Nursing Diagnosis for Retained Placenta

Nursing Diagnosis for Retained Placenta

Nursing Diagnosis for Retained Placenta
Retained placenta is a condition where all or part of the placenta or membranes are left behind in the uterus during the third stage of labour.

In humans, retained placenta is generally defined as a placenta that has not undergone placental expulsion within 30 minutes of the baby’s birth.

Risks of retained placenta include hemorrhage and infection.

Nursing Diagnosis for Retained Placenta
  1. Deficient Fluid Volume: Hypovolemia related to excessive loss through vascular.

  2. Risk for Infection related to the trauma network.

  3. Acute Pain related to trauma or tissue distension.

  4. Ineffective Tissue Perfusion related to hipovalemia.

  5. Anxiety related to the threat of changes in health status.

  6. Knowledge Deficit related to lack of information obtained.

Nursing Diagnosis for Myasthenia Gravis

Nursing Diagnosis for Myasthenia Gravis

Nursing Diagnosis for Myasthenia Gravis

Myasthenia Gravis

Myasthenia Gravis is a condition in which the body’s immune system damages nerve receptors on your muscles. This results in apparent muscle weakness, as these receptors are necessary for your muscles to contract. If the eyelid muscles are affected by MG, this can result in lid droop (ptosis). If it involves the muscles needed for eye movement, it can result in double vision.

Nursing Diagnosis for Myasthenia Gravis
  1. Ineffective Breathing Pattern related to respiratory muscle weakness.

  2. Impaired Physical Mobility related to weakness of voluntary muscles.

  3. Self-Care Deficit related to muscle weakness, general fatigue

  4. Imbalanced Nutrition: Less than Body Requirements related to dysphagia, intubation, or muscle paralysis.

How to Write a Nursing Diagnosis

How to write a nursing

In this audio clip, you will learn the simple steps for writing a nursing diagnosis.

101 Nursing Tips- NANDA

101 Nursing Tips- NANDA- Video

This video provided best tutorial issues about nurses.. -NANDA

Online Education For A Nursing Degree

You can earn your registered nursing degree online and you can get there faster and with ease. There are a lot of alternatives so when you search for a masters in nursing online degree, you will learn that finding the right one can be overwhelming. Some institutions with masters in nursing online degrees also offer programs for those who want to pursue a career in nursing administration. Even programs in nursing education are offered.

The online degrees are popular because the number of people who would like to return to college, but who do not have the time. So colleges have decided to take advantage of the internet and offer classes as well as degree programs.

To earn an advanced nursing degree has many advantages, and earning it online can have often more. All educational choices have pros and cons, but the advantages of an online nursing masters degree allow you to continue your education, and your life, with fewer interruptions than may occur through a traditional learning setting. Most think that the advantages of earning a degree in nursing online are many and can help you reach your career goals and enter a rapidly growing industry.

To continue your education gives you more opportunities so if you are considering the method of moving from one level of degree to the next, online education allows you to do just that. You have to understand what is required for a nursing education. As all education, a nursing education also requires time, effort, enthusiasm and self-motivation. As a successful graduate from an MSN-MBA program you will enjoy many benefits of that education and advantages that emphasize just that.

For highly motivated students there is an option that is growing in popularity, the accelerated bachelor nursing degree. The student should understand that getting an accelerated nursing degree is not for everyone, it requires extremely long hours and dedication to achieve.

The industry is changing and by offering career choices in the form of more educational opportunities and options you can choose the steps you want to take at the time. There is no doubt that nursing is an excellent career choice. You can find programs that are for those who are looking into nursing to see if it is the right career choice for them. If you decide to take a master degree, that will equip you with the education and credentials to qualify for a larger number of career opportunities in the health care industry.

Why should a student consider earning an online nursing degree? Except from individual values and criteria, the whole industry has a continuing increase in demand and cannot keep up with the demand. And as said before, the online degrees can be earned in less time, at less of a cost and get your career started faster.

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Using Herbs for Asthma Treatment

In addition to the most common treatments for asthma, there are other means of controlling the symptoms that are not the regular, conventional means. Many asthma patients rely on unconventional treatment means as to not have to endure any possible side effects of medicine that could pose more harm than good.

The asthma patient can achieve a full life and experience all that they can, despite the fact that they suffer from a debilitating and non-curable disease. Asthma can really take a toll on a patient. Asthma is the condition of inflammation and constriction of airways in the bronchial tubes and respiratory system. With recent discoveries underway, many patients have found that herbs have found their way into a possible treatment plan for people with asthma.

Though the asthma patient cannot reach a full recovery with their disease, they can achieve a sense of balance and relief by implementing the appropriate treatments. Using herbs for asthma is one treatment that may continue to progress and provide relief.

It is important, however, that if the patient decides to use herbs for asthma treatment, that they should not overestimate the ability of the herbs for asthma. In some cases, herbs for asthma may not work. The treatment may fail and the asthma patient should and must discuss all possible risks and side effects with their physician. The asthma patient must always have a backup plan in case using herbs for asthma does not work as effectively for them as they may have initially desired.

The Basics of Herbal Asthma Treatment

In the cultural climate of Chinese Herbalists, many experiments have been done to investigate the effects of herbs for asthma treatment. One of the herbs that they have done testing with is called Ephedra Sinica. In modern day tests, this herb for asthma has been highly valued because of its ability to treat the disease. Another herb, called Ma Huang, had the substance, Ephedrine, extracted from it in order to create a pharmaceutical for the treatment. Experts believe that this particular herb for asthma helps to alleviate the breathing difficulty in the asthma sufferer.

Licorice Root has also been proven as an effective herb for asthma treatment. Licorice Root has been evaluated in the treatment of asthma and scientists have discovered that it assists in defeating the inflammation that constricts the airways in the asthma patient. This is the most highly rated herb for asthma today as a result of its healing properties.

Many other herbs for asthma treatment have been evaluated for properties that help the asthma sufferer. Some of these herbs for asthma treatment include; seed of lobelia, marshmallow root, garlics and onions and other remedies on the holistic front.

Once again, an asthma treatment is only as effective as the planning and effort put into it. If the patient decides that they would like to experiment with various herbs for asthma treatment, they should discuss this treatment method with their physician or another medical specialist. They should understand that not everyone succeeds with this form of asthma treatment and should have a backup plan in case using herbs for asthma doesn't work for them.

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Nursing Scholarships For Men

O.K. men, it's your turn. Take the nursing field and run with it. First of all congratulations and salutations to all men entering the nursing field. It is about time, thank you. With that said, how about finding some scholarships to help you achieve your goals. Yes, there are scholarships out there just for you gentlemen. Take advantage of them. Nursing school is a whole other ball field now that men have entered into it full swing. As most of you know, it is not a pretty sight.

