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Nursing Diagnosis for Hyperemesis Gravidarum

Nursing Diagnosis for Hyperemesis Gravidarum

Hyperemesis gravidarum

Hyperemesis gravidarum is extreme, persistent nausea and vomiting during pregnancy that may lead to dehydration.



Causes

Nearly all women have some nausea or vomiting, or "morning sickness," particularly during the first 3 months of pregnancy. The cause of nausea and vomiting during pregnancy is believed to be rapidly rising blood levels of a hormone called HCG (human chorionic gonadotropin), which is released by the placenta.

Extreme nausea and vomiting during pregnancy can happen if you are pregnant with twins (or more) or if you have a hydatidiform mole.

Nursing Diagnosis for Hyperemesis Gravidarum
  1. Imbalanced Nutrition : Less Than Body Requirements related to the frequency of excessive nausea and vomiting.
  2. Fluid Volume Deficit related to excessive fluid loss.
  3. Ineffective Coping related to physiological changes of pregnancy.
  4. Activity Intolerance related to weakness.

Nursing Diagnosis for Myocarditis

Nursing Diagnosis for Myocarditis

Myocarditis is an inflammatory disease of the myocardium with a wide range of clinical presentation, from subtle to devastating. It is diagnosed by established histologic, immunologic, and immunochemical criteria. Myocarditis is described as "an inflammatory infiltrate of the myocardium with necrosis and/or degeneration of adjacent myocytes." It usually manifests in an otherwise healthy person and can result in rapidly progressive (and often fatal) heart failure and arrhythmia. In the clinical setting, myocarditis is synonymous with inflammatory cardiomyopathy.


Nursing Diagnosis for Myocarditis


  1. Pain related to inflammation of the myocardium, systemic effects of infection, tissue ischemia.
  2. Activity Intolerance related to inflammation and degeneration of myocardial muscle cells, decreased cardiac output.
  3. Risks for Decrease Cardiac Output related to degeneration of heart muscle, decreased / constricting ventricular function.
  4. Knowledge Deficit : about the condition, treatment plan related to less knowledge / memory.

Nursing Diagnosis for Hemorrhagic Stroke

Nursing Diagnosis for Hemorrhagic Stroke

Hemorrhagic Stroke

Hemorrhagic stroke involves bleeding within the brain, which damages nearby brain tissue.



Causes

Hemorrhagic stroke occurs when a blood vessel bursts inside the brain. The brain is very sensitive to bleeding and damage can occur very rapidly. Bleeding irritates the brain tissue, causing swelling. Bleeding collects into a mass called a hematoma. Bleeding also increases pressure on the brain and presses it against the skull.
Hemorrhagic strokes are grouped according to location of the blood vessel:
  • Intracerebral hemorrhage: Bleeding in the brain
  • Subarachnoid hemorrhage: Bleeding in the area between the brain and the thin tissues that cover the brain
Hemorrhagic stroke is most often due to high blood pressure, which stresses the artery walls until they break.
Other causes of hemorrhagic stroke include:
  • Aneurysms, which create a weak spot in an artery wall, which can eventually burst
  • Abnormal connections between arteries and veins, such as an arteriovenous malformation (AVM)
  • Cancer, particularly cancer that spreads to the brain from distant organs such as the breast, skin, and thyroid
  • Cerebral amyloid angiopathy, a build up of amyloid protein within the artery walls in the brain, which makes bleeding more likely
  • Conditions or medications (such as aspirin or Warfarin) that can make you bleed excessively
  • Illicit drugs, such as cocaine

Nursing Diagnosis for Hemorrhagic Stroke
  1. Ineffective tissue perfusion (cerebral) related to bleeding or vasospasm
  2. Disturbed sensory perception related to medically imposed restrictions (aneurysm precautions)
  3. Anxiety related to illness and/or medically imposed restrictions (aneurysm precautions)

Nursing Diagnosis for Ischemic Stroke

Ischemic stroke is a stroke caused by inadequate blood flow to a part of the brain. Because the brain requires a continuous supply of oxygen and other nutrients from the blood, this interruption in blood flow leads to dysfunction of the brain and death of the cells in the affected area.

The term stroke refers to any new neurological symptoms with a sudden onset. While the term is sometimes used to refer to other sudden neurological events, such as subarachnoid hemorrhage or spontaneous hypertensive hemorrhage, it is most commonly used to refer to ischemic stroke.

If ischemic (decreased blood flow) is severe enough and/or prolonged enough it causes death of the part of brain which is involved. This is also termed cerebral infarction. While lower levels of ischemia may cause symptoms, they can be reversible if reversed before a full infarction occurs.



