List of Nursing Diagnosis

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.

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