Nursing Diagnosis Statement
|
Impaired Cardiac Output (10025557) |
Dyspnoea (Specify Type) (10029433) |
Pain (Specify Type) (10023130) |
Edema (Specify Degree) |
Decreased Body Mass Index |
Pressure Ulcer (Specify Stage) (10025798) |
Nausea (10000859) |
Ineffective Tissue Perfusion (10001344) |
Ineffective Peripheral Tissue Perfusion (10044239) |
Risk for Aspiration (10015024) |
Risk for Cardiogenic Shock |
Risk for Infection (10015133) |
Risk For Deep Vein Thrombosis (10027509) |
Cough (10047143) |
Hypervolaemia (10042012) |
Nursing Intervention Statement
|
1. Administering and monitoring oxygen therapy; 2. Administering nutritional supplement (10037037); 3. Suctioning the airway (10044890); 4. Listening to and assess intestinal noises daily; 5. Listening to heart rate paying attention to the presence of 3rd heart sound; 6. Listening to breathing noises before and after aspiration; 7. Assessing the cause of impaired sleep pattern; 8. Assessing oral cavity condition; 9. Assessing nutritional status; 10. Assessing discomfort (type, orientation, intensity); 11. Assessing pain (presence, orientation, onset, duration, intensity); 12. Assessing intestinal eliminations (frequency, quantity, fecal aspects); 13. Assessing pressure ulcer staging; 14. Assessing previous pain experiences, including individual and family history of chronic pain or resulting disability; 15. Assessing and monitoring the presence and degree of edema; 16. Assessing and monitoring pulmonary artery pressure; 17. Assessing and monitoring central venous pressure or right atrial pressure; 18. Assessing and monitoring signs of dehydration (decreased skin turgor, dry mucosa); 19. Assessing and monitoring person's level of consciousness; 20. Assessing and monitoring skin (color, temperature, pain, edema, sensitivity, humidity, signs of infection); 21. Assessing and monitoring cough reflex, nausea and ability to swallow; 22. Monitoring vital signs (10032113); 23. Assessing urinary bladder functioning and integrity; 24. Assessing body mass index; 25. Assessing dietary fiber intake; 26. Assessing the lesion (degree, color, secretion, foul odor, pain, temperature); 27. Assessing upper and lower limbs (temperature, color, pulse rate); 28. Assessing moving the pain/discomfort to other locations; 29. Assessing the need for airway aspiration; 30. Assessing the need for wound dressing and coverage; 31. Assessing tissue perfusion; 32. Monitoring weight (10032121); 33. Assessing the presence of flatus; 34. Assessing oral problems that make eating and chewing difficult (prosthesis, wound); 35. Evaluating response to fluid therapy (10007176); 36. Interpreting arterial blood gas result (10010503); 37. Assessing signs of pulmonary edema (respiratory rate, sputum); 38. Assessing situations that cause discomfort; 39. Assessing type of dyspnea (night, intermittent, decubitus, at rest); 40. Assessing cough (sputum, discharge); 41. Catheterising urinary bladder (10030884); 42. Determining person's degree of dependence; 43. Determining degree of jugular vein distension; 44. Implementing enteral feeding (10046178); 45. Implementing artificial airway; 46. Investigating person's food preferences; 47. Washing hands before and after care; 48. Keeping person's head sideways; 49. Keeping person on bed rest; 50. Maintaining airway clearance (10037351); 51. Monitoring fasting person's abdominal circumference daily; 52. Monitoring decreased mobility in bed; 53. Monitoring urinary elimination (frequency, quantity, color, pain and foul odor); 54. Monitoring electrolyte balance; 55. Monitoring fluid balance, if greater than 2.5 liters; 56. Monitoring fluid balance, if less than 2.5 liters; 57. Monitoring fluid balance (10040852); 58. Monitoring degree of urinary bladder distension; 59. Monitoring blood oxygen saturation using pulse oximeter (10032047); 60. Monitoring sedation; 61. Offering small portions of meal often; 62. Offering drink (10050313); 63. Placing person on the bed with a raised headboard (30°, 45° or 60°); 64. Preventing injury during transfer