Nursing Diagnosis and Nursing Intervention for Myocarditis

Nursing Diagnosis and Nursing Intervention for Myocarditis

Myocarditis

Myocarditis is inflammation of the heart muscle.


Myocarditis Nursing Assessment


Nursing Diagnosis

Activity Intolerance

Related to :
  • generalized weakness;
  • reduced energy stores,
  • increased metabolic rate from massive production of leukocytes,
  • imbalance between oxygen supply and demand (anemia and hypoxia),
  • therapeutic restrictions—isolation,
  • bedrest;
  • effect of drug therapy

Can be evidenced by
  • Verbal report of fatigue or weakness
  • Exertional discomfort or dyspnea
  • Abnormal heart rate or BP response

Expected Result / criteria for evaluation of patients will :
  • Endurance
  • Report a measurable increase in activity tolerance.
  • Participate in ADLs to level of ability.
  • Demonstrate a decrease in physiological signs of intolerance—pulse, respiration, and BP remain within client’s normal range.

Nursing intervention and Rationale for Myocarditis :
  1. Assess patient's response to the activity. Watch for changes and complaints of weakness, fatigue, and dyspnea related to activity.
    R: myocarditis causing inflammation and possible damage to the function of myocardial cells.

  2. Monitor frequency / heart rhythm, BP, and respiratory frequency before and after activity and as long as necessary.
    R: helps determine the degree of cardiac and pulmonary decompensation. Decrease in blood pressure, tachycardia, dysrhythmias, and tachypnea is indicative of damage to the heart of activity tolerance.

  3. Maintain bed rest during febrile period and according to indications.
    R: improving the resolution of inflammation during the acute phase.

  4. Plan of care, with periods of rest / sleep without interruption.
    R: provide balance in the needs which the activity relies on the heart.

  5. Assist patients in gradually progressive exercise program as soon as possible to get out of bed, noting the response of vital signs and patient tolerance to the increase in activity.
    R: when inflammatory / basic condition is resolved, the patient may be able to perform the desired activity, except for permanent myocardial damage / complications.

  6. Collaboration supplemental oxygen administration as indicated.
    R: maximizing the availability of oxygen to reduce the heart's workload.

Nursing Diagnosis and Nursing Intervention for Urolithiasis

Urolithiasis is the condition where urinary calculi are formed or located anywhere in the urinary system. The term nephrolithiasis (or "renal calculus") refers to stones that are in the kidney, while ureterolithiasis refers to stones that are in the ureter. The term cystolithiasis (or vesical calculi) refers to stones which form or have passed into the bladder.

Urolithiasis Nursing Diagnosis and Nursing Intervention



Nursing Diagnosis and Nursing Intervention for Urolithiasis

Nursing Diagnosis

Acute Pain

Related to :
  • increased frequency and force of ureteral contractions,
  • tissue trauma,
  • edema formation,
  • cellular ischemia

Can be evidenced by :
  • Reports of colicky pain
  • Guarding or distraction behaviors, restlessness, moaning, self-focusing, facial mask of pain, muscle tension
  • Autonomic responses

Expected Result / criteria for evaluation of patients will :
  • Pain Level
  • Report pain is relieved, with spasms controlled.
  • Appear relaxed and be able to sleep and rest appropriately.

Nursing intervention and Rationale for Urolithiasis
  1. Document location, duration, intensity (0 to 10 scale), and radiation. Note nonverbal signs—elevated BP and pulse, restlessness, moaning, and thrashing about.
    Rationale: Helps evaluate site of obstruction and progress of calculi movement. Flank pain suggests that stones are in the kidney area, upper ureter. Flank pain radiates to back, abdomen, groin, and genitalia because of proximity of nerve plexus and blood vessels supplying these areas. Sudden, severe pain may precipitate apprehension, restlessness, and severe anxiety.

  2. Explain cause of pain and importance of notifying caregivers of changes in pain occurrence or characteristics.
    Rationale: Provides opportunity for timely administration of analgesia and alerts caregivers to possibility of passing of stone or developing complications. Sudden cessation of pain usually indicates stone passage.