Nursing Diagnosis for Ischemic Stroke

  1. Impaired Physical Mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain injury.
  2. Acute Pain (painful shoulder) related to hemiplegia and disuse
  3. Self-care Deficits (bathing, hygiene, toileting, dressing, grooming, and feeding) related to stroke sequelae
  4. Disturbed Sensory Perception related to altered sensory reception, transmission, and/or integration
  5. Impaired swallowing
  6. Total urinary incontinence related to flaccid bladder, detrusor instability, confusion, or difficulty in communicating
  7. Disturbed thought processes related to brain damage, confusion, or inability to follow instructions
  8. Impaired verbal communication related to brain damage
  9. Risk for impaired skin integrity related to hemiparesis, hemiplegia, or decreased mobility
  10. Interrupted family processes related to catastrophic illness and caregiving burdens

Nursing Diagnosis Fatigue

Definition

Fatigue An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at usual level



Characteristics:

Inability to restore energy even after sleep; lack of energy or inability to maintain usual level of physical activity; increase in rest requirements; tired; inability to maintain usual routines; verbalization of an unremitting and overwhelming lack of energy; lethargic or listless; perceived need for additional energy to accomplish routine tasks; increase in physical complaints; compromised concentration; disinterest in surroundings, introspection; decreased performance; compromised libido; drowsy; feelings of guilt for not keeping up with responsibilities


Related Factors:
  • Boring lifestyle; stress; anxiety; depression
  • Humidity; lights; noise; temperature
  • Negative life events; occupation
  • Sleep deprivation; pregnancy; poor physical condition; disease states (cancer, HIV, multiple sclerosis); increased physical exertion; malnutrition; anemia

NOC Outcomes (Nursing Outcomes Classification)
  • Endurance
  • Concentration
  • Energy Conservation
  • Nutritional Status: Energy

Client Outcomes
  • Verbalizes increased energy and improved well-being
  • Explains energy conservation plan to offset fatigue

NIC Interventions (Nursing Interventions Classification)
  • Energy Management

Nursing Interventions
  • Assess severity of fatigue on a scale of 0 to 10; assess frequency of fatigue, activities associated with increased fatigue, ability to perform activities of daily living (ADLs), times of increased energy, ability to concentrate, mood, and usual pattern of activity.
  • Evaluate adequacy of nutrition and sleep. Encourage the client to get adequate rest. Refer to Imbalanced Nutrition: less than body requirements or Disturbed Sleep pattern if appropriate.
  • Determine with help from the primary care practitioner whether there is a physiological or psychological cause of fatigue that could be treated, such as anemia, electrolyte imbalance, hypothyroidism, depression, or medication effect.
  • Work with the physician to determine if the client has chronic fatigue syndrome.
  • Encourage client to express feelings about fatigue; use active listening techniques and help identify sources of hope.
  • Encourage client to keep a journal of activities, symptoms of fatigue, and feelings.
  • Assist client with ADLs as necessary; encourage independence without causing exhaustion.
  • Help client set small, easily achieved short-term goals such as writing two sentences in a journal daily or walking to the end of the hallway twice daily.
  • With physician's approval, refer to physical therapy for carefully monitored aerobic exercise program.
  • Refer client to diagnosis-appropriate support groups such as National Chronic Fatigue Syndrome Association or Multiple Sclerosis Association.
  • Help client identify essential and nonessential tasks and determine what can be delegated.
  • Give client permission to limit social and role demands if needed (e.g., switch to part-time employment, hire cleaning service).
  • Refer client to occupational therapy to learn new energy-conserving ways to perform tasks.
  • If client is very weak, refer to physical therapy for prescription and use of a mobility aid such as a walker.
  • Identify recent losses; monitor for depression as a possible contributing factor to fatigue.
  • Review medications for side effects. Certain medications (e.g., beta-blockers, antihistamines, pain medications) may cause fatigue in the elderly.

Home Care Interventions
  • Assess client's history and current patterns of fatigue as they relate to the home environment. Fatigue may be more pronounced in specific settings for physical or psychological reason.
  • Assess home for environmental and behavioral triggers of increased fatigue
  • When assisting client with adapting to home and daily patterns, avoid activities of high energy output. Refer to occupational therapy to accomplish this if necessary.
  • Assist client with identifying or creating a safe, restful place within the home that can be used routinely (e.g., a room with familiar, nonthreatening, or nonfrightening belongings).

Client/Family Teaching
  • Share information about fatigue and how to live with it, including need for positive self-talk.
  • Teach strategies for energy conservation
  • Teach client to carry a pocket calendar, make lists of required activities, and post reminders around the house.
  • Teach the importance of following a healthy lifestyle with adequate nutrition and rest, pain relief, and appropriate exercise to decrease fatigue.
  • Teach stress-reduction techniques such as controlled breathing, imagery, and use of music. See Anxiety care plan if appropriate; anxiety is correlated with increased fatigue.