technique (elevation); 65. Preventing spontaneous extubation (fix artificial airway with adhesive tape); 66. Providing food not accompanied by liquids; 67. Providing food with a high nutritional index; 68. Providing oral hygiene in bed every 6 hours; 69. Providing decubitus change every 2 hours; 70. Use transfer technique (10041135); 71. Performing physical examination of the chest (inspection, palpation, percussion and auscultation); 72. Performing abdominal physical examination (inspection, auscultation, percussion and palpation); 73. Rotating venipuncture site; 74. Recording sleep pattern in hours; 75. Nighttime fluid restriction; 76. Liquid restriction or supply; 77. Supervising insertion site of invasive devices (temperature, coloration, pain, secretion); 78. Wound dressing change (10045131); 79. Wound dressing change (10045131); 80. Use pain scales (verbal, facies, visual, numerical); 81. Wearing gloves according to standard precautions; 82. Use antimicrobial soap for hand hygiene; 83. Use aseptic technique (10041784); 84. Measuring height (10037000); 85. Checking and monitoring body temperature of the lower limbs; 86. Checking for residues from the nasogastric catheter or gastrostomy and irrigate every 4-6 hours during continuous feeding and before intermittent feeding; 87. Checking residual enteral catheter volume; |
EDUCATIONAL PROCESS
|
Nursing Diagnosis Statement
|
Conflicting Attitude Toward Medication Management (10022299) |
Self Care Deficit (10023410) |
Impaired Family/Caregiver's Ability to Manage Care |
Nursing Intervention Statement
|
88. Assessing person's knowledge about disease and treatment; 89. Encouraging person's autonomy in self-care, according to the degree of ability; 90. Facilitating person's ability to communicate conflicts in medication management; 91. Informing medication side effect; 92. Explaining to person/family/caregiver the causes of fatigue; 93. Teaching family/caregiver about the importance of stimulating the person's self-care; 94. Teaching family /caregiver about post-discharge care in managing the disease; 95. Teaching family/caregiver about illness and treatment; 96. Teaching family about treatment regimen (10024656); 97. Teaching about eating not accompanied by liquids; 98. Teaching about procedures, including sensations that the person can experience during procedures; 99. Teaching about moisturizer use; 100. Teaching breathing technique (10039213); 101. Provide an explanation about care to be performed; 102. Teaching pain (10039115); 103. Providing routine times for administering medications together with the person; 104. Providing techniques to minimize medication side effects (relaxation, rest, schedule); 105. Strengthening communication about disease and treatment; |
PSYCHOSOCIAL SUPPORT FOR PATIENTS AND FAMILIES
|
Nursing Diagnosis Statement
|
Spiritual Distress (10018583) |
Anxiety (10000477) |
Situational Low Self Esteem (10000844) |
Conflicting Spiritual Belief (10022769) |
Hopelessness (10000742) |
Unfavorable Religious Coping |
Lack of Family Support (10022473) |
Intervention Statement |
Fear (10000703) |
Nursing Intervention Statement
|
106. Helping to identify situations that cause anxiety; 107. Helping to identify situations that cause hopelessness; 108. Helping to identify situations that cause fear; 109. Assessing anxiety level; 110. Encouraging Bible reading; 111. Promoting acceptance of health status (10037783); 112. Teach relaxation techniques (reading, music therapy); 113. Facilitating person's ability to communicate needs related to self-esteem; 114. Facilitating person's ability to communicate needs related to spiritual demands; 115. Facilitating person's ability to communicate feelings related to hospitalization; 116. Facilitating family/caregiver's ability to communicate needs related to care management; 117. Facilitating family/caregiver's ability to communicate feelings related to hospitalization; 118. Identifying obstruction to communication (10009683); 119. Identifying spiritual beliefs; 120. Identifying factors