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...
Hyperthermia and Acute Pain related to Dengue Fever Hemorrhagic (DHF)
.jpg)
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...
Signs and Symptoms of Psychiatric Disorders : Motor Behavior
Aspects of life including impulse, motivation, hope, encouragement, instinct and craving, as expressed by one's behavior or motor activity.
1. Echopraxia : Echopraxia is the involuntary repetition or imitation of another person's actions.
2. Catatonia : motor...
Mental State Examination : Affect and Mood
Affect and Mood
A complex feeling state with psychic, somatic and behavioral components related to
affective and mood.
Affect
Afek is a visible expression of emotion ; may not be consistent with the emotions that said the patient.
Appropriate Affect : emotional...
Nursing Care Plan for Acute Psychotic
Definition of Acute Psychotic
Psychotic is mental disorder characterized by the inability of the individual to assess what actually happened, for example, there are hallucinations, delusions or chaotic behavior / weird.
Clinical Manifestations
The behavior...
Nursing Care Plan for Crohn's Disease
Crohn's disease is an autoimmune disease characterized by inflammation of any part of the digestive tract starts from mouth to anus. Crohn's disease typically affects the ileum, the lower part of the small intestine. This condition occurs when the immune system...
Risk for Fluid Volume Excess and Activity Intolerance related to CHF
Nursing Diagnosis and Interventions for Congestive Heart Failure (CHF)
Nursing Diagnosis : Risk for Excess Fluid Volume ; extravascular related to decreased renal perfusion, increased sodium / water retention, increased hydrostatic pressure or a decrease in...
Disturbed Sleep Pattern and Risk for Injury related to BPH
Nursing Care Plan for Benign Prostatic Hyperplasia (BPH)
Nursing Diagnosis for Benign Prostatic Hyperplasia : Disturbed Sleep Pattern related to pain / surgery effects.
Goal : The need for sleep and rest are met.
Outcomes :
Clients are able to rest / sleep...
Nursing Diagnosis related to Fluid and Electrolyte
Fluid and Electrolyte
1. Deficient Fluid volume: less than body requirements related to excessive fluid output.
Intervention:
Observation of vital signs.
Observed signs of dehydration.
Measure the input and output of fluid (fluid balance).
Provide and encourage...
Nursing Diagnosis for Urinary / Bowel Elimination : Diarrhea, Constipation
Nanda Nursing Diagnosis for Urinary / Bowel Elimination : Diarrhea, Constipation
1. Alteration in Bowel Elimination : Diarrhea
Intervention:
Help need for defecation (if bed rest to prepare the necessary tools near the bed, attach the curtains and immediately...
Causes of Diarrhea : Virus, Bacteria, Protozoa and Helminth
Cause of Diarrhea: (Tantivanich, 2002; Sirivichayakul, 2002; Pitisuttithum, 2002)
1. Virus:
Is the highest cause of acute diarrhea in children (70-80%). Some types of viruses that cause acute diarrhea:
Rotavirus serotypes 1,2,8, and 9: in humans. Serotype...
Pathophysiology of Diarrhea - NCP
Pathophysiology of Diarrhea
The main function of the gastrointestinal tract is preparing food for living cells, the secretion of bile from the liver restriction and expenditure leftover food that is not digested. This function requires a variety of diverse physiological...
Nanda for Malaria
Nanda Nursing Diagnosis for Malaria
Malaria is a disease caused by a parasite called Plasmodium. The disease is transmitted by the bite of mosquitoes infected with the parasite. In the human body, the parasites Plasmodium proliferate in the liver and then red...
Nursing Care Plan for Chickenpox
Nursing Diagnosis for Chickenpox
Chickenpox is an infectious disease caused by the varicella-zoster virus infection. The disease is transmitted aerogen.
Incubation time
When exposed to the plague within 2 to 3 weeks. this can be characterized by the body...
Imbalanced Nutrition : less than body requirements related to nausea and vomiting
Nursing Diagnosis : Imbalanced Nutrition : more than body requirements related
Nausea
Nausea is the sensation (feeling) issued a food or want to vomit. Usually accompanied by autonomic signs such as hypersalivation, diaphoresis, tachycardia, pallor, and tachypnea,...
Acute Pain related to Ischemia
Ischemia is a symptom of reduced blood flow that can lead to functional changes in normal cells. Ischemia is a restriction in blood supply to the tissues, causing lack of oxygen and glucose needed for cell metabolism. Ischemic generally caused by problems with...
Bowel Incontinence - Home Care Interventions and Client / Family Teaching
Home Care Interventions
1. Assess and teach a bowel management program to support continence.
2. Provide clothing that is nonrestrictive, can be manipulated easily for toileting, and can be changed with ease.
R/ : Avoidance of complicated maneuvers increases...
Nursing Interventions for Bowel Incontinence
Bowel Incontinence Definition: Change in normal bowel habits characterized by involuntary passage of stool.
Nursing Interventions and Rationales
1. In a reasonably private setting, directly question any client at risk about the presence of fecal incontinence....
Spiritual Distress Nursing Interventions and Rationales
Definition: Disruption in the life principle that pervades a person's entire being and that integrates and transcends one's biological and psychosocial nature
Nursing Interventions and Rationales
1. Observe client for self-esteem, self-worth, feelings of futility,...
Nursing Interventions for Ineffective Airway Clearance
Nursing Diagnosis : Ineffective Airway Clearance
Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway
Nursing Interventions and Rationales :
1. Auscultate breath sounds q __ h(rs).
Breath sounds are...
Ineffective Airway Clearance - Home Care Interventions and Client / Family Teaching
Home Care Interventions
1. Assess home environment for factors that exacerbate airway clearance problems (e.g., presence of allergens, lack of adequate humidity in air, stressful family relationships).
2. Limit client exposure to persons with upper respiratory...
Nursing Interventions for Impaired Tissue Integrity
Nursing Interventions for Impaired Tissue Integrity
Nursing Diagnosis : Impaired Tissue Integrity
Definition: Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues.
Nursing Interventions :
1. Assess site of impaired tissue integrity and...
Acute Pain related to Urinary Retention
Nursing Care Plan for Urinary Retention
Urinary retention is the inability to empty the bladder completely during the process of urine. (Brunner and Suddarth. (2010). Text Book Of Medical Surgical Nursing 12th Edition. Thing in 1370).
Causes of urinary retention,...
Subscribe to:
Posts (Atom)