Nanda - Hyperthermia - NIC NOC

Definition: the body temperature rises above the normal range

Limitation Characteristics:

• The increase in body temperature above the normal range
• Offensive or convulsions (seizures)
• Skin redness
• Addition of RR
• Tachycardia
• Hand feels warm to the touch

Related Factors:

• disease / trauma
• increased metabolism
• excessive activity
• the influence of medication / anesthesia
• inability / reduced ability to sweat
• exposure to hot environment
• dehydration
• improper attire

NOC: Thermoregulation

Expected outcomes:

• Body temperature within normal range
• Pulse and RR in the normal range
• No skin discoloration and no dizziness, feeling comfortable

NIC:

Fever Treatment

• Monitor the temperature as much as possible
• Monitor IWL
• Monitor skin color and temperature
• Monitor blood pressure, pulse and RR
• Monitor decreased level of consciousness
• Monitor WBC, Hb, and Hct
• Monitor intake and output
• Give anti-pyretic
• Provide treatment to address the cause of the fever
• Cover the patient
• Perform tapid sponge
• Give intravenous fluids
• Compress patients in the groin and axilla
• Increase air circulation
• Provide treatment to prevent shivering

Temperature regulation

• Monitor the temperature at least every 2 hours
• Plan for continuous temperature monitoring
• Monitor blood pressure, pulse, and RR
• Monitor skin color and temperature
• Monitor signs of hyperthermia and hypothermia
• Increase fluid intake and nutrition
• Cover the patient to prevent the loss of body warmth
• Teach the patient how to prevent fatigue due to heat
• Discuss the importance of temperature regulation and the possible negative effects of the cold
• Tell about the indications of fatigue and needed emergency treatment
• Teach indication of hypothermia and handling required
• Give anti pyretic if necessary

Vital sign monitoring

• Monitor blood pressure, pulse, temperature, and RR
• Note the fluctuations in blood pressure
• Monitor vital signs while the patient is lying down, sitting or standing
• Auscultation of blood pressure in both arms and compare
• Monitor blood pressure, pulse, RR, before, during, and after activity
• Monitor the quality of the pulse
• Monitor respiratory rate and rhythm
• Monitor lung sounds
• Monitor abnormal breathing patterns
• Monitor temperature, color, and moisture
• Monitor peripheral cyanosis
• Monitor the Cushing's triad (widening pulse pressure, bradycardia, increased systolic)
• Identify the causes of changes in vital sign

Nanda - Ineffective Individual Coping - NIC NOC

Defining characteristics:

• Sleep disorders
• Chemical abuse
• Decline in the use of social support
• Poor concentration
• Fatigue
• Complained about the inability of coping
• Destructive behavior toward self / others
• The inability to meet the expectations of the role

Related factors:

• Gender differences in coping strategies
• Confidence level is inadequate
• Uncertainty
• Ineffective social support
• Situational crisis / maturasional
• The degree of high-level treatment

NOC Labels: Coping

Expected outcomes:

• Shows the flexibility of the role
• Shows the flexibility of the role of family members
• Conflict issues
• Can set the value of family issues
• Manage the problem
• Involving family members in making decisions
• Express feelings and emotional freedom
• Shows a strategy to manage the problem
• Using stress reduction strategies
• Care for the needs of family members
• Determine priorities
• Determine the timetable for the routine, and family activities
• Schedule for respite care
• Have a plan on the condition of gravity
• Maintain financial stability
• Seeking help when needed
• Using social support

NOC assessment information:

1 = not done at all

2 = rarely done

3 = sometimes done

4 = often

5 = always done


NIC: Improved coping

• Respect the patient's understanding of the disease process and self-concept
• Appreciate and discuss the substitute response to the situation
• Respect the client's attitude toward the changing roles and relationships
• Support the use of spiritual resources upon request
• Use a calm approach and provide assurance
• Provide information about the actual diagnosis, and prognosis handlers
• Provide a realistic option at this aspect of care
• Support the use of appropriate defensive mechanism
• Encourage family involvement in an appropriate manner
• Help patients to identify positive strategies to overcome these limitations and to manage lifestyle and role changes
• Help clients to adapt and anticipate changes in client
• Help clients identify the possibilities that can occur.

Nursing Diagnosis for Decubitus Ulcer - 7 Nanda

Nursing Care Plan for Decubitus Ulcer

Decubitus ulcer: A bed sore, a skin ulcer that comes from lying in one position too long so that the circulation in the skin is compromised by the pressure, particularly over a bony prominence such as the sacrum (sacral decubitus).

