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RANK NURSING DIAGNOSIS JUSTIFICATION

1 Ineffective airway clearance In nearly all circumstances airway management is the

highest priority for clinical care. This is because if

there is no airway, there can be no breathing, hence nooxygenation of blood and therefore circulation (and

hence all the other vital body processes) will sooncease. Getting oxygen to the lungs is the first step in

almost all clinical treatments. Furthermore, the problemis categorized under first level of Maslows hierarchyof basic human need, which is the physiologic level.

Since physiologic needs are the most essential in life

therefore they have the highest priority. In addition, itis an actual problem that requires immediate

interventions. An obstructed airway means that thebody is deprived of oxygen. If ventilation is not

reestablished, brain death will occur within minutes.Therefore, it has a high preventive potential.

2 Impaired gas exchange In nearly all circumstances breathing management is

the second priority for clinical care according to ABC

management. This is because if there is an impaired gasexchange, there can be no oxygenation of blood and

therefore circulation will soon cease. Getting oxygen tothe lungs is a priority in almost all clinical treatments.

Furthermore, the problem is categorized under first

level of Maslows hierarchy of basic human needs,which is the physiologic level. Since physiologic needs

are the most essential in life therefore they have thehighest priority. In addition, it is an actual problem that

requires immediate interventions. An impaired gas

exchange means that the body can be deprived ofoxygen. If proper ventilation is not reestablished, vital

body processes will be affected. Therefore, it has a

high preventive potential.

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3 Ineffective breathing pattern related

to hyperventilation secondary tostatus asthmaticus

The nursing diagnosis is an actual problem thatneeded prompt intervention. It is based on the principleof airway-breathing-circulation that needed to beaddressed first.

4 Impaired/ineffective tissueperfusion: Cardiopulmonary

In nearly all circumstances breathing management is

the second priority for clinical care according to ABC

management. Hypoventilation is too shallow or tooslow breathing, which does not meet the needs of the

body. It may also refer to reduced lung function. If aperson hypoventilates, the body's carbon dioxide level

rises, which results in too little oxygen in the blood.

This is because if there is a hypoventilation, there canbe insufficiency of oxygenation of blood and therefore

circulation will soon cease.

5 Decreased cardiac output related todehydration

The nursing diagnosis is an actual problem that needsa prompt intervention. Addressing this problem cansolve other conditions of the client.

6 Hyperthermia

7 Deficient fluid volumeThe nursing intervention is an actual problem that maycause harm to the client. Immediate attention is

necessary to prevent further problem. Deficiency influid volume may cause imbalanced in fluid andelectrolytes.

8 Impaired swallowing The nursing diagnosis is an actual problem but can bemanage through use of different resources. Food/water/fluids for nutrition can be provided through anNGT or IVT.

9 Impaired urinary elimination relatedto tissue hypoperfusion

The nursing diagnosis is an actual problem that needsprompt intervention. Urinary elimination is a

physiologic need and not addressing this problem cancause further complications.

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10 Impaired oral mucous membrane

related to frequent suctioningThe nursing intervention is an actual problem but it isnot the main priority because it is not as critical as theother problems.

11 FatigueHindi i2 applicable

12 Imbalance nutrition: less than bodyrequirements

13 Acute confusion Hindi i2 applicable

14 Activity intolerance related togeneralized weakness

The nursing diagnosis is an actual problem but doesntneed immediate intervention. It is a long-term plan ofcare that needs ample time to be implemented.

15 Impaired physical mobility

16 Disturbed sensory perception Hindi i2 applicable

17 Impaired verbal communicationHindi i2 applicable

The nursing diagnosis is actual problem but ismanageable. Use of resources is utilized tocommunicate with the client even without talking.

18 Trauma related to loss of muscle

coordination secondary to seizures.

The nursing diagnosis was an actual problem but it is

not the main prioritization. The clients problem is along-term process of care.

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ASSESSMENT NURSING

DIAGNOSIS

ANALYSIS PLANNING NURSING

INTERVENTION

RATIONALE EVALUATION

SUBJECTIVE-The clients significant others

verbalizedSobrangnahihirapansiyanghuminga

kaya dinalananaminsa hospital.

OBJECTIVE

-Labored breathing-Cyanotic

-Restlessness

-Unproductive cough-Presence of wheezing

-Tacypnea

Vital Signs:Temperature: 39 C

BP: 120/ 80 mmHgPR: 110 beats/ min.

RR: 42 breaths/ min.

O2 Sat: 77%

INEFFECTIVE

AIRWAY

CLEARANCE

related to

Retained

Mucous

Secretion

secondary to

Presence of

Wheezing.

Inability to clearsecretions or

obstructions fromthe respiratory

tract to maintain a

clear airway.

Irritant(inhalation)

Inflammatory

response

Increaseproduction

of secretions

Airwayconstriction

Dyspnea

Objectives:

After 4 hoursof nursing

intervention

the client willmaintain

airwaypatency as

manifest by

expectoratesecretions and

no difficultyof breathing.

After 2 hours

of nursingintervention

the client:

*Respirations

will normalizewithin the rate

of 12-20

breaths/min.

Independent:

Monitor and recordVital Sign

Position the client

in Semi fowler

position

Monitor pulse

oximetry todetermine

oxygenation;evaluate lung

volumes and forced

vital capacity

Provide Chestphysiotherapy

To obtainbaseline date.

Notes progress

& changes ofcondition.

To prevent

aspiration andto breathe more

comfortably.

To assess forrespiratory

insufficiency

To remove the

secretion and ithelp to relieve

difficulty of

Objectives metas manifested

by:

The clientmaintain airway

patency asmanifested by

expectorate

secretions andno difficulty of

breathing.