Nursing Diagnosis Disturbed Sleep Pattern

Definition :

Disturbed Sleep pattern Time-limited disruption of sleep
Disturbed Sleep pattern


Characteristics:

Prolonged awakenings, sleep maintenance insomnia, self-induced impairment of normal pattern, sleep onset more than 30 minutes, early morning insomnia, awakening earlier or later than desired, verbal complaints of difficulty falling asleep, verbal complaints of not feeling well-rested, increased proportion of Stage 1 sleep, dissatisfaction with sleep, less than age-normed total sleep time, three or more nighttime awakenings, decreased proportion of Stages 3 and 4 sleep, decreased ability to function


Related Factors:

Daytime activity pattern, Thinking about home, Body temperature, Temperament, Dietary, Childhood onset, Inadequate sleep hygiene, Sustained use of antisleep agents, Circadian asynchrony, Frequently changing sleep-wake schedule, Depression, Loneliness, Frequent travel across time zones, daylight/darkness exposure, grief, anticipation, shift work, delayed or advanced sleep phase syndrome, loss of sleep partner, life change, preoccupation with trying to sleep, periodic gender-related hormonal shifts, biochemical agents, fear, separation from significant others; social schedule inconsistent with chronotype, aging-related sleep shifts, anxiety, medications, fear of insomnia, maladaptive conditioned wakefulness, fatigue, boredom


NIC Interventions (Nursing Interventions Classification)
  • Sleep Enhancement
  • Nursing Interventions nursing care Plans Disturbed Sleep pattern
  • Assess client's sleep patterns and usual bedtime rituals and incorporate these into the plan of care.
  • Determine current level of anxiety, if client is anxious.
  • Assess for signs of new onset of depression: depressed mood state, statements of hopelessness, poor appetite.
  • Observe client's medication, diet, and caffeine intake. Look for hidden sources of caffeine, such as over-the-counter medications.
  • Provide measures to take before bedtime to assist with sleep.
  • Provide pain relief shortly before bedtime and position client comfortably for sleep.
  • Keep environment quiet.
  • Do a careful history of all medications including over-the-counter medications and alcohol intake.
  • If client is waking frequently during the night, consider the presence of sleep apnea problems and refer to a sleep clinic for evaluation.
  • Evaluate client for presence of depression or anxiety.
  • Encourage social activities.
  • Suggest light reading or TV viewing that does not excite as an evening activity.
  • Increase daytime physical activity. Encourage walking as client is able.
  • Avoid use of hypnotics and alcohol to sleep.
  • Reduce daytime napping in the late afternoon; limit naps to short intervals as early in the day as possible.
  • Use soothing sound generators with sounds of the ocean, rainfall, or waterfall to induce sleep, or use "white noise" such as a fan to block out other sounds.
  • Determine if client has a physiological problem that could result in insomnia such as pain, cardiovascular disease, pulmonary disease, neurological problems such as dementia, or urinary problems.
  • Observe elimination patterns. Have client decrease fluid intake in the evening, and ensure that diuretics are taken early in the morning.
  • If client continues to have insomnia despite developing good sleep hygiene habits, refer to a sleep clinic for further evaluation.

Client/Family Teaching for Disturbed Sleep Pattern
  • Teach the following guidelines for good sleep hygiene to improve sleep habits: Go to bed only when sleepy, When awake in the middle of the night, go to another room, do quiet activities, and go back to bed only when sleepy, Use the bed only for sleeping not for reading or snoozing in front of the television, Avoid afternoon and evening naps, Get up at the same time every morning, Recognize that not everyone needs 8 hours of sleep, Move the alarm clock away from the bed if it is a source of distraction.
  • Encourage client to avoid coffee and other caffeinated foods and liquids and also to avoid eating large high-protein or high-fat meals before bedtime.
  • Advise client to avoid use of alcohol or hypnotics to induce sleep.
  • Ask client to keep a sleep diary for several weeks.
  • Teach relaxation techniques, pain relief measures, or the use of imagery before sleep.
  • Teach client need for increased exercise.
  • Encourage client to develop a bedtime ritual that includes quiet activities such as reading, television, or crafts.

Nursing Outcomes
  • Sleep
  • Rest
  • Well-Being
  • Psychosocial Adjustment: Life Change
  • Quality of Life
  • Pain Level
  • Comfort Level

Client Outcomes
  • Wakes up less frequently during night
  • Awakens refreshed and is not fatigued during day
  • Falls asleep without difficulty
  • Verbalizes plan to implement bedtime routines

Nursing Diagnosis for Disturbed Body Image

Definition :

Confusion in mental picture of one's physical self Defining Characteristics: Nonverbal response to actual or perceived change in structure and/or function; verbalization of feelings that reflect an altered view of one's body in appearance, structure, or function; verbalization of perceptions that reflect an altered view of one's body in appearance, structure, or function; behaviours of avoidance, monitoring, or acknowledgment of one's body.


