List of Nursing Diagnosis

Nursing Care Plan for Malaria

Imbalanced Nutrition Less Than Body Requirements related to inadequate food intake ; anorexia ; nausea / vomiting.

Goal :

Nutrients are met.

Outcomes :
Increased nutrient intake.

Intervention :
1. Assess the nutritional history, including the preferred food . Observation and record food intake.
Rational : Keep an eye on caloric intake or lack of quality of food consumption.

2. Give a little to eat, and a little extra food right.
Rational : Gastric dilatation can occur when feeding too quickly after a period of anorexia.

3. Maintain a schedule of regular weighing.
Rational : Keep an eye on the effectiveness of weight loss or nutritional intervention.

4. Discuss preferred by the client and input in a pure diet.
Rational : It can increase input, increase the sense of participation / control.

5. Observe and record the presence of nausea / vomiting , and other symptoms associated.
Rational : GI symptoms may show the effects of anemia ( hypoxia ) in the organ.

6. Collaboration to perform to a dietitian.
Rationale : Need help in planning a diet that meets nutritional needs.


Knowledge Deficit : about the disease, prognosis and treatment needs related to lack of exposure / recall errors of interpretation of information, cognitive limitations.

Interventions :

1. Review the disease process and future expectations.
Rationale : This action provides the knowledge base in which the patient can make a choice.

2. Provide information on drugs, drug interactions, side effects and adherence to the program.
Rationale : Increase understanding and enhance cooperation in healing and reducing recurrence of complications.

3. Discuss the need for proper nutritional intake and balanced.
Rational : That the need for optimal healing and general well-being.

4. Encourage periods of rest and activity scheduled.
Rational : That the energy savings and improve healing.

5. Review the need for personal hygiene and environmental cleanliness.
Rationale : Helps control the exposure environment, by reducing the number of disease-causing there.

6. Identify signs and symptoms that require medical evaluation.
Rationale : Early recognition of the development / recurrence of infection.

7. Emphasize the importance of antibiotic treatment as needed.
Rationale : The use of the prevention of infection.

Assessment

1. Activity / Rest
Symptoms : Insomnia, increased sensitivity ; muscle weakness, impaired coordination ; Severe fatigue.
Signs : muscle atrophy.

2. Circulation
Symptoms : Palpitations, chest pain (angina).
Signs : dysrhythmias (atrial fibrillation), gallop rhythm, murmurs ; Increased blood pressure with a heavy tone pressure, tachycardia ; Circulatory collapse, shock (crisis thyrotoxicosis)

3· Ego Integrity
Symptoms : Experiencing severe stress both emotionally and physically.
Signs : Emotions labile (euphoria moderate to delirium), depression.


Physical Examination (ROS : Review of Systems)

1. Respiratory B1 (breath)
circulatory collapse, shock (crisis thyrotoxicosis), increased respiratory rate, dyspnea, and pulmonary edema.

2. Cardiovascular B2 (blood)
Hypertension, arrhythmia, palpitations, heart failure, lymphocytosis, anemia, splenomegaly, enlarged neck.

3. Nerves B3 (Brain)
Rapid and guttural speech, impaired mental status and behavior, such as confusion, disorientation, anxiety, sensitive excitatory, delirium, psychosis, stupor, coma, tremors smooth on hands, without purpose, some parts jerky, hyperactive deep tendon reflexes.

4. Urinary B4 (bladder)
Oligomenorrhea, amenorrhea, down libido, infertility, gynekomastia.

5. Digestive B5 (bowel)
Sudden weight loss, increased appetite, eat a lot, eat often, thirst, nausea and vomiting.

6. Musculoskeletal / integument B6 (bone)
Weakness, fatigue.


Nursing Diagnosis for Hyperthyroidism

Nursing Diagnosis : Hyperthermia related to inflammatory processes.

Goal : Normal body temperature.

Outcomes :

• No signs of dehydration,
• Lips moist.

Intervention :
1. Give warm water compress as needed.
R / : Can help decrease heat experienced by the patient.

2. Encourage clients to use clothes that can absorb sweat.
R / : Due to the humid conditions of the body triggers the growth of fungi that cause risk of complications.

3. Maintain a cool environment.
R / : To help maintain the body temperature of the patient to be in a normal state.

4. Collaboration with the medical team in drug delivery.
R / : Helps reduce body temperature of the patient.


Nursing Diagnosis : Imbalanced nutrition : less than body requirements related to the inability to absorb nutrients.

Goal : Nutritional needs fulfilled.

Outcomes :

• Return to normal eating,
• Normal weight,
• Normal laboratory examination,
• Showed no signs of malnutrition,
• Not nausea,
• Not vomiting.

Intervention :
1. Supervise dietary supply, give eat little but often.
R / : To avoid nausea and vomiting and nutritional needs of patients.

2. Encourage the patient to eat little but often.
R / : Increased appetite.

3. Provide information about the importance of nutrition for the body.
R / : Improving patients' knowledge about nutrition.