  3. Provide such comfort measures as back rub and restful environment.
    Rationale: Promotes relaxation, reduces muscle tension, and enhances coping.

  4. Apply warm compresses to back.
    Rationale: Relieves muscle tension and may reduce reflex spasms.

  5. Assist with and encourage use of focused breathing, guided imagery, and diversional activities.
    Rationale: Redirects attention and aids in muscle relaxation.

  6. Encourage and assist with frequent ambulation as indicated; increase fluid intake to at least 3 to 4 L/day within cardiac tolerance.
    Rationale: Renal colic can be worse in the supine position. Vigorous hydration promotes passing of stone, prevents urinary stasis, and aids in prevention of further stone formation.

  7. Note reports of increased or persistent abdominal pain.
    Rationale: Complete obstruction of ureter can cause perforation and extravasation of urine into perirenal space. This represents an acute surgical emergency.

  8. Administer medications, as indicated, for example: Opioids, such as morphine sulfate (Astramorph, Duramorph); oral opioid combination analgesics, such as oxycodone and acetaminophen (Percocet); and nonsteroidal antiinflammatory drugs (NSAIDs), such as ketorolac (Toradol)
    Rationale: Opioid and NSAID combination is often given intravenously (IV) during acute episode to quickly decrease ureteral colic and promote muscle and mental relaxation.

  9. Administer Antispasmodics, such as flavoxate (Urispas) and oxybutynin (Ditropan); calcium channel blocker, such as nifedipine (Adalat); and alpha-adrenergic blockers, such as tamsulosin (Flomax)
    Rationale: Decreases reflex spasm and relaxes ureteral smooth muscle, which facilitates stone passage. Note: Oral analgesics, NSAIDs, and alpha-adrenergic blockers help facilitate stone passage after acute attack.

  10. Maintain patency of catheters when used.
    Rationale: Prevents urinary stasis or retention, reduces risk of increased renal pressure and infection.

Nursing Diagnosis and Nursing Intervention for Myocardial Infarction

Myocardial infarction (MI) or acute myocardial infarction (AMI), commonly known as a heart attack, is the interruption of blood supply to a part of the heart, causing heart cells to die. This is most commonly due to occlusion (blockage) of a coronary artery following the rupture of a vulnerable atherosclerotic plaque, which is an unstable collection of lipids (fatty acids) and white blood cells (especially macrophages) in the wall of an artery. The resulting ischemia (restriction in blood supply) and oxygen shortage, if left untreated for a sufficient period of time, can cause damage or death (infarction) of heart muscle tissue (myocardium).
wikipedia

Nursing Assessment for Acute Myocardial Infarction (AMI)

Myocardial Infarction (AMI) Nursing Diagnosis and Nursing Intervention


Nursing Diagnosis

Activity Intolerance

Related to :
  • imbalance between myocardial oxygen supply and demand;
  • presence of ischemia and necrotic myocardial tissues;
  • cardiac depressant effects of certain drugs, such as beta blockers, antidysrhythmics.

Can be evidenced by :
  • Alterations in heart rate and BP with activity
  • Development of dysrhythmias
  • Changes in skin color and moisture
  • Exertional angina
  • Generalized weakness

Expected Result
/ criteria for evaluation of patients will

  • Activity Tolerance
  • Demonstrate measurable, progressive increase in tolerance for activity with heart rate and rhythm, BP within client’s normal
  • limits, and skin warm, pink, and dry.
  • Report absence of angina with activity.

Nursing Intervention and Rationale for Myocardial Infarction :
  1. Record and document heart rate and rhythm and BP changes before, during, and after activity, as indicated. Correlate with reports of chest pain or shortness of breath.
    Rationale: Trends determine client’s response to activity and may indicate myocardial oxygen deprivation that may require decrease in activity level, return to bedrest, changes in medication regimen, or use of supplemental oxygen.

