List of Nursing Diagnosis

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