Many of the nursing instructors have been holding their own as women for quite sometime. I really don't think they had planned to see so many men in the field. So What! Right? Wrong. I realize that it is an uphill battle sometimes.

The mind and mentality of a nursing student with respect to their instructor is not much different than the humility that the student must show his Samurai Sensi, as he backs up to leave the room never turning his back out of respect for his teacher. Yeah, I know, corny, but hey you have to know how to roll with the punches. Sometimes that doesn't even work. However men, hang in there. You will make it, and be good nurses, no, great nurses you will be.

Up to this point, I hope that I have not shaken, not stirred those men who are contemplating going into the nursing field. From my own personal experience as a second year nurse with only fifteen weeks left to go, all I can say is that the male nursing students are intelligent, kind, patient and all around very pleasant to be with. Albeit there are not many men in our clinical but those who are do fantastic.

So, with that let's get down to business and get those scholarships for nursing school. Where to go? Well, there is an excellent scholarship for men going into the nursing field called, The American Assembly for. Men in Nursing.

That is not the only nursing school scholarship that you can or should apply for. Your sex has nothing to do with nursing school scholarships. The key is to apply, apply and apply. Get as many as you can. If any of you are veterans, then you must already know that you have some excellent scholarships available. Just like the nursing school scholarships for women who are the sole head of household and bread winners, so too can men apply for the same scholarships.

Balancing a family, job and nursing school is no easy feat. The more time that you devote to nursing school the better off you will be. Studying the nursing texts are not the same as taking pre-requisites. Those texts are the big guns and you need time. So, don't hesitate in applying for as many grants as you can qualify for. Always go to your school of choice to determine what types of grants and nursing school scholarships are available. Then go online to see what else you may qualify for.

Many web sites have toll free numbers that you can call. Just don't get caught up in the free money traps. Those flashy ads won't get you anywhere but in debt. Also, ask around. I have found that the more you communicate with other students in the nursing field the better informed you will be.

It is surprising to find out that no matter how much you think you were able to dig up on scholarships, there is always that someone that found another one. So be sure to ask. There are many nursing forums online. These are an excellent way to give and take information. Let's face it, there are not enough nurses, so the more that join the field the better. Best Wishes in your careers.

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Nursing Diagnosis for Mental Retardation

Nursing Diagnosis for Mental Retardation

Mental retardation is a condition diagnosed before age 18 that includes below-average general intellectual function, and a lack of the skills necessary for daily living.

Mental retardation affects about 1 - 3% of the population. There are many causes of mental retardation, but doctors find a specific reason in only 25% of cases.

A family may suspect mental retardation if the child's motor skills, language skills, and self-help skills do not seem to be developing, or are developing at a far slower rate than the child's peers. Failure to adapt (adjust to new situations) normally and grow intellectually may become apparent early in a child's life. In the case of mild retardation, these failures may not become recognizable until school age or later.

Nursing Diagnosis for Mental Retardation
  1. Self-care Deficit : feeding, bathing, dressing / ornate, toileting related to disability

  2. Impaired Social Interaction related to speech impediment / difficulty of social adaptation

  3. Interrupted Family Processes related to a child mental retardation

  4. Risk for Injury related to the behavior of aggressive / uncontrolled motor coordination

  5. Impaired Verbal Communication related to the slow reception of expression and language skills

Nursing Intervention for Congenital Dislocation of the Hip (CDH)

Congenital Dislocation of the Hip (CDH) is an orthopedic deformity obtained immediately before or during birth.

Most babies born with congenital dislocatoin of hip have parents who obviously do not have health problems or risk factors. A pregnant woman who has attended all her doctor's advice for one day give birth to healthy babies, it may be later gave birth to babies with congenital abnormalities. 60% of cases of congenital disorder of unknown cause, the rest are caused by environmental or genetic factors or a combination of both.

Nursing Intervention for Congenital Dislocation of the Hip (CDH)

Impaired Physical Mobility related to pain during mobilization

Goal :
Clients can move freely

Expected Result :
Clients can move freely

Nursing Intervention
  1. Assess client's level of mobilization
    Rational: To identify the scope of the problem early, as a guide further action
  2. Give exercises ROM
    Rational: Restoring or improving joint function and muscle strength are reduced because of the illness or accident
  3. Instruct the tool if needed
    Rational: to assist in doing a thing.

Nursing Diagnosis for Congenital Dislocation of the Hip (CDH)

Nursing Diagnosis for Congenital Dislocation of the Hip

Congenital Dislocation of the Hip (CDH) is an orthopedic deformity obtained immediately before or during birth.

Most babies born with congenital dislocatoin of hip have parents who obviously do not have health problems or risk factors. A pregnant woman who has attended all her doctor's advice for one day give birth to healthy babies, it may be later gave birth to babies with congenital abnormalities. 60% of cases of congenital disorder of unknown cause, the rest are caused by environmental or genetic factors or a combination of both.

Nursing Diagnosis for Congenital Dislocation of the Hip (CDH)
  1. Acute Pain related to dislocations.
  2. Impaired Physical Mobility related to pain during mobilization.
  3. Disturbed Body Image related to changes in body shape.

Nursing Intervention for Impetigo

Nursing Intervention for Impetigo
Nursing Diagnosis and Nursing Intervention for Impetigo

Risk for Infection related to the durability of the body decreases, malnutrition, inflammatory processes, and invasive procedures.

Nursing Intervention for Impetigo

Goal :
No infection

Expected Results :
  1. Free from signs and symptoms of infection.
  2. Showing the ability to prevent infection.
  3. Show healthy behavior.
  4. Describe the process of transmission of disease, factors that affect transmission.

Nursing Intervention for Impetigo
  1. Monitor signs and symptoms of infection.
  2. Monitor susceptibility to infection.
  3. Limit the visitor when necessary.
  4. Instruct guests to wash their hands during a visit and after leaving the patient.
  5. Maintain aseptic environment during treatments take place.
  6. Give your skin care in the area epidema.
  7. Inspection of skin and mucous membranes of the redness, heat.
  8. Inspection of the condition of the wound.
  9. Give anibiotik therapy if necessary.
  10. Teach them how to avoid infection.

Nursing Diagnosis for Impetigo

Nursing Diagnosis for Impetigo

Impetigo is a contagious skin infection that usually produces blisters or sores on the face, neck, hands, and diaper area is one of the most common skin infections among kids.

It is generally caused by one of two bacteria: staphylococcus aureus or group A streptococcus. Impetigo usually affects preschool and school-age children. A child may be more likely to develop impetigo if the skin has already been irritated by other skin problems, such as eczema, poison ivy, and insect bites.

Nursing Diagnosis for Impetigo
  1. Impaired Skin Integrity related to lesions and mechanical injury (scratching an itch on the skin)
  2. Risk for Infection related to the durability of the body decreases, malnutrition, inflammatory processes, and invasive procedures
  3. Body Image Disturbance related to changes in the appearance of secondary.
  4. Anxiety related to changes in health status
  5. Deficient Knowledge : about the disease, prognosis and treatment needs.

