List of Nursing Diagnosis

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.

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.

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.

Nursing Care Plan for Gastritis

Gastritis is an inflammation of the stomach lining. The main acute causes are excessive alcohol consumption or prolonged use of nonsteroidal anti-inflammatory drugs (also known as NSAIDs) such as aspirin or ibuprofen. Sometimes gastritis develops after major surgery, traumatic injury, burns, or severe infections.

In some cases, the stomach lining may be "eaten away," leading to sores (peptic ulcers) in the stomach or first part of the small intestine. Gastritis can occur suddenly (acute gastritis) or gradually (chronic gastritis). In most cases, gastritis does not permanently damage the stomach lining.

Risk Factors:

• Infection with H. pylori
• Acquired immunodeficiency syndrome (AIDS)
• Any condition that requires relief from chronic pain using NSAIDS, such as chronic low back pain, fibromyalgia, or arthritis
• Alcoholism
• Cigarette smoking
• Older age
• Herpes simplex virus or cytomegalovirus
• Inflammatory bowel disease

Signs and Symptoms:

The most common symptoms of gastritis are stomach upset and pain. Other possible symptoms include:

• Indigestion (dyspepsia)
• Heartburn
• Abdominal pain
• Hiccups
• Loss of appetite
• Nausea
• Vomiting, possibly of blood or material that looks like coffee grounds
• Dark stools

Nursing Diagnosis: Risk for Ineffective Tissue Perfusion related to Hypovolemia

Nursing Intervention:

1. Investigate changes in level of consciousness, complaining of dizziness / headaches.
Rationale: The change may indicate inadequate cerebral perfusion as a result of artery blood pressure.

2. Investigate complaints of chest pain
Rationale: May indicate cardiac ischemia in relation to decreased perfusion.

3. Assess skin to cold, pale, sweating, slow capillary refill and peripheral pulses are weak.
Rational: Sympathetic Vasoconstriction is a response to the decline in circulating volume and / or can occur as a side effect of vasopressin administration.

4. Record the output of urine specific gravity and
Rationale: Decreased systemic perfusion can lead to ischemia / renal failure manifested by decreased urine output.

5. Record report abdominal pain, particularly sudden, severe pain or pain spreading to the shoulders.
Rationale: Pain caused by gastric ulcers are often lost after acute hemorrhage due to buffer the effects of the blood. Severe pain persists or suddenly can show respect to ischemia vasokinstriksi therapy.

6. Observation for pale skin, redness, massage with oil. Change positions frequently
Rational: disturbances in the peripheral circulation increases the risk of skin damage.

collaboration
7. Provide supplemental oxygen as indicated
Rational: treat hypoxemia and lactic acidosis during acute hemorrhage.

8. Give IV fluids as indicated
Rational: to maintain circulating volume and perfusion.

Nursing Diagnosis for Diabetes Mellitus: Imbalanced Nutrition Less Than Body Requirements related to an increased metabolism of proteins, fats.

Goal: patient's nutritional needs can be met.

the expected outcomes:
Patients can ingest calories or nutrients right.
Stable weight or addition to the usual range.

Nursing Interventions imbalanced Nutrition Less Than Body Requirements - Nursing Care Plan for Diabetes Mellitus

Independent

1. Measure weight as indicated.
Rational:
Assessing adequate food intake.

2. Determine the diet program, diet, and compare it with foods that can be spent on the client.
Rational:
Identify deficiencies and irregularities of therapeutic needs.

3. Auscultation of bowel sounds, record abdominal pain, or abdominal bloating, nausea, vomiting and maintain a state of fasting as indicated.
Rational:
Hyperglycemia, fluid and electrolyte balance disorders decrease gastric motility or function (distension or paralytic ileus).

4. Give liquid foods that contain nutrients and electrolytes. Furthermore, providing a more solid foods.
Rational:
Oral feeding is better given to the client's conscious and gastrointestinal function well.

5. Identify the preferred food.
Rational:
Cooperation in planning meals.

6. Involve the family in meal planning.
Rational:
Increase the sense of involvement, providing information to families to understand the nutritional needs of the client.