Related Factors
  • Situational changes (e.g., pregnancy, temporary presence of a visible drain or tube, dressing, attached equipment)
  • Permanent alterations in structure and/or function (e.g., mutilating surgery, removal of body part [internal or external])
  • Malodorous lesions
  • Change in voice quality

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
  • Body Image Enhancement
  • Grief Work Facilitation
  • Coping Enhancement

Client Outcomes
  • States or demonstrates acceptance of change or loss and an ability to adjust to lifestyle change
  • Calls body part or loss by appropriate name
  • Looks at and touches changed or missing body part
  • Cares for changed or nonfunctioning part without inflicting trauma
  • Returns to previous social involvement
  • Correctly estimates relationship of body to environment

NIC Interventions (Nursing Interventions Classification)
  • Use a tool such as the Body Image Instrument (BII) to identify clients who have concerns about changes in body image.
  • Observe client's usual coping mechanisms during times of extreme stress and reinforce their use in the current crisis
  • Acknowledge denial, anger, or depression as normal feelings when adjusting to changes in body and lifestyle.
  • Identify clients at risk for body image disturbance (e.g. body builders, cancer survivors).
  • Clients should not be rushed into sharing their feelings.
  • Do not ask clients to explore feelings unless they have indicated a need to do so.
  • Explore strengths and resources with client. Discuss possible changes in weight and hair loss; select a wig before hair loss occurs.
  • Encourage client to purchase clothes that are attractive and that de-emphasize their disability.
  • Allow client and others gradual exposure to the body change.
  • Encourage client to discuss interpersonal and social conflicts that may arise.
  • Encourage client to make own decisions, participate in plan of care, and accept both inadequacies and strengths.
  • Help client accept help from others; provide a list of appropriate community resources.
  • Help client describe self-ideal, identify self-criticisms, and be accepting of self.
  • Encourage client to write a narrative description of their changes.
  • Avoid looks of distaste when caring for clients who have had disfiguring surgery or injuries. Provide privacy; care should be completed without unnecessary exposure.
  • Encourage client to continue same personal care routine that was followed before the change in body image.
  • Focus on remaining abilities. Have client make a list of strengths.

Home health Care Interventions
  • Assess client's stage of grieving or acceptance of body change upon return to home setting. Include the future role of sexuality in the psychological assessment of acceptance as appropriate.
  • Assess family/caregiver level of acceptance of client's body changes.
  • Be accepting of changes in all interactions with client and family/caregivers.
  • Help client to see new or changing roles in family.
  • Refer to medical social services for level of acceptance and possible financial impact of changes.
  • Teach all aspects of care. Involve client and caregivers in self-care as soon as possible. Do this in stages if client still has difficulty.
  • Teach family and client complications of medical condition and when to contact physician.
  • Refer to occupational therapy if necessary to evaluate home setting for safety and adaptive equipment and to assist client with return to normal activities.
  • If appropriate, provide home health aide support to help the client and family through ADL transition.
  • Refer to physical therapy if necessary to build range-of-joint-motion (ROJM) flexibility and strength, prevent contractures.
  • Assess for and promote good nutrition and sleep patterns. Adapt nutrition to specific physiological situations.

Nursing Diagnosis for Ineffective Coping

NANDA Definition: Inability to form a valid appraisal of internal or external stressors, inadequate choices of practiced responses, and/or inability to access or use available resources

Defining Characteristics: Lack of goal-directed behavior or resolution of problem, including inability to attend; difficulty with organized information; sleep disturbance; abuse of chemical agents; decreased use of social support; use of forms of coping that impede adaptive behavior; poor concentration; fatigue; inadequate problem solving; verbalized inability to cope or ask for help; inability to meet basic needs; destructive behavior toward self or others; inability to meet role expectations; high illness rate; change in usual communication patterns; risk taking

Related Factors: Gender differences in coping strategies; inadequate level of confidence in ability to cope; uncertainty; inadequate social support created by characteristics of relationships; inadequate level of perception of control; inadequate resource availability; high degree of threat; situational crises; maturational crises; disturbance in pattern of tension release; inadequate opportunity to prepare for stressor; inability to conserve adaptive energies; disturbance in pattern of appraisal of threat; chronic conditions; alteration in body integrity; cultural variables



Client Outcomes

1. Verbalize ability to cope and ask for help when needed
2. Demonstrate ability to solve problems related to current needs
3. Remain free of destructive behavior toward self or others
4. Communicate needs and negotiate with others to meet needs
5. Discuss how recent life stressors have overwhelmed normal coping strategies
6. Demonstrate new effective coping strategies
7. Have illness and accident rates not excessive for age and developmental level