10 Foods that Make You Fat

ice cream

Here is 10 foods that are easy to make fat. If you can not get rid of the menu list, replace it with a kind of low calorie and fat-free, or do not eat them too often.
  1. Mashed potatoes. Especially if its processing using the cream and butter. Imagine, 1 / 2 cup serving contains 200 calories.

  2. Candy. Apart from containing bad fats, sugar candy is also very high. Similarly, a type snacks such as donuts, cakes and cake rolls.

  3. Ice cream. Although ecstasy is very inviting, ice cream is a dish that is very high in fat, sugar and calories. So, consider returning to enjoy it if you're dieting.

  4. Potato chips. This tasty snack is one of the foods most likely to make fat because of its salt content is very high. Not to mention the fat and sugar content, so the total calorie high. In addition, many potato chips contain preservatives, artificial flavorings and sweeteners that are clearly harmful to health.

  5. Processed meat. Although very practical, hot dogs, sausage and processed meats like, containing fat is not good. Levels are so high, as much salt they contain.

  6. Fried snacks. This type of food is not good for health because it is generally fried in oil is not replaced each time the fry. Also very high fat content and lack of cleanliness guaranteed if sold on the roadside.

  7. Fast food. Among hamburgers, nachos and fries. Very high fat content, as well as calorie content. While the nutrient content of healthy, almost non-existent.

  8. Soft drinks. Though bringing freshness of a moment, these drinks have absolutely no nutritional value. Unless, rich in sugar content, sodium, and calories.

  9. Sweet cereals. Cereals with high carbohydrate content, is increasingly becoming a threat when meeting with the sweetness of sugar. This type of food will increase blood sugar and causes the body to hoard fat.

  10. Whole milk. Although calcium is good for the body, this type of milk has a very high fat content which will increase body fat. So, if you want to take the benefits of calcium, replace it by eating fat-free milk or at least the ones that have reduced fat content.

8 Natural Ways to Increase Fertility

8  Natural Ways to Increase FertilityInfertility is very common; in America occurs in one out of eight couples. This problem can also be overcome, either from your own efforts or with medical assistance. If you intend to improve fertility in a natural way, there are some things you can do.

Intercourse on a regular basis
Intercourse on a regular basis are able to control your monthly cycle, as well as delay the decline in estrogen levels as we age. Second it can increase fertility, according to research Winnifred Cutler, PhD, founder of the Athena Institute in Chester Springs, Pennsylvania. Increased estrogen levels are also often associated with bone density, a healthier cardiovascular system, lower bad cholesterol, and higher good cholesterol, and menopause are much lighter.

Keep your weight
Having a body mass index (BMI) higher than 25 can improve many health problems, such as polycystic ovary syndrome, which messes up your menstrual cycle and hinder your plan to become pregnant without complications. Exercise regularly, to make your BMI between 18.5 and 25.

Stop smoking
Smoking is not only disrupt the health of the lungs and heart. The new study shows that smoking can increase the risk of premature menopause. Toxins in the nicotine can interfere with ovulation. However, with a stop smoking now you can protect your fertility.

Sleep enough
From research, it appears that women who have reduced fertility have low leptin levels. Leptin is a hormone that affects hunger and weight. Leptin levels will decrease if you do not get enough sleep. So, try to sleep 7-8 hours every day.

Cleaning house
The chemicals contained in household cleaning products could actually undermine fertility. According to a study published in the journal Environmental Health Perspectives, polybrominated diphenyl ethers (PBDE, fire prevention materials in some toys, plastics, and fabrics), PBDE levels in women with high blood takes twice as long to be fertilized than those who have PBDE levels are lower. These chemicals can alter thyroid function and disrupt sex hormones. PBDE can survive in dust that we breathe or touch. Therefore, wash your hands every time you finish the move, to eliminate a variety of toxic residues.

Diligently check
Sexually transmitted infection such as chlamydia can cause pelvic inflammation, and leave scars in the oviduct. This, can cause infertility. If you are classified as sexually active, do safer sex, and consult regularly with your doctor to monitor the content of your reproductive health.

Eating ice cream
Ice cream lovers certainly love with this news. For according to a study from Harvard School of Public Health, Boston, all ulahan dairy products with full fat (like cheese, ice cream, and milk) can help you to get pregnant. Fat-soluble compounds, which are found in these products, the possibility of increasing your chances of conception.

Folic Acid
First, folic acid is only recommended for pregnant women. But these supplements (preferably with a dose of 400 mcg per day) is now considered as a treatment for all women in reproductive age, according to Mark Gapinski, MD, gynecologist and obstetrician at Central DuPage Hospital in Winfield, Illinois. Folic acid, which is part of the vitamin B complex, is used to produce and maintain new cells in skin, hair, nails, and the whole body. Folate, which can also be found in various foods such as lentils, green leafy vegetables like spinach, avocado, and kiwi fruit, also serves to prevent miscarriages and brain defects in babies.

Nursing Intervention for Diabetes Mellitus

Nursing Intervention for Diabetes Mellitus

Nursing Interventions for Diabetes Mellitus

Diabetes mellitus is a group of metabolic diseases characterized by high blood sugar (glucose) levels, that result from defects in insulin secretion, or action, or both. Diabetes mellitus, commonly referred to as diabetes (as it will be in this article) was first identified as a disease associated with "sweet urine," and excessive muscle loss in the ancient world. Elevated levels of blood glucose (hyperglycemia) lead to spillage of glucose into the urine, hence the term sweet urine.

Normally, blood glucose levels are tightly controlled by insulin, a hormone produced by the pancreas. Insulin lowers the blood glucose level. When the blood glucose elevates (for example, after eating food), insulin is released from the pancreas to normalize the glucose level. In patients with diabetes, the absence or insufficient production of insulin causes hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be controlled, it lasts a lifetime.(

Nursing Diagnosis for Diabetes Mellitus

Imbalanced Nutrition: More than Body Requirements related to intake in excess of activity expenditures

Nursing Interventions for Diabetes Mellitus
  1. Assess current timing and content of meals.
  2. Assist patient to identify problems that may have an impact on dietary adherence and possible solutions to these problems. Emphasize that lifestyle changes should be maintainable for life.
  3. Assist patient to establish goals for weekly weight loss and incentives to assist in achieving them.
  4. Advise patient on the importance of an individualized meal plan in meeting weight-loss goals. Reducing intake of carbohydrates may benefit some patients; however, fad diets or diet plans that stress one food group and eliminate another are generally not recommended.
  5. Discuss the goals of dietary therapy for the patient. Setting a goal of a 10% (of patient’s actual body weight) weight loss over several months is usually achievable and effective in reducing blood sugar and other metabolic parameters.
  6. Explain the importance of exercise in maintaining/reducing body weight.
    • Caloric expenditure for energy in exercise
    • Carryover of enhanced metabolic rate and efficient food utilization
  7. Strategize with patient to address the potential social pitfalls of weight reduction.