*Respirations iswithin the rate of

12-20breaths/min.

* O2 Saturation

is within normalrange of 90-

100%

* Presence of

labor breathing

19 Self-care deficit The nursing diagnosis is an actual problem but themain priority for ABC clients is to save them topossible death.

20 risk for fall The nursing diagnosis is preventable to occur. The riskcan be eliminated through safety interventions.

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* O2

Saturation

will increasefrom 77 to

normal rangeof 90-100%

* Presence oflabor

breathing willdiminish as

clients breath

with rise andfall of the

chest innormal

rhythm.

*The client

cough willchange from

unproductiveto productive

cough.

* The clients

adventitious

breath soundwill diminish

as auscultated.

* The clientwill become

undistress and

uncyanotic asclient color of

conjunctiva

and lips willbecome pink.

Dependent

Administer oxygenas ordered by the

physician

Suctioning asordered by the

physician

Administer IVtherapy as ordered

by the physician

Administermedications as

ordered by the

physician.

Collaborative

Discuss the

condition of theclient with other

member of thehealth care team.

breathing

Formanagement of

respiratorydistress

To remove thesecretion

To prevent

dehydration

For continuous

wellness.

Ensurescontinuous

intervention.

was diminished

as clients breath

with rise and fallof the chest in

normal rhythm.

*The client

cough changefrom

unproductive toproductive

cough.

* The clients

adventitiousbreath sound

was diminished

as auscultated.

* The clientbecome

undistress anduncyanotic as

client color of

conjunctiva andlips become

pink.

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ASSESSMENT NURSING

DIAGNOSIS


INTERVENTION


SUBJECTIVE

-The clients significant others

verbalized

Sobrangnahihirapansiyanghumingakaya dinalananaminsa hospital.

OBJECTIVE

-Labored breathing-Cyanotic

-Restlessness-Tacypnea

-Tachycardia

-Diaphoresis

Impaired Gas

Exchange

related to altered

oxygensupply(obstruction

of airways

bysecretion)

asevidenced

bywheezes

uponauscultation

Entry of

noxiousparticles or

gasesto the lungs

Release of mediators

Abnormalinflammation

of thelungs

Chronicinflammation

Scar tissueformation

Narrowing of airway

lumen

Objectives

After 4 hours

of nursinginterventionthe client will

demonstrate

improvedventilation

and adequateoxygenation

of tissues by

ABGs withinclients

normal limits

Independent:

Monitor and record

Vital Sign

Elevate the head of

the bed andposition the client

at semi fowler.

Note respiratory

rate, depth, use of

To obtain

baseline date.Notes progress& changes of

condition.

To preventaspiration and

to breathe

morecomfortably.

The objectives

met as

evidenced by :

The client

demonstrated

improvedventilation and

adequateoxygenation of

tissues by ABGs

within clientsnormal limits

and absence of

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Vital Signs:

Temperature: 39 C

BP: 120/ 80PR: 110 beats/min.

RR: 42 breathes/ min.

ABG:

Ph: 7.25

PCO2: 30HCO3: 23

O2 Sat: 77%

Airflow limitations

Impaired gasexchange

wheezes

Reference:Pathophysiology by

Gold, 4th

edition, Pg.

345

and absence

of symptoms

of respiratorydistress.

ABG Results

will become :

Ph: 7.35-7.45PCO2: 35-45

HCO3: 22-26O2 Sat: 95-

100 %

After 2 hours

of nursingintervention

the client:

*Respirationswill

normalize

within therate of 12-20

breaths/min.

* Pulse ratewill be

normalwithin the rat

of 60-100

beats/ min.

* O2Saturation

accessory muscles,

pursed-lip

breathing, andareas of pallor/

cyanosis.

Monitor pulseoximetry to

determineoxygenation;

evaluate lung

volumes andforced vital

capacity

Auscultate the

lungs and not foradventitious breath

sounds

Provide Chest

physiotherapy

Dependent

To assess for

respiratoryinsufficiency


insufficiency

Presence ofadventitious

breath soundsnote as a

pulmonary

congestion andsecretion

collection,

indicatingneed for

furtherintervention.

Promotes

optimal lungexpansion and

drainage of

secretion.

symptoms of

respiratory

distress.

ABG Resultswill:

Ph: 7.40

PCO2: 37HCO3: 25

O2 Sat: 98 %

*Respirationswithin the rate

of 12-20breaths/min.

* Pulse rate

within the rateof 60-100 beats/

min.

* O2 Saturationwithin normal

range of 90-

100%

*No presence oflabor breathing

as clientsbreaths with rise

and fall of the

chest in normalrhythm.

* Diminishedadventitious

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will increase

from 77 to

normal rangeof 90-100%

* Presence of

labor

breathingwill diminish

as clientsbreath with

rise and fall

of the chestin normal

rhythm.

* The clients

adventitiousbreath sound

will diminishas

auscultated.

* The client

will becomeundistress

and

uncyanotic asclient color

ofconjunctiva

and lips willbecome pink.

* Presence ofdiaphoresis

Administer oxygen

as ordered by the

physician

Suctioning as

ordered by the

physician

Administer IV

therapy as ordered

by the physician


ordered by the

physician.

Collaborative

Discuss thecondition of the

client with other

member of thehealth care team.

For

management

of respiratorydistress

To remove thesecretion

To prevent

dehydration

For continuous

wellness.

Ensurescontinuous

intervention.

breath sound as

auscultated.

* The client is

undistress anduncyanotic as

client color of

conjunctiva andlips is pink.

*No presence of

diaphoresis asthe client

perspire

normally withmoist skin.

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will diminish

as the client

perspirenormally

with moistskin.