  2. Encourage bedrest to chair rest initially. Thereafter, limit activity on basis of pain or adverse cardiac response. Provide nonstress diversional activities.
    Rationale: Reduces myocardial workload and oxygen consumption, reducing risk of complications, such as extension of MI. Clients with uncomplicated MI are encouraged to engage in mild activity out of bed, including short walks 12 hours after incident.

  3. Instruct client to avoid increasing abdominal pressure, such as straining during defecation.
    Rationale: Activities that require holding the breath and bearing down, such as Valsalva’s maneuver, can result in bradycardia with temporarily reduced cardiac output and rebound tachycardia with elevated BP.

  4. Explain pattern of graded increase of activity level, such as getting up to commode or sitting in chair, progressive ambulation, and resting after meals.
    Rationale: Progressive activity provides a controlled demand on the heart, increasing strength and preventing overexertion.

  5. Review signs and symptoms reflecting intolerance of present activity level or requiring notification of nurse or physician.
    Rationale: Palpitations, pulse irregularities, development of chest pain, or dyspnea may indicate need for changes in exercise regimen or medication.

Nursing Diagnosis and Nursing Intervention for Leukemia

Leukemia Nursing Diagnosis and Nursing Intervention


Nursing Diagnosis and Nursing Intervention for Leukemia


Nursing Diagnosis for Leukemia

Activity Intolerance related to general weakness, increased metabolic rate

Goal: Patient is able to tolerate the activity

Expected outcomes:
  • a. Increased tolerance activity can be measured
  • b. Participate in daily activities according to ability level
  • c. Showed decreased physiological signs of intolerance such as pulse, respiration and blood pressure within normal limits.

Nursing Intervention for Leukemia

  1. Evaluate reports of fatigue, noting inability to Participate in activities or ADLs.
    Rationale: Effects of leukemia, anemia, and chemotherapy may be cumulative, ESPECIALLY During acute and active treatment phase, necessitating assistance.

  2. Encourage clients to keep a diary of daily routines and energy levels, noting activities That increase of fatigue.
    Rationale: Helps clients prioritize activities and arrange around Them fatigue pattern.

  3. Provide quiet environment and uninterrupted rest periods. Encourage rest periods before meals.
    Rationale: RestoreS energy needed for activity and cellular regeneration and tissue healing.

  4. Implement energy-saving techniques, Such as sitting, rather than standing and use of shower chair. Assist with ambulation or other activities, as indicated.
    Rationale: Maximizes energy available for self-care tasks.

  5. Recommend small, Nutritious, high-protein meals and snacks throughout the day.
    Rationale: Smaller meals require less energy for digestion than larger meals. Increased intake provides fuel for energy.

  6. Provide supplemental oxygen.
    Rationale: Maximizes oxygen available for cellular uptake, Improving tolerance of activity.

  7. Administer blood and blood components, as indicated.
    Rationale: Correcting anemia improves client's stamina and tolerance for activity.

Nursing Diagnosis and Nursing Intervention for Rheumatoid Arthritis

Nursing Diagnosis and Nursing Intervention for Rheumatoid Arthritis

Nursing Diagnosis and Nursing Intervention for Rheumatoid Arthritis

Nursing Diagnosis

Pain (Acute / Chronic)

Related to:
  • Tissue distension by fluid accumulation / inflammation
  • Joint destruction.

Can be evidenced by :
  • Complaints of pain, discomfort, fatigue.

  • Self-focusing / narrowing of focus
  • Behavior distraction / autonomic response
  • Behavior that is carefully / protect

Expected Result / criteria for evaluation of patients will :
  • Showed pain relief / control
  • Looks relaxed, sleep / rest and participate in activities according to ability.
  • Follow the program prescribed pharmacological
  • Combining the skills of relaxation and entertainment activities into a program of pain control.

Nursing Interventions and Rational for Rheumatoid Arthritis :
  1. Assess complaints of pain, note the location and intensity (scale 0-10). Note factors that accelerate and signs of pain non-verbal.
    Rational: To assist in determining the need for pain management and program effectiveness.

