List of Nanda Nursing Diagnosis

Nursing Care Plan

Risk for Impaired Gas Exchange - Nursing Diagnosis for Rheumatic Heart Disease


Rheumatic heart disease is a condition in which permanent damage to heart valves is caused by rheumatic fever. The heart valve is damaged by a disease process that generally begins with a strep throat caused by bacteria called Streptococcus, and may eventually cause rheumatic fever.

Symptoms may include:
  • Joint inflammation - including swelling, tenderness, and redness over multiple joints. The joints affected are usually the larger joints in the knees or ankles. The inflammation "moves" from one joint to another over several days.
  • Small nodules or hard, round bumps under the skin.
  • A change in your child's neuromuscular movements (this is usually noted by a change in your child's handwriting and may also include jerky movements).
  • Rash (a pink rash with odd edges that is usually seen on the trunk of the body or arms and legs).
  • Fever.
  • Weight loss.
  • Fatigue.
  • Stomach pains.

Nursing Diagnosis and Interventions for Rheumatic Heart Disease

Risk for Impaired Gas Exchange related to the accumulation of blood in the lungs due to increased atrial filling

Goal: risk for impaired gas does not occur

Expected outcomes:
  • Demonstrating adequate ventilation and oxygenation of the tissue, indicated by blood gas analysis / oximetry in the normal range and free of symptoms of respiratory distress.
  • Participate in a treatment program within the ability / situation.

Intervention and rationale:

1. Auscultation of breath sounds, note: crackles, mengii.
2. Instruct the patient to cough effectively, breathing deeply.
3. Maintain a semi-Fowler position, chock the hand with a pillow if possible
4. Collaboration in the provision of supplemental oxygen as indicated.
5. Collaboration for the examination of blood gas analysis.
6. Collaboration for the administration of diuretics.
7. Collaboration for the administration of bronchodilator drugs.

Rational:

1. Stating pulmonary congestion / collecting secretions indicate the need for further intervention.
2. Clearing the airway and facilitate the flow of oxygen.
3. Lowering the oxygen consumption / needs and enhance maximum lung expansion.
4. Increasing alveolar oxygen concentration, which can improve / lower tissue hypoxemia.
5. Can be severe hypoxemia during pulmonary edema.
6. Lowers alveolar congestion, improve gas exchange.
7. Increasing the flow of oxygen to dilate small airways and emit a mild diuretic effect to reduce pulmonary congestion.

Acute Pain - NCP Atherosclerosis

Nursing Care Plan for Atherosclerosis

Atherosclerosis is a slow disease in which your arteries become clogged and hardened. Fat, cholesterol, calcium, and other substances form plaque, which builds up in arteries.

Signs and Symptoms:

Many times, people with atherosclerosis don't have any symptoms until an artery is 40% clogged with plaque. Symptoms vary depending upon which arteries are affected.


Nursing Diagnosis for Atherosclerosis : Acute Pain related to an impaired ability of blood vessels to supply oxygen to the tissues.

Goal: reduced pain

Expected outcomes: patient states chest pain disappear, or can be controlled, the patient did not seem grimace, demonstrate relaxation techniques.

Intervention and Rational:

1. Monitor characteristics of pain through verbal and hemodynamic responses (crying, pain, grimacing, can not rest, respiratory rhythm, blood pressure and changes in heat rate).
Rationale: Each patient has a different response to pain, verbal and hemodynamic changes in response to detecting a change in comfort.

2. Assess the description of pain experienced by patients include: place, intensity, duration, quality, and distribution.
Rationale: Pain is a subjective feeling that is experienced and is described by the patient and should be compared with other symptoms to obtain accurate data.

3. Provide a comfortable environment, reduce the activity, limit visitors.
Rationale: Helps reduce external stimuli that can add to the tranquility so patients can rest in peace and the power of the heart is not too hard.

4. Teach relaxation techniques with a sigh
Rationale: Helps relieve pain experienced by patients psychologically which can distract the patient that is not focused on the pain experienced.

5. Observation of vital signs before and after drug administration.
Rationale: Knowing the patient's progress, after being given the drug.

Ineffective Tissue Perfusion: Peripheral related to impaired circulation

Ineffective Tissue Perfusion: Peripheral related to impaired circulation

Nursing Diagnosis for Atherosclerosis : Ineffective Tissue Perfusion: Peripheral related to impaired circulation

Goal: clients show improvement perfusion with

Expected outcomes: a peripheral pulse / same, normal skin color and temperature, an increase in behaviors that increase tissue perfusion.

Intervention and Rational:

1. Observation of skin color on the sick.
Rationale: The skin color typically occurs when cyanosis, cold skin. During the color change, the sick to be cool then throbbing and tingling sensations.

2. Note the decrease in pulse; traffic change skin (no color, glossy / tense).
Rationale: This change indicates progress or chronic process.

3. View and examine the skin for ulceration, lesions, gangrene area.
Rationale: Lesions may occur from the size of a pin needle to involve all the fingertips and can lead to infection or damage / loss of tissue seriously.

4. Advise for the proper nutrients and vitamins.
Rationale: The balance of a good diet includes protein and adequate hydration, necessary for healing of the sick.

5. Monitor signs of tissue perfusion adequacy.
Rationale: To identify the early signs of impaired perfusion.

6. Encourage patients perform the exercises or exercises gradually extremities.
Rationale: For circulation.

Risk for Impaired Skin Integrity NCP Heart Failure

Nursing Diagnosis Risk for impaired skin integrity related to pitting edema.

Expected outcomes:
clients can demonstrate behaviors / techniques to prevent skin damage.
Maintaining the integrity of the skin.

Interventions:

1. Change position often in bed / chair, assistive range of motion exercises passive / active.
2. Provide frequent skin care, minimizing the moisture / excretion.
3. Check narrow shoes / sandals and change as needed.
4. Monitor skin, bone protrusion noted, edema, impaired circulation area / pigmentation or overweight / underweight.
5. Massage the area red or white.

Rational:

1. Improving circulation / lowering an area that interfere with blood flow.
2. Too dry or moist skin damage and accelerating damage.
3. Dependent edema can cause the shoe is too narrow, increasing the risk of stress and damage to the skin on the feet.
4. Lowering the pressure on the skin, improve circulation.
5. Skin disorders are at risk due to the peripheral circulation, physical immobilization and impaired nutritional status. Increase blood flow, minimizing tissue hypoxia.

Ineffective Tissue Perfusion related to Glomerulonephritis

Glomerulonephritis- Ineffective Tissue Perfusion
Nursing Care Plan for Glomerulonephritis

Nursing Diagnosis: Ineffective Tissue Perfusion related to water retention and hypernatremia

Expected outcomes:
Clients will show marked normal cerebral tissue perfusion with blood pressure within normal limits, decrease water retention, no signs of hypernatremia.

Nursing Interventions Ineffective Tissue Perfusion related to Glomerulonephritis:

1. Monitor and record blood pressure every 1-2 hours a day during the acute phase.
Rational: to detect early symptoms of blood pressure changes and determine interventions.

2. Keep the airway, suction prepare.
Rational: the attack can occur due to lack of oxygen to the brain perfusion.

3. Arrange provision of anti hypertension, monitor client reactions.
Rationale: Anti-Hypertension can be given, because uncontrolled hypertension can lead to kidney damage.

4. Monitor the status of the volume of fluid every 1-2 hours, monitor urine output (N: 1-2 ml / kg / hour).
Rationale: Monitor is necessary for the expansion of the volume of fluid can cause increased blood pressure.

5. Assess neurological status (level of consciousness, reflexes, pupil response) every 8 hours.
Rational: To detect early changes that occur in neurological status, facilitate interventions.

6. Set diuretic administration.
Rational: A diuretic can increase the excretion of fluids.

Knowledge Deficit NCP Rheumatoid Arthritis

Nursing Care Plan for Rheumatoid Arthritis

Nursing Diagnosis for Rheumatoid Arthritis

Knowledge Deficit (learning need): the disease, prognosis, and treatment

Related to:
  • Lack of exposure / recall.
  • Misinterpretation of information.

Can be evidenced by:
  • Questions / requests for information, statements misconceptions.
  • Not exactly follow the instructions / occurrence of complications that can be prevented.

The expected outcomes / evaluation criteria, patients will:
  • Demonstrate an understanding of the condition / prognosis, treatment.
  • Develop a plan for self-care, including lifestyle modification and consistent with mobility or activity restrictions.

Knowledge Deficit Nursing Interventions NCP Rheumatoid Arthritis:

1. Review the process of disease, prognosis, and future expectations.
Rationale: Provides knowledge that patients can make informed choices.

2. Discuss the habits of the patient in pain management through diet, medication, and a balanced diet, exercise and rest.
Rationale: The purpose of control is to suppress inflammatory disease self / other tissue to maintain joint function and prevent deformities.

3. Assist in planning a realistic schedule of activities integrated, rest, personal care, administration of medication, physical therapy, and stress management.
Rationale: Provide structure and reduce anxiety at the time of handling complex chronic disease processes.

4. Emphasize the importance of continuing medication management.
Rationale: The advantage of drug therapy depends on the accuracy of dose.

5. Encourage digest medicine with food, milk, or an antacid at bedtime.
Rationale: Limiting gastric irrigation, reduction of pain in the HS will improve sleep and reduce morning stiffness.

6. Emphasize the importance of reading product labels and reduce the use of drugs are sold freely without doctor's approval.
Rationale: Many products contain hidden salicylates may increase the risk of a decent pint of drugs / dangerous side effects.

7. Review the importance of a balanced diet with foods rich in vitamins, protein and iron.
Rationale: Increased sense of well-general and tissue repair.

8. Encourage obese patients to lose weight and weight loss provide information as needed.
Rationale: Weight loss will reduce the pressure on the joints, especially the hips, knees, ankles, feet.

9. Provide information about the tools
Rationale: Reduce compulsion to use the joints and allows individuals to participate more comfortably in activities that are needed.

10. Discuss energy saving techniques, eg sitting than standing for preparing food and bathing.
Rationale: Prevent fatigue, providing ease of self-care, and independence.

11. Push maintain correct posture both at rest and during activity, such as keeping the joints remain stretched, no flexion, using a splint for the specified period, placing hands near the center of the body during use, and shifting rather than lifting if possible.
Rationale: good body mechanics should be part of the patient's lifestyle to reduce joint stress and pain

12. Review the need for frequent inspection of the skin and other skin care under the bandage, plaster, backer tool. Indicate giving proper bearings.
Rationale: Reduce the risk of irritation / skin breakdown.

13. Discuss the importance of continued drug / laboratory test.
Rational: drug therapy requires assessment / continuous improvement to ensure optimal effect.

14. Give sexual counseling as needed
Rationale: Information on different positions and techniques or other options for sexual fulfillment may improve personal relationships and a sense of self esteem / confidence

15. Identify community resources, eg: arthritis foundation (if any).
Rationale: Help / support from others to increase the maximum recovery.

Acute Pain - Hydatidiform Mole

Acute Pain Nursing Care Plan Hydatidiform Mole

Nursing Diagnosis for Hydatidiform Mole: Acute Pain

Objective: Clients will show pain reduced / lost

Expected outcomes:
  • Clients say the pain is reduced / lost
  • Calm facial expression
  • Vital signs are within normal limits

Nursing Intervention:

1. Assess the level of pain, location and scale of pain, perceived client.
Rationale: Knowing the level of pain that is felt so it can help determine appropriate interventions.

2. Observation of vital signs every 8 hours
Rationale: Changes in vital signs, especially temperature and pulse rate is one indication of increased pain experienced by the client.

3. Instruct client to perform relaxation techniques
Rationale: Relaxation techniques can make the client feel comfortable and a little distraction to divert the attention of clients to pain so that they can help children reduce the pain.

4. Give a comfortable position
Rationale: a comfortable position to avoid an emphasis on the area of ​​injury / pain.

5. Collaboration of analgesic
Rational: analgesic drugs block the pain receptors so that the pain can not be perceived.

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