ASSESSMENT(cues)

NURSINGDIAGNOSIS

ANALYSIS GOALS ANDOBJECTIVES

NURSINGINTERVENTION


Subjective:

The significantother stated that

Ineffectivebreathing

pattern relatedto

Inspiration andexpiration that

does not provideadequate

Goal:

After 8 hours ofnursing

After 8 hours ofnursing

intervention, goalwas met as

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the client ishaving a difficultyof breathingbefore arriving atthe hospital..

Objective:

Dyspnea

Tachypnea

Pale

Irritability

Wheezing

Grimace

Use ofaccessorymuscles tobreath

Nasal flaring Increased

anterior-posteriordiameter

Alterations indepth ofbreathing

Pursed lipbreathing

hyperventilationsecondary tostatusasthmaticus

ventilation.

Thepathophysiologyof asthma iscomplex andinvolves airwayinflammation,

intermittentairflowobstruction, andbronchial hyperresponsiveness.

Airwayhyperresponsiveness or bronchialhyperreactivity inasthma is anexaggeratedresponse tonumerousexogenous andendogenousstimuli. Themechanismsinvolved includedirect stimulationof airway smoothmuscle andindirectstimulation bypharmacologicallyactive substancesfrom mediator-secreting cellssuch as mastcells ornonmyelinatedsensory neurons.The degree ofairwayhyperresponsiven

interventions, theclient will be able tohave effectivebreathing pattern.

Objectives:

After 8 hours of

nursinginterventions theclient will manifest:

A. Vital signswithinnormallimits.Respiratoryrate of 12-20breathes/min

B. Normaldepth andrate ofrespiration

Administeroxygen atlowestconcentrationindicated andprescribedrespiratorymedications.

Monitor pulseoximetry, asindicated.

Elevate head ofbed or haveclient sit-up inchair, asappropriate.

Encourageslower/deeperrespirations,use of pursed-lip technique.

Have client

breath into apaper bag, if

For managementof underlyingpulmonarycondition,respiratory distressor cyanosis.

To verifymaintenance/improvement inoxygen saturation.

To promotephysiological/psychological ease ofmaximalinspiration.

To assist client intaking control ofthe situation.

To correct

hyperventilation.

manifested byclients respiratoryrate of 18breaths/min,vesicular breathsound over thelung fields, normaldepth and rate of

breathing, distressupon breathing,relax andcomfortable.

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ess generallycorrelates withthe clinicalseverity ofasthma.

(NANDA 11th

edition page 140)

(http://emedicine.medscape.com/article/296301-overview0)

C. Normal

breathsounds

D. Verbalization ofunderstanding to healthteaching

appropriate.

Avoidovereating/ gasforming foods.

Maintainemergencyequipment inreadilyaccessiblelocation andincludeage/sizeappropriate ET/tracheostomytubes.

Provide healthteachings asfollows:

a. Stressimportance ofgood postureand effectiveuse ofaccessorymuscles.

Assist client inbreathingtraining.(diaphragmatic, abdominalbreathing,pursed lip)

b. Encourageadequate restperiods

May causeabdominaldistention.

When ventilatorsupport might beneeded.

To promotewellness.

To maximizerespiratory effort.

To limit fatigue.

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E. Desiredresponse toregimen

betweenactivity.

c. Reviewenvironmentalfactors(exposure todust, high

pollen counts,severeweather,perfumes,householdchemicals,second-handsmoke)

d. Advise regularmedical

evaluation withprimary careprovider.

Administeranalgesics asordered by thephysician.

It may requireavoidance/modification of lifestyle orenvironment tolimit impact onclients breathing.

To determineeffectiveness ofcurrent therapeuticregimen and topromote generalwellbeing.

To promote deeperrespiration.

(NANDA 11th

ed.142-144)

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ASSESSMENT NURSING

DIAGNOSIS


INTERVENTION


SUBJECTIVE-The clients significant others

verbalized

Sobrangnahihirapansiyanghuminga

kaya dinalananaminsa hospital.

OBJECTIVE

-Labored breathing

-Cyanotic-Restlessness

-Tachypnea-Tachycardia

-Bronchospasm

Vital Signs:Temperature: 39 C

BP: 120/ 80

PR: 110 beats/min.RR: 42 breathes/ min.

O2 Sat: 77%

Ineffective

Cardiopulmonary

Tissue Perfusion

related to

Hypoventilation

Decrease inoxygen

resulting in the

failure to

nourish thetissues at the

capillary level.

Hypoventilationis too shallow or

too slowbreathing,

which does not

meet the needs

of the body. Itmay also referto reduced lung

function.If a

personhypoventilates,

the body'scarbon dioxide

level rises,

which results in

too little oxygenin the blood.

Objectives

After 4 hours

the client will

demonstrateincreased

perfusion as

individually

appropriatevital signs

within thenormal rate.

Vital Sign:

Temperature:36.5-37.5 CBP: 120/ 80

mmHg

PR: 60-100beats/min.

RR: 12-20breathes/ min.

*Respirations

will normalizewithin the rateof 12-20

breaths/min.

* Pulse ratewill be normal

within the rat

of 60-100

beats/ min.

Independent:

Monitor and record

Vital Sign

Elevate the head ofthe bed and

position the clientat semi fowler.

Note respiratory

rate, depth, use ofaccessory muscles,pursed-lip

breathing, and areas

of pallor/ cyanosis.

Monitor pulse

oximetry to

determine

oxygenation;evaluate lungvolumes and forced

vital capacity

Dependent

To obtain

baseline date.

Notes progress& changes ofcondition.

To prevent

aspiration andto breathe more

comfortably.


insufficiency

To assess for

respiratoryinsufficiency

The objectives

met as

evidenced by:

* The clientdemonstrateincreased

perfusion as

individuallyappropriate vital

signs within thenormal rate.