  2. Give a hard mattress, small pillows, bed linen Elevate as needed.
    Rational: A soft mattress, large pillows, will prevent the maintenance of proper body alignment, placing stress on joints that hurt. Elevation of bed linen lowering the pressure in the inflamed joints / pain.

  3. Place / monitor the use of pillows, sandbags, splint, brace.
    Rational: Resting sore joints and maintain a neutral position. Use of the brace can reduce pain and can reduce damage to the joints.

  4. Suggest to frequently change positions, Help to move in bed, prop a pain in the joints above and below, avoid jerky movements.
    Rationale: Prevent the occurrence of general fatigue and joint stiffness. Stabilize the joint, reducing the movement / pain in the joints.

  5. Instruct the patient to a warm bath or shower at the time awake and / or at bedtime. Provide a warm washcloth to compress the joints are sick several times a day. Monitor water temperature, water bath, and so on.
    Rational: Heat increases muscle relaxation, and mobility, reduce pain and release the stiffness in the morning. Sensitivity to heat can be removed and dermal wound can be healed.

  6. Give a massage.
    Rationale: Increase relaxation / pain relief.

  7. Encourage the use of stress management techniques, such as progressive relaxation, therapeutic touch, biofeed back, visualization, imagination guidelines, self hypnosis, and breath control.
    Rationale: Increase relaxation, giving a sense of control and possibly enhance the coping abilities.

  8. Engage in activities of entertainment that is appropriate for individual situations.
    Rational: To focus attention again, provide stimulation, and increased self-confidence and feeling healthy.

  9. Give the drug prior to activity / exercise that is planned as directed.
    Rationale: Increase relaxation, reduce muscle tension / spasm, making it easier to participate in therapy.

  10. Collaboration: Give medicines as directed.
    Rational: As an anti-inflammatory and mild analgesic effect in reducing stiffness and improving mobility.

  11. Give ice-cold compress if needed
    Rational: The cold can relieve pain and swelling during the acute period.

Nursing Diagnosis and Nursing Intervention for BPH

Nursing Diagnosis and Nursing Intervention for BPH

Nursing Diagnosis :

Impaired sense of comfort: pain related to muscle spasm spincter

Goal :
Pain is reduced / no pain

Result Criteria :

  • The patient revealed reduced pain or no pain
  • Patients can rest easy.

Nursing Intervention :
  • Assess pain, note the location, intensity (scale 0 - 10)
  • Monitor and record the presence of pain, location, duration and trigger factors and pain relief.
  • Observation of non-verbal signs of pain (anxiety, forehead wrinkle, increased blood pressure and pulse)
  • Give a warm compress on the abdomen, especially the lower abdomen.
  • Instruct patient to avoid stimulants (coffee, tea, smoking, abdominal strain)
  • Set the position of the patient as comfortable as possible, teach relaxation techniques.
  • Perform therapeutic treatment of aseptic.
  • Report to the doctor if the pain increases.

Source : http://ncp-nursingcareplans.blogspot.com/2011/02/nursing-diagnosis-and-nursing_06.html

Nursing Diagnosis and Nursing Intervention for Leptospirosis

Nursing Diagnosis and Nursing Intervention for Leptospirosis



Nursing Diagnosis

  1. Impaired nutritional needs related to anorexia
  2. Increased body temperature (hipertemia) related to increased metabolic diseases
  3. Disruption of daily activities related to physical weakness

Nursing Intervention
  1. Impaired nutritional needs related to anorexia

    Expected results :
    • Nutritional needs are met
    • Patients are able to eat in accordance with a given portion

    Intervention :
    • Review complaints of nausea and vomiting
    • Give food a little but often
    • Assess how to eat that served
    • Give a warm meal
    • Measure the patient's body weight per day


  2. Increased body temperature (hipertemia) related to increased metabolic diseases

    Expected results :
    • Temperature within normal limits, free from cold
    • Do not experience complications related

    Intervention :
    • Give your bathroom a warm compress, avoid alcohol use
    • Instruct patient to drink plenty
    • Collaboration in the provision of antipyretic


  3. Disruption of daily activities related to physical weakness

    Expected results :
    • Activities of daily needs are met
    • Patients capable of self-

    Intervention :
    • Assess the patient's complaint
    • Assess the things that can and can not be patient
    • Help the patient to meet their activity
    • Help the patient to self-
    • Put things in place, easily accessible

Source : http://ncp-nursingcareplans.blogspot.com/2011/02/nursing-diagnosis-and-nursing.html

Nursing Diagnosis and Nursing Intervention for Anxiety

Nursing Diagnosis And Nursing Intervention For Anxiety


NANDA Definition: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat.