Nursing Interventions and Rationales


  • Observe for causes of ineffective coping such as poor self-concept, grief, lack of problem-solving skills, lack of support, or recent change in life situation.
  • Observe for strengths such as the ability to relate the facts and to recognize the source of stressors.
  • Assess the risk of the client's harming self or others and intervene appropriately.
  • Help the client set realistic goals and identify personal skills and knowledge.
  • Use empathetic communication and encourage the client and family to verbalize fears, express emotions, and set goals.
  • Encourage the client to make choices and participate in the planning of care and scheduled activities.
  • Provide mental and physical activities within the client's ability (e.g., reading, television, radio, crafts, outings, movies, dinners out, social gatherings, exercise, sports, games).
  • If the client is physically able, encourage moderate aerobic exercise.
  • Provide information regarding care before care is given. Adequate information and training before and after treatment reduces anxiety and fear (Herranz and Gavilan, 1999).
  • Discuss changes with the client before making them.
  • Discuss the client's and family's power to change a situation or the need to accept a situation.
  • Use active listening and acceptance to help the client express emotions such as sadness, guilt, and anger (within appropriate limits).
  • Encourage the client to describe previous stressors and the coping mechanisms used.
  • Be supportive of coping behaviors; allow the client time to relax.
  • Help the client to define what meaning his or her symptoms might have for the client.
  • Encourage the use of cognitive behavioral relaxation (e.g., music therapy, guided imagery).
  • Use distraction techniques during procedures that cause the client to be fearful. Distraction is used to direct attention toward a pleasurable experience and block the attention to the feared procedure (DuHamel, Redd, and Johnson-Vickberg, 1999).
  • Use systematic desensitization when introducing new people, places, or procedures that may cause fear and altered coping. Fear of new things diminishes with repeated exposure (DuHamel, Redd, and Johnson-Vickberg, 1999).
  • Provide the client and/or family with a video of any feared procedure to view before the procedure. Ensure that the video shows a client of similar age and background. Videos provide the client and/or family with the information necessary to eliminate fear of the unknown (DuHamel, Redd, and Johnson-Vickberg, 1999).
  • Refer for counseling as needed.
    Geriatric
  • Engage the client in reminiscence. Reminiscence activates positive memories and evokes well-being (Puentes, 2002).
  • Assess and report possible physiological alterations (e.g., sepsis, hypoglycemia, hypotension, infection, changes in temperature, fluid and electrolyte imbalances, and use of medications with known cognitive and psychotropic side effects).
  • Determine if the individual is displaying a change in personality as a manifestation of difficulty with coping. An older individual's responses to age-related stress will depend on the balance of personality strengths and weaknesses.
  • Increase and mobilize the support available to the elderly client. Encourage interaction with family and friends.
    Multicultural
  • Assess for the influence of cultural beliefs, norms, and values on the client's perceptions of effective coping.
  • Assess for intergenerational family problems that can overwhelm coping abilities.
  • Encourage spirituality as a source of support for coping.
  • Negotiate with the client with regard to the aspects of coping behavior that will need to be modified.
  • Identify which family members the client can count on for support.
  • Use an empowerment framework to redefine coping strategies.
  • Assess the influence of fatalism on the client's coping behavior.
  • Assess the influence of cultural conflicts that may affect coping abilities.

    Home Care Interventions

    • The interventions described previously may be adapted for home care use.
    • Observe the family for coping behavior patterns. Obtain family and client history as possible.
    • Assess for suicidal tendencies. Refer for mental health care immediately if indicated. Identify an emergency plan should the client become suicidal. Ineffective coping can occur in a crisis situation and can lead to suicidal ideation if the client sees no hope for a solution. A suicidal client is not safe in the home environment unless supported by professional help.
    • Encourage the client to use self-care management to increase the experience of personal control. Identify with the client all available supports and sense of attachment to others.
    • Refer to medical social services for evaluation and counseling, which will promote adequate coping as part of the medical plan of care. If no primary medical diagnosis has been made, request medical social services to assist with community support contacts. If the client is involved with the mental health system, actively participate in mental health team planning. Based on knowledge of the home and family, home care nurses can often advocate for clients. These nurses are frequently requested to monitor medication use and therefore need to know the plan of care.
    • Refer the client and family to support groups.
    • If monitoring medication use, contract with the client or solicit assistance from a responsible caregiver. Prepouring of medications may be helpful with some clients. Caregivers in the home benefit from interventions that promote self-efficacy and provide a nurse for support (Dibartolo, 2002).
    • Institute case management for frail elderly clients to support continued independent living. Difficulties in coping with changes in health care needs can lead to increasing needs for assistance in using the health care system effectively. Case management combines the nursing activities of client and family assessment, planning and coordination of care among all health care providers, delivery of direct nursing care, and monitoring of care and outcomes. These activities are able to address continuity of care, mutual goal setting, behavior management, and prevention of worsening health problems (Guttman, 1999).
    • If the client is homebound, refer for psychiatric home health care services for client reassurance and implementation of a therapeutic regimen. Psychiatric home care nurses can address issues relating to the client's ability to adjust to changes in health status. Behavioral interventions in the home can help the client to participate more effectively in the treatment plan (Patusky, Rodning, and Martinez-Kratz, 1996).
    • NOTE: All of the previously mentioned interventions may be applied in the home setting. Home care may offer psychiatric nursing or the services of a licensed clinical social worker under special programs. Traditionally, insurance does not reimburse for counseling that is not related to a medical plan of care unless it falls under one of the programs just described. Public health agencies generally do not have the clinical support needed to offer psychiatric nursing services to clients. Clients are usually treated in the ambulatory mental health system.