Vital Sign:

Temperature:37CBP: 120/ 80

mmHg

PR: 80beats/min.

RR: 16 breathes/min.

*Respirationswithin the rate of12-20

breaths/min.

* Pulse ratewithin the rate of

60-100 beats/

min.

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* O2

Saturationwill increase

from 77 tonormal range

of 90-100%

* Presence of

laborbreathing will

diminish as

clients breathwith rise and

fall of thechest in

normal

rhythm.

* The client

will becomeundistress and

uncyanotic as

client color ofconjunctiva

and lips will

become pink.

Administer oxygen

as ordered by the

physician

Administer IV

therapy as ordered

by the physician


ordered by the

physician.

Collaborative

Discuss thecondition of the

client with othermember of the

health care team.

For

management of

respiratorydistress

To preventdehydration

For continuous

wellness.

Ensurescontinuous

intervention.

* O2 Saturation

within normal

range of 90-100%

*No presence of

labor breathing

as clientsbreaths with rise

and fall of thechest in normal

rhythm.

* The client isundistress and

uncyanotic as

client color ofconjunctiva and

lips is pink.

ASSESSMENT(cues)

NURSINGDIAGNOSIS


NURSINGINTERVENTION


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S:

O:-blood pressure:100/70-pulse rate: 140bpm-Respiratory rate:

40 bcm-temperature:39C-poor skin turgor-capillaryrefill:2sec-confusion-O2 saturation:83%-diaphoresis

Decreasedcardiac outputrelated todehydration

High fever,diaphoresis andvomiting will leadto dehydrationwhich candecrease thecirculating blood

volume. Anothercondition thatmay havecaused the lowcardiac output isthe retention ofcarbon dioxidethat may lead toacidosis whichcausesvasodilation

resulting tohypotension.Decreasedcardiac output isa conditionwherein there isan inadequateblood pumpedby the heart tomeet themetabolic

demand of thebody.

After 8 hours ofnursing interventionthe client willmaintain bloodpressure withinnormal range.

INDEPENDENT:

Assess vitalsigns.

Assess forimpendingfailure/shock.

Keep thepatient on bedrest.

DEPENDENT:

Administer IVfluids asprescribed

Administerhigh flowoxygen viamask orventilator asprescribed.

Administer

drugs asordered.

Provides basis forcomparison tofollow trends andevaluateresponse to

interventions.

Early detection ofchanges in theseparameterspromotes timelyintervention tolimit degree ofcardiacdysfunction.

To decreaseoxygen andmetabolicdemands

To regulate bodyfluids

To increaseoxygen availablefor tissueperfusion

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1. Impaired/ineffective tissue perfusion: Cerebral- edam

ASSESSMENT(cues)

NURSINGDIAGNOSIS


NURSINGINTERVENTION


* Increase inbody

Elevated bodytemperature

Bodytemperature is

After giving nursingintervention, the

Does the clientable to maintain

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temperature(40 C)* Flushed skin*Tachypnea*Tachycardia*Seizures

related todisturbance inthehypothalamus.

elevated abovenormal rangedue to physicalmanifestations(asconvulsions,sensorydisturbances,

or loss ofconsciousness)resulting fromabnormalelectricaldischarges inthe brain.

client will be able tobe free ofcomplication suchas irreversible braindamage.

After 15 minutes of

nursing intervention,the client will beable to maintaincore temperaturewithin normal range.

After 10 minutes ofnursing intervention,the client will beable to be free of

seizure activity.

After 20 minutes ofnursing intervention,

the client conditionwill improve.

Monitor coretemperature.

Monitorrespirations

Perform tepidsponge bath

Assessneurologicalresponse,noting level ofconsciousnessand orientation,reaction to

To evaluatedegree ofhyperthermia

To evaluatethe effectsofhyperthermia

to controlshiveringandseizures

To assistwithmeasures toreduce bodytemperature

core temperature?

YES__NO__WHY?

Does the clientable to be free of

seizures?

YES__NO__WHY?

Does the clientcondition able toimprove?

YES__

NO__WHY?

Does theinterventionappropriate for theclient?

YES__NO__WHY?

Does theintervention donewithin the allottedtime?

YES__NO__WHY?

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7.

stimuli, reactionto pupil.

administeredprescribedmedications

(diazepam orchlorpromazine)

>Administerantipyretics,orally or rectally.(acetaminophen, aspirin) asordered.

>Promotesurface coolingby means ofundressing.

/ restorenormal body/ organfunction.

ASSESSMENT(cues)

NURSINGDIAGNOSIS


NURSINGINTERVENTION


Deficient fluid A decrease After 8 hours Assess After 8

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Subjective:

Objective:

Diaphoresis

Delayedcapillary refill(4 seconds)

Oliguria

hypotension

poor skinturgor

altered serumsodium

volume relatedto renaldysfunction

blood volumeleads todecreased tissueperfusion. Asvolume lossoccurs, variouscompensatorymechanisms

producevasoconstrictionof thevasculature,retain fluid viathe renaltubules, andincreasedcardiac output.Thesecompensatory

mechanism-such asstimulation of thesympatheticnervous system;releases renin,angiotensinaldosterone andantidiuretichormones; andfluid shifts-

continue in aneffort to restoretissue perfusion,thus ensuringcell survival.However thesemechanisms arelimited in scope,and if the loss ofvolume is notrestored

eventually

of nursinginterventionthe client willbe able tomaintain fluidvolume at afunctionallevel as

evidence byadequateurinaryoutput, stablev/s, moistmucousmembranes,and goodskin turgor.

physicalsigns of fluidvolumedeficit

Observeurinaryoutput, color,

and amount

Administer IVto replacefluid losses

To evaluate

degree of

fluid deficit

To know

how muchfluid theclient islosing.