Anxiety is probably present at some level in every individual’s life, but the degree and the frequency with which it manifests differs broadly. Each individual’s response to anxiety is different. Some people are able to use the emotional edge that anxiety provokes to stimulate creativity or problem-solving abilities; others can become immobilized to a pathological degree. The feeling is generally categorized into four levels for treatment purposes: mild, moderate, severe, and panic. The nurse can encounter the anxious patient anywhere in the hospital or community. The presence of the nurse may lend support to the anxious patient and provide some strategies for traversing anxious moments or panic attacks.


Anxiety

Related to :
  • Anesthesia
  • Anticipated/actual pain
  • Disease
  • Invasive/noninvasive procedure:
  • Loss of significant other
  • Threat to self-concept

Evidenced by
  • Physiological :
    • Increase in blood pressure, pulse, and respirations
    • Dizziness, light-headedness
    • Perspiration
    • Frequent urination
    • Flushing
    • Dyspnea
    • Palpitations
    • Dry mouth
    • Headaches
    • Nausea and/or diarrhea
    • Restlessness
    • Pacing
    • Pupil dilation
    • Insomnia, nightmares
    • Trembling
    • Feelings of helplessness and discomfort
  • Behavioral :
    • Expressions of helplessness
    • Feelings of inadequacy
    • Crying
    • Difficulty concentrating
    • Rumination
    • Inability to problem-solve
    • Preoccupation
Outcome :

1. Demonstrate a decrease in anxiety A.E.B.:
  • A reduction in presenting physiological, emotional, and/or cognitive manifestations of anxiety.
  • Verbalization of relief of anxiety.

Nursing InterventionAssist patient to reduce present level of anxiety by :
  • Provide reassurance and comfort.
  • Stay with person.
  • Don't make demands or request any decisions.
  • Speak slowly and calmly.
  • Attend to physical symptoms. Describe symptoms:

2. Discuss/demonstrate effective coping mechanisms for dealing with anxiety.

Nursing Intervention
  • Discuss alternate strategies for handling anxiety. (Eg.: exercise, relaxation techniques and exercises, stress management classes, directed conversation (by nurse), assertiveness training)
  • Set limits on manipulation or irrational demands.
  • Help establish short term goals that can be attained.
  • Identify and reinforce coping strategies patient has used in the past.
  • Discuss advantages and disadvantages of existing coping methods.
  • Give clear, concise explanations regarding impending procedures.
  • Focus on present situation.
  • Reinforce positive responses.
  • Initiate health teaching and referrals as indicated :

Source : http://www.rncentral.com

http://ncp-blog.blogspot.com/2011/01/nursing-diagnosis-and-nursing.html

Nursing Diagnosis and Nursing Intervention for Osteoarthritis

Nursing Diagnosis and Nursing Intervention for Osteoarthritis


Nursing Care Plan for Osteoarthritis


Nursing Diagnosis (Postoperative)
  • Acute pain, related to surgical incision
  • Risk for infection, related to disruption in skin integrity
  • Impaired physical mobility, related to activity and weightbearing
    restrictions
  • Risk for ineffective tissue perfusion, right leg, related to vascular
    disruption and edema.

Exepected Outcomes
  • Maintain an adequate level of comfort postoperatively as demonstrated by :
    • The ability to move easily within restrictions.
    • Compliance with instructions to cough and breathe deeply.
    • Verbal expressions of comfort.
  • Remain free of adverse consequences of immobility such as pneumonia, pressure areas, thromboembolism, or contracture.
  • Remain free of infection.
  • Maintain adequate perfusion of affected leg.
  • Remain free of injury postoperatively.