7. Observation sign of hypoglycemia (altered levels of consciousness, or cold clammy skin, rapid pulse, hunger, sensitive stimuli, anxiety, headache, dizziness).
Rational:
On carbohydrate metabolism (blood sugar will be reduced and while still given insulin, the hypoglycemic events occurred without showing changes in level of consciousness.

Collaboration

8. Make checks blood sugar with a finger stick.
Rational:
Analysis on a bed of blood sugar monitoring is more accurate than the sugar in the urine.

9. Monitor laboratory tests (blood glucose, acetone, pH, HCO3)
Rational:
Blood sugar decreases slowly with the use of fluid and insulin therapy can be controlled so that glucose enter the cells and be used for a source of calories. Currently, acetone levels decreased and acidosis can be corrected.

10. Give regular insulin treatment with iv
Rational:
Regular insulin has a rapid onset and quickly too helps move glucose into the cells. Giving through IV because of absorption from the subcutaneous tissue is very slow.

11. Give glucose solution (destroksa, half normal saline).
Rational:
Glucose solution was added after insulin and blood sugar liquids carrying about 250 mg / dl. With nearly normal carbohydrate metabolism, care be taken to avoid hypoglycemia.

12. Consultation with a dietician.
Rational:
Useful in calculating and adjusting the diet to meet nutritional needs.


Defining Characteristics of Imbalanced Nutrition Less than Body Requirements

Imbalance Nutrition Less than Body Requirements related to psychological factors

Signs and Symptoms of Alzheimer's Disease

Mild Alzheimer's disease

As the disease progresses, memory loss worsens, and changes in other cognitive abilities are evident. Problems can include:
getting lost
trouble handling money and paying bills
repeating questions
taking longer to complete normal daily tasks
poor judgment
losing things or misplacing them in odd places
mood and personality changes

Moderate Alzheimer's disease

Symptoms may include:
increased memory loss and confusion, problems recognizing family and friends, inability to learn new things, difficulty carrying out tasks that involve multiple steps (such as getting dressed), problems coping with new situations, hallucinations, delusions, and paranoia, impulsive behavior

Severe Alzheimer's disease

Their symptoms often include:
inability to communicate, weight loss, seizures, skin infections, difficulty swallowing, groaning, moaning, or grunting, increased sleeping, lack of control of bowel and bladd


Nursing Diagnosis for Alzheimer's Disease: Disturbed Sleep Pattern related to changes in the sensory.
Nursing Care Plan for Alzheimer's Disease

Purpose:

Having given nursing care, the client is expected to change in sleep patterns can be resolved
the expected outcomes:
No changes in the behavior and appearance (agitated), Being able to create adequate sleep patterns with a decrease of the mind hovering (daydreaming), Being able to determine the cause of inadequate sleep.

Nursing Interventions:

1. Provide a comfortable environment for improving sleep (turn off the light, adequate ventilation, appropriate temperature. Avoiding noise)

2. Encourage exercise during the day and lower mental activity / physical in the afternoon.

3. Give the afternoon snack, warm milk, bath, and massage back.

4. Decrease the number of drinks the afternoon. Perform voiding before bed.

5. Encourage clients to listen to music.



1. Cortical inhibition in the reticular information will be reduced during sleep, improving automatic response, thereby increasing cardiovascular response to noise during sleep.

2. Physical activity and mental fatigue that can lead to long increase confusion, programmed activities without excessive stimulation increased sleep time.

3. Increase relaxation with drowsiness.

4. Reduce the need for up to urinate during the night.

5. Lowering the sensory stimulation by blocking other sounds from the environment around that will inhibit sleep.

Nursing Diagnosis for Pleural Effusion : Impaired Gas Exchange related to changes in capillary membrane - alveolar

Purpose:

• Breathing the air in the balance between the concentration of arterial blood

The expected outcomes:

• Showed an increase in ventilation and oxygen sufficient
• Analysis of blood gases within normal limits.