Nursing Diagnosis for Diabetes Mellitus

Risk for Injury (hypoglycemia) related to effects of insulin, inability to eat

Nursing Interventions for Diabetes Mellitus
  1. Assess patient for the signs and symptoms of hypoglycemia.
    • Adrenergic (early symptoms) sweating, tremor, pallor, tachycardia, palpitations, nervousness from the release of adrenalin when blood glucose falls rapidly
    • Neurologic (later symptoms) light-headedness, headache, confusion, irritability, slurred speech, lack of coordination, staggering gait from depression of central nervous system as glucose level progressively falls.
  2. Assess patient for cognitive or physical impairments that may interfere with ability to accurately administer insulin.
  3. Closely monitor blood glucose levels to detect hypoglycemia.
  4. Instruct patient in the importance of accuracy in insulin preparation and meal timing to avoid hypoglycemia.
  5. Encourage patient to carry a portable treatment for hypoglycemia at all times.
  6. Between-meal snacks as well as extra food taken before exercise should be encouraged to prevent hypoglycemia.

Source :

Head To Toe Nursing Assessment Video

Head To Toe Nursing Assessment

Nursing Diagnosis and Nursing Intervention for Pneumonia

Nursing Intervention for Pneumonia


Cough (both productive and non productive) nasal output, shortness of breath, tachipnea, breath sounds are limited, retraction, fever, diaporesis, ronchii, cyanosis, leukocytosis.


Children will experience effective breathing pattern characterized by:

  • Voice lung breath clean and the same on both sides
  • The body temperature within the limits of 36.5 to 37.2 OC
  • The rate of breathing within the normal range
  • There is no coughing, cyanosis, nasal output, retraction and diaporesis

Nursing Intervention

Perform assessments every 4 hours of respiration rate, temperature, and the signs of the effectiveness of the airway.
R /: Evaluation and reassessment of the actions that will be / have been granted.

Perform chest physiotherapy is scheduled
R /: Removing the secretion of the airway, preventing obstruction

Give Oxygen moist, review the effectiveness of therapy
R /: Increased lung tissue oxygen supply

Give antibiotics and antipyretic, review the effectiveness and side effects (rash, diarrhea)
R /: Eradication of germs as factors causing interference.

Make a check photo thoracic
R /: Evaluation of the effectiveness of the circulation of oxygen, evaluating the condition of lung tissue

Perform suction gradually
R: Helping cleaning airway

Record the results of pulse oximeter when installed, every 2-4 hours
R: Evaluate periodically the success of therapy / health team action.

Source :
Nursing Diagnosis for Pneumonia: Ineffective Breathing Pattern

Nursing Diagnosis for Encephalitis

Nursing Diagnosis for Encephalitis

Encephalitis is an acute inflammation of the brain. Encephalitis with meningitis is known as meningoencephalitis. Symptoms include headache, fever, confusion, drowsiness, and fatigue. More advanced and serious symptoms include seizures or convulsions, tremors, hallucinations, and memory problems.

Nursing Diagnosis for Encephalitis

  1. Risk for injury related to general seizure activity.

  2. Risk for Infection related to inadequate primary defenses.

  3. Acute Pain / Chronic related to the infection process, which is marked with the child crying, anxiety.

  4. Impaired physical mobility related to decreased muscle strength, marked with limited ROM.

  5. Imbalanced Nutrition : Less Than Body Requirements related to nausea and vomiting.

  6. Disturbed sensory perception (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory) related to damage to the central nervous system.

Cognitive Behavioral Response in Anxiety

Cognitive Behavioral Response in Anxiety

Response System


• Restlessness
• Physical Tension
• Tremor
• Nervous
• Talk fast
• No coordination
• The tendency to harm
• Withdrew
• Avoidance
• Inhibited activity


• Impaired attention
• Concentration is lost
• Forgetful
• Incorrect interpretation
• The existence of blocking in mind
• Reduced land perceptions
• Creative and productive decline
• Confused
• Excessive Worry
• Missing assess the objectivity
• Fear of losing control
• Fear of excessive


• Easily distracted
• Can not wait
• Restlessness
• Tense
• Nerveus
• Fear
• Alarm
• Tremor
• Nervous
• Restlessness

Cognitive Behavioral Response in Anxiety

Physiological Responses to Anxiety

Physiological Responses to Anxiety

Physiological Responses to Anxiety

Response System


• Palpitations
• Heart palpitations
• Increased blood pressure and pulse decrease
• Sense of going to faint and eventually fainted.


• Rapid breathing
• Breathing shallow
• Feeling depressed in the chest
• Swelling in the Throat
• Sense of choking
• Panting

Neuro muscular

• Increased reflexes
• Reaction surprises
• Insomnia
• Fear
• Restlessness
• Face tense
• Weaknesses in general
• Slow motion
• Movement is awkward


• Loss of appetite
• Refusing to eat
• Feelings of shallow
• Abdominal discomfort
• Burning sensation in the heart
• Nausea
• Diarrhea

Urinary Tract

• Unable to hold urine
• Frequent urination

Skin System

• Burning sensation in the mucosa
• Sweating a lot in your palm
• Itching
• feeling hot or cold on skin
• Front pale and sweating throughout the body

Physiological Responses to Anxiety

Levels of Anxiety

Levels of Anxiety

Levels of Anxiety

Some theories divide anxiety into four levels :

Mild Anxiety

Mild Anxiety associated with the tension will the events of daily life and cause a person to be vigilant and perceptions of land increases. Anxiety can motivate learning and produce growth and creativity.

Moderate Anxiety

At this level the field of perception of the environment decreases. Individuals are more important things to focus on that moment and the exclusion of other things.

Severe Anxiety

In the field of perception becomes severe anxiety is decreased. Individuals tend to think of something very small and ignore other things. Individuals are not able to think realistically and requires a lot of direction, in order to concentrate on other areas.


At this stage it is very narrow perception of land, so that individuals can no longer control himself and can not do anything, despite being given a briefing / demands. In a state of panic increased motor activity, decreased ability to deal with people laindan loss of rational thinking.