    Client/Family Teaching

  • Teach the client to problem solve. Have the client define the problem and cause, and list the advantages and disadvantages of the options.
  • Provide the seriously ill client and his or her family with needed information regarding the condition and treatment.
  • Teach relaxation techniques.
  • Work closely with the client to develop appropriate educational tools that address individualized needs.
  • Teach the client about available community resources (e.g., therapists, ministers, counselors, self-help groups).

Nursing Diagnosis for Imbalanced Nutrition : Less Than Body Requirements

Nursing Diagnosis for Imbalanced Nutrition : Less Than Body Requirements

Definition: Intake of nutrients insufficient to meet metabolic needs.


Characteristics :
  • Loss of weight
  • Lack of interest in food
  • Pale conjunctiva and mucous membranes
  • Poor muscle tone
  • Amenorrhea
  • Poor skin turgor
  • Edema of extremities
  • Electrolyte imbalances
  • Weakness
  • Constipation
  • Anemias

Related Factors
  • Inability to ingest food because of:
  • Depressed mood
  • Loss of appetite
  • Energy level too low to meet own nutritional needs
  • Regression to lower level of development
  • Ideas of self-destruction

Goals
  • Client will gain 2 pounds per week for the next 3 weeks.
  • Client will exhibit no signs or symptoms of malnutrition by time of discharge from treatment (e.g., electrolytes and blood counts will be within normal limits; a steady weight gain will be demonstrated; constipation will be corrected; client will exhibit increased energy in participation in activities).

Nursing Diagnosis for Typhoid Fever

Typhoid fever, also known as enteric fever, is a potentially fatal multisystemic illness caused primarily by Salmonella typhi. The protean manifestations of typhoid fever make this disease a true diagnostic challenge. The classic presentation includes fever, malaise, diffuse abdominal pain, and constipation. Untreated, typhoid fever is a grueling illness that may progress to delirium, obtundation, intestinal hemorrhage, bowel perforation, and death within one month of onset. Survivors may be left with long-term or permanent neuropsychiatric complications.

Nursing Diagnosis for Typhoid Fever

  1. Risk for Fluid and Electrolyte Imbalances related to hyperthermia and vomiting .
  2. Risk for Imbalanced Nutrition : Less than Body Requirements related to inadequate intake.
  3. Hyperthermia related to the process of infection, salmonella thypi
  4. Inability to Meet Daily Needs related to physical weakness
  5. Deficient Knowledge : about the disease related to lack of information or inadequate information

Nursing Diagnosis for Diabetes Mellitus

Diabetes Mellitus

Diabetes mellitus is a group of metabolic diseases characterized by high blood sugar (glucose) levels, that result from defects in insulin secretion, or action, or both. Diabetes mellitus, commonly referred to as diabetes (as it will be in this article) was first identified as a disease associated with "sweet urine," and excessive muscle loss in the ancient world. Elevated levels of blood glucose (hyperglycemia) lead to spillage of glucose into the urine, hence the term sweet urine.

Normally, blood glucose levels are tightly controlled by insulin, a hormone produced by the pancreas. Insulin lowers the blood glucose level. When the blood glucose elevates (for example, after eating food), insulin is released from the pancreas to normalize the glucose level. In patients with diabetes, the absence or insufficient production of insulin causes hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be controlled, it lasts a lifetime.

Nursing Diagnosis for Diabetes Mellitus
  1. Risk for Impaired Skin Integrity related to elevated levels of blood sugar
  2. Impaired Physical Mobility related to pain in the leg wound
  3. Chronic pain related to ischemic tissue
  4. Imbalanced Nutrition : Less Than Body Requirements related to the lack of food intake
  5. Potential occurrence of spread of infection: sepsis related to high blood sugar levels.
  6. Disturbed Sleep pattern related to pain in the wound in the leg
  7. Impaired physical mobilization associated with weakness of limbs
  8. Knowledge Deficit : about the disease process, diet, care, and treatment related to a lack of information
  9. Anxiety related to lack of knowledge about the disease.

Nursing Diagnosis for Diabetes Mellitus

Nursing Diagnosis for Hyperthermia

Hyperthermia

Definition: The body temperature rises above the normal range.

Characteristics :
  • Increase in body temperature above the normal range
  • Attacks or convulsions (seizures)
  • Skin redness
  • Increase respiratory rate
  • Tachycardia
  • Hands felt warm to the touch

Related Factors :
  • Illness / injury
  • Increased metabolism
  • Excessive activity
  • The influence of medication / anesthesia
  • Inability / reduced ability to sweat
  • Exposure to hot environment
  • Dehydration
  • Inappropriate clothing

Nursing Diagnosis for Risk for Injury

Risk for Injury

Definition:

The risk of injury as a result of the interaction of environmental conditions with individual adaptive response and defense sources.


Risk Factors :

External
  • Mode of transport or manner displacement.
  • Human or health care provider (eg, nosocomial agent).
  • Patterns of employment: cognitive, affective, and psychomotor factors.
  • Physical (example: the design of the structure and direction of the community, building and or equipment).
  • Nutrition (example: vitamins and food type.)
  • Biological (eg, immunization rates in communities, microorganisms).
  • Chemistry (pollutants, toxins, drug, pharmaceutical agent, alcohol, caffeine, nicotine, preservatives, cosmetics, dye (dye fabric)).