that cause low self-esteem; 121. Facilitating family ability to participate in care plan (10035927); 122. Observing feelings of sadness, irritability, fear, anxiety and loneliness, seeking to offer support; 123. Providing a suitable environment for meals; 124. Providing an adapted environment without obstacles; 125. Teaching techniques to reduce anxiety (relaxation, rest, reading, music therapy); 126. Promoting effective family communication (10036066); 127. Providing an adequate environment (comfortable bed, noise and odor control, lighting and temperature); 128. Providing a calm and safe environment; 129. Providing activities that increase self-esteem (hygiene, reading, music therapy); 130. Providing active communication to interpret the conflict; 131. Providing prayer time; 132. Providing privacy for spiritual behavior (10024504); 133. Providing privacy for religious behavior in bed; 134. Providing routine care so as not to interrupt the person's sleep and rest; 135. Distraction (10039232); 136. Providing alternative techniques for anguish relief (image building, relaxation); 137. Providing techniques to perform spirituality (reading, music therapy); 138. Providing visits by religious entities; 139. Respecting spiritual beliefs; 140. Respecting religious beliefs; |
SUPERVISED CARDIOVASCULAR REHABILITATION PROGRAM
|
Nursing Diagnosis Statement
|
Discomfort (Specify Location) (10023066) |
Increased nocturnal urinary frequency |
Deficient food intake (10000607) |
Damaged skin integrity (10001290) |
Decreased intestinal motility |
Impaired mobility in bed (10001067) |
Increased body weight |
Altered blood pressure (10022954) |
Risk for impaired skin integrity (10015237) |
Risk for pressure ulcer (10027337) |
Risk for decreased intestinal motility |
Impaired sleep and rest |
Hypovolaemia |
Nursing Intervention Statement
|
141. Applying elastic stockings (10030486); 142. Assisting with the search for comfortable body position; 143. Assisting with mobility in bed (10045972); 144. Assistance with food in bed; 145. Assisting with bed/bathroom bath; 146. Assisting with better positioning for eating in bed; 147. Assisting with get dressed in bed; 148. Assisting with oral hygiene in bed every 6 hours; 149. Evaluating lower limb edema; 150. Assessing the need for help in self-care; 151. Identifying factors that alleviate/worse pain; 152. Identifying factors that cause pain; 153. Identifying factors that cause dyspnea; 154. Skin care (10032757); 155. Maintaining a sodium-restricted diet for increased blood pressure; 156. Maintaining intimate hygiene; 157. Keeping lower limbs elevated; 158. Keeping skin hydrated; 159. Keeping skin clean and dry; 160. Monitoring medication adherence (10043878); 161. Monitoring person's degree of ability to perform self-care; 162. Teaching about not eating too hot or too cold food; 163. Promoting and assisting skin hygiene; 164. Protecting bony body regions, allowing adequate tissue perfusion; 165. Providing assistance until the person is fully capable of performing autonomous self-care; 166. Providing daily body hygiene; 167. Providing routine times for medication administration together with the person avoiding diuretic medications at night; 168. Providing exchange of equipment for person's care; Use special mattress (pneumatic, pyramidal) |
EXERCISE-BASED THERAPY
|
Nursing Diagnosis Statement
|
Fatigue (10000695) |
Activity intolerance (10000431) |
Impaired mobility (10001219) |
Nursing Intervention Statement
|
169. Helping person to stand up and walk around; 170. Helping person to sit on the edge of the bed for postural management; 171. Educating about physical exercise regimen; 172. Encouraging autonomous walking; 173. Identifying factors that cause fatigue; 174. Monitoring activity tolerance (10036622); 175. Teaching light to moderate exercise; 176. Providing person's body alignment during the transfer technique; 177. Providing active exercise therapy (walking); 178. Providing therapy with passive physical exercises (range movements, standing, stretching). |