Nursing Intervention
  • Assess pain at least hourly during first 24 to 48 hours postoperatively, and as needed thereafter.
  • Instruct in the use of patient-controlled analgesia (PCA) and monitor its effectiveness.
  • Help change position at least every 2 hours; encourage the use of the overhead trapeze to shift positions frequently.
  • Maintain sequential compression device and antiembolic stocking as ordered; remove for 1 hour daily.
  • Encourage the use of the incentive spirometer hourly for first 24 hours, then at least every 2 hours while awake.
  • Assist out of bed three times a day after the first 24 hours.
  • Maintain abduction of the right hip with pillows.
  • Perform passive ROM exercises of unaffected extremities every shift.
  • Encourage frequent quadriceps-setting exercises and plantar and dorsiflexion of feet.
  • Assess the surgical site frequently; report signs of excess bleeding or inflammation.
  • Monitor temperature every 4 hours.
  • Assess pulses, color, movement, and sensation of right foot hourly for the first 24 hours, then every 2 hours for 24 hours, then every 4 hours.


Source : wps.prenhall.com/wps/media/objects/737/755395/osteoarthritis.pdf
http://nursing-careplans.blogspot.com/2011/01/nursing-diagnosis-and-nursing.html

Nursing Diagnosis and Nursing Intervention for Decubitus Ulcer

Nursing Diagnosis and Nursing Intervention for Decubitus Ulcer

Nursing Diagnosis for Decubitus Ulcer

  1. Impaired tissue integrity related to mechanical tissue destruction secondary to pressure, friction and factions.
  2. Impaired physical mobility related to movement restrictions are required, the status of the conditioned, loss of motor control due to changes in mental status.


Nursing Intervention for Decubitus Ulcer
  1. Impaired tissue integrity related to mechanical tissue destruction secondary to pressure, friction and factions

    Nursing Intervention :
    • Apply the principles of prevention of decubitus ulcers.
      R: the principle of prevention of decubitus ulcers, including reducing or rotate the pressure of soft tissue.

    • Adjust the position of the patient as comfortable as possible.
      R: minimize the occurrence of decubitus affected tissue.

    • Wound dressing with a bandage that maintains humidity environment on the foundations of the wound.
      R: a moist wound to accelerate recovery.


  2. Impaired physical mobility related to movement restrictions are required, the status of the conditioned, loss of motor control due to changes in mental status.

    Nursing Intervention :
    • Support higher level of mobilization.
      R: regular movement relieve pressure consistently above the bony ridge.

    • Assist / encourage self care / hygiene, like bathing.
      R: improve muscle strength and circulation, improve the control patients in the situation and improving environmental health.

    • Give special attention to the skin.
      R: research shows that the skin is very susceptible to damage because the concentration of weight.

Related Post :
Nursing Care Plan for Decubitus Ulcer

Source : http://nursing-careplans.blogspot.com/2011/04/nursing-diagnosis-and-nursing.html

Nursing Diagnosis and Nursing Intervention for Neonatal Tetanus


Nursing Diagnosis for Neonatal Tetanus

  1. Ineffective breathing pattern related to respiratory muscle fatigue
  2. Imbalanced nutrition, Less than body requirements related to the baby's sucking reflex is inadequate.


Nursing Intervention for Neonatal Tetanus

Nursing Diagnosis I

Ineffective breathing pattern related to respiratory muscle fatigue

Nursing Intervention:
  • Assess the frequency and pattern of breath
  • Note the presence of apnea, the frequency change of heart, muscle tone and skin color.
  • Perform cardiac and respiratory monitoring continuously.
  • Suction airway as needed.
  • Give the tactile stimulation immediately after apnea.
  • Monitor laboratory tests as indicated.
  • Give oxygenation as indicated.
  • Give medications as indicated.


Nursing Diagnosis II

Imbalanced nutrition, Less than body requirements related to the baby's sucking reflex is inadequate.