Nursing Assessment for Anxiety

Nursing Assessment for Anxiety
  1. Predisposing Factors

    Theory developed to explain the causes of anxiety are :

    • Psychoanalytic Theory
      Anxiety is an emotional concept that occurs between two elements of personality-ad and the superego. Id represents the impulse of instinct, and primitive impulse person, while the superego reflects one's conscience and controlled by one's cultural norms. Ego or I function mediate the demands of two conflicting elements and functions of the ego's anxiety is reminded that there is danger.
    • Interpersonal Theory
      Anxiety resulting from fear of interpersonal rejection. It is also associated with trauma in the development of such loss, separation causes a person helpless. Individuals who have low self-esteem is usually very easy to experience severe anxiety.
    • Behavioral Theory
      Anxiety behavior is a product of frustration that is all things that interfere with a person's ability to achieve desired goals.
    • Family Study
      Family studies indicate that anxiety disorders are usually found within a family.
    • Biological Assessment
      Biological Assessment showed that the brain contains specific receptors for benzodiazepines. These receptors may help manage anxiety.

  2. Precipitation Factor

    Precipitation factor in anxiety disorders comes from external and internal sources as below :
    • The threat to the integrity of a person includes a physiological inability or reduced capacity to perform activities of daily living.
    • The threat to the system can endanger a person's self identity, self esteem, and the integration of social functions.

  3. Behavior
    Anxiety can be expressed directly through changes in physiology and behavior and indirectly through the development of symptoms or coping mechanism in the struggle against anxiety. The intensity of behavior will increase in line with increased levels of anxiety.

Nursing Diagnosis for Anxiety

Nursing Assessment Nursing Care Plan for Anxiety

Nursing Intervention for Gastritis

Nursing Intervention for Gastritis

1. Risk for activity intolerance related to physical weakness.


Activity limitation is resolved.

Expected results:

Clients are not assisted by the family in the activity.

Nursing Intervention for Gastritis

Increase bed rest or sit, give a quiet and comfortable environment, limit visitors, encourage the use of relaxation techniques, review the tenderness in the stomach, give the medicine according to the indication.

2. Acute Pain related to inflammation of gastric mucosa


Pain can be reduced / lost.

Expected results:

Pain gone / controlled, looked relaxed and able to sleep / rest, pain scale shows the number 0.

Nursing Intervention for Gastritis

Review pain scale and location of pain, observation Vital Signs, provide a quiet and comfortable environment, encourage relaxation techniques with breath in, do the collaboration in the provision of drugs in accordance with the indication to reduce the pain.

3. Impaired nutrition needs Less than body requirements related to inadequate intake, anorexia.

Goal :

Nutritional deficiencies resolved.

Expected results:

Stable weight, normal laboratory values ​​albumin, no nausea and vomiting, weight within normal limits, normal bowel sounds.

Nursing Intervention for Gastritis

Assess food intake, body weight measured regularly, give oral care on a regular basis, encourage clients to eat little but often, give food in warm, auscultation bowel sounds, assess food preferences, supervised laboratory tests such as: Hb, Ht, Albumin.

Nursing Intervention for Scabies

Nursing Diagnosis and Nursing Intervention for Scabies
  1. Risk of infection related to damaged skin tissue and invasive procedures

    Goal :
    Avoid the risk of infection

    Criteria for outcome :
    • Clients are free from signs and symptoms of infection
    • Showing the ability to prevent infection
    • Demonstrate healthy behavior
    • Describe the process of transmission of disease, factors that affect transmission.

    Plan of action :
    • Monitor signs and symptoms of infection
    • Monitor susceptibility to infection
    • Limit visitors when necessary
    • Instruct the guests to wash their hands during a visit and after leaving the patient
    • Maintain aseptic environment during installation tool
    • Give skin care in the area epidema
    • Inspection of skin and mucous membranes of the redness, hot
    • Inspection of the wound
    • Provide antibiotic therapy if necessary
    • Teach how to avoid infection.
  2. Damage to skin integrity related to edema

    Goal :
    Layer of the skin looks normal

    Criteria for outcome :
    • A good skin integrity can be maintained (sensation, elasticity, temperature)
    • No cuts or lesions on the skin
    • Able to protect skin and keep skin moist and natural treatments

    Plan of action :
    • Instruct the patient using a loose-fitting clothing
    • Keep the skin clean to keep them clean and dry
    • Monitor the skin is a reddish
    • Wash the patient with warm water and soap

Source : Nursing Diagnosis and Nursing Intervention for Scabies

Nursing Assessment for Appendicitis

Nursing Assessment for Appendicitis

a condition characterized by inflammation of the appendix. It is classified as a medical emergency and many cases require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly because of the risk of rupture leading to peritonitis and shock. Reginald Fitz first described acute and chronic appendicitis in 1886, and it has been recognized as one of the most common causes of severe acute abdominal pain worldwide. A correctly diagnosed non-acute form of appendicitis is known as "rumbling appendicitis". wikipedia

Nursing Assessment for Appendicitis
  1. The identity of the client
  2. Health History
    • Current medical history; complaints of pain in postoperative wound, nausea, vomiting, increased body temperature, increased leukocytes.
    • Past medical history
    • Physical examination
      1. Cardiovascular System: To determine vital signs, presence or absence of jugular venous distension, pale, edema, and abnormal heart sounds.
      2. Hematological system: To determine whether there is any increase in leukocytes is a sign of infection and bleeding, nosebleeds splenomegaly.
      3. Urogenital system: Presence or absence of tension of the bladder and back pain complaints.
      4. Musculoskeletal System: To determine whether there is any difficulty in movement, pain in bones, joints and there are fractures or not.
      5. The immune system: To determine whether there is lymph node enlargement.
  3. Other Examination

    • Routine blood tests: to determine an increase in leukocytes is a sign of infection.
    • Abdominal x-ray examination: to know the existence of post-surgical complications.

Nursing Diagnosis for Appendicitis


is defined as an inflammation of the inner lining of the vermiform appendix that spreads to its other parts. This condition is a common and urgent surgical illness with protean manifestations, generous overlap with other clinical syndromes, and significant morbidity, which increases with diagnostic delay (see Clinical Presentation). In fact, despite diagnostic and therapeutic advancement in medicine, appendicitis remains a clinical emergency and is one of the more common causes of acute abdominal

Nursing Diagnosis for Appendicitis

Nursing Diagnosis for Appendicitis

Nursing Diagnosis for Appendicitis Preoperative

1. Imbalanced Nutrition: Less Than Body Requirements related to vomiting pre surgery.

2. Acute Pain related to distention of intestinal tissue by inflammation.

3. Anxiety related to changes in health status.

Nursing Diagnosis for Appendicitis Postoperative

1. Acute Pain related to the existence of postoperative wound.

2. Imbalanced Nutrition: Less Than Body Requirements related to anorexia, nausea.

3. Risk for Infection related to surgical incisions, less knowledge about treatments and diseases associated with lack of information.

Nursing Diagnosis for Anxiety

Nursing Diagnosis for Anxiety

NANDA Definition: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat.

