NANDA Approved Nursing Diagnosis 2012 - 2014

NANDA Nursing Diagnoses 2009-2011 : Definitions and Classification

NANDA Approved Nursing Diagnosis 2007-2008 contains 188 nursing diagnosis, latest NANDA-I Approved Nursing Diagnosis 2009-2011 contains an additional 21 new nursing diagnosis, 9 revisions diagnosis and some of diagnosis are not used again. Total nursing diagnosis at this time is 205 nursing diagnosis.

Nanda I usually revised every 2 years, but this time NANDA I publish a list of NANDA Nursing Diagnosis for period of three years.

NANDA Approved Nursing Diagnosis 2009-2011

for complete list of NANDA Approved Nursing Diagnosis 2012 - 2014 ----> Nursing Diagnoses: Definitions and Classification 2012-14 (NANDA International Nursing Diagnosis)

Nursing Care Plan Acute Pain related to Uterine Fibroids

Nursing Diagnosis Acute Pain related to inflammation due to the addition of mass in the uterus

Objectives:
  • Pain can be reduced or lost
Expected outcomes are:
  • Pain scale (1-10) = 1-3.
  • Respiration = 16-24 beats / minute.
  • Pulse = 60 -100 beats / min.
  • Expression showed no signs of pain and seemed to relax.

1. Observation of a pain scale (1-10)
Rational: Observation of a pain scale is necessary for us to know the level of pain experienced by the client so that we can provide appropriate interventions for clients.

2. Find the area, location, and intensity of pain
Rational: To determine the location of pain, pain in the abdomen may indicate the likelihood of complications

3. Give a sitting position while hugging a pillow or a position in the sense of comfort by the client
Rational: It can provide comfort to the client.

4. Give instruction in relaxation techniques and deep breathing techniques
Rational: relaxation and deep breathing techniques to increase comfort and reduce the level of pain experienced by the client

5. Encourage clients to use a warm compress
Rational: Warm compresses can increase vasodilation of blood vessels at the site of pain so that pain can be reduced.

6. Collaboration in the delivery of analgesics and antiemetics, as indicated when necessary.
Rational: The provision of analgesia is necessary if the client is a pain scale of 7-10, this analgesic increase relaxation, decrease attention to pain, and control the adverse action.

7. Provide information about the use of analgesics that are prescribed or not prescribed
Rational: The specific instructions about the use of drugs, increasing awareness of safe use and side effects.

8. Evaluation of vital signs.
Rational: To determine the condition of clients after the intervention so that it can be done to determine further action.

Source : http://careplannursing.blogspot.com

Nursing Diagnosis Interventions Pneumonia Care Plan

Pneumonia is the condition that causes inflammation in lungs. Pneumonia is commonly caused by viruses, such as the influenza virus (flu) and adenovirus. Influenza H1N1 (swine flu) can also become a significant cause of pneumonia. During such situations, the lungs inevitably experience build up of fluids. Several micro-organisms cause pneumonia. