NANDA Impaired Swallowing Nursing Diagnosis

NANDA Definition: Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function

Defining Characteristics:

Oral phase impairment

Lack of tongue action to form bolus;
weak suck resulting in inefficient nippling;
incomplete lip closure;
food pushed out of mouth;
slow bolus formation;
food falls from mouth;
premature entry of bolus;
nasal reflux;
inability to clear oral cavity;
long meals with little consumption;
coughing, choking, or gagging before a swallow;
abnormality in oral phase of swallow study;
piecemeal deglutition;
lack of chewing;
pooling in lateral sulci;
sialorrhea or drooling

Pharyngeal phase impairment

Altered head positions;
inadequate laryngeal elevation;
food refusal;
unexplained fevers;
delayed swallow;
recurrent pulmonary infections;
gurgly voice quality;
nasal reflux;
choking, coughing, or gagging;
multiple swallows;
abnormality in pharyngeal phase by swallowing study

Esophageal phase impairment

Heartburn or epigastric pain;
acidic smelling breath;
unexplained irritability surrounding mealtime;
vomitous on pillow;
repetitive swallowing or ruminating;
regurgitation of gastric contents or set burps;
bruxism;
nighttime coughing or awakening;
observed evidence of difficulty in swallowing (e.g., stasis of food in oral cavity, coughing, or choking);
hyperextension of head, arching during or after meals;
abnormality in esophageal phase by swallow study;
odynophagia;
food refusal or volume limiting;
complaints of "something stuck";
hematemesis;
vomiting

Related Factors:

Congenital deficits;
upper airway anomalies;
failure to thrive;
protein energy malnutrition;
conditions with significant hypotonia;
respiratory disorders;
history of tube feeding;
behavioral feeding problems;
self-injurious behavior;
neuromuscular impairment (e.g., decreased or absent gag reflex, decreased strength or excursion of muscles involved in mastication, perceptual impairment, or facial paralysis);
mechanical obstruction (e.g., edema, tracheotomy tube, or tumor);
congenital heart disease;
cranial nerve involvement;
neurological problems;
upper airway anomalies;
laryngeal abnormalities;
achalasia;
gastroesophageal reflux disease;
acquired anatomic defects;
cerebral palsy;
internal or external traumas; tracheal, laryngeal, esophageal defects;
traumatic head injury;
developmental delay;
nasal or nasopharyngeal cavity defects;
oral cavity or oropharynx abnormalities;
premature infants

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

Swallowing Status
Swallowing Status: Esophageal Phase, Oral Phase, Pharyngeal Phase

Client Outcomes

Demonstrates effective swallowing without choking or coughing
Remains free from aspiration (e.g., lungs clear, temperature within normal range)

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

Aspiration Precautions
Swallowing Therapy

NANDA Risk for Falls Nursing Diagnosis

NANDA Definition: Increased susceptibility to falling that may cause physical harm

Related Factors: See Risk Factors

Risk Factors:

Adults

History of falls;
wheelchair use;
(65 years of age;
female (if elderly);
lives alone;
lower limb prosthesis;
use of assistive devices (e.g., walker, cane)

Physiological

Presence of acute illness;
postoperative conditions;
visual difficulties;
hearing difficulties;
arthritis;
orthostatic hypotension;
sleeplessness;
faintness when turning or extending neck;
anemias;
vascular disease;
neoplasms (i.e., fatigue/limited mobility, urgency and/or incontinence, diarrhea, decreased lower extremity strength, posprandial blood sugar changes, foot problems, impaired physical mobility, impaired balance, difficulty with gait, unilateral neglect, proprioceptive deficits, neuropathy)

Cognitive

Diminished mental status (e.g., confusion, delerium, dementia, impaired reality testing)

Medication

Antihypertensive agents;
ACE-inhibitors;
diuretics;
tricyclic antidepressants;
alcohol use;
antianxiety agents;
opiates;
hypnotics or tranquilizers

Environment

Restraints;
weather conditions (e.g., wet floors/ice);
throw/scatter rugs;
cluttered environment;
unfamiliar, dimly lit room;
no antislip material in bath and/or shower

Children (<2 years of age)

Male gender when <1 year of age;
lack of auto restraints; lack of gate on stairs;
lack of window guard; bed located near window;
unattended infant on bed/changing table/sofa;
lack of parental supervision

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

Safety Behavior: Fall Prevention
Knowledge: Child Safety

Client Outcomes

Remains free of falls
Changes environment to minimize the incidence of falls
Explains methods to prevent injury

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

Fall Prevention
Dementia Management
Safety

NANDA Urinary Retention Nursing Diagnosis

NANDA Definition: Incomplete emptying of the bladder

Defining Characteristics:

Measured urinary residual >150 to 200 ml or 25% of total bladder capacity;
obstructive lower urinary tract symptoms (poor force of stream, intermittency of stream, hesitancy of urination, postvoiding dribbling, feelings of incomplete bladder emptying);
irritative lower urinary tract symptoms (urgency to urinate, diurnal frequency of urination, nocturia);
overflow incontinence (dribbling urine loss caused when intravesical pressure overwhelms the sphincter mechanism)

Related Factors:

Bladder outlet obstruction: benign prostatic hyperplasia, prostate cancer, prostatitis, urethral stricture, bladder neck dyssynergia, bladder neck contracture, detrusor striated sphincter dyssynergia, obstructing cystocele or urethral distortion, urethral tumor, urethral polyp, posterior urethral valves, postoperative complication
Deficient detrusor contraction strength: sacral level spinal lesions, cauda equina syndrome, peripheral polyneuropathies, herpes zoster or simplex affecting sacral nerve roots, injury or extensive surgery causing denervation of pelvic plexus, medication side effect, complication of illicit drug use, impaction of stool

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

Urinary Elimination
Urinary Continence

Client Outcomes

Completely and regularly eliminates urine from the bladder; measured urinary residual volume is <150 to 200 ml or 25% of total bladder capacity (voided volume plus urinary residual volume)
Correction or relief from obstructive symptoms
Correction or alleviation of irritative symptoms
Client is free of upper urinary tract damage (renal function remains sufficient; absence of febrile urinary infections)

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

Urinary Catheterization

NANDA Wandering Nursing Diagnosis

NANDA Definition:
Meandering; aimless or repetitive locomotion that exposes the individual to harm; frequently incongruent with boundaries, limits, or obstacles

Defining Characteristics:

Frequent or continuous movement from place to place, often revisiting the same destinations;
persistent locomotion in search of "missing" or unattainable people or places;
haphazard locomotion;
locomotion in unauthorized or private spaces;
locomotion resulting in unintended leaving of a premise;
long periods of locomotion without an apparent destination;
fretful locomotion or pacing;
inability to locate significant landmarks in a familiar setting;
locomotion that cannot be easily dissuaded or redirected;
following behind or shadowing a caregiver's locomotion;
trespassing;
hyperactivity;
scanning, seeking, or searching behaviors;
periods of locomotion interspersed with periods of nonlocomotion (e.g., sitting, standing, sleeping);
getting lost

Related Factors:

Cognitive impairment, specifically memory and recall deficits, disorientation, poor visuoconstructive (or visuospatial) ability, and language (primarily expressive) defects;
cortical atrophy;
premorbid behavior (e.g., outgoing, sociable personality);
premorbid dementia;
separation from familiar people and places;
sedation;
emotional state, especially frustration, anxiety, boredom, or depression (agitation);
overstimulating/understimulating social or physical environment;
physiological state or need (e.g., hunger/thirst, pain, urination, constipation);
time of day

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

Safety Status: Falls Occurrence
Safety Behavior: Fall Prevention
Caregiver Home Care Readiness

Client Outcomes

Decreased incidence of falls (preferably free of falls)
Decreased incidence of elopements
Appropriate body weight maintained
Caregiver able to explain interventions can use to provide a safe environment for care receiver who displays wandering behavior

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

Dementia Management

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

What Definition of Diarrhea?
What Etiology of Diarrhea?
How Pathophysiology of Diarrhea?
What Are the Clinical Symptoms of Diarrhea?
What are the Complications of Diarrhea?
How Nursing Care Plan of Diarrhea?

Purpose

Knowing the Definition of Diarrhea.
Knowing the etiology of diarrhea.
Knowing the pathophysiology of diarrhea.
Know the Clinical Symptoms Diarrhea.
Knowing the Complications of diarrhea.
Knowing Nursing diarrhea.

Pathophysiology and Clinical Manifestation of Appendicitis

Pathophysiology of Appendicitis

Appendix inflamed and had edema as a result of congestion, possibly by fecalith (hard mass of feces), tumor or a foreign object. Inflammatory process, increased intraluminal pressure that will impede lymph flow resulting in edema, diapedesis bacteria and ulceration of the mucosa cause upper abdominal pain or severe diffuse progressively, within a few hours, localized to the right lower quadrant of the abdomen. Finally, the inflamed appendix contains pus.

When mucus secretion continues, the pressure will continue to rise causing widespread inflammation and the resulting local peritoneum, causing pain under the right side is called acute suppurative appendicitis. If then the flow will be disrupted arterial wall infarction followed by a gangrenous appendix called gangrenous appendicitis. If the walls are already fragile perforated appendicitis rupture will occur. If all of the above process is slow, omentum and adjacent bowel will move toward an appendix to arise a local mass dsebut appendicular infiltrates. Inflammation of the appendix may be an abscess or disappear.

In children, shorter omentum and appendix are longer, thinner wall of the appendix. The situation is coupled with immune system becomes less ease of perforation. In older people perforation easily happen because there is an interruption of blood vessels (Mansjoer, 2000).

Clinical Manifestations of Appendicitis

Lower quadrant pain
Mild fever
Nausea and vomiting
Loss of appetite
Local tenderness at the point mc Burney
Tenderness off (or intesifikasi result of pain when pressure is released)
Signs rovsing can arise by doing palpoasi lower left quadrant which paradoksimal cause pain felt in the lower right quadrant
Abdominal distension due to paralytic ileus
The patient's condition deteriorates

Nursing Diagnosis Decreased Cardiac Output for Hyperthyroidism

Decreased Cardiac Output related to uncontrolled hyperthyroidism, hypermetabolism, increased cardiac workload.

Patients objective / evaluation criteria;

Maintain adequate cardiac output according to the needs of the body

characterized by:

Stable vital signs,
normal peripheral pulses,
normal capillary refill,
good mental status,
no dysrhythmias

Nursing Intervention:

Independent

Monitor vital signs. Note the magnitude of the pressure pulse.
Check / meticulous possibility complained of chest pain patients.
Assess pulse / heart rate while the patient sleeps.
Auscultation of heart sounds, note the extra heart sounds, a gallop rhythm and a systolic murmur.
ECG monitor, record or note rate or in cardiac rhythm and the presence of dysrhythmias
Observation of signs and symptoms of severe thirst, dry mucous membranes, weak pulse, slow capillary refill, decreased urine output, and hypotension
Note adnya history of asthma / bronkokontriksi, pregnancy, sinus bradycardia / heart block progress to heart failure

Collaboration

Give fluids through IV as indicated
Give medications as indicated:
Monitor the results of lab tests: serum potassium, serum calcium, sputum culture
Perform regular ECG monitoring
Give oxygen as indicated
Prepare for surgery

Nursing Diagnosis Intervention

NANDA Impaired Swallowing Nursing Diagnosis

NANDA Risk for Falls Nursing Diagnosis

NANDA Urinary Retention Nursing Diagnosis

NANDA Wandering Nursing Diagnosis

Risk for Ineffective Airway Clearance - Goiter

Activity Intolerance - Pneumonia

Nursing Interventions Deficient Fluid and Electrolyte Volume - DHF

Nursing Management for Diarrhea

Pathophysiology and Clinical Manifestation of Appendicitis

Nursing Diagnosis Decreased Cardiac Output for Hyperthyroidism

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