Skip to main content

Posts

Activity Intolerance NIC NOC

Insufficient physiological or psychological energy to endure or complete required or desired daily activities Defining Characteristics: Verbal report of fatigue or weakness, abnormal heart rate or blood pressure response to activity, exertional discomfort or dyspnea, electrocardiographic changes reflecting dysrhythmias or ischemia Related Factors: Bed rest or immobility; generalized weakness; sedentary lifestyle; imbalance between oxygen supply and demand NOC Suggested NOC Labels Endurance Energy Conservation Activity Tolerance Self-Care: Activities of Daily Living (ADLs) Client Outcomes Participates in prescribed physical activity with appropriate increases in heart rate, blood pressure, and breathing rate; maintains monitor patterns (rhythm and ST segment) within normal limits States symptoms of adverse effects of exercise and reports onset of symptoms immediately Maintains normal skin color and skin is warm and dry with activity Verbalizes an understa...
Recent posts

Nursing Diagnosis : Bowel Incontinence

Nursing Diagnosis : Bowel Incontinence Mikel Gray NANDA Definition : Change in normal bowel habits characterized by involuntary passage of stool. Defining Characteristics: Constant dribbling of soft stool, fecal odor; inability to delay defecation; rectal urgency; self-report of inability to feel rectal fullness or presence of stool in bowel; fecal staining of underclothing; recognizes rectal fullness but reports inability to expel formed stool; inattention to urge to defecate; inability to recognize urge to defecate, red perianal skin Related Factors: Change in stool consistency (diarrhea, constipation, fecal impaction); abnormal motility (metabolic disorders, inflammatory bowel disease, infectious disease, drug induced motility disorders, food intolerance); defects in rectal vault function (low rectal compliance from ischemia, fibrosis, radiation, infectious proctitis, Hirschprung's disease, local or infiltrating neoplasm, severe rectocele); sphincter dysfunction (obste...

Ineffective Breastfeeding Nursing Interventions and Rationales

Nursing Interventions and Rationales Refer to care plan for Effective Breastfeeding 1. Assess for presence/absence of related factors or conditions that would preclude breastfeeding. Some conditions (e.g. certain maternal drugs, maternal HIV-positive status, infant galactosemia) may preclude breastfeeding, in which case the infant needs to be started on a safe alternative method of feeding (Riordan, Auerbach, 2000; Lawrence, 2000). 2. Assess breast and nipple structure. Normal nipple and breast structure or early detection and treatment of abnormalities with continuing support are important for successful breastfeeding (Vogel, Hutchison, Mitchell, 1999). 3. Evaluate and record the mother's ability to position, give cues, and help the infant latch on. Correct positioning and getting the infant to latch on is critical for getting breastfeeding off to a good start and contributes to breastfeeding success (Duffy, Percival, Kershaw, 1997; Brandt, Andrews, Kvale, 1998)...

Ineffective Breastfeeding NANDA Definition

NANDA Definition: Dissatisfaction or difficulty a mother, infant, or child experiences with the breastfeeding process Defining Characteristics: Unsatisfactory breastfeeding process;  nonsustained suckling at the breast;  resisting latching on;  unresponsive to comfort measures;  persistence of sore nipples beyond first week of breastfeeding;  observable signs of inadequate infant intake; insufficient emptying of each breast per feeding;  infant inability to latch on to maternal breast correctly;  infant arching and crying at the breast; infant exhibiting fussiness and crying within the first hour after breastfeeding;  actual or perceived inadequate milk supply;  no observable signs of oxytocin release;  insufficient opportunity for suckling at the breast Related Factors: Nonsupportive partner/family;  previous breast surgery;  infant receiving supplemental feedings with artificial nipple;  prematur...

Hyperthermia related to Malaria

Nursing Diagnosis and Interventions for Malaria Hyperthermia related to dehydration increased metabolism, direct effects of circulating germs in the hypothalamus. Nursing Intervention: 1. Monitor the patient's temperature (degrees and patterns), note the chills. Rational: hyperthermia showed an acute infectious disease process. Pattern suggests the diagnosis of malaria fever. 2. Monitor the temperature of the environment. Rational: indoor temperature / number of blankets to be changed to maintain near-normal temperatures. 3. Give warm compresses bath, avoid the use of alcohol. Rational: to help reduce the fever, the use of ice / alcohol may cause freezing. Addition of alcohol can also cause dry skin. 4. Give antipyretic drugs. Rational: is used to reduce fever with central action on the hypothalamus. 5. Give a cooling blanket. Rationale: This blanket is used to reduce fever with hyperthermia. Source : http://screware.blogspot.com/2013/06/malaria-5-nursing-in...

Handbook of Nursing Diagnosis

The ideal quick reference, this handbook offers practical guidance on nursing diagnoses and associated care. Sections cover Nursing Diagnoses, Health Promotion/Wellness Nursing Diagnoses, and Diagnostic Clusters—medical conditions with relevant collaborative problems and nursing diagnoses. NEW! The newest nursing diagnoses approved by NANDA International for 2012–2014 are included in this edition. NEW! Free eBook available on thePoint. NEW! New resources such as medical and surgical care plans Lynda Juall Carpenito RN MSN CRNP (Author) Read More : Handbook of Nursing Diagnosis Nursing Diagnosis (Nursing Diagnosis Application to Clinical Practice) Now in its 14th edition, this respected resource offers definitive guidance on key elements of nursing diagnosis, its role in the nursing process, and its application to clinical practice. Section 1 thoroughly explains the role of nursing diagnosis in the nursing process and in care planning. Section 2 offers a comprehensive A-...

Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care

Use this convenient resource to formulate nursing diagnoses and create individualized care plans! Updated with the most recent NANDA-I approved nursing diagnoses, Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care, 9th Edition shows you how to build customized care plans using a three-step process: assess, diagnose, and plan care. It includes suggested nursing diagnoses for over 1,300 client symptoms, medical and psychiatric diagnoses, diagnostic procedures, surgical interventions, and clinical states. Authors Elizabeth Ackley and Gail Ladwig use Nursing Outcomes Classification (NOC) and Nursing Interventions Classification (NIC) information to guide you in creating care plans that include desired outcomes, interventions, patient teaching, and evidence-based rationales. Promotes evidence-based interventions and rationales by including recent or classic research that supports the use of each intervention. Unique! Provides care plans for every NANDA-I approved nursi...