To correct/reverse fluidvolumedeficit

hours ofnursinginterventionwas theclient ableto maintainfluid volumeat a

functionallevel asevidence byadequateurinaryoutput,stable v/s,moistmucousmembranes, and good

skin turgor?

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8.

ASSESSMENT(cues)

NURSINGDIAGNOSIS


NURSINGINTERVENTION


Objective: Impaired Frequent After 8 hours Assess the To check After 8

cellularstructures incurirreversibledamage fromoxygen debt.

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Coughingbeforeswallowing

Long mealswith littleconsumption

Food refusal

Difficulty ofswallowing

swallowingrelated tofrequentsuctioning

suctioning cancause trauma tooral, pharyngeal,or esophagealstructure leadingto difficulty intaking in food.

of nursinginterventionthe client willbe able topass foodand fluidfrom mouthto stomach

safely withlessdiscomfort.

clients abilityto swallow

Auscultatebreath sounds

Recordcurrent weight

Identifyindividualfactors thatcanprecipitateaspiration/compromiseairway

Determine thefoodpreferences ofthe client

Provideconsistency offood andfluids

Encouragerest periodsbefore meals

Provideanalgesics ifallowedbefore meals

or prior tofeeding

the capacityof the clientfor foodintake.

To evaluatethepresence ofaspiration

Baselinedata tomonitor thenutritionalstatus of theclient

To preventaspirationandmaintainairwaypatency

Toincorporateas possibleenhancingintake

To promoteeasierswallowing

To minimizefatigueduringfeeding

To relievediscomfortduring

feeding

hours ofnursingintervention wasthe clientable topassfood and

fluid frommouth tostomachsafelywith lessdiscomfort?

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9.

ASSESSMENT(cues)

NURSINGDIAGNOSIS


NURSINGINTERVENTION


S:

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O:-Open wound inthe lips andbuccal mucosa

-frequentirritation from

frequentsuctioning

Impaired oralmucousmembranerelated tofrequentsuctioning

Frequentsuctioning isneeded toremoveexcessivemucussecretions in theairway.

Repeatedsuctioning canirritate anddisrupt thesurrounding softtissue.

After 8 hours ofnursinginterventions theclients willdemonstrate adecrease in thesymptoms asnoted in the

definingcharacteristics.

INDEPENDENT:

Encourageadequate fluidintake

Use suction

machinecautiously

Provide gentlegum massage andtongue brushingwith soft toothbrush

Provide dietarymodifications

DEPENDENT

Administer medsas ordered.

To prevent drymouth anddehydration.

To preventadded injury.

Limits mucosaland gumirritation.

To reducediscomfort.

After 8 hours ofnursinginterventionsWas the clientable todemonstrate adecrease in thesymptoms as

noted in thedefiningcharacteristics?

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11.

Fatigue-

eda

m

12.

ASSESSMENT

(cues)

NURSING

DIAGNOSIS

ANALYSIS GOALS AND

OBJECTIVES

NURSING

INTERVENTION


Goal:

ASSESSMENT(cues)

NURSINGDIAGNOSIS


NURSINGINTERVENTION


S:

O:-Increase BUN-oliguria-Urinaryretention

Impaired urinary

eliminationrelated to tissuehypoperfusion

Adequate tissue

perfusion isneeded by theorgans tofacilitate properdistribution ofoxygen andnutrients that isessential for theorgans tofunctionefficiently.

Without this vitalorgans such askidney starts todegenerate.Having thisconditions wasteproducts of thebody is notfiltered properand not will notbe properly

disposed.

After 8 hours of

nursingintervention theclient willachieve normalurinaryelimination.

INDEPENDENT:

Assess patency ofthe foley catheter.

Use asepsis andhand hygiene inproviding care andmanipulatingdrainage system

Assess color,volume and odorof the urinecomponents

DEPENDENT:

Administer IVfluids asprescribed

Provides basisfor furtherassessmentand actions.

Preventscontaminationof the foleycatheter.

Providesinformationabout theadequacy ofthe urineoutput,condition of thefoley catheter

and debris inthe urine.

To regulatebody fluids

After 8 hours of

nursingintervention,Was the clientable to achievenormal urinaryelimination?

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Cues:

Weak in

appearance

Cues:

Loss of

weight

Hyperactive

bowel

sounds

Pallor

Pale mucous

membrane

Subjective:

Reported

food intake

less than

RDA

Lack ofinterest in

food

Abdominal

pain

Malaise stated

by the client

Imbalanced

Nutrition: less

than body

requirements

Intake ofnutrientsinsufficient tomeet metabolicneeds.

Adequatenutrition is

necessary tomeet the bodysdemands.Nutritional statuscan be affectedby disease orinjury states(e.g.,gastrointestinal[GI]malabsorption,

cancer, burns);physical factors(e.g., muscleweakness, poordentition, activityintolerance,pain, substanceabuse); socialfactors (e.g.,lack of financialresources to

obtain nutritiousfoods); orpsychologicalfactors (e.g.,depression,boredom).During times ofillness (e.g.,trauma, surgery,sepsis, burns),adequate

nutrition plays an

After 2 weeks of

Nursing

Intervention the

client will be

able to improve

her nutritional

status.

Objectives:

After 2 weeks of

nursing

intervention the

client will be

able to:

Gainandmaintainappropriateweight.

The S.Owill beable toverbalizeunderstanding

about

Obtain clientsBaseline weight

Discuss theimportance ofmaintaining adequatecaloric intake andfour basic foodgroups as well as theneed for specificminerals andvitamins.

For evaluationof the nursingintervention

Patients maynot understandwhat isinvolved in abalanced diet.They arebetter beingable to askquestions andseek

Was theclient able toGain andmaintainappropriateweight?