The root cause of which is always pressure on a point of the body which isn't relieved, this causes an ulcer to develop. Bed sores are most prevalent on the bed bound or immobile as they cannot move their body to prevent these sores appearing.

If a patient is bed-ridden or immobile, proper monitoring is essential to prevent bed sores from becoming a real problem. The staff in hospitals, care homes etc. must make sure they are constantly vigilant of the signs that an decubitus ulcer is starting to form and try and relieve the pressure on the patient. This can be done by moving the patient into another comfortable position thus relieving the pressure on the part of the body.

The pressure on the skin must be reduced by turning the patient in bed every 2 hours and by the use of a pressure-reducing mattress. Pressure-reducing mattresses include low–air loss beds, air-fluidized beds, and Roho cushion mattress seats for wheelchairs. Furthermore, sitting patients should shift their body weight every 15 minutes.

A pressure ulcer starts as reddened skin that gets worse over time. It forms a blister, then an open sore, and finally a crater.

The most common places for pressure ulcers to form are over bones close to the skin, like the elbow, heels, hips, ankles, shoulders, back, and back of the head.

Pressure sores are categorized by how severe they are, from Stage I (earliest signs) to Stage IV (worst):

• Stage I: A reddened area on the skin that, when pressed, does not turn white. This indicates that a pressure ulcer is starting to develop.
• Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.
• Stage III: The skin breakdown now looks like a crater. There is damage to the tissue below the skin.
• Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints.

7 Nursing Diagnosis for Decubitus Ulcer

1. Impaired Skin Integrity
related to:
mechanical damage of tissue secondary to stress,
shearing and friction.

2. Acute Pain
related to:
skin trauma,
infections of the skin
wound care.

3. Risk for Infection
related to:
display of decubitus ulcers to feces / urine drainage
personal hygiene is lacking.

4. Imbalanced Nutrition, Less Than Body Requirements
related to:
anorexia insufficiency secondary to oral input.

5. Impaired Physical Mobility
related to:
restriction of movement required,
status that is not conditioned,
loss of motor control or change in mental status.

6. Ineffective Individual Coping
related to:
chronic wounds,
changes in body image.

7. Disturbed Body Image
related to:
loss of skin layers.

Diabetes Mellitus - 6 Nanda Nursing Diagnosis

Diabetes mellitus is a condition in which the pancreas no longer produces enough insulin or cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed into the cells of the body.

Diabetes mellitus is a chronic disease that causes serious health complications including renal (kidney) failure, heart disease, stroke, and blindness.

Risk factors for type 2 diabetes mellitus are greater for some ethnicities, as mentioned before. Furthermore, those people who have a family history of type 2 diabetes, who are overweight or inactive also face a greater risk of type 2 diabetes mellitus.

Diabetes mellitus affects a variety of people of all races, ages and nations. It is unkown why some people develop type 1 diabetes.

It may be linked to environmental factors or a virus however it has been estabilished if there is a family history of type 1 diabetes then there is a higher risk of developing type 1 diabetes.

Symptoms include frequent urination, lethargy, excessive thirst, and hunger. The treatment includes changes in diet, oral medications, and in some cases, daily injections of insulin.

Symptoms of diabetes can develop suddenly (over days or weeks) in previously healthy children or adolescents, or can develop gradually (over several years) in overweight adults over the age of 40. The classic symptoms include feeling tired and sick, frequent urination, excessive thirst, excessive hunger, and weight loss.

Diabetes is suspected based on symptoms. Urine tests and blood tests can be used to confirm a diagnose of diabetes based on the amount of glucose found. Urine can also detect ketones and protein in the urine that may help diagnose diabetes and assess how well the kidneys are functioning. These tests also can be used to monitor the disease once the patient is on a standardized diet, oral medications, or insulin.

Research continues on diabetes prevention and improved detection of those at risk for developing diabetes. While the onset of Type I diabetes is unpredictable, the risk of developing Type II diabetes can be reduced by maintaining ideal weight and exercising regularly. The physical and emotional stress of surgery, illness, pregnancy, and alcoholism can increase the risks of diabetes, so maintaining a healthy lifestyle is critical to preventing the onset of Type II diabetes and preventing further complications of the disease.

There is currently no cure for diabetes. The condition, however, can be managed so that patients can live a relatively normal life. Treatment of diabetes focuses on two goals: keeping blood glucose within normal range and preventing the development of long-term complications. Careful monitoring of diet, exercise, and blood glucose levels are as important as the use of insulin or oral medications in preventing complications of diabetes. In 2003, the American Diabetes Association updated its Standards of Care for the management of diabetes. These standards help manage health care providers in the most recent recommendations for diagnosis and treatment of the disease.

