes, giving tranquilizers, antibiotics with broad-spectrum antibiotics are continued in accordance with the culture, transfusion to treat anemia, and treatment of septic shock in the intensive , if any.

Preoperative Nursing Interventions for Apendicitis
Copyright © Nursing Diagnosis Intervention. All rights reserved. Template by CB | Published By Kaizen Template | GWFL | KThemes