Anxiety is probably present at some level in every individual’s life, but the degree and the frequency with which it manifests differs broadly. Each individual’s response to anxiety is different. Some people are able to use the emotional edge that anxiety provokes to stimulate creativity or problem-solving abilities; others can become immobilized to a pathological degree. The feeling is generally categorized into four levels for treatment purposes: mild, moderate, severe, and panic. The nurse can encounter the anxious patient anywhere in the hospital or community. The presence of the nurse may lend support to the anxious patient and provide some strategies for traversing anxious moments or panic attacks.

Related Factors:
  • Threat or perceived threat to physical and emotional integrity
  • Changes in role function
  • Intrusive diagnostic and surgical tests and procedures
  • Changes in environment and routines
  • Threat or perceived threat to self-concept
  • Threat to (or change in) socioeconomic status
  • Situational and maturational crises
  • Interpersonal conflicts

Defining Characteristics:
  • Increase in blood pressure, pulse, and respirations
  • Dizziness, light-headedness
  • Perspiration
  • Frequent urination
  • Flushing
  • Dyspnea
  • Palpitations
  • Dry mouth
  • Headaches
  • Nausea and/or diarrhea
  • Restlessness
  • Pacing
  • Pupil dilation
  • Insomnia, nightmares
  • Trembling
  • Feelings of helplessness and discomfort
  • Expressions of helplessness
  • Feelings of inadequacy
  • Crying
  • Difficulty concentrating
  • Rumination
  • Inability to problem-solve
  • Preoccupation

Expected Outcomes
  • Patient is able to recognize signs of anxiety.
  • Patient demonstrates positive coping mechanisms.
  • Patient may describe a reduction in the level of anxiety experienced.

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
  • Anxiety Control
  • Coping

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
  • Anxiety Reduction
  • Presence
  • Calming Technique
  • Emotional Support

Nursing Diagnosis for Decreased Cardiac Output

Nursing Diagnosis for Decreased Cardiac Output

NANDA Definition: Inadequate blood pumped by the heart to meet the metabolic demands of the body

Common causes of reduced cardiac output include myocardial infarction, hypertension, valvular heart disease, congenital heart disease, cardiomyopathy, pulmonary disease, arrhythmias, drug effects, fluid overload, decreased fluid volume, and electrolyte imbalance. Geriatric patients are especially at risk because the aging process causes reduced compliance of the ventricles, which further reduces contractility and cardiac output. Patients may have acute, temporary problems or experience chronic, debilitating effects of decreased cardiac output. Patients may be managed in an acute, ambulatory care, or home care setting. This care plan focuses on the acute management.

Related Factors:
  • Increased or decreased ventricular filling (preload)
  • Alteration in afterload
  • Impaired contractility
  • Alteration in heart rate, rhythm, and conduction
  • Decreased oxygenation
  • Cardiac muscle disease

Defining Characteristics:
  • Variations in hemodynamic parameters (blood pressure [BP], heart rate, central venous pressure [CVP], pulmonary artery pressures, venous oxygen saturation [SVO2], cardiac output)
  • Arrhythmias, electrocardiogram (ECG) changes
  • Rales, tachypnea, dyspnea, orthopnea, cough, abnormal arterial blood gases (ABGs), frothy sputum
  • Weight gain, edema, decreased urine output
  • Anxiety, restlessness
  • Syncope, dizziness
  • Weakness, fatigue
  • Abnormal heart sounds
  • Decreased peripheral pulses, cold clammy skin
  • Confusion, change in mental status
  • Angina
  • Ejection fraction less than 40%
  • Pulsus alternans

Expected Outcomes
Patient maintains BP within normal limits; warm, dry skin; regular cardiac rhythm; clear lung sounds; and strong bilateral, equal peripheral pulses.

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
  • Cardiac Pump Effectiveness
  • Circulation Status
  • Knowledge: Disease Process
  • Knowledge: Treatment Program

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
  • Cardiac Care
  • Hemodynamic Regulation
  • Teaching: Disease Process

List of Nursing Diagnoses 2007 - 2008 NANDA Approved

List of NANDA Nursing diagnosis Accepted for Use and Research 2007-2008: Divided into 13 domains and 47 classes, below the full list of 13 Domains and 47 classes NANDA Nursing diagnosis. And complete list of NANDA Nursing diagnosis based on alphabetical order.

Domains Health Promotions
Health awareness
Health management

Domains nutrition's

Domains Elimination/exchange
Urinary System
Gastrointestinal System
Integumentary system
Pulmonary System

Domains Activity/Rest
Energy Balance
Cardiovascular-pulmonary Responses

Domains Perception/Cognition

Domains Self Perception
Body Image

Domains Role Relationship
Caregiving Roles
Family Relationship
Role Performance

Domains Sexuality
Sexual Identity
Sexual Function

Domains Coping/Stress Tolerance
Post-Trauma Responses
Coping Responses
Neuro-behavioral Stress

Domains Life Principles
Values/Belief/action Congruence

Domains Safety/protection
Physical Injury
Enviromental Hazards
Defensive Processes

Domains Comfort
Physical Comfort
Environmental Comfort
social Comfort

Domains Growth/Development

Nursing Diagnoses 2009-2011: Definitions and Classification (NANDA NURSING DIAGNOSIS)

Nursing Diagnosis for Bronchopneumonia

Nursing Diagnosis for Bronchopneumonia

Bronchopneumonia or bronchial pneumonia or "Bronchogenic pneumonia" (not to be confused with lobar pneumonia) is the acute inflammation of the walls of the bronchioles. It is a type of pneumonia characterised by multiple foci of isolated, acute consolidation, affecting one or more pulmonary lobules.

It is one of two types of bacterial pneumonia as classified by gross anatomic distribution of consolidation (solidification), the other being lobar pneumonia.

Nursing Diagnosis for Bronchopneumonia

1) Ineffective airway clearance related to the buildup of secretions.

2) Impaired gas exchange related to changes in alveolar capillaries.

3) Deficit fluid volume related to the excessive output.

4) Imbalanced nutrition: less than body requirements related to inadequate nutritional intake.

5) Risk for Imbalanced Body Temperature related to the infection process

6) Deficient Knowledge: about diseases related to lack of information.

7) Anxiety related to hospitalization.

Nursing Diagnosis for Brain Injury

A brain injury is any injury occurring in the brain of a living organism. Brain injuries can be classified along several dimensions. Primary and secondary brain injury are ways to classify the injury processes that occur in brain injury, while focal and diffuse brain injury are ways to classify the extent or location of injury in the brain. Specific forms of brain injury include:
  • Brain damage, the destruction or degeneration of brain cells.
  • Traumatic brain injury, damage that occurs when an outside force traumatically injures the brain.
  • Stroke, a vascular event causing damage in the brain.
  • Acquired brain injury, damage to the brain that occurs after birth, regardless of whether it is traumatic or nontraumatic, or whether due to an outside or internal cause.