Nursing Interventions:

Airway Management

• Clear the airway
• Encourage breathing long and lasting cough
• Set the appropriate humidity
• Set the position to reduce dyspnoea
• Monitor frequency of breath associated with oxygen adjustment

Respiration Monitor

• Monitor rate, rhythm, depth and effort to breathe
• Note the movement of the chest, breast symmetry, using tools and intercostal muscle retraction
• Monitoring nasal breathing, the snoring
• Monitor breathing patterns, bradipneu, takipneu, hyperventilation, resirasi kusmaul, etc.
• Palpation similarity lung expansion
• Anterior and posterior chest percussion of both lungs
• Monitor the diaphragm muscle fatigue
• Auscultation breath sounds, record or ketidakadanya area reduction and ventilation and breath sounds
• Monitor restlessness, anxiety and anger
• Note the characteristic cough and duration
• Monitor respiratory secretions
• Dyspnoea and monitor the development and progression of events
• Perform maintenance nebulized therapy if necessary
• Place the patient laterally to prevent aspiration

Management Asid Base

• Send a laboratory examination of acid-base balance (eg, blood gas analysis, urine and serum levels)
• Monitor blood gas analyzer for low PH
• Position the patient for optimum ventilation perfusion
• Maintain the cleanliness of the air (suction and chest therapy)
• Monitor respiration pattern
• Monitor work pernafsan (respiratory rate).

Nursing Care Plan for Appendicitis

Nursing  Diagnosis: Acute  Pain related to Surgical Incision

Purpose:
After nursing care, client comfort level increased, pain controlled with the expected outcomes:

• Clients report reduced pain, pain scale 2-3
• Calm facial expression, and can rest, sleep.
• Vital signs are within normal limits.

Nursing  Intervention for Appendicitis : Acute  Pain related to Surgical Incision

Pain Management:

• Assess pain comprehensively including location, characteristics, duration, frequency, quality factor and precipitation.
• Observation of nonverbal reactions inconvenience.
• Use therapeutic communication techniques to determine the client's experience of pain before.
• Provide a quiet environment
• Reduce pain precipitation factor.
• Teach non-pharmacological techniques (relaxation, distraction, etc.) to overcome the pain.
• Give analgesics to reduce pain.
• Evaluation of pain reducers / pain control.
• Collaboration with the doctor if there are complaints about the administration of analgesics to no avail.
• Monitor client's acceptance of pain management.

Analgesic  Administration:.

• Check program providing analgesic; types, dosage, and frequency.
• Check history of allergy.
• Determine the analgesic of choice, route of administration and optimal dosage.
• Monitor vital signs
• Give analgesics on time especially when pain appears.
• Evaluation of analgesic efficacy, side effects signs and symptoms.

Nursing Diagnosis for Hypertension:

Acute Pain (headache) related to increased cerebral vascular pressure

Purpose:

• Having given nursing care, pain expectancy is reduced / controlled.

Expected outcomes:

• Clients reported pain / discomfort disappeared / controlled.

Nursing Intervention for Hypertension - Acute Pain :

1. Maintain bed rest during the acute phase.

2. Give non-pharmacological measures to relieve headaches eg, a cold compress on the forehead, neck and back massage, quiet, Dim the room lights room lights, relaxation techniques (your imagination, diktraksi) and leisure time activities.

3. Eliminate / minimize vasoconstriction activity can increase headache eg, straining during defecation, coughing and bending length.

4. Assist patients in ambulation as needed.

5. Berikancairan, soft foods, regular oral care in the event of bleeding nose or nasal pack has been done to stop the bleeding.

6. Collaboration of analgesic drugs.

Rational:

1. Minimizing stimulation / enhance relaxation.

2. Measures that reduce cerebral vascular pressure and that slow / block sympathetic responses are effective in eliminating the headaches and complications.