Internal
  • Psikolgik (affective orientation)
  • Mal nutrition
  • Forms of abnormal blood, eg, leukocytosis / leukopenia, changes in clotting factors, thrombocytopenia, sickle cell, thalassemia, decreased hemoglobin, Immune-autoimum not working.
  • Biochemistry, regulatory functions (eg sensory dysfunction)
  • Disfugsi combined
  • Dysfunction effector
  • Hypoxia of tissue
  • The development of age (physiological, psychosocial)
  • Physical (eg skin damage / not intact, associated with mobility)

Nursing Diagnosis for Risk for Injury

Nursing Diagnosis for Excess Fluid Volume

Excess Fluid Volume

Definition: Increased retention of isotonic fluid

Characteristics :
  • Weight increase in a short time
  • Excessive intake than output
  • Blood pressure changes, pulmonary artery pressure changes, increased CVP
  • Jugular venous distension
  • Changes in the pattern of breath, dyspnea / shortness of breath, orthopnoe, abnormal breath sounds (Rales or crackles), pulmonary congestion, pleural effusion
  • Hemoglobin and hematocrit decrease, changes in electrolytes, particularly changes in specific gravity
  • Voice SIII heart
  • Reflexes positive hepatojugular
  • Oliguria, azotemia
  • Changes in a mental position, restlessness, anxiety

Related Factors :
  • Mechanism weakened settings
  • Excessive fluid intake
  • Excessive intake of sodium

Nursing Diagnosis for Risk for Deficient Fluid Volume

Risk for Deficient Fluid Volume

Definition: The decrease intravascular fluid, interstitial, and / or intrasellular. This leads to dehydration, loss of fluids with sodium expenditure.

Characteristics :
  • Weakness

  • Thirst

  • Decreased skin turgor / tongue

  • Mucous membrane / dry skin

  • Increased pulse rate, decreased blood pressure, decrease in volume / pulse pressure

  • Completion of decreased venous

  • Changes in the mental position

  • The concentration of urine increased

  • Increased body temperature

  • Elevated hematocrit

  • Weight loss immediately (except on third spacing)

Related Factors :
  • Loss of active fluid volume

  • Failure of regulatory mechanisms

Nursing Diagnosis for Ineffective Breathing Pattern

Nursing Diagnosis for Ineffective Breathing Pattern



Definition: The exchange of air inspiration and / or expiration inadequate.


Characteristics:
  • Decrease pressure inspiration / expiration
  • Decrease in air changes per minute
  • Using additional respiratory muscle
  • Nasal flaring
  • Dyspnea
  • Orthopnea
  • Changes in chest deviation
  • Shortness of breath
  • Assumption of 3-point position
  • Breathing pursed-lip
  • Phase lasts very long expiratory
  • Increased anterior-posterior diameter
  • Respiratory average / minimum
    • Infants: less than 25 or more than 60
    • Age 1-4: less than 20 or more than 30
    • Age 5-14: less than 14 or more than 25
    • Age over 14: less than 11 or more than 24
  • Depth of respiration
    • Adult tidal volume of 500 ml at rest
    • Infant tidal volume of 6-8 ml / kg
  • Timing ratio
  • Decrease in vital capacity


Related Factors:
  • Hyperventilation
  • Bone deformities
  • Chest wall deformity
  • Decreased energy / fatigue
  • Destruction / impairment musculoskeletal
  • Obesity
  • Body position
  • Fatigue of respiratory muscles
  • Hypoventilation syndrome
  • Pain
  • Anxiety
  • Neuromuscular dysfunction
  • Damage to the perception / cognition
  • Injury to spinal nerve tissue
  • Neurological immaturity

Nursing Diagnosis for Asthma

Nursing Diagnosis for Asthma

Asthma is a chronic disease that affects your airways. Your airways are tubes that carry air in and out of your lungs. If you have asthma, the inside walls of your airways become sore and swollen. That makes them very sensitive, and they may react strongly to things that you are allergic to or find irritating. When your airways react, they get narrower and your lungs get less air. This can cause wheezing, coughing, chest tightness and trouble breathing, especially early in the morning or at night.

When your asthma symptoms become worse than usual, it's called an asthma attack. In a severe asthma attack, the airways can close so much that your vital organs do not get enough oxygen. People can die from severe asthma attacks.

Asthma is treated with two kinds of medicines: quick-relief medicines to stop asthma symptoms and long-term control medicines to prevent symptoms.

NIH: National Heart, Lung, and Blood Institute




  1. Ineffective Airway Clearance related to bronchospasm and mucosal Similarly, edema
  2. Fatigue related to hypoxia and increased respiratory work
  3. Imbalanced Nutrition: Less than Body Requirements related to GI distress
  4. Deficient Fluid Volume related to increased respiratory and decreased oral intake
  5. Anxiety related to hospitalization and respiratory distress
  6. Interrupted Family Processes related to chronic conditions
  7. Deficient Knowledge : the disease process and treatment related to less information.