Nursing Diagnosis for Brain Injury
  1. Ineffective airway clearance and impaired gas exchange related to brain injury
  2. Ineffective cerebral tissue perfusion related to increased ICP, decreased CPP, and possible seizures
  3. Deficient fluid volume related to decreased LOC and hormonal dysfunction
  4. Imbalanced nutrition, less than body requirements related to increased metabolic demands, fluid restriction, and inadequate intake
  5. Risk for injury (self-directed and directed at others) related to seizures, disorientation, restlessness, or brain damage
  6. Risk for imbalanced body temperature related to damaged temperature-regulating mechanisms in the brain
  7. Risk for impaired skin integrity related to bed rest, hemiparesis, hemiplegia, immobility, or restlessness
  8. Disturbed thought processes (deficits in intellectual function, communication, memory, information processing) related to brain injury
  9. Disturbed sleep pattern related to brain injury and frequent neurologic checks
  10. Interrupted family processes related to unresponsiveness of patient, unpredictability of outcome, prolonged recovery period, and the patient’s residual physical disability and emotional deficit
  11. Deficient knowledge about brain injury, recovery, and the rehabilitation process

Source :

Nursing Diagnosis for Epilepsy

Epilepsy is a brain disorder that causes people to have recurring seizures. The seizures happen when clusters of nerve cells, or neurons, in the brain send out the wrong signals. People may have strange sensations and emotions or behave strangely. They may have violent muscle spasms or lose consciousness.

Epilepsy has many possible causes, including illness, brain injury and abnormal brain development. In many cases, the cause is unknown.

Doctors use brain scans and other tests to diagnose epilepsy. It is important to start treatment right away. There is no cure for epilepsy, but medicines can control seizures for most people. When medicines are not working well, surgery or implanted devices such as vagus nerve stimulators may help. Special diets can help some children with epilepsy.

NIH: National Institute of Neurological Disorders and Stroke

Nursing Diagnosis for Epilepsy
  1. Risk for injury related to seizure activity
  2. Ineffective individual coping related to stresses imposed by epilepsy
  3. Fear related to the possibility of seizures
  4. Deficient knowledge related to epilepsy and its control

Nursing Diagnosis for Craniotomy


A craniotomy is a procedure to remove a lesion in the brain through an opening in the skull (cranium).

A craniotomy is a type of brain surgery. It is the most commonly performed surgery for brain tumor removal . It also may be done to remove a blood clot (hematoma), to control hemorrhage from a weak, leaking blood vessel (cerebral aneurysm), to repair arteriovenous malformations (abnormal connections of blood vessels), to drain a brain abscess, to relieve pressure inside the skull, to perform a biopsy, or to inspect the brain.

Nursing Diagnosis for Craniotomy
  1. Ineffective cerebral tissue perfusion related to cerebral edema
  2. Potential for impaired gas exchange related to hypoventilation, aspiration, and immobility
  3. Risk for imbalanced body temperature related to damage to the hypothalamus, dehydration, and infection
  4. Disturbed sensory perception related to periorbital edema, head dressing, endotracheal tube, and effects of ICP
  5. Body image disturbance related to change in appearance or physical disabilities

Nursing Diagnosis for Increased Intracranial Pressure

Increased intracranial pressure

Increased intracranial pressure is a rise in the pressure inside the skull that can result from or cause brain injury.

Causes, incidence, and risk factors:

Increased intracranial pressure can be due to a rise in cerebrospinal fluid pressure. It can also be due to increased pressure within the brain matter caused by a mass (such as a tumor), bleeding into the brain or fluid around the brain, or swelling within the brain matter itself.

An increase in intracranial pressure is a serious medical problem. The pressure itself can damage the brain or spinal cord by pressing on important brain structures and by restricting blood flow into the brain.

Nursing Diagnosis for Increased Intracranial Pressure

  1. Ineffective airway clearance related to diminished protective reflexes (cough, gag)
  2. Ineffective breathing patterns related to neurologic dysfunction (brain stem compression, structural displacement)
  3. Ineffective cerebral tissue perfusion related to the effects of increased ICP
  4. Deficient fluid volume related to fluid restriction
  5. Risk for infection related to ICP monitoring system (fiberoptic or intraventricular catheter)

Diagnosis of Ischemic Stroke

Doctors can usually diagnose an ischemic stroke based on the history of events and results of a physical examination. Doctors can usually identify which artery in the brain is blocked based on symptoms (see Brain Dysfunction:IntroductionFigures). For example, weakness or paralysis of the left leg suggests blockage of the artery supplying the area on the right side of the brain that controls the left leg's muscle movements.

Computed tomography (CT) is usually done first. CT helps distinguish an ischemic stroke from a hemorrhagic stroke, a brain tumor, an abscess, and other structural abnormalities. Doctors also measure the blood sugar level to rule out a low blood sugar level (hypoglycemia), which can cause similar symptoms. If available, diffusion magnetic resonance imaging (MRI), which can detect ischemic strokes within minutes of their start, may be done next.

Identifying the precise cause of the stroke is important. If the blockage is a blood clot, another stroke is very likely unless the underlying disorder is corrected. For example, if blood clots result from an abnormal heart rhythm, treating that disorder can prevent new clots from forming and causing another stroke. Tests for causes may include the following:

Electrocardiography (ECG) to look for abnormal heart rhythms
Continuous ECG monitoring (done at home or in the hospital—see Symptoms and Diagnosis of Heart and Blood Vessel Disorders: Continuous Ambulatory Electrocardiography) to record the heart rate and rhythm continuously for 24 hours (or more), which may detect abnormal heart rhythms that occur unpredictably or briefly
Echocardiography to check the heart for blood clots, pumping or structural abnormalities, and valve disorders
Imaging tests—color Doppler ultrasonography, magnetic resonance angiography, CT angiography, or cerebral (standard) angiography—to determine whether arteries, especially the internal carotid arteries, are blocked or narrowed
Blood tests to check for anemia, polycythemia, blood clotting disorders, vasculitis, and some infections (such as heart valve infections and syphilis) and for risk factors such as high cholesterol levels or diabetes

Imaging tests enable doctors to determine how narrowed the carotid arteries are and thus to estimate the risk of a subsequent stroke or TIA. Such information helps determine which treatments are needed.

For cerebral angiography, a thin, flexible tube (catheter) is inserted into an artery, usually in the groin, and threaded through the aorta to an artery in the neck. Then, a dye is injected to outline the artery. Thus, this test is more invasive than other tests that provide images of the brain's blood supply. However, it provides more information (see Common Imaging Tests: Angiography). Cerebral angiography may be done before atheromas are removed surgically or when vasculitis is suspected.

Rarely, a spinal tap (lumbar puncture) is done—for example, after CT, when doctors still need to determine whether strokelike symptoms are due to an infection or whether a subarachnoid hemorrhage is present (see Stroke (CVA): Subarachnoid Hemorrhage). This procedure is done only if doctors are sure that the brain is not under excess pressure (usually determined by CT or MRI).