3. Activities that enhance vasoconstriction causing headaches in the increased cerebral vascular pressure.

4. Dizziness and blurred vision often associated with pain also experience episodes kepala.pasien postural hypotension.

5. Improve comfort umum.kompres nose can disrupt the ingestion or require breath with your mouth, causing stagnation oral secretions and mucous membranes dry out.

6. Lose / control pain and reduce sympathetic nervous system stimulation.

Nursing Diagnosis: Activity Intolerance related to general weakness, imbalance between supply and oxygen demand.

Purpose:

• Having given nursing care, the client is expected to be able to do activities that are tolerated

Expected outcomes:

• Clients participate in activities desired / required.
• Reported an increase in tolerance activity can be measured.
• Showed a decrease in physiological signs of intolerance.

Intervention Activity Intolerance - Hypertension Care Plan :

• Assess the client's response to the activity, attention pulse rate more than 20 times per minute in the frequency of breaks; significant increase in BP during / after activity, dyspnea, chest pain; excessive fatigue and weakness; diaphoresis; dizziness or fainting.
• Instruct patients about energy saving techniques, eg, using the bath seat, sitting as combing hair or brushing teeth, doing activities slowly.
• Encourage activity / self-care gradually if tolerated. Provide assistance as needed.

Rational:

• Mention parameter helps in assessing response to stress physiology and activity when there is an indicator of excess work-related activity levels.
• Energy saving techniques reduce energy penggurangan also helps balance between supply and oxygen demand.
• Progress activity increased gradually to prevent sudden cardiac work, provide only limited assistance needs will encourage independence in their daily activities.

Nursing Diagnosis Ineffective Individual and Family Coping related to the prognosis of the disease, the false self-image, change roles.

Goal: Individuals or families are able to develop positive coping.

Nursing Intervention:

1. Assess changes in perceptions of disorder and relationship to the degree of disability.
R / determine individual assistance in preparing nursing plans, or the selection of interventions.

2. Identify the meaning of the loss or dysfunction of the client
R / multiple clients can accept and manage change effectively function with minimal adjustment, while others have difficulty comparing recognize and manage shortages.

3. Encourage clients to express their feelings, including hostility and anger.
R / indicates acceptance helps clients to remember and begin to adjust to the feeling.

4. Note when the client states affected like dying or avoid and declare this is death.
R / supports the rejection of the parts of the body or negative feelings about body image and the ability to show the need and intervention as well as emotional support.

5. Provide information on the health status of clients and families.
R / clients with hemophilia often need help in dealing with chronic conditions, life space limitations and the fact that the condition is a disease that will be handed down to the next generation.

6. Supports effective coping mechanisms.
R / since childhood helped clients to accept himself and his illness and to identify positive aspects of their lives. They should be encouraged to be brave and be independent to prevent trauma that can cause acute bleeding episodes and disrupt normal activities.

7. Avoid emotional stress enhancement factor.
R / nurse should know the effect of stress is professionally and personally, and explore all sources of support for themselves as well as for clients and their families.

8. Assist and encourage good maintenance and repair habits.
R / help boost self-esteem and feelings of control over one area of ​​life.

9. Encourage people closest to allow clients do as much stuff for him.
R / revive the feeling of independence and fosters self-esteem and affect the rehabilitation process.

10. Support efforts such behavior or increased interest or participation in rehabilitation activities.
R / improve the independence to help meet the physical needs and indicate the position to be more active in social activities.

11. Monitor sleep disturbances increasing concentration difficulties, lethargy, and low self-esteem.
R / can identify the occurrence of depression generally occurs as the result of a stroke that requires intervention and further evaluation.

12. Collaboration: refer patients to specialists neuropsychology and counseling when indicated.
R / mempasilitasi can change an important role for the development of feelings.

Nursing Diagnosis for CVA - Stroke: Ineffective Cerebral Tissue Perfusion  related to inadequate cerebral blood supply, occlusive disorder, hemorrhage, cerebral vasospasm, cerebral edema

Goal: Maintain adequate cerebral tissue perfusion

Evaluation Criteria:
a) Maintain the level of awareness
b) stable vital signs
c) No increase in ICT

Intervention:
a) Monitor / record neurological status
b) Monitor vital signs
c) Evaluation of the pupil, record the size, shape, equality and reaction to light
d) Put the head with a slightly elevated position
e) Maintain a state of bedrest.