Nursing Diagnosis for Appendicitis

Nursing Diagnosis for Appendicitis

The appendix is a small, tube-like organ attached to the first part of the large intestine, also called the colon. It is located in the lower right area of the abdomen. It has no known function. A blockage inside of the appendix causes appendicitis. The blockage leads to increased pressure, problems with blood flow and inflammation. If the blockage is not treated, the appendix can break open and leak infection into the body.
Symptoms may include
  • Pain and/or swelling in the abdomen
  • Loss of appetite
  • Nausea and vomiting
  • Constipation or diarrhea
  • Inability to pass gas
  • Low fever
Not everyone with appendicitis has all these symptoms.
Appendicitis is a medical emergency. Treatment almost always involves removing the appendix. Anyone can get appendicitis. It happens most often to people between the ages of 10 and 30.
National Institute of Diabetes and Digestive and Kidney Diseases


Nursing Diagnosis for Appendicitis
  1. Ineffective Breathing Pattern related to the act of anesthetics.
  2. Acute Pain related to the surgical incision.
  3. Risk for Fluid Volume Deficit related to vomiting.
  4. Imbalanced Nutrition: Less than Body Requirements related to anorexia.
  5. Risk of Infection related to surgical incision.

Nursing Diagnosis for Lung Abscess

Nursing Diagnosis for Lung Abscess

Lung abscess is defined as necrosis of the pulmonary tissue and formation of cavities containing necrotic debris or fluid caused by microbial infection. The formation of multiple small (< 2 cm) abscesses is occasionally referred to as necrotizing pneumonia or lung gangrene. Both lung abscess and necrotizing pneumonia are manifestations of a similar pathologic process. Failure to recognize and treat lung abscess is associated with poor clinical outcome.

In the 1920s, approximately one third of patients with lung abscess died; Dr David Smith postulated that aspiration of oral bacteria was the mechanism of infection. He observed that the bacteria found in the walls of the lung abscesses at autopsy resembled the bacteria noted in the gingival crevice. A typical lung abscess could be reproduced in animal models via an intratracheal inoculum containing, not 1, but 4 microbes, thought to be Fusobacterium nucleatum, Peptostreptococcus species, a fastidious gram-negative anaerobe, and, possibly, Prevotella melaninogenicus.

Nursing Diagnosis for Lung Abscess
  1. Hyperthermia related to the direct effects of circulating endotoxin, on the hypothalamus.
  2. Ineffective Airway Clearance related to bronchoconstriction, increased production of secretions, retained secretions, ineffective cough, and infections bronkopulmonal.
  3. Impaired Gas Exchange related to oxygen supply disruptions and damage to the alveoli.
  4. Pain related to pulmonary parenchymal inflammation, cellular reaction to the toxin circulation, cough settled.
  5. Activity Intolerance related to imbalance between supply and demand of oxygen, general weakness, fatigue associated with excessive coughing and dipsneu.
  6. Knowledge Deficit related to lack of information, misunderstanding about the information, cognitive limitations.

Nursing Diagnosis for Pyelonephritis

Nursing Diagnosis for Pyelonephritis

Pyelonephritis is a bacterial infection of the kidney. It can be serious because of the important function of the kidneys. Also, the infection may enter the bloodstream. Another problem is that it can cause pregnant women to go into labor too early (premature labor).

Kidney infections are much more common in women than men.

Nursing Diagnosis for Pyelonephritis
  1. Risk for Infection related to the presence of bacteria in the kidneys.
  2. Imbalanced Body Temperature related to immunological response to infection.
  3. Impaired Urinary Elimination (dysuria, urge, frequency, and / or nocturia) related to infections of the kidney.
  4. Acute Pain related to infections of the kidney.
  5. Deficient Knowledge related to lack of information about the disease process, methods of prevention, and care instructions at home.

Nursing Diagnosis for Tuberculous Spondylitis

Nursing Diagnosis for Tuberculous Spondylitis

Tuberculous spondylitis, or Pott's disease, results from the hematogenous spread of M. tuberculosis. Bony destruction usually results in some degree of vertebral collapse, while anterior wedging causes the typical gibbous deformity of focal kiphosis. Usually there is involvement of multiple vertebral bodies, relative sparing of the intervertebral discs and posterior elements, and limited periosteal reaction. Rare cases of isolated posterior vertebral body involvement have been reported. Paraspinal extension is very common, with calcification in a psoas abscess being nearly pathognomonic for tuberculous infection.

Nursing Diagnosis for Tuberculous Spondylitis
  1. Impaired Physical Mobility related to musculoskeletal damage and pain.
  2. Pain: joints and muscles related to the inflammation of joints.
  3. Disturbed Body Image related to the disturbances of the body structure.
  4. Deficient Knowledge related to lack of informationabout management of home care .