Nursing Intervention:

  • Assess the maturity of the reflex with respect to feeding, sucking, swallowing and coughing.
  • Auscultation bowel sounds.
  • Review the signs of hypoglycemia.
  • Give appropriate medication electrolyte supplements.
  • Give parenteral nutrition.
  • Monitor laboratory tests as indicated.
  • Make provision of drinking according to tolerance.

Related Articles :

Source : http://nanda-nursing.blogspot.com/2011/04/nursing-diagnosis-and-nursing_20.html

Nursing Diagnosis and Nursing Interventions for Anemia

Nursing Diagnosis and Nursing Interventions for Anemia


Nursing Diagnosis and Nursing Interventions for Anemia

Nursing Diagnosis for Anemia

Activity intolerance related to muscle weakness

Nursing Interventions for Anemia
  1. Assess the level of client activity
    Rational: To know the client and the activities undertaken to determine the next intervention.
  2. Put the tools needed client
    Rational: To assist clients in meeting their needs.
  3. Assist patients in active and passive exercises
    Rational: To improve the circulation of tissue.
  4. Assist patients in meeting the needs of daily activities
    Rational: With the help of nurses and families to meet client needs.
  5. Provide quiet environment
    Rationale: Increasing the rest to reduce strain the heart and lungs.

Nursing Diagnosis and Nursing Intervention for Hypertension

Nursing Diagnosis and Nursing Intervention for Hypertension


Nursing Diagnosis and Nursing Intervention for Hypertension


Nursing Diagnosis for Hypertension

Risk for Ineffective Tissue Perfusion: Peripheral, Renal, Gastrointestinal, Cardiopulmonary related to impaired circulation

Nursing Intervention for Hypertension

  • Maintain bed rest, elevate head of bed
  • Assess blood pressure at admission in both arms, sleeping, sitting with arterial pressure monitoring if available
  • Maintain fluid and drugs.
  • Observe the sudden hypotension.
  • Measure inputs and expenditures
  • Monitor electrolytes, BUN, creatinine.
  • Ambulation according to ability; avoid fatigue


Nursing Diagnosis for Hypertension

Decreased Cardiac Output related to increased afterload, vasoconstriction, myocardial ischemia, ventricular hypertrophy

Nursing Intervention for Hypertension
  • Monitor blood pressure
  • Note the central and peripheral pulse quality
  • Auscultation of heart and breath sounds
  • Observe skin color, moisture, temperature and capillary filling time
  • Observe the general edema
  • Provide quiet environment, comfortable
  • Suggest to reduce activity.
  • Maintain restrictions on activities such as recess ditemapt bed / chair
  • Help perform self-care activities as needed
  • Perform actions such as a comfortable back and neck massage
  • Encourage relaxation techniques
  • Give fluid restriction and sodium diet as indicated.

Nursing Diagnosis and Nursing Intervention for COPD

Nursing Diagnosis and Nursing Intervention COPD


Nursing Diagnosis and Nursing Intervention for Chronic Obstructive Pulmonary Disease

Nursing Diagnosis for COPD

Ineffective Breathing Pattern related to shortness of breath, mucus, bronchoconstriction and airway Irritants.

Goal:
Improvement of breathing patterns


Nursing Intervention for COPD
  1. Teach client diaphragmatic breathing exercises and breathing lips sealed.
  2. Give encouragement to intersperse activity with periods of rest. Let the patient make decisions about treatment based on patient tolerance level.
  3. Give encouragement to use the muscles of breathing exercises if required.


Nursing Diagnosis for COPD

Ineffective Airway Clearance related to bronchoconstriction, Increased sputum production, ineffective cough, fatigue / decreased energy and bronkopulmonal infection.