Diabetes Mellitus - 6 Nanda Nursing Diagnosis

1. Fluid Volume Deficit

related to:
osmotic diuresis (hyperglycemia).

2. Imbalanced Nutrition, Less Than Body Requirements

related to
poor nutrition intake.

3. Risk for Infection

related to:
high glucose levels
reduction in leukocyte function.

4. Knowledge Deficit: about the disease process

related tyo: lack of information.

5. Risk for Impaired Skin Integrity

related to:
immobilization
neuropathy.

6. Activity Intolerance

related to:
physical weakness.

9 Sample of Pulmonary Tuberculosis (PTB) Nursing Diagnosis - Nanda

Tuberculosis (TB) is an infectious disease that is caused by a bacterium called Mycobacterium tuberculosis.

Symptoms of TB in the lungs may include

• A bad cough that lasts 3 weeks or longer
• Weight loss
• Coughing up blood or mucus
• Weakness or fatigue
• Fever and chills
• Night sweats

Tuberculosis is ultimately caused by the Mycobacterium tuberculosis that is spread from person to person through airborne particles. It is not guaranteed, though, that you will become infected with TB if you inhale the infected particles. Some people have strong enough immune systems that quickly destroy the bacteria once they enter the body. Others will develop latent TB infection and will carry the bacteria but will not be contagious and will not present symptoms. Still others will become immediately sick and will also be contagious. 

9 Sample of Pulmonary Tuberculosis (PTB) Nursing Diagnosis - Nanda

1. Impaired Gas Exchange

related to:

• the exudate in alveo
• surface of the lung function decline.

2. Ineffective Airway Clearance

related to:

• increased sputum
• reduction effort to cough.

3. Ineffective Breathing Pattern

related to

• inflammation
• fatigue.

4. Hyperthermia

related to:

• the infection process.

5. Fluid Volume Deficit

related to:

• fever
• fatigue due to lack of fluid intake.

6. Imbalanced Nutrition, Less Than Body Requirements

related to:

• decreased appetite,
• fatigue
• dyspnea.

7. Risk for [spread] of Infection

related to:

• lower resistance of others who are around people.

8. Ineffective management Therapeutic regimen

related to:

• lack of knowledge about the disease process.

9. Activity Intolerance

related to:

• fatigue,
• changes in nutritional status
• fever.

10 NANDA COPD Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a general term which includes the conditions chronic bronchitis and emphysema. COPD is the preferred term, but you may still hear it called chronic obstructive airways disease (COAD).

•     Chronic means persistent.
•     Bronchitis is inflammation of the bronchi (the airways of the lungs).
•     Emphysema is damage to the smaller airways and air sacs (alveoli) of the lungs.
•     Pulmonary means 'affecting the lungs'.

The term COPD is used to describe airflow obstruction due to chronic bronchitis, emphysema, or both.

The sudden risk caused by COPD is due to the increase in people who smoke and the demographic changes in many countries. In the US, COPD is considered as the fourth leading cause of death. In economic terms the cost of the disease to the US economy in 2007 is pegged at $42.6 billion in terms of health care costs and loss in productivity.

The symptoms of COPD include: constant cough; excess sputum (mucus) production; shortness of breath while doing activities you used to be able to do; wheezing, or whistling sound when you breathe; and tightness in the chest.

The most common symptoms of COPD are breathlessness, or a 'need for air', excessive sputum production, and a chronic cough. However, COPD is not just simply a "smoker's cough", but a under-diagnosed, life threatening lung disease that may progressively lead to death.

The loss of lung function in COPD patients is so gradual that many patients do not realize that they have the condition until it is severe. By the time most patients seek medical attention, they may have lost 50% of their pulmonary function.

There is a need for greater awareness of COPD and early diagnosis and treatment can retard progression of disease and improve quality of life. A person who has COPD should adopt a number of strategies in order to manage and to combat this lung disease. Some of these important strategies include saying no to smoking, vaccinations, rehabilitation and drug therapy. Drug therapies can be done thru the use of inhalers.

The inhalers that are suggested help dilate the airways and the theophylline. Most of the time, the inhaled steroids can be used to contain lung inflammation and can suppress flare-ups. Usually antibiotics are also used during the flare-ups of the symptoms of COPD.

10 NANDA - Nursing Diagnosis for COPD Chronic Obstructive Pulmonary Disease 

1. Ineffective airway clearance 
2. Ineffective breathing pattern 
3. Impaired gas exchange 
4. Activity intolerance
5. Imbalanced Nutrition: less than body requirements
6. Disturbed sleep pattern
7. Bathing / Hygiene Self-care deficit 
8. Anxiety 
9. Ineffective individual coping 
10. Deficient Knowledge