4. Collaboration with the medical team in drug delivery.
R / : To provide appropriate therapy for patients.

Imbalanced Nutrition Less Than Body Requirements
related to :

• Decreased oral intake, discomfort in the mouth, nausea, vomiting.
• Decreased absorption of nutrients.
• Vomiting, anorexia, impaired digestion.
• Depression, stress, social isolation.

Outcomes : The client will :
consume the daily nutritional needs in accordance with the level of activity and metabolic demand.

Indicator :

• Explaining the importance of adequate nutrition.
• Identify gaps or deficiencies in the daily intake.
• Mention the methods to increase appetite.

Intervention


1. Explaining the need for the consumption of carbohydrates, fats, proteins, vitamins, minerals and adequate fluid.
2. Consult with a nutritionist to establish a daily calorie needs and the type of food that is in accordance with the client.
3. Discuss with the client the possible causes of loss of appetite.
4. Encourage clients to rest before eating.
5. Instruct food in small amounts but often .
6. On the condition of decreased appetite, limit fluid intake during meals and avoid consuming fluids one hour before and after meals.
7. Encourage and assist clients to maintain good oral hygiene.
8. Set the position of foods high in calories and high in protein are presented when the client is usually the most hungry.
9. Perform the following steps to increase appetite :

• Determine the client's food preferences and set it to the food presented whenever possible.
• Eliminate odors and unpleasant sight of the dining area.
• Control pain and nausea before eating.
• Instruct the nearest person is allowed to bring food from home if possible.
• Create a relaxing environment while eating.

10. Give the client a list of diet nutrient material , which consists of :

• High intake of complex carbohydrates and fiber .
• Reduction of the intake of sugar , salt , cholesterol , total fat and saturated fat .
• The use of alcohol only in moderation .
• Appropriate caloric intake to maintain ideal weight .

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.

Causes

• 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.

NOC :
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.

NIC :

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.

Nursing Care Plan for Vertigo

Vertigo is a sensation of motion or spinning that is often described as dizziness.

Vertigo is actually different from the dizzy in the head or headache. People with impaired vertigo feel as though they are actually spinning or moving, and the nature that is around them also began to spin.

The main symptom is a sensation felt like moving or rotating space. The spinning sensation may cause nausea and vomiting.

Other symptoms can include :

• Difficulty focus look.
• Dizziness.
• Hearing loss in one ear.
• Loss of balance (can lead to falls).
• Ringing in the ears.

If interference vertigo due to problems in the brain (central vertigo), usually feel other symptoms, such as :

• Difficulty swallowing.
• Double vision.
• Eye movement problems.
• Facial paralysis.
• Slurred speech.
• The weakness of the limbs on a limb.

Nursing Diagnosis for Vertigo : Imbalance Nutrition Less than Body Requirements related to loss of appetite, nausea and vomiting


NOC :

• Nutritional status : the level of nutrients available to meet metabolic needs.
• Nutritional status : food and fluid intake : the amount of food and fluid intake in the body for 24 hours.
• Nutritional status : nutritional value : adequacy of the body of nutrients consumed.

Outcomes : The client will :

• maintaining ideal body weight.
• expressed tolerance to the recommended diet.
• maintain body mass and body weight in the normal range.
• reported adequacy of energy levels.

NIC Interventions :

• Management of eating disorders.
• Nutrient management.
• Help raise the weight.

Nursing Interventions :

• Measure weight at appropriate intervals.
• Determine the client's weight idea.
• Provide information regarding the resources available. Such as dietary counseling, exercise programs.
• Discuss with client regarding a medical condition affecting body weight.
• Discuss the risks associated with excess weight or deficiency.
• Assist clients in developing a balanced eating plan and consistent with the level of energy use.

Related Articles :

Defining Characteristics of Imbalanced Nutrition Less than Body Requirements

Imbalanced Nutrition Less Than Body Requirements - Diabetes Mellitus

Imbalance Nutrition Less than Body Requirements related to psychological factors

The author suggests the use of this diagnosis only if there is one among the following signs :

• Weight less than 20 % or more below ideal weight for height and body frame.
• Food intake is less than the metabolic needs, both total calories and certain nutrients.
• Losing weight baan with adequate food intake.
• Reported inadequate food intake less than RDA.

Subjective :
Abdominal cramps.

• Abdominal pain.
• Refusing to eat.
• Perception inability to digest a meal.
• Reported changes in taste sensation.
• Reported a lack of food.
• Feeling full quickly after eating.

Objective :

• Fragile capillaries.
• Diarrhea or steatorrhea.
• Evidence of lack of food.
• Excessive hair loss.
• Hyperactive bowel sounds.
• Lack of information / misinformation.
• Lack of interest in food.
• Oral cavity hurt.
• Muscle weakness which serves to swallow or chew.

Imbalanced Nutrition Less Than Body Requirements - Diabetes Mellitus

Imbalance Nutrition Less than Body Requirements related to psychological factors

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

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