Ineffective Airway Clearance - Nursing Care Plan for Hypoglycemia

Nursing Diagnosis and Interventions for Hypoglycemia

Ineffective Airway Clearance related to airway obstruction / increase in tracheobronchial secretions.

Defining characteristics :
  • Dyspnoea.
  • Orthopnea.
  • Cyanosis.
  • Crackles / crepitations.
  • Difficulty speaking.
  • Cough is ineffective or non-existent.
  • Eyes widened.
  • Increased sputum production.
  • Restless.
  • Changes in the frequency and rhythm of breathing.


Goal : Effective airway

Outcomes :
  • Respiration Status : Patency Road Breath :
  • Breath sounds clean.
  • No cyanosis.
  • No shortness of breath / dyspnea.
  • The rhythm of breathing and respiratory rate within normal range.
  • Do not feel suffocated.
  • No cyanosis.
  • No agitated.
  • Sputum is reduced.

Respiratory Status : Ventilation
  • Demonstrate effective cough.
  • Breath sounds were clean.
  • No cyanosis.
  • No dyspnoea (able to breathe more easily).
  • No pursed lips.

NIC / Intervention

Airway Suctioning :
  1. Ensure suctioning needs .
  2. Auscultation of breath sounds before and after suctioning.
  3. Inform the client and family about suctioning.
  4. Asking clients a deep breath before suctioning.
  5. Give oxygen by nasal cannula to facilitate nasotracheal suctioning.
  6. Use sterile equipment every action.
  7. Encourage clients a deep breath and rest after the catheter is removed from the nasotracheal.
  8. Monitor the status of the client oxygen.
  9. Stop suction when the client showed bradycardia.
Airway Management :
  1. Open the airway, use techniques chin lift or jaw thrust if necessary.
  2. Position the client to maximize ventilation.
  3. Identification of the need for client installation artificial airway.
  4. Attach the OPA if necessary.
  5. Perform chest physiotherapy if necessary.
  6. Remove secretions by coughing or suctioning.
  7. Auscultation of breath sounds, note the presence of additional noise.
  8. Collaboration of bronchodilators if necessary.
  9. Monitor respiration and oxygen status.
Cough Enhancement :
  1. Monitor lung function, vital capacity, and maximal inspiration.
  2. Encourage the patient to do deep breathing, coughing arrested last 2 seconds 2-3 times.
  3. Encourage clients a deep breath several times, released slowly and cough at the end of expiration.

Oxygen Therapy :
  1. Clean the secret in the mouth, nose and trachea / throat.
  2. Maintain airway patency.
  3. Explain to the client / family about the importance of giving oxygen.
  4. Give oxygen as needed.
  5. Select the appropriate equipment needs : nasal cannula 1-3 l / min, head box 5-10 l / min , etc..
  6. Monitor O2 flow.
  7. Monitor O2 hose.
  8. Periodically check the O2 hose, humidifier, O2 flow.
  9. Observation O2 deficiency signs : restlessness, cyanosis, etc..
  10. Monitor signs of poisoning O2.
  11. Maintain O2 during transport.
  12. Instruct client / family to observe the O2 supply, water humidifier, if the report finished guard.
Adjusting the position
  • Adjust the position of the patient semi-Fowler , head extension .
  • Tilt the head when vomiting .
Cchest Physiotherapy
  1. Determine the presence of contraindications chest physiotherapy .
  2. Determine lung segments that require chest physiotherapy .
  3. Position the client with lung segments which require drainage placed higher .
  4. Use a pillow to help position the head .
  5. Combine techniques posturnal percussion and drainage .
  6. Combine fibrasi and posturnal drainage techniques .
  7. Manage inhalation therapy .
  8. Manage administration of a bronchodilator , mucolytics .
  9. Monitor and type of sputum .
  10. Encourage coughing before and after posturnal drainage .

Acute Pain - Nursing Care Plan for Diabetes Mellitus

Nursing Care Plan for Diabetes Mellitus

Nursing Diagnosis : Acute Pain related to injury of biological agents (decreased peripheral tissue perfusion)

  • level of pain
  • pain controlled
  • level of comfort
Clients can :
1 Controlling pain, with indicators :
  • Know the factors that cause.
  • Know the onset of pain.
  • Non-pharmacological aid measures.
  • Analgesic use.
  • Reported pain symptoms to the health care team.
  • Pain controlled.
2. Shows the level of pain, the indicator :
  • Reported pain.
  • Frequency of pain.
  • The duration of pain episodes.
  • The expression of pain ; face.
  • Changes in respiration rate.
  • Changes in blood pressure.
  • Loss of appetite.

Interventions (NIC)

Pain Management :
  • Perform a comprehensive pain assessment includes the location, characteristics, duration, frequency , quality and ontro precipitation.
  • Observation of nonverbal reactions of discomfort.
  • Use therapeutic communication techniques to determine the client's experience of pain before.
  • Environmental controls that affect pain such as room temperature, lighting, noise.
  • Reduce pain ontro precipitation.
  • Choose and pain management (pharmacological / non- pharmacological).
  • Teach non- pharmacological techniques ( relaxation , distraction, etc.) to mengetasi pain.
  • Give analgesics to reduce pain.
  • Evaluation of pain -reducing action / ontrol pain.
  • Collaboration with a physician if there are complaints about the administration of analgesics to no avail.
  • Monitor client acceptance of pain management.

Analgesics Administration :
  • Check program providing analogetik ; the type, dosage, and frequency.
  • Check history of allergy.
  • Determine the analgesic of choice, the optimal route of administration and dose.
  • Monitor vital signs before and after the administration of analgesics.
  • Give analgesic especially timely when the pain arises.
  • Evaluation of the effectiveness of analgesics, signs and symptoms of side effects.

Imbalanced Nutrition Less Than Body Requirements - NCP Acute Lymphoblastic Leukemia

Nursing Care Plan for Acute Lymphoblastic Leukemia

Acute lymphoblastic leukemia (ALL) also called acute lymphocytic leukemia or acute lymphoid leukemia is a malignant (clonal) disease of the bone marrow in which early lymphoid precursors proliferate and replace the normal hematopoietic cells of the marrow.

  • Most of the time, no clear cause can be found. But the following may play a role in the development of leukemia in general:
  • Certain chromosome problems
  • Past treatment with chemotherapy drugs
  • Exposure to radiation, including x-rays before birth
  • Toxins, such as benzene
  • Receiving a bone marrow transplant

Signs and symptoms
  • Fever
  • Bone and joint pain
  • Feeling weak or tired
  • Easy bruising and bleeding (such as bleeding gums, skin bleeding, nosebleeds, abnormal periods)
  • Pain or feeling of fullness below the ribs
  • Loss of appetite and weight loss
  • Paleness
  • Swollen glands (lymphadenopathy) in the neck, under arms, and groin
  • Night sweats
  • Pinpoint red spots on the skin (petechiae)

Nursing Diagnosis for Acute Lymphoblastic Leukemia : Imbalanced Nutrition Less Than Body Requirements related to fluid restriction, diet, and the loss of protein.

Definition : Intake of nutrients is not sufficient for the purposes of the body's metabolism.

Defining characteristics :
  • Weight 20 % or more below the ideal.
  • Reports of food intake less than RDA (Recomended Daily Allowance)
  • Pale mucous membranes and conjunctiva.
  • Weakness of the muscles used for swallowing / chewing.
  • Wounds, inflammation of the oral cavity.
  • Easy to feel full , shortly after the chewing of food.
  • Reported or the fact that there is a shortage of food.
  • Reported a change in taste sensation.
  • The feeling of inability to chew food.
  • Misconceptions.
  • Losing weight with enough food.
  • Reluctance to eat.
  • Cramps in the abdomen.
  • Poor muscle tone.
  • Abdominal pain with or without pathology.
  • Less interested in food.
  • Fragile capillary vessels.
  • Diarrhea and or steatorrhea.
  • Hair loss is quite a lot (loss).
  • Hyperactive bowel sounds.
  • Lack of information, misinformation.

Related factors :
  • Inability to enter or digest food or absorb nutrients associated with biological factors, psychological or economic.

Nutritional status : food and Fluid Intake

Outcomes :
  • An increase in body weight in accordance with the purpose.
  • Ideal weight according to height.
  • Being able to identify nutritional needs.
  • No signs of malnutrition.
  • Weight loss does not happen that means.


Nutrition Management
  • Assess the food allergy.
  • Collaboration with a nutritionist to determine the amount of calories and nutrients needed by the patient.
  • Instruct the patient to increase the intake of Fe.
  • Instruct the patient to increase the protein and vitamin C.
  • Give the substance of sugar.
  • Make sure the diet contains high fiber eaten to prevent constipation.
  • Give foods elected (already consulted with a nutritionist).
  • Teach patients how to make food diaries.
  • Monitor the amount of nutrients and calories.
  • Provide information about nutritional needs.