Yes__ No__

If No, Why?

____

Was the S.Oable toverbalizeunderstanding about theimportance of

propernutrition?

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important role inhealing andrecovery.Cultural andreligious factorsstrongly affectthe food habitsof patients.

Women exhibit ahigher incidenceof voluntaryrestriction offood intakesecondary toanorexia,bulimia, and self-constructed faddieting. Patientswho are elderly

likewiseexperienceproblems innutrition relatedto lack offinancialresources,cognitiveimpairmentscausing them toforget to eat,

physicallimitations thatinterfere withpreparing food,deterioration oftheir sense oftaste and smell,reduction ofgastric secretionthataccompanies

aging and

theimportance ofpropernutrition.

Withcollaborationwith thenurses,make aset of

nutritious foodsto beincludedin herdiet.

Demonstrate behaviors,lifestylechanges toregain and/or maintainappropriateweight.

Plan with the clienther desired butnutritious meals.

Monitor the clientsweight daily.

assistancewhen theyknow basicinformation.

To promotethe feeling ofindependence.It alsopersonalizesthe plan ofcare since theclient doesmake the

choices insome aspectof the plan.

For evaluationof the plan of

care

Yes__ No__

If No, Why?

____

Was theclient ableto withcollaboration with thenurses,make a setof nutritiousfoods to beincluded in

her diet?Yes__ No__

If No, Why?

____

Was theclient able todemonstrate

behaviors,lifestylechanges toregain and/or maintainappropriateweight?

Yes__ No__

If No, Why?

____

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interferes withdigestion, andsocial isolationand boredomthat cause a lackof interest ineating. This careplan addresses

generalconcerns relatedto nutritionaldeficits for thehospital or homesetting.

Exerciseregularly

Discourage theclient to drinkbeverages that arecaffeinated orcarbonated.

Make a plan ofminimalexercise andencourage theclient toparticipate

This maydecreaseappetite andlead to earlysatiety.

Metabolismand utilizationof nutrients areenhanced byactivity

Was the clientable to exerciseregularly?

Yes__ No__

If No, Why?

____

13.

ASSESSMENT(cues)

NURSINGDIAGNOSIS


NURSINGINTERVENTION


*Fluctuation in

cognition / levelof consciousness

Acute confusion

related todelirium

Abrupt onset of

reversibledisturbances to

After

giving

Does the client

able to maintainlevel of

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*Increaseagitation

*restlessness

*Fluctuation inpsychomotor

activity

*Lack ofmotivation toinititate / follow-throughpurposefulbehavior

consciousness,attention,cognition, andperception thatdevelop over acertain period oftime.

nursingintervention, theclientwill beable toregainusual

realityorientation.

After3days ofnursingintervention the

clientwill beable tomaintainlevel ofconsciousness

After2days ofnursingintervention, theclient

will be

Evaluatemental status,noting extentof impairmentin orientation,attention span,

ability to followdirections,ability to send /receivecommunication,appropriateness of response.

>Identifyfactors presentsuch as acuteillness,trauma/fall,history orcurrent

seizures,

>Todeterminedegree ofimpairment

>To assesscausativeorcontributing factors

consciousness?

YES__NO__WHY?

Does the clientable to verbalize

understanding ofcausativefactors?

YES__NO__WHY?

Des the clientable to initiatebehavior

changes toprevent furtherdeterioration?

YES__NO__WHY?

Does theinterventionappropriate for

the client?

YES__NO__WHY?

Does theinterventiondone within theallotted time?

YES__

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able toverbalizeunderstanding ofcausative factorswhen

known

After aweek ofnursingintervention, the

clientwill beable toinitiatebehaviorchangestopreventrecurrence ofproblem

history of feverand pain.

>Evaluate Vitalsigns

>Notepresence of

anxiety andagitation

>Assist withtreatment ofunderlyingproblems

>Monitor /adjustmedication

regimen andnote response

>Orient clienttosurroundings,staff,necessaryactivities asneeded.

> Maintain

>Toidentifyindicatorsof poortissueperfusion

> Tomaximizelevel offunctionandpreventdeterioration

NO__WHY?

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calmenvironmentand eliminateextraneousnoise / stimuli

14.

ASSESSMENT

(cues)

NURSING

DIAGNOSIS

ANALYSIS GOALS AND

OBJECTIVES

NURSING

INTERVENTION


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Subjective:Since her seizure,she cant do herdaily activities on herown. She alwaysneeds assistanceas verbalized by the

mother of thepatient.

Objective:

Dyspnea

Fatigue atrest

Pallor

Poor capillaryrefill

Weakness

Activity intolerancerelated togeneralizedweakness.

Insufficientphysiological orpsychologicalenergy to endureor competerequired ordesired daily

activities.

Most activityintolerance isrelated togeneralizedweakness anddebilitationsecondary toacute or chronicillness and

disease.

(http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick01.ht

ml)

(NANDA 10th

Edition, page 65)

Long Term:

After 1 month ofnursinginterventions theclient will:

A. Be able to

tolerateactivities;performactivities ofdaily livingfrom minimalto maximalindependence and withoutassistance.

Monitorvital/cognitivesigns,watching for

changes inbloodpressure,heart andrespiratoryrate; note skinpallor/cyanosis presence ofconfusion.Monitorresponse to

supplementaloxygen andmedicationsand changesin treatmentregimen.

Assist withactivities andprovideclients use of

assistive

Forbaselinedata andto manage

activitieswithinindividualslimit.

To protectclient frominjury.

After 1 month ofnursingintervention thegoal was met asmanifested bypatientstoleration to

activities of dailylivingindependentlyand withoutassistance.

