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.

NCP Edema - Fluid Volume Excess NIC NOC

Definition: increased isotonic fluid retention

Defining characteristics:

• Body weight increased in a short time
• Excessive intake than output
• Altered blood pressure, pulmonary artery pressure changes, increased CVP
• Jugular venous distention
• Changes in breathing pattern, dyspnoe / shortness of breath, orthopnoe, abnormal breath sounds (Rales or crackles), pulmonary congestion, pleural effusion
• Decreased hemoglobin and hematocrit, electrolyte changes, particularly changes in density
• Heart sound SIII
• Reflex positive hepatojugular
• Oliguria, azotemia
• Mental position changes, nervousness, anxiety

Related Factor:

• Weak regulatory mechanisms
• Excessive fluid intake
• Excessive sodium intake

NOC Labels:

• Electrolit and acid base balance
• Fluid balance
• Hydration

Expected outcomes:

• Free from edema, effusion, anasarca
• The sound of breathing clean, no dyspnea / orthopnea
• Free from jugular venous distention, reflexes hepatojugular (+)
• Maintaining central venous pressure, pulmonary capillary wedge pressure, cardiac output and vital sign within normal limits
• Free from fatigue, anxiety or confusion
• Explaining the excess fluid indicator

NIC:


Fluid management

• Weigh diapers / pads if needed
• Maintain a record of intake and output accurately
• Insert urinary catheter if necessary
• Monitor lab results that correspond to fluid retention (BUN, Hmt, urine osmolality)
• Hemodynamic Monitor position including CVP, MAP, PAP, and PCWP
• Monitor vital sign
• Monitor indications retention / excess fluid (cracles, CVP, edema, distended neck veins, ascites)
• Assess the location and size of edema
• Monitor the input of food / liquid and count daily calorie intake
• Monitor portion of nutrients
• Give diuretics as instructed
• Limit fluid intake on the state of dilution hyponatremia with serum Na less than 130 mEq / l
• Collaboration doctor if signs of excess fluid appears to deteriorate.

Fluid Monitoring

• Determine history of the number and type of fluid intake and elimination
• Determine the possible risk factors of fluid imbalance (Hyperthermia, diuretic therapy, renal disorders, heart failure, diaphoresis, liver dysfunction, etc.)
• Monitor weight
• Monitor serum and urine electrolytes
• Monitor serum and urine osmilalitas
• Monitor BP, HR, and RR
• Monitor blood pressure and orthostatic changes in heart rhythm
• Monitor invasive hemodynamic parameters
• Record intake and output accurately
• Monitor the neck distention, peripheral eodem and weight gain
• Give drugs that can increase urine output
• Monitor signs and symptoms of edema.