Source :

Nursing Diagnosis for Ischemic Stroke

Stroke is characterized by the sudden loss of blood circulation to an area of the brain, resulting in a corresponding loss of neurologic function. Also previously called cerebrovascular accident (CVA) or stroke syndrome, stroke is a nonspecific term encompassing a heterogeneous group of pathophysiologic causes.

Broadly, however, strokes are classified as either hemorrhagic or ischemic. Acute ischemic stroke refers to stroke caused by thrombosis or embolism and is more common than hemorrhagic stroke. (Prior literature indicated that only 8-18% of strokes are hemorrhagic, but a retrospective review from a stroke center found that 40.9% of 757 strokes included in the study were hemorrhagic.

Nursing Diagnosis for Ischemic Stroke
  • Impaired physical mobility related to hemiparesis, loss of balance and coordination, spasticity, and brain injury
  • Acute pain (painful shoulder) related to hemiplegia and disuse
  • Self-care deficits (bathing, hygiene, toileting, dressing, grooming, and feeding) related to stroke sequelae
  • Disturbed sensory perception related to altered sensory reception, transmission, and/or integration
  • Impaired swallowing
  • Total urinary incontinence related  to flaccid bladder, detrusor instability, confusion, or difficulty in communicating
  • Disturbed thought processes related to brain damage, confusion, or inability to follow instructions
  • Impaired verbal communication related to brain damage
  • Risk for impaired skin integrity related to hemiparesis, hemiplegia, or decreased mobility
  • Interrupted family processes related to catastrophic illness and caregiving burdens
 Nursing Diagnosis for Ischemic Stroke


Filled under:

The primary organization for defining, dissemination and integration of standardized nursing diagnoses worldwide is NANDA-International formerly known as the North American Nursing Diagnosis Association. For nearly 40 years NANDA-I has worked in this area to ensure that diagnoses are developed through a peer-reviewed process requiring standardized levels of evidence, standardized definitions, defining characteristics, related factors and/or risk factors that enable nurses to identify potential diagnoses in the course of a nursing assessment. NANDA-I believes that it is critical that nurses are required to utilize standardized languages that provide not just terms (diagnoses) but the embedded knowledge from clinical practice and research that provides diagnostic criteria (definitions, defining characterisitcs) and the related or etiologic factors upon which nurses intervene. NANDA-I terms are developed and refined for actual (current) health responses and for risk situations , as well as providing diagnoses to support health promotion. Diagnoses are applicable to individuals, families, groups and communities. Contributing diagnostic associations include AENTDE (Spain), AFEDI (French language), and JSND (Japan). NANDA-I also has several regional networks including Brasil, Peru, Honduras, Nigeria-Ghana and a German-language group. The taxonomy is published in multiple countries and has been translated into 18 languages; it is in use worldwide. The terminology is an American Nurses' Association-recognized terminology, is included in the UMLS, is HL7 registered, ISO-compatible and available within SNOMED CT with appropriate licensure.

Nursing diagnoses are a critical part of ensuring that the knowledge and contribution of nursing practice to patient outcomes are found within the electronic health record and can be linked to nurse-sensitive patient outcomes.


Structure of Nanda Diagnosis

The NANDA-I system of nursing diagnosis provides for four categories.
  1. Actual diagnosis - "A clinical judgment about human experience/responses to health conditions/life processes that exist in an individual, family, or community". An example of an actual nursing diagnosis is: Sleep deprivation.
  2. Risk diagnosis - "Describes human responses to health conditions/life processes that may develop in a vulnerable individual/family/community. It is supported by risk factors that contribute to increased vulnerability." An example of a risk diagnosis is: Risk for shock.
  3. Health promotion diagnosis - "A clinical judgment about a person’s, family’s or community’s motivation and desire to increase wellbeing and actualize human health potential as expressed in the readiness to enhance specific health behaviors, and can be used in any health state." An example of a health promotion diagnosis is: Readiness for enhanced nutrition.
  4. Syndrome diagnosis - "A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions." An example of a syndrome diagnosis is: Relocation stress syndrome.

Diagnosis of Stroke

Diagnosis of Stroke

If stroke is suspected, prompt, accurate diagnosis and treatment is necessary to minimize brain tissue damage. Diagnosis includes a medical history and a physical examination including neurological examination to evaluate the level of consciousness, sensation, and function (visual, motor, language) and determine the cause, location, and extent of the stroke.

Physical examination includes assessing the airway, breathing, and circulation (ABCs) and the vital signs (i.e., pulse, respiration, temperature). The head (including ears, eyes, nose, and throat) and extremities are also examined to help determine the cause of the stroke and rule out other conditions that produce similar symptoms (e.g., Bell's palsy).

Blood tests (e.g., complete blood count) and imaging procedures (e.g., CT scan, ultrasound, MRI) help the physician determine the type of stroke and rule out other conditions, such as infection and brain tumor.

Imaging Procedures to Diagnose Stroke

When stroke is suspected, computed tomography (CT scan) is performed as soon as possible. CT scan produces x-ray images of the brain and is used to determine the location and extent of hemorrhagic stroke. CT scan usually cannot produce images showing signs of ischemic stroke until 48 hours after onset, so a repeat scan may be performed.

Ultrasound uses high-frequency sound waves to produce images of blood flow through the arteries in the neck that supply blood to the brain (i.e., carotid arteries) and may be used to detect blockage.

Source :

Nursing Diagnosis for Stroke

Nursing diagnosis is a statement of the problem be an actual or potential patients and requires nursing action so that the problem of patients, can be overcome or reduced. (Lismidar, 1990)

Nursing Diagnosis for Stroke
  1. Impaired brain tissue perfusion related to intracerebral hemorrhage. (Marilynn E. Doenges, 2000)
  2. Impaired physical mobility related to hemiparese / hemiplegia (Donna D. Ignativicius, 1995)
  3. Impaired sensory perception related to sensory impairment, vision impairment (Donna D. Ignativicius, 1995)
  4. Impaired verbal communication related to the decrease in brain blood circulation (Donna D. Ignativicius, 1995)
  5. Impaired elimination (constipation) related to immobilization, inadequate fluid intake (Donna D. Ignativicius, 1995)
  6. The risk of nutritional deficiencies related to muscle weakness of chewing and swallowing (Barbara Engram, 1998)
  7. Lack of compliance with self care related to hemiparese / hemiplegi (Donna D. Ignativicius, 1995)
  8. The risk of disruption of skin integrity related long bed rest (Barbara Engram, 1998)
  9. The risk of ineffective airway clearance related to the decrease in cough reflex and swallowing. (Juall Lynda Carpenito, 1998)
  10. Impaired elimination uri (uri incontinence) related to lesions in the upper motor neuron (Juall Lynda Carpenito, 1998)

Nursing Diagnosis for Stroke

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