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devised.(cane)

Adjustactivities.Reduceintensity levelor discontinue

activities thatcauseundesiredphysiologicalchanges.

Increaseexercise/activity levelgradually;

teachmethods,such asstopping torest for 3minutesduring a 10-minute walk.

Plan care withrest periods

betweenactivities.

Providepositiveatmosphere.Involvesignificantothers inplanning ofactivities as

much as

To preventoverexertion

Toconserveenergy.

To reducefatigue.

Helps tominimizefrustration,rechannelinjury.

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possible.

Promotecomfortmeasures andprovide forrelief of pain.

Providereferral tootherdisciplines asindicated(physicaltherapists).

Provide

healthteaching tothe patient aswell withsignificantothers:

A. Reviewexpectations ofclients/sig

nificantothers.

B. Instructclient/significantothers inmonitoringresponseto activity

and

Toenhanceability toparticipateinactivities.

Todevelopindividuallyappropriate regimen.

To

promotewellness.

Toestablishindividualgoals.

Indicatesneed toalteractivitylevel.

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recognizing signsandsymptoms.

C. Give

clientinformation thatprovidesevidencedaily/weekly.

D. Assistclient inlearning

anddemonstratingappropriate safetymeasures.

E. Provideinformation about

the effectof lifestyleandoverallhealthfactors onactivitytolerance.(nutrition,adequatefluid

intake).

To sustain

motivation.

To preventinjuries.

Toenhancesense of

well-being.

(NANDA 10th

Edition)

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Encourage client tomaintainpositiveattitude;suggestuse ofrelaxation

techniques, such asvisualization/guidedimageryasappropriate

15.Impaired physical mobility- angel

16.

ASSESSMENT(cues)

NURSINGDIAGNOSIS


NURSINGINTERVENTION


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Objective:

*Change in usualresponse to stimuli

*Change inbehavior pattern

(restlessness)

*Disorientation

*Impairedcommunication

Disturbedsensoryperceptionrelated toaltered sensoryreception

Change in theamount ofpatterning ofincoming stimuliaccompanied bya diminished,exaggerated,

distorted, orimpairedresponse tosuch stimuli.

After givingnursingintervention, theclient will beable to regainusual level ofcognition

After 3 days ofnursingintervention, theclient will be tocompensate forsensoryimpairment

After 5 days ofnursingintervention, theclient will beable to identify /modify externalfactors thatcontribute toalterations insensory

>Provide means ofcommunication, asindicated

>Encourage use oflistening devices

>Avoid isolation ofclient, physically oremotionally

>Reorient to person,place, time, andevents, asnecessary

>Identify clientcondition that can

affect sensing,interpreting, andcommunicatingstimuli.

>Assist with/reviewof diagnostic studiesand sensory/motorneurological testing

>Record perceptual

deficit on chart

>To promotenormalization ofresponse tostimuli

>To assist inmanagingauditoryimpairment

>To preventsensorydeprivation / limitconfusion

>To assesscausative /contributingfactors

Does the clientable tocompensate forsensoryimpairment?

YES__

NO__WHY?

Does the able toidentify / modifyexternal factorsthat cancontribute toalteration insensory?

YES__NO__WHY?

Does the clientable to be freeof injury?

YES__NO__WHY?

Does theinterventionappropriate forthe client?YES__NO__WHY?

Does theintervention

done within the

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After 8 hours ofnursingintervention, theclient will beable to be freeof injury

>Provide safetymeasures (secureside rails, bed in lowposition, adequatelighting) >For the

caregivers to beaware

>To preventinjury /complications

allotted time?

YES__NO__WHY?

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17.

ASSESSMENT(cues)

NURSINGDIAGNOSIS

ANALYSIS GOAL andOBJECTIVES

NURSINGINTERVENTION


Objective:

The patientdoes notspeak

Difficulty touse facial orbodyexpressions

Impaired verbal

communicationrelated topresence ofphysicalbarrier(intubation)

An ET tube

provides a stableairway andfacilitatesremoval ofsecretions. It alsoprevents verbalcommunicationbecause itpasses throughthe vocal chords,and the distal tip

is positioned justabove thebifurcation of themain stem of thebronchus(carina).

After 8 hours

of nursingintervention theclient will beable toestablishanother methodofcommunicationon which theclient needs areexpressed.

Determine the

ability to read/write.

Establishrelationship

with the client,observingcarefully andattending toclients non-verbalexpressions

Keepcommunicatio

n simple usingall modes foraccessinginformation:Visual,auditory, andkinesthetic

To know the

possible wayofcommunicating with theclient

Non- verbalcues are

important.This will giveyou signal ofclients

concern/needs.

Alternativeways ofcommunicatin

g with theclient will giveyouinformation toattend toclients needs.

After 8 hours of

nursinginterventionwas the clientable toestablishanother methodofcommunicationon which theclient needs areexpressed?

18

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ASSESSMENT

(cues)

NURSING

DIAGNOSIS

ANALYSIS GOAL and

OBJECTIVES

NURSING

INTERVENTION


Subjective:

Objective:

Pale

Tachycardia Tachypnea

Facial grimace

Irritability

Weakness

Decreased levelof awareness tosurroundings

Less socialinteractions

Trauma related toloss of musclecoordinationsecondary to

seizures.

As a result ofconditionsinteracting withthe individuals

adaptive anddefensiveresources.

A seizure is the

physical findings

or changes in

behavior that

occur after an

episode of

abnormal

electrical activityin the brain.

The term

"seizure" is often

used

interchangeably

with "convulsion."

Convulsions are

when a person's

body shakes

rapidly anduncontrollably.

During

convulsions, the

person's muscles

contract and relax

repeatedly that

may cause

trauma to the

person who

experiences it.