Nursing Care Plan for Palatoschisis and Cheiloschisis

Cleft lip (cheiloschisis) and cleft palate (palatoschisis), which can also occur together as cleft lip and palate, are variations of a type of clefting congenital deformity caused by abnormal facial development during gestation.

A cleft lip or palate can be successfully treated with surgery, especially so if conducted soon after birth or in early childhood.

If the cleft does not affect the palate structure of the mouth it is referred to as cleft lip. Cleft lip is formed in the top of the lip as either a small gap or an indentation in the lip (partial or incomplete cleft) or it continues into the nose (complete cleft). Lip cleft can occur as a one sided (unilateral) or two sided (bilateral). It is due to the failure of fusion of the maxillary and medial nasal processes (formation of the primary palate).

A mild form of a cleft lip is a microform cleft. A microform cleft can appear as small as a little dent in the red part of the lip or look like a scar from the lip up to the nostril. In some cases muscle tissue in the lip underneath the scar is affected and might require reconstructive surgery. It is advised to have newborn infants with a microform cleft checked with a craniofacial team as soon as possible to determine the severity of the cleft.

Nursing Diagnosis for Cheiloschisis and Palatoschisis

1. Imbalanced Nutrition, Less Than Body Requirements related to inability to ingest / difficulty in eating, secondary disability and surgery.
2. Risk for aspiration related to inability to secrete secretion, secondary Palatoschisis.
3. Risk for infection related to disability (before surgery) and or surgical incision.
4. Knowledge Deficit: family related to techniques of feeding and care at home.
5. Acute Pain related to surgical incision.
6. Ineffective airway clearance related to the effects of anesthesia, post-operative edema, increased secretions.
7. Impaired skin integrity related to surgical incision.

List of Nursing Diagnosis for Congestive Heart Failure

People with congestive heart failure sometimes do not suspect a problem with their heart or have symptoms that may not obviously be from the heart.

1. Early symptoms may include shortness of breath, cough, or a feeling of not being able to get a deep breath, especially when lying down.
2. If a person has a known breathing problem, such as asthma, chronic obstructive pulmonary disease (COPD), or emphysema, they may they are having an "attack" or worsening of that condition.
3. If a person usually does not have breathing problems, they may think they have a cold, flu, or bronchitis.
4. Any or several of these above conditions may coexist along with congestive heart failure.

List of Nursing Diagnosis for Congestive Heart Failure

1. Activity Intolerance related to insufficient oxygen for activities of daily living.

2. Anxiety related to breathlessness.

3. Imbalanced Nutrition: Less Than Body Requirements related to nausea; anorexia secondary to venous congestion of gastrointestinal tract and fatigue.

4. Impaired Peripheral Tissue Perfusion related to venous congestion secondary to right-sided heart failure.

5. Disturbed Sleep Pattern related to nocturnal dyspnea and inability to assume usual sleep position.

6. Powerlessness related to progressive nature of condition.

7. Risk for Ineffective Therapeutic Regimen Management related to lack of knowledge of low-salt diet, drug therapy (diuretic, digitalis vasodilators), activity program, signs and symptoms of complications.

8. Risk for Impaired Skin Integrity related to edema and decreased tissue perfusion.

Constipation

A situation where an individual experience or a higher risk of static in the large intestine, resulting in a rare bowel movements, hard, dry stools.

