Nursing Blog

Nursing Diagnosis Urinary Tract Infections Impaired sense of comfort: pain related to inflammation and infection of the urethra, bladder and other urinary tract structures. Elimination pattern changes related to mechanical obstruction of the bladder or other urinary tract structures. Nursing Interventions Urinary Tract Infections     Impaired sense of comfort: pain related to inflammation and infection of the urethra, bladder and other urinary tract structures     Expected results :         Pain reduced / lost during and after micturition     Nursing Intervention :         Monitor changes in urine color, monitor the pattern of urination, the input and output every 8 hours and monitor the results of urinalysis repeated.         R /: to identify indications of progress or deviations from expected results       ...

Nursing Care Plan for Acute Pain NANDA Acute Pain Definition : Feelings and unpleasant emotional experience arising from actual tissue damage and potential, or the picture of the damage. It can occur suddenly or slowly, the intensity of the light or heavy. With predictions roughly healing time of less than 6 months. Defining characteristics: Reports of verbal and nonverbal Observation reports Position the patient to be careful to avoid the pain The movement to protect Cautious behavior Face mask Sleep disturbances (eyes glazed, looking tired, difficult or chaotic movement, smirk) Focus on self- Focus narrows (decreased perception of time, damage to the thought, decreased interaction with people and the environment) Distraction activity (walk, meet other people or activities, repetitive activity) Response autonomy (diaphoresis, changes in blood pressure, changes in breathing, pulse and dilated pupils). Autonomy in response to changes in muscle tone (visible from weak to stiff) Expressi...

Nanda Ineffective Airway Clearance Definition: Inability to clear secretions or obstructions from the respiratory tract to maintaina clear airway RELATED FACTORS Environmental Smoking; secondhand smoke; smoke inhalation Obstructed airway Retained secretions; secretions in the bronchi; exudate in the alveoli; excessive mucus; airway spasm; foreign body in airway; presence of artificial airway Physiological Chronic obstructive pulmonary disease (COPD); asthma; allergic airways; hyperplasia of the bronchial walls Neuromuscular dysfunction Infection DEFINING CHARACTERISTICS Subjective Dyspnea Objective Diminished/adventitious breath sounds [rales, crackles, rhonchi, wheezes] Cough, ineffective/absent; excessive sputum Changes in respiratory rate and rhythm Difficulty vocalizing Wide-eyed; restlessness Orthopnea Cyanosis Sample Clinical Applications: COPD, pneumonia, influenza, acute respiratory distress syndrome (ARDS), cancer of lung/head and neck, congestive heart failure (CHF), cystic f...

Nursing Diagnosis Activity intolerance Insufficient physiologicalor psychological energy to endure or complete required or desired daily activities Defining Characteristics Abnormal blood pressure response to activity; abnormal heart rate response to activity; EKG changes reflecting arrhythmias; EKG changes reflecting ischemia; exertional discomfort; exertional dyspnea; verbal report of fatigue; verbal report of weakness Related Factors (r/t) Bed rest; generalized weakness; imbalance between oxygen supply/demand; immobility; sedentary lifestyle Suggested NOC Outcomes Activity Tolerance, Endurance, Energy Conservation, Self-Care: Instrumental Activities of Daily Living (IADLs) Example NOC Outcome with Indicators Endurance as evidenced by the following indicators: Performance of usual routine/Activity/Concentration/Muscle endurance/Eating pattern/Libido/Energy restored after rest/Blood oxygen level (Rate the outcome and indicators of Endurance: 1 severely compromised, 2 substantially com...

Source: NANDA Nursing Diagnoses: Definitions and Classification, 2007–2008. Philadelphia: North American Nursing Diagnosis Association. Used with permission. Activity Intolerance Activity Intolerance, Risk for Airway Clearance, Ineffective Anxiety Anxiety, Death Aspiration, Risk for Attachment, Parent/Infant/Child, Risk for Impaired Autonomic Dysreflexia Autonomic Dysreflexia, Risk for Blood Glucose, Risk for Unstable Body Image, Disturbed Body Temperature: Imbalanced, Risk for Bowel Incontinence Breastfeeding, Effective Breastfeeding, Ineffective Breastfeeding, Interrupted Breathing Pattern, Ineffective Cardiac Output, Decreased Caregiver Role Strain Caregiver Role Strain, Risk for Comfort, Readiness for Enhanced Communication: Impaired, Verbal Communication, Readiness for Enhanced Confusion, Acute Confusion, Acute, Risk for Confusion, Chronic Constipation Constipation, Perceived Constipation, Risk for Contamination Contamination, Risk for Coping: Community, Ineffective Coping: Commun...

NANDA-I Process of Diagnoses Conduct a nursing assessment - collection of subjective and objective data relevant to the care recipient's (person, family, group, community) human responses to actual or potential health problems / life processes. Cluster and interpret cues/patterns - Assessment data must be clustered and interpreted before the nurse can plan, implement or evaluate a plan to support patient care Generate Hypotheses - possible alternatives that could represent the observed cues/patterns. Validation & Prioritization of Nursing Diagnoses - taking necessary steps to rule out other hypotheses, to confirm with the patient(s) the validity of the hypotheses, and to prioritize the list of diagnoses. A focused assessment may be needed to obtain data for one or more diagnoses Planning - Determining appropriate (realistic) patient outcomes and interventions most likely to support attainment of those outcomes through evidence-based practice Implementation - Putting the plan of...

The NANDA-I system of nursing diagnosis provides for four categories. Actual diagnosis - "A clinical judgment about human experience/responses to health conditions/life processes that exist in an individual, family, or community". An example of an actual nursing diagnosis is: Sleep deprivation. Risk diagnosis - "Describes human responses to health conditions/life processes that may develop in a vulnerable individual/family/community. It is supported by risk factors that contribute to increased vulnerability." An example of a risk diagnosis is: Risk for shock. Health promotion diagnosis - "A clinical judgment about a person’s, family’s or community’s motivation and desire to increase wellbeing and actualize human health potential as expressed in the readiness to enhance specific health behaviors, and can be used in any health state." An example of a health promotion diagnosis is: Readiness for enhanced nutrition. Syndrome diagnosis - "A clinical judgme...

List of NANDA Nursing diagnosis Accepted for Use and Research Divided into 13 domains and 47 classes, below the full list of 13 Domains and 47 classes NANDA Nursing diagnosis . And complete list of NANDA Nursing diagnosis based on alphabetical order. Domains Health Promotions Health awareness Health management Domains nutrition’s ingestion digestion Absorption Metabolism Hydration Domains Elimination/exchange Urinary System Gastrointestinal System Integumentary system Pulmonary System Domains Activity/Rest Sleep/Rest Activity /Exercise Energy Balance Cardiovascular-pulmonary Responses Self-Care Domains Perception/Cognition Attention Orientation Sensation/Perception Cognition Communication Domains Self Perception Self-Concept Self-Esteem Body Image Domains Role Relationship Caregiving Roles Family Relationship Role Performance Domains Sexuality Sexual Identity Sexual Function Reproduction Domains Coping/Stress Tolerance Post-Trauma Responses Coping Responses Neuro-behavioral Stress Do...