Goal:
Achieving client airway clearance


Nursing Intervention for COPD

  1. Give the patient 6 to 8 glasses of fluid per day unless there is Cor pulmonale.
  2. Teach and give the use of diaphragmatic breathing and coughing techniques.
  3. Assist in the provision of a nebulizer action, measured dose inhalers.
  4. Perform postural drainage with percussion and vibration in the morning and at night as required.
  5. Instruct patient to avoid irritants such as cigarette smoke, aerosols, temperature extremes, and smoke.
  6. Teach about the early signs of infection should be reported to your doctor immediately: increased sputum, change in color of sputum, sputum viscosity, increased shortness of breath, chest tightness, fatigue.
  7. Give antibiotics as required.
  8. Give encouragement to patients to immunize against influenzae and Streptococcus pneumoniae.

Nursing Diagnosis and Nursing Intervention Alzheimer's Disease

Nursing Diagnosis and Nursing Intervention Alzheimer's Disease

Nursing Diagnosis and Nursing Intervention Alzheimer's Disease

Nursing Diagnosis for Alzheimer's Disease

Disturbed Thought Processes related to :
  • Irreversible neuro degeneration
  • Memory Loss
  • Psychological Conflict
  • Deprivation lie

Nursing Intervention for Alzheimer's Disease
  • Assess the level of cognitive disorders such as changes orientasiterhadap people, places and times, range, attention, thinking skills.
  • Talk with the people closest to the usual behavior change / length of the existing problems.
  • Maintain a nice quiet neighborhood.
  • Face-to-face when talking with patients.
  • Call patient by name.
  • Use a rather low voice and spoke slowly in patients.

Rational:
  • Provide the basis for the evaluation / comparison that will come, and influencing the choice of intervention.
  • Noise, crowds, the crowds are usually the excessive sensory neurons and can increase interference.
  • Cause concern, especially in people with perceptual disorders.
  • The name is a form of self-identity and lead to recognition of reality and the individual.
  • Increasing the possibility of understanding.


Nursing Diagnosis for Alzheimer's Disease

Risk for Injury related to:

  • Unable to recognize / identify hazards in the environment.
  • Disorientation, confusion, impaired decision making.
  • Weakness, the muscles are not coordinated, the presence of seizure activity.

Nursing Intervention for Alzheimer's Disease
  • Assess the degree of impaired ability of competence emergence of impulsive behavior and a decrease in visual perception.
  • Help the people closest to identify the risk of hazards that may arise.
  • Eliminate / minimize sources of hazards in the environment
  • Divert attention to a client when agitated or dangerous behaviors like getting out of bed by climbing the fence bed.

Rational:
  • Impairment of visual perception increase the risk of falling. Identify potential risks in the environment and heighten awareness so that caregivers more aware of the danger.
  • An impaired cognitive and perceptual disorders are beginning to experience the trauma as a result of the inability to take responsibility for basic security capabilities, or evaluating a particular situation.
  • Maintain security by avoiding a confrontation that could improve the behavior / increase the risk for injury.

Nursing Diagnosis and Nursing Intervention for Gastritis

Nursing Diagnosis and Nursing Intervention for Gastritis


Nursing Diagnosis for Gastritis



Risk for Imbalanced Fluid Volume and Electrolytes : less than body requirements related to inadequate intake, vomiting

Goal:
Disorders of fluid balance did not occur.

Expected results:
Moist mucous membranes, good skin turgor, electrolytes returned to normal, capillary filling pink, vital signs stable, the balance of input and output.


Nursing Intervention for Gastritis

Assess signs and symptoms of dehydration, observation of vital signs, measuring intake and output, encourage clients to drink ± 1500-2500ml, observation of skin and mucous membranes, collaboration with doctor in the provision of intravenous fluids.


Nursing Diagnosis for Gastritis

Imbalanced Nutrition: Less than Body Requirements: less than body requirements related to inadequate intake, anorexia

Goal:
Nutritional deficiencies resolved.

Expected results:
Normal albumin value, no nausea and vomiting, weight within normal limits, normal bowel sounds.


Nursing Intervention for Gastritis

Assess food intake, body weight measured regularly, give oral care on a regular basis, encourage clients to eat little but often, give food in warm, auscultation bowel sounds, assess food preferences, check the laboratory, for example: Hemoglobin, hematocrit, albumin.

NANDA NURSING

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