NANDA 2011

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)

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;  prematurity;  previous history of breastfeeding failure;  poor infant

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

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-

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

Key features 2012-2014 edition arranged by diagnostic concepts Core references and level of evidence for each diagnosis New chapters on appropriate use of nursing diagnoses in clinical practice, education, administration and electronic health record 16 new diagnoses 11 revised diagnoses Aimed at students, educators, clinicians, nurse administrators and informaticians Companion website available, including a video on assessment, clinical reasoning and diagnosis NANDA International (Author) Read More : Nursing Diagnoses: Definitions and Classification 2012-14 (Nanda International) Nursing Diagnoses 2009-2011: Definitions and Classification (NANDA NURSING DIAGNOSIS) A nursing diagnosis is defined as a clinical judgement about individual, family or community responses to actual or potential health problems or life processes which provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. Accurate and valid nursing

A brain tumor is an abnormal growth of cells within the brain, which can be cancerous or non-cancerous (benign). Brain tumors can be grouped by the type of cell involved (such as meningioma, astrocytoma, lymphoma, etc.) or by the location in the brain. Metastasized cells may grow in one or several areas of the brain. Almost half of all brain tumors are non-cancerous (benign), slow growing and respond well to treatment. A primary malignant brain tumour is a cancer which arises from a cell within the brain. The cells of the tumour grow into and damage normal brain tissue. Also, like benign brain tumours, they can increase the pressure inside the skull. However, unlike most other types of malignant tumours, primary brain tumours rarely spread (metastasise) to other parts of the body. A secondary malignant brain tumour means that a cancer which started in another part of the body has spread to the brain. Many types of cancer can spread (metastasise) to the brain. The most

Nursing Diagnosis for Diabetes Mellitus : Fatigue related to : Increased energy demands: hypermetabolic state/infection Altered body chemistry: insufficient insulin Decreased metabolic energy production Evidenced by : Impaired ability to concentrate, listlessness, disinterest in surroundings Overwhelming lack of energy, inability to maintain usual routines, decreased performance, accident-prone. Outcomes : Display improved ability to participate in desired activities. Verbalize increase in energy level. Nursing Interventions : 1. Monitor BP, pulse, respiratory rate before/after activity. Rationale : Indicates physiological levels of tolerance. 2. Increase patient participation in ADLs as tolerated. Rationale : Increases confidence level/self-esteem and tolerance level. 3. Alternate activity with periods of rest/uninterrupted sleep. Rationale : Prevents excessive fatigue. 4. Discuss with patient the need for activity. Plan schedule with patient and ide

NANDA Definition: The inability to identify, manage, or seek out help to maintain health Defining Characteristics: History of lack of health-seeking behavior;  reported or observed lack of equipment, financial, and/or other resources;  reported or observed impairment of personal support systems;  expressed interest in improving health behaviors;  demonstrated lack of knowledge regarding basic health practices;  demonstrated lack of adaptive behaviors to internal and external environmental changes;  reported or observed inability to take responsibility for meeting basic health practices in any or all functional pattern areas Related Factors: Disabled family coping, perceptual-cognitive impairment (complete or partial lack of gross or fine motor skills);  lack of or significant alteration in communication skills (written, verbal, or gestural);  unachieved developmental tasks;  lack of material resources;  dysfunctional grieving;  disabling spiritual distress;  inabi

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 (obstetric or traumatic induced

Many factors are thought to play a role in getting Graves' disease. These might include: Genes. Some people are prone to Graves' disease because of their genes. Researchers are working to find the gene or genes involved. Gender. Sex hormones might play a role, and might explain why Graves' disease affects more women than men. Stress. Severe emotional stress or trauma might trigger the onset of Graves' disease in people who are prone to getting it. Pregnancy. Pregnancy affects the thyroid. As many as 30 percent of young women who get Graves' disease have been pregnant in the 12 months prior to the onset of symptoms. This suggests that pregnancy might trigger Graves' disease in some women. Infection. Infection might play a role in the onset of Graves' disease, but no studies have shown infection to directly cause Graves' disease. Graves disease is an autoimmune disorder that leads to overactivity of the thyroid gland (hyperthyroidism). The

Risk for Impaired Gas Exchange related to the accumulation of blood in the lungs due to increased atrial filling Goal: risk for impaired gas does not occur Expected outcomes: Demonstrating adequate ventilation and oxygenation of the tissue, indicated by blood gas analysis / oximetry in the normal range and free of symptoms of respiratory distress. Participate in a treatment program within the ability / situation. Intervention and rationale: 1. Auscultation of breath sounds, note: crackles, mengii. 2. Instruct the patient to cough effectively, breathing deeply. 3. Maintain a semi-Fowler position, chock the hand with a pillow if possible 4. Collaboration in the provision of supplemental oxygen as indicated. 5. Collaboration for the examination of blood gas analysis. 6. Collaboration for the administration of diuretics. 7. Collaboration for the administration of bronchodilator drugs. Rational: 1. Stating pulmonary congestion / collecting secretions indicate the need

Nursing Diagnosis for Anema : Risk for Infection related to decreased immunity, invasive procedures Goal: There are no risk factors for infection Expected outcomes: free of symptoms of infection, normal leukocyte numbers (4-11000) vital signs within normal limits. Nursing Interventions: Control of infection: Clean up the environment after use for other patients. Limit visitor when necessary and recommended for adequate rest. Instruct patient’s family to wash their hands before and after contact with the client. Use anti-microbe soap for hand washing. Make hand washing before and after nursing actions. Use clothes and gloves as a protective device. Maintain aseptic environment during the installation of equipment. Perform wound care, and dresing infusion, catheter every day if any. Increase intake of nutrients, and adequate fluid. Give antibiotics according to the program. Protection of infection: Monitor signs and symptoms of systemic and local infections.

Assessment for Brain Tumor (Intracranial Tumor) Focal neurological disorders. In the frontal lobe, occurred personality disorders, affective disorders, the motor system dysfunction, seizures, aphasia. Precentral gyrus can be found on Jacksonian seizures. In the occipital lobe, visual disturbances, and headache. Temporal lobe can occur auditory hallucinations, visual or gustatory and psychomotor seizures, aphasia. In the parietal lobe can be found the inability to distinguish left – right, sensory deficit (contralateral). Increased ICT: lethargy, decreased HR, decreased level of consciousness, papilledema, projectile vomiting, seizures, changes in breathing patterns, changes in vital signs. Mental. Personality changes, depression, decreased memory and ability to make decisions. Pituitary dysfunction. Cushing’s syndrome, acromegaly, giantisme, hypopituitarism. Pain. Persistent headache. Seizure activity. Fluid status. Nausea and vomiting, decreased urine output, dry muc

Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care, 9e Betty J. Ackley (Author), Gail B. Ladwig (Author) Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care, 9e 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