List of Nursing Diagnosis

Nursing Diagnosis for Anaphylactic Shock : Impaired Gas Exchange

Anaphylactic shock is a hypersensitivity response mediated by immunoglobulin E (hypersensitivity type I) is characterized by cardiac output and arterial pressure decreased great. This is caused by the presence of an antigen-antibody reaction which arises as soon as a sensitive antigen into the circulation. Anaphylactic shock is a clinical manifestation of anaphylaxis which is a distributive shock, characterized by the presence of significant hypotension due to sudden vasodilation of the blood vessels and accompanied the collapse of blood circulation which can lead to death. Anaphylactic shock is a case of gravity, but too narrow to describe anaphylaxis as a whole, because of severe anaphylaxis can occur in the absence of hypotension, as the main symptoms of anaphylaxis with airway obstruction.

Clinical manifestations of anaphylaxis vary widely. In the clinic, there are 3 types of anaphylactic reaction, namely the rapid reaction which occurs several minutes to 1 hour after exposure to the allergen; moderate reaction occurs between 1 and 24 hours after exposure to the allergen; and slow reactions occurred more than 24 hours after exposure to the allergen.

Symptoms may begin with a new prodormal symptoms become severe, but sometimes directly heavy. Based on the degree of the complaint, anaphylaxis is also divided into mild, moderate, and severe. Mild often with symptoms of peripheral tingling, warm sensation, tightness in the mouth, and throat. Can also occur nasal congestion, periorbital swelling, pruritus, sneezing, and watery eyes. Onset of symptoms started within the first 2 hours after exposure. Degrees were able to cover all the mild symptoms plus bronchospasm and airway or laryngeal edema with dyspnea, cough and wheezing. Facial redness, warm, anxiety, and itching are also common. Onset of symptoms similar to a mild reaction. The degree of weight have a very sudden onset with signs and symptoms are the same as those mentioned above with the rapid progress towards bronkospame, laryngeal edema, severe dyspnea, and cyanosis. Can be accompanied by symptoms of dysphagia, abdominal cramps, vomiting, diarrhea, and convulsions. Cardiac arrest and coma are rare. Death can result from respiratory failure, ventricular arrhythmias or irreversible shock.

Symptoms can occur immediately after exposure to the antigen and can occur in one or more target organs, such as cardiovascular, respiratory, gastrointestinal, skin, eyes, central nervous system and urinary system, and other systems. Complaints are often found in the initial phase is fear, burning in the mouth, itching of the eyes and skin, heat and tingling in the limbs, shortness, hoarseness, nausea, dizziness, fatigue and abdominal pain.

In the respiratory system occur hyperventilation, decreased pulmonary blood flow, decreased oxygen saturation, increased pulmonary pressure, respiratory failure, and a decrease in tidal volume. Upper respiratory tract can be impaired if the tongue or oropharynx involved causing stridor. Hoarse voice could even no sound at all if edema continues to deteriorate. Complete airway obstruction is the most frequent cause of death in anaphylaxis. Wheezing breath sounds occur when the lower respiratory tract is interrupted due to bronchospasm or mucosal edema. In addition, a cough, nasal congestion, and sneezing.


Nursing Care Plan for Anaphylactic Shock

Nursing Diagnosis : Impaired gas exchange related to ventilation perfusion imbalance.
characterized by: shortness of breath, tachycardia, flushing, hypotension, shock, and bronchospasm.

Goal: expected gas exchange problems handled
with expected outcomes: no shortness of breath, adequate ventilation, no symptoms of respiratory distress.

Nursing Interventions:

• Assess frequency, depth and ease breathing.
• Maintain patency of the airway to give the position, exploitation, and the use of tools.
• Assess the level of consciousness / mental changes.
• Collaboration give oxygen therapy correctly, according to the condition of clients.
• Collaboration give medicines.

Rational :

• Increased respiratory effort may indicate the degree of hypoxemia and useful in the evaluation of the degree of respiratory distress.
• Because airway obstruction may affect ventilation and impairs gas exchange.
• Therefore, systemic hypoxemia can be demonstrated first by the restless and sensitive excitatory later by progressive mental decline.
• The aim of oxygen therapy is to maintain PaO 2 above 60 mm Hg, oxygen is supplied with appropriate delivery methods tolerance client.
• Used to prevent allergic reactions / inhibit histamine release, lose weight and spasm of the airway, respiratory inflammation and dyspnea.

Nursing Care Plan for Pneumonia


Nursing Diagnosis 1. Ineffective Airway Clearance related to excessive secretions secondary to infection.

Goal : demonstrate a patent airway with breath sounds clean.