Long term:After 3 days ofnursinginterventions the

client will regainmuscle integrityand coordination.

Objectives:

After 8 hours ofnursinginterventions theclient will showevidence of:

a. Vital signswithinnormalrange

b. Increasedlevel ofawareness

Provide bedrest.

Provideinformationregardingconditions

that mayresult inincreaseinjury.

Identifyinterventions/safetydevices.

To gainstrengthand reducefatigue.

To reduceindividualrisk factors.

To promotesafephysicalenvironment andindividual

safety.

After 3 days ofnursingintervention,goal was met as

evidenced bypatientsperformingactivities of dailylivingindependentlywith propermusclecoordination.

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(NANDA 10th

Edition pg. 325 )

(http://www.nlm.nih.gov/medlineplus/ency/article/003200.htm)

c. Improve

Encourageuse oftechniquesto manage

stress andventemotions.Discussimportanceof selfmonitoring ofconditions/emotions.

Provide

writtenresources.

Encourageparticipationin self-helpprogramssuch asassertivenes

s andtrainingpositive self-image.

Refer toothersources asindicated(counseling,physical

therapists)

To increaseawarenessand well-being.

For later

review andself-pacedlearning.

Toenhanceself-esteemand worth.

To promotewellness.
http://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htm

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socialinteraction

d. Recoveringmuscular

strength

Providerange ofmotionexercises,passive/active.

Administermedicationsprescribedby thephysician.

Increasemusclestrength.

To facilitatetreatment.

(NANDA 10th

and 11th

Edition)

19.

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ASSESSMENT(cues)

NURSINGDIAGNOSIS


NURSINGINTERVENTION


(+) Impairedphysical mobility

Self care Deficitspecific: partial

groomingrelated to

neuromuscular-impairment

Self Care Deficit -When an individualis very unable tomeet their ownself-care requisites

Goals:

After 2 weeksof nursingintervention, theclient will be able toassist at least 50%

of self careeffectively.

Objectives:

After 30 minutesof nursingintervention, theclient and theS.O will be ableto express

cooperation forthe plan of care.

After 30 minutesof nursingintervention, theclient will beable to verbalizeunderstanding

of self care andits importanceby citing at least3 out of 5importance ofself care viawriting or handsignals.

Explain the planof care to theclient and theS.O and howthey cancooperate in it.

Discuss withthe client andthe S.O aboutthe self careand itsimportance.

To build rapportand to promotecooperation ofthe client and theS.O.

To give the clientbasic knowledgeabout thesubject.

After 2 weeks ofnursingintervention, wasthe client will beable to assist at

least 50% of selfcare effectively?

___Yes ___No,Why? ___

After 30 minutesof nursingintervention,were the clientand the S.O ableto express

cooperation forthe plan of care?

___Yes ___No,Why? ___

After 30 minutesof nursingintervention, wasthe client able toverbalizeunderstanding of

self care and itsimportance byciting at least 3out of 5importance ofself care viawriting or handsignals.

___Yes ___No,Why? ___

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Oral Care: After 20

minutes ofnursingintervention,the significant

other will beable toperformproper oralcare for theclient with theclient to assist.

Feeding:

After 30

minutes ofnursingintervention,the client willbe able toidentify propernutrition andcite at least 3out of 5importance ofproper

nutrition viawriting or handsignals.

The significantother will beable to feedthe client withNaso-gastrictube properly,with strict

aspiration

Perform oralcare and allowthe S.O toassist duringoral care. Thenrepeat for the

returndemonstration.

Discuss withthe client the

nutrition and itsimportance.

Demonstrateproper NGTfeeding andevaluate byreturndemonstration.

To maintain theclient`s selfesteem.

To educate theclient and the

S.O.

To preventaspiration.

Oral Care:After 20 minutesof nursingintervention, wasthe significantother able to

perform properoral care for theclient with theclient to assist?

___Yes ___No,Why? ___

Feeding:After 30 minutes

of nursingintervention, wasthe client able toidentify propernutrition and citeat least 3 out of 5importance ofproper nutritionvia writing orhand signals?

___Yes ___No,

Why? ___

Was thesignificant otherwill be able tofeed the clientwith Naso-gastrictube properly,with strict

aspiration

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precaution.

After 30 minutesof nursingintervention, the

client will beable to expressmaintenance ofself-esteem

Encouragethe client toexpress his

feelings aboutthe care plan.

Encouragethe client toexpress

appreciationvia smiling ofhand shaking.

For evaluation ofclient`s feelingsto the care plan.

For evaluation ofclient`s feelingsto the care plan.

precaution?___Yes ___No,Why? ___

After 30minutes ofnursing

intervention,was the clientable toexpressmaintenanceof self-esteem

___Yes ___No,Why? ___

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20.

ASSESSMENT(cues)

NURSINGDIAGNOSIS


NURSINGINTERVENTION


Risk Factors:

Fatigue

Confusion Difficulty

moving

Risk for falls Temporary loss ofenergy or staminadue to over

stimulation of motorand sensory organsafter occurrence ofseizure.

After 8 hours ofnursing interventionthe client will not be

able to be at risk forfall and will gainknowledgeregarding diseaseprocess.

Provideknowledge/information for

the clientsdiseasecondition.

Discuss theimportance ofmonitoring theclients

condition thatcan contributeto occurrenceof injury.

Always put siderails up

To gainknowledgeand

awareness ofthe clientsdiseaseprocess togainawareness ofthecontributingrisk factorsfor fall.

To preventinjury

Prevention offalling out of

bedespeciallywhensleeping.

After 8 hours ofnursingintervention is

client not at riskfor fall and didthe client gainknowledgeregardingdisease process.

NCP & PRIO!!!

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