Related Factors

• Inadequate fluid intake
• Low-fiber diet
• Inactivity, immobility
• Medication use
• Lack of privacy
• Pain
• Fear of pain
• Laxative abuse
• Pregnancy
• Tumor or other obstructing mass
• Neurogenic disorders

Defining Characteristics

• Infrequent passage of stool
• Passage of hard, dry stool
• Straining at stools
• Passage of liquid fecal seepage
• Frequent but nonproductive desire to defecate
• Anorexia
• Abdominal distention
• Nausea and vomiting
• Dull headache, restlessness, and depression
• Verbalized pain or fear of pain

Expected Outcomes

Individuals will:

   1. Describe the therapeutic program defecation
   2. reported or showed increased bowel elimination
   3. explain the rationale of intervention

Self-care deficit: feeding

An obstacle to the ability of the feeding of the plate to the mouth, put the food to the plate, holding or eating, manipulating food in the mouth, open container, take a cup / glass, preparing the food, swallow food, use tools.

Intervention priorities - NIC
Environmental management: the manipulation of the environment around the patient for therapeutic purposes.
Self-care assistance: toileting, help with elimination.

Self-care deficit: dressing / grooming

An obstacle ability to meet activity.
Fully dressed and makeup.

Defining characteristics:

Objective: ability to wear barriers, retrieve or change clothes, put on and release the parts of clothing is important, the inability to choose clothes, taking clothes, dressed the body (bottom, top), wearing (shoes, socks), undressing, using tools, using a zipper.

Intervention priorities - NIC
Dress: selecting, wearing and removing clothes for people who can not do this alone.
Hair care: an increase in the appearance of hair is clean neat and attractive.
Self-care assistance: dressing / make up: assist patients in dressing and wearing makeup.

Self-care Deficit: bathing / hygiene
Impaired ability to perform or meet activities / bathroom hygiene.

Defining characteristics:

Objective: inability to perform the following tasks: dry off, take a shower fixtures, in and out the shower, getting / providing water, set the temperature and flow of the water bath, cleans the body or limbs.

Intervention priorities - NIC
Bath: cleanse body to relaxation cleanliness and healing.
Assistance with personal care, bathing / personal hygiene patients to meet personal hygiene.

Nursing Diagnosis: Risk for Infection NIC NOC

NOC and indicators

NOC: infection control and risk control, after nursing interventions, there is no secondary infection, with:

Indicator:

1. Free of any signs of infection.
2. Normal leukocyte numbers.
3. Patients say knew about the signs of infection.

NIC and activities

NIC:  Wound Care
Activity:

1. Observe signs of wound infection.
2. Perform breast care with aseptic technique and use sterile gauze to treat and cover wounds.
3. Instruct the patient to report and recognize the signs of infection.
4. Manage your therapy according to the program.

Rational

1. Marker of the infection process.
2. Avoid infection.
3. Preventing infection.
4. Accelerate healing.

NIC: Control of infection
Activity:

1. Limit visitors.
2. Wash hands before and after treating patients.
3. Increase nutrient inputs sufficient.
4. Encourage adequate rest.
5. Ensure aseptic handling area IV.
6. Provide health education about risk for infection.

Rational :

1. Prevent secondary infection.
2. Prevent nosocomial infection.
3. Increase endurance.
4. Helps relaxation and helps protect the infection.
5. Prevent infection.
6. Increasing patient knowledge.

Nursing Diagnosis: Imbalance nutrition less than body requirements related to psychological factors
NOC and indicators
NOC: nutritional status, after being given an explanation and treatment, patient's nutritional needs are met, with

Indicator:

1. Adequate nutrient intake.
2. The patient was able to spend a diet that was served.
3. There are no signs of malnutrition.
4. Laboratorim value, total protein, albumin, globulin, hemoglobin.
5. Mucous membranes and conjunctiva was not pale.

NIC and activities

NIC: nutritional therapy
Activity:

1. Monitor the input of food / drinks, and daily calorie count correctly.
2. Kaloborasi nutritionist.
3. Make sure the diet can be high in calories and high in protein.
4. Provide oral care.
5. Monitor results labioratoriun protein, albumin, globulin, HB
6. Keep away from things that are not pleasant to look like urinals, drainage boxes, dressing and bedpans.
7. Serve warm with interesting variations

Rational

1. Markers of malnutrition.
2. Determination of the amount of calories and foods that meet nutritional standards
3. Preventing loss of appetite
4.  
5. Markers of nutritional deficiencies
6. Can reduce appetite
7. Adding to the patient's appetite.

Defining Characteristics of Imbalanced Nutrition Less than Body Requirements

Imbalanced Nutrition Less Than Body Requirements - Diabetes Mellitus

Nursing Diagnosis: Self-Care Deficit related to Pain

NOC and indicators

NOC: Self-care: (bathing, dressing), after being given a motivational treatment, patients were able to perform bathing and dressing themselves, with:

Indicator:

• The body is free from odor and maintain skin integrity.
• Explains how to bathe and dress safely.

NIC and activities

NIC: Assist patients in self-care
Activity:

1. Place the bath means the patient bedside.
2. Involve families and patients.
3. Provide assistance during the patient is still able to work on their own.

Rational

1. Facilitate outreach
2. Exercising independence
3. Increase confidence

NIC: ADL dress
Activity:

1. Inform the patient in choosing the outfit during treatment.
2. Provide clothes in handy.
3. Assist dress accordingly.
4. Keep privcy patients.
5. Provide personal clothing favored, and appropriate.

Rational

1. Facilitate intervention
2. Exercising independence
3. Avoiding pain increases
4. Provide comfort
5. Provide patient confidence

Nursing Diagnosis and Interventions for Acute Pain 

Acute Pain related to Biological and Physical Agents Injury 

NOC and Indicators

NOC: pain control, after the intervention of care, reduced patient pain

Indicators:

• Using a pain scale to identify the level of pain
• Patient states pain is reduced
• Patients are able to rest / sleep
• Using non-pharmacological techniques

NIC and Activities

1. Management of pain

• Activity:
• Perform an assessment of pain, location, characteristics and factors that may increase the pain.
• Observe non-verbal cues about restless.
• Facilitation comfortable environment.
• Give painkillers.
• Help patients find a comfortable position.
• Teach techniques without the use of medication (eg, relaxation, distraction, massage, guidet imageri).
• Compress the chest while coughing exercises.

2. Manage analgesic :  Determine the location, karaketristik, quality
3. Relaxation therapy
4. Environmental management

Rational

• To determine appropriate interventions and the effectiveness of a given therapy.
• Assist in identifying the degree of discomfort.
• Increase comfort.
• Reduce pain and allow patients to mobilize without pain.
• Elevation of the arm causes the patient to relax.
• Increase relaxation and help to focus attention so as to improve coping resources.
• Facilitate participation in the activity without discomfort arises. 

Nursing Diagnosis and Interventions for Knowledge Deficit

NOC and Indicators
NOC:

• Knowledge about the disease, after being given an explanation for 2 times, the patient understand the disease process and treatment programs and therapies are provided with:

Indicator:

• Patients are able to:
• Explain again about the disease,
• Know the needs of the care and treatment without worry

NIC and Activities

NIC:

• Knowledge of disease

Activity:

1. Assess the client's knowledge about the disease.
2. Explain the disease process (signs and symptoms), identify possible causes. Describe the condition of the client.
3. Tell us about treatment programs and alternative medicine.
4. Discuss lifestyle changes that may be used to prevent complications.
5. Discuss about therapies and options.
6. Exploration of possible sources that can be used / supported.
7. Instruct when to the ministry.
8. Ask the client's knowledge about the disease, nursing procedures and treatment.

Rational:

1. Simplify the explanation on the client.
2. Increase knowledge and reduce anxiety.
3. Facilitate intervention.
4. Preventing disease severity.
5. Giving an overview of treatment options that can be used.
6. Reviewing

Nursing Interventions for Tuberculosis

Nursing diagnosis: ineffective airway clearance related to hypersecretion

characterized by a thick secretions or blood.

Objective:

• ffective airway clearance.

Expected outcomes:

• Finding a comfortable position that allows increased air exchange.
• Demonstrate effective cough.
• Stated strategy to reduce the viscosity of secretions.

Plan of Action:

1. Explain to the client about the use of effective coughing and why there is a buildup of secretions in the respiratory tract.
Rationale: Knowledge that will hopefully help develop adherence to the treatment plan.

2. Teach the client about the proper method of controlling cough.
Rationale: Uncontrollable cough is exhausting and ineffective, causing frustration.

3. Breath deeply and slowly when sitting as upright as possible.
Rationale: Allows greater lung expansion.

4. Perform respiratory diaphragm.
Rationale: Respiratory diaphragm lower frequency of breath, and increased alveolar ventilacion.

5. Hold your breath for 3-5 seconds and then slowly remove as much as possible through the mouth. Do a second breath, hold it and batukan of the chest by two short and strong cough.
Rationale: Increasing the volume of air in the lung secretions facilitate spending.

6. Auscultation of the lungs before and after coughing clients.
Rationale: This helps evaluate the effectiveness.

7. Teach client action to reduce secretion: adequate hydration, increase fluid intake 1000 till 1500 cc / day if not contraindicated.
Rational: viscous secretion is difficult to dissolve and can cause blockage of mucus that leads to atelectasis.

8. Perform chest physio claping / vibrating.
Rationale: With a gravity discharge will come out to big and ease spending alveol secretions.

9. Collaboration with other health team physicians, radiology.

• Giving expectoran.
• Giving antibiotics.
• Consul thorax X-ray.

Rational: Expektoran to facilitate mucus and evaluate client improvement of lung development.

Nursing Intervntions for Heart Failure

Nursing Diagnosis : Activity intolerance related to imbalance between supply and demand of oxygen

Goals / Criteria results:

• Clients can perform daily activities with good

Expected outcomes:

• Participating in physical activity with blood pressure, pulse, respiration appropriate
• Normal skin color, warm and dry
• Said the importance of activity gradually
• Expressing the sense of the importance of balancing exercise and rest
• Tolerance activity

Interventions:

• Determining the cause of intolerance activity and determine whether the cause of the physical, psychological / motivation.
• Assess the suitability of activity and rest everyday.
• Increased activity gradually, allow clients to participate can change position, moving & self-care.
• Make sure the client change positions gradually.
• Monitor activity intolerance symptoms.
• When helping clients stand, observation intolerance symptoms such as nausea, pallor, dizziness, impaired consciousness and vital signs.
• Perform ROM exercises if the client can not tolerate activity.

Rational:

• Determining the cause can help determine intolerance.
• Prolonged bedrest can contribute to activity intolerance.
• Increased activity helps maintain muscle strength, tone.
• Bedrest in the supine plasma volume causes postural hypotension and syncope →
• Vital signs in response to orthostatic very diverse.
• Inactivity contributes to muscle strength and joint structure.

Nursing Interventions for Heart Failure

Nursing Diagnosis : Decrease Cardiac Output related to Myocardial Infarction

Goals / Criteria results:

NOC:

• After nursing intervention on the client:
• Clients can have a heart pump effectively,
• status of the circulation, tissue perfusion and vital signs were normal status.

Expected outcomes:
Shows adequate cardiac output indicated by blood pressure, pulse, normal rhythm, strong peripheral pulses, without dipsnea activity and pain.
Free from side effects of medications used

Cardiac Care: acute

• Evaluation of chest pain
• Auscultation of heart sounds
• Evaluation of the krackels
• Monitor the status of neurology
• Monitor intake / output, urine output
• Create an environment that is conducive to rest

Circulatory Care:

• Evaluation arteries and peripheral edema
• Monitor skin and extremities
• Monitor vital signs
• Move the client's position every 2 hours if needed
• Teach ROM during bedrest
• Monitor compliance with liquids

Rational:

• The presence of pain suggests inadequate blood supply to the heart
• Still a gallop rhythm, crackels, tachycardia indicate heart failure
• Role in CNS disorders may be associated with decreased cardiac output
• Spending urine less than 30 ml / hour showed a decrease in cardiac output
• The emergence of signs of heart failure, showed a decrease in cardiac output

Ineffective Breathing Pattern - NCP for Acute Myocardial Infarction