Interventions :
1. Assess the frequency / depth of breathing and chest movement.
Rationale : tachypnea , shallow breathing and chest movement is not symmetrical movements often occur due to discomfort or chest wall and the lung fluid.

2. Auscultation of the lung area, note areas of decreased / no air flow and breath sounds crackles.
Rationale : reduction in air flow occurs in the area of ​​consolidation with fluid, crackles audible in response to fluid collection, secret.

3. Provide warm water rather than cold water.
Rationale : warm fluid mobilizing and removing secret.

4. Collaboration of mucolytic , expectorant.
Rationale : helps reduce bronchospasm with secret mobilization.



Nursing Diagnosis 2. Acute Pain related to inflammation of the lung parenchyma.

Goal : pain diminished or disappeared.
Interventions :
1. Determine the characteristics of the pain, ie sharp, stabbed, constant.
Rationale : Chest pain is usually present in some degree in pneumonia, a complication of pneumonia can also occur as pericarditis and endocarditis.

2. Monitor vital signs.
Rationale : changes in heart rate or BP indicates that the patient is experiencing pain.

3. Provide convenient measures, such as : relaxation, massage your back.
Rationale : non- analgesic action is given with a gentle touch can eliminate the discomfort and increase the therapeutic effect of analgesics.

4. Collaboration in analgesic administration.
Rationale : expected to help reduce pain.



Nursing Diagnosis 3. Ineffective Breathing Pattern related to excessive secretion secondary to infection.

Goal : maintain adequate ventilation.

Interventions :
1. Assess the frequency, depth of breathing.
Rationale : tachypnea, shallow breathing often occurs due to discomfort or movement of the chest wall and the lung fluid.

2. Auscultation of breath sounds.
Rationale : indicates the occurrence of complications (additional sound indicates the presence of fluid accumulation / secretion).

3. Monitor vital signs.
Rationale : continuous vital sign abnormalities requiring further evaluation.

4. Collaboration of O2 as indicated.
Rationale : maintain PaO 2 above 60 mmHg.



Nursing Diagnosis 4. Imbalanced Nutrition Less Than Body Requirements related to decreased appetite secondary to nausea and vomiting.

Goal : show increased appetite .

Intrervention :
1. Identification of factors that cause nausea and vomiting.
Rationale : the choice of intervention depends on the causes of the problem.

2. Auscultation of bowel sounds.
Rationale : bowel sounds may be reduced / no if the infection is severe / elongated.

3. Feed small portions but frequently , including food attractive to patients.
Rationale : This action can increase appetite though slow to return.

4. Collaboration of antiemetics.
Rationale : expected to prevent vomiting.



Nursing Diagnosis 5. Activity Intolerance related to imbalance between oxygen supply and demand.

Goal : show increased tolerance to activity.

Interventions :
1. Evaluation of the patient's response to the activity.
Rationale : define needs and facilitate patient choice of intervention.

2. Provide quiet environment and limit visitors during the acute phase as indicated.
Rationale : reduce stress and excessive stimulation , increasing the break.

3. Help needed self-care activities.
Rationale : minimize fatigue and help balance supply and oxygen demand.



Nursing Diagnosis 6. Hyperthermia related to inflammatory lung parenchyma.

Goal : maintain the temperature within normal limits.

Interventions :
1. Monitor the patient's temperature.
Rationale : temperature 38.9 ° C - 41.1 ° C showed an acute infectious disease process.

2 . Give compress warm bath.
Rationale : can help reduce fever.

3. Collaboration of antipyretics.
Rationale : expected to help reduce fever by central action on the hypothalamus.



Nursing Diagnosis 7. Disturbed Sleep Pattern related to frequent waking tehadap secondary respiratory disorders, cough.

Goal : Sleep patterns of patients adequately.

Interventions :
1. Determine usually sleeping habits and changes that occur.
Rationale : the need to assess and identify appropriate interventions.

2. Give a comfortable bed.
Rationale : improve sleep comfort and psychological support.

3. Instruct relaxation action.
Rationale : to help induce sleep.

4. Provide a comfortable position, aids in changing positions.
Rationale : changing the position of the pressure change and improve rest area.


Nursing Diagnosis 8. Risk for Fluid Volume Deficits related to excessive fluid loss from vomiting.

Goal : demonstrate adequate fluid volume.

Interventions :
1. Assess changes in vital signs.
Rationale : the increase in temperature increases the metabolic rate and fluid loss through evaporation.

2. skin turgor , mucous membrane moisture.
Rationale : a direct indicator of the strength of the liquid volume.

3. Make a note of the report of nausea and vomiting.
Rationale : the presence of these symptoms indicate oral input.

4. Collaboration of antipyretics, antiemetics.
Rationale : useful decrease fluid loss.