Nutrition Monitoring
  • Patient's weight within normal limits.
  • Monitor change in body weight.
  • Monitor the type and amount of regular activity.
  • Monitor interaction between children or parents during meals.
  • Monitor the environment for eating.
  • Schedule of treatment and no action during a meal.
  • Monitor dry skin and pigmentation changes.
  • Monitor skin turgor.
  • Monitor dryness, dull hair, and brittle.
  • Monitor nausea and vomiting.
  • Monitor levels of albumin, total protein, hemoglobin, and hematocrit levels.
  • Monitor food preferences.
  • Monitor growth and development.
  • Monitor pale, redness, and dryness of the conjunctiva tissue.
  • Monitor and calorie intake nuntrisi.
  • Note the presence of edema, hyperaemic, hypertonic papillae of the tongue and oral cavity.
  • Note if the tongue magenta, scarlet.
  • Assess the patient's ability to get needed nutrients.

Social Isolation - Nursing Diagnosis and Interventions for Schizophrenia

Nursing Care Plan for Schizophrenia

Nursing Diagnosis :
Social isolation related to low self-esteem

General objectives
  • Clients can engage social, gradually

Specific objectives 1.
  • Clients can build a trusting relationship.

Outcomes :
  • The client can express his feelings.
  • Friendly facial expression.
  • There is eye contact.
  • Show some love.
  • Want to shake hands.
  • Want to reply greetings.
  • Clients want to sit side by side.
  • Clients want to express the problems encountered.
Interventions :
  • Develop a relationship of mutual trust :
  • ·Greet clients friendly, both verbally and nonverbally.
  • · Introduce yourself politely.
  • · Ask the client 's full name and preferred nickname.
  • · Explain the purpose of the meeting , be honest and keep our promises.
  • · Show empathy and receives the client is.
  • · Pay attention to the client.
  • Give a chance to express his feelings about the illness.
  • Take time to listen to the client.
  • Tell the client that he is a valuable and responsible and able to help themselves.

Rationale :
  • Trusting relationship will lead to trust the client to the nurse that will facilitate the implementation of further action .

Specific objectives 2.
  • Clients can identify the capabilities and positive aspects possessed.

Outcomes :
  • Clients are able to maintain the positive aspects.
Interventions :
  • Discuss capabilities and positive aspects of the client owned and reinforcement give up the ability to express feelings.
  • When meeting with clients avoid giving a negative assessment.

Rationale :
  • Positive reinforcement will increase the client's self-esteem.
  • Prioritizing realistic compliment.

Specific objectives 3.
  • Clients can assess the ability of the data used.
Outcomes :
  • Clients' needs are met.
  • Clients can perform purposeful activity.

Interventions :
  • Discuss the ability of clients that can still be used when sick.
  • Discuss also the ability that can be continued in hospital use it at home later.

Rationale :
  • Improved client capabilities will encourage the client to an Independent.

Specific objectives 4.
  • Clients can define and plan activities according to ability.

Outcomes :
  • Clients are able to move according to ability.
Intervention :
  • Plan with client activity to do each day according to ability, independent activities, activities with minimal assistance , the activities with the help of the total.
  • Increase activity as tolerated client client's condition.
  • Give an example of how to implement the activities the client should do (often clients are afraid to carry it out).

Rationale :
  • Implementation activities independently into the initial capital to boost self-esteem.

Specific objectives 5.
  • Clients can perform activities in accordance with the conditions of pain and ability.

Outcomes :
  • Clients are able to move according to ability.

  • Give the client the opportunity to try activities that have been planned.
  • Give praise to the efforts and success of the client.
  • Discuss the possibility of implementation at home.
Rationale :
  • Through the activity, the client will know the capabilities.

Specific objectives 6.
  • Clients can take advantage of existing support systems.

Outcomes :
  • Clients are able to do what has been taught.
  • Clients want to provide support.
Interventions :
  • Give health education to families about how to care for clients with social isolation and low self esteem.
  • Help provide support for the family of the client being treated.
  • Help families prepare a home environment.

Rationale :
  • Attention families and family understanding will help improve self esteem clients.

Self-Care Deficit - Nursing Care Plan for Schizophrenia

Nursing Diagnosis and Interventions for Schizophrenia

Schizophrenia is a syndrome with various descriptions of the cause (many not yet known) and the course of the disease (not always a chronic or "deteriorating") wide, as well as a number of which depends on the balance due to the influence of genetic, physical, and social culture. Generally characterized by fundamental and characteristic deviations of mind and perception, as well as the affect that is not fair (inappropiate) or blunt. Consciousness is clear (clear consciousness) and intellectual ability is usually maintained, although certain cognitive decline may develop later.

Schizophrenia is equally prevalence between men and women. However, there are differences in the onset and course of the disease. Men have earlier onset than women. Peak age of onset for males is 15 to 25 years ; the peak age for women is 25 to 35 years. Onset of schizophrenia before age 10 years or after 50 years is very rare.

Principal symptoms of schizophrenia can be grouped into four disturbance on :
1). Natural Mind
  • Thought disorder in patients with schizophrenia is a disorder of mind and the current form of the content of thought disorder. (Roan, 1997). In schizophrenic patients there was indeed a core disturbance in thought processes and is particularly disturbed association, namely :
  • Patients sometimes have an unfinished idea expressed, but had other ideas arise.
  • People with schizophrenia often using symbolic meaning, so that the schizophrenic mind can not be followed and understood by others.
  • In patients with schizophrenia often also found what is called the blocking, ie the contents of the mind which sometimes arise stops and no idea anymore.
  • Other symptoms are hallucinations that the patient feels no noises in his ears.
  • Strange way of thinking (ambivalence).
  • The presence of delusions are under control.
  • Feeling no pain and feel self -righteous themselves (egocentric). (Yusuf and Ismed, 1991).

2). Responsiveness (Perseption)
  • In this disorder can occur any illusion that an event response of an outside stimulus. Or a response in the absence of external stimuli. Major disruption of perceptual disorders are various types of true hallucinations (Roan, 1997).

3). Natural feelings
At the beginning of mood disorders , patients are usually more sensitive than normal people. Patients who appear are easily offended, irritable and sensitive to things that small should not be offended or upset. In a state of further disruption or worse, the atmosphere will actually care about the people around it (Yusuf and Ismed, 1991). Feelings or emotional disturbances in people with schizophrenia can be classified in two ways, namely :
  • Mood disorder.
  • Impaired expression of feelings.
In daily life the sense of disorder appears in behavior, usually expressed as :
  • Chirpy (nood elevasion).
  • Sad (depression).
  • Lost sense (perplekxity).
  • Excessive emotion.
  • Loss of emotional rapport.
  • Ambivalaensi (fragmented personality).
4). Behavior disorders
Behavior disorder (psychomotor) of diverse often seen , especially in the form of acute attacks and real. Schizophrenic behavior is often strange and incomprehensible. such as :
  • Can occur from the great reduction in reactivity to the environment in the form of reduced movement and spontaneous activity, the patient will be stiff and reject efforts to move.
  • Excessive motor movements (exited) and looks not intended and are not influenced by external stimuli (such as no noise / furor catatonic).
Lots of behavior that can be found in people with schizophrenia , but most often are :
  • Restless rowdy (exitement).
  • Stupor.
  • Impulsive behavior. (Wibisono, S. 1998).

Nursing Care Plan for Schizophrenia

Nursing Diagnosis : Self-Care Deficit related to withdraw

General objectives :
  • Clients expressed a desire to perform activities of daily living.
Specific objective :
  • Able to perform activities of daily living independently and demonstrate a desire to do so.
Outcomes :
  • Clients are able to perform daily activities.
  • Clients feed themselves without assistance.
  • Clients choose appropriate clothing, taking care to dress themselves without help.
  • Clients maintain optimal personal hygiene by bathing every day and perform procedures unassisted defecation and urination.
Interventions :
  • Encourage the patient to perform activities of daily living fit the patient's level of ability .
  • Support the patient's autonomy , but give assistance when the patient can not perform some activities .
  • Show concretely , how do the activity to which the client is difficult to do so.
  • Assist in preparing equipment ADLs .
  • Give positive recognition and awards for its ability to be independent.

Rationale :
  • Independent activity can improve the ability to do client activity.

Fluid Volume Deficit - Nursing Care Plan for Leptospirosis

Nursing Diagnosis and Interventions

Leptospirosis is a zoonotic disease caused by microorganisms, ie Leptospira that regardless of serotype -specific form. This disease can be passed on via the male or female of all ages. Mostly found in the tropics, and usually the disease is also known by various names such as mud fever, slime fever, swamp fever, autumnal fever, infectious jaundice, filed fever, fever cutre cane and others.

Manifestations of leptospirosis infection have a very varied and sometimes asymptomatic. Nearly 15-40 % of patients exposed to infection are asymptomatic but serologically positive. The incubation period of 7-12 days with a range of 2-20 days. Approximately 90% of patients with mild jaundice , severe jaundice 5-10 % is often known as Weil's disease. Leptospires disease course consists of two phases , namely phase and phase immune septicemia. In the period of 1-3 days during the phase transition condition of the patient improved.

1. Initial phase is known as septicemic phase or leptospiremic phase because bacteria can be isolated from blood, cerebrospinal fluid, and most of the body's tissues. Initial phase of approximately 4-7 days, marked nonspecific flu-like symptoms with a few variations. The clinical manifestations of fever, chills, weakness and pain especially the ribs, back and stomach. Other symptoms are sore throat, cough, chest pain, vomiting of blood, rash, frontal headache, photophobia, mental disturbances, and meningitis. Physical examination often get a fever of about 40 0C accompanied by tachycardia. Subconjunctival suffusion, pharyngeal injection, splenomegaly, hepatomegaly, mild jaundice, mild jaundice, muscle weakness, lymphadenopathy and skin manifestations in the form of macular, maculopapular, erythematous, urticaria, or rash was also obtained in the early phase of disease.

2. Second phase is often called the immune phase or leptospiruric phase, because circulating antibodies can be detected by isolation of bacteria from the urine ; may not be obtained again from the blood or cerebrospinal fluid. This phase occurs at 0-30 days due to the response of the body's defense against infection. Symptoms depend the body's organs such as the lining of the brain, heart, eyes or kidneys. Nonspecific symptoms such as fever and muscle aches may be lighter than the initial phase for 3 days to several weeks. Approximately 77 % of patients experienced a continuous headache unresponsive to analgesics. These symptoms are often associated with the early symptoms of meningitis other than delirium. In the more severe phases obtained prolonged mental disorders including depression, anxiety, psychosis and dementia.

Nursing Diagnosis for Leptospirosis : Fluid volume deficit related to lack of fluids and electrolytes active

  • Fluid balance
  • Hydration
  • Nutritional Status : Food and Fluid Intake

Outcomes :
  • Maintain urine output in accordance with the age and body weight, urine specific gravity normal.
  • Blood pressure, pulse, body temperature within normal limits.
  • No signs of dehydration, good elasticity of skin turgor , moist mucous membranes, no excessive thirst.

  • Fluid management
  • Measure diapers if needed.
  • Maintain a record of intake and output accurately.
  • Monitor hydration status ( mucous membrane moisture, adequate pulse, orthostatic blood pressure ) , if necessary.
  • Monitor vital signs.
  • Monitor the input of food / fluids and calculate daily caloric intake.
  • Collaborate IV fluid administration.
  • Monitor nutritional status.
  • Give IV fluids at room temperature.
  • Encourage oral input.
  • Provide appropriate replacement nesogatrik output.
  • Encourage families to help patients eat.
  • Give snack (fruit juice , fresh fruit).
  • Collaboration doctor if signs of excess fluid appears to worsen.
  • Adjust the possibility of transfusion.
  • Preparation for transfusion.

Impaired Physical Mobility - related to Ischialgia

Nursing Care Plan for Ischialgia

Ischialgia is one manifestation of lower back pain is caused due to the clamping nervous ischiadicus.

Pain in the lumbar region can basically be:
  • Radicular pain ( often ) patients with radicular pain and low back pain showed radicular pain along the nerve ischiadicus.
  • Referred pain.
  • Pain does not radiate.

Nursing Diagnosis for Ischialgia

Impaired Physical Mobility related to pain, muscle spasm, restrictive therapies and neuromuscular damage.

  • Joint Movement : Active
  • Mobility Level
  • Self care : ADLs
  • Transfer performance

Outcomes :
  • Clients increase in physical activity.
  • Understand the purpose of improving mobility.
  • Verbalize feelings in improving the strength and ability to move.
  • Demonstrate the use of aids to mobilization (walker).

  • Exercise therapy : ambulation
  • Monitoring vital signs before / after exercise and see the patient's response during exercise.
  • Consult with a physical therapy plan of ambulation as needed.
  • Help clients to use a cane when walking and prevent against injury.
  • Teach the patient or other health professionals about ambulation techniques.
  • Assess the patient's ability to mobilize.
  • Train patients in meeting the needs of ADLs independently according to ability.
  • Facilitate and assist the patient when the mobilization and help meet the needs of ADLs.
  • Give the tool if the client requires.
  • Teach patients how to change the position and provide assistance if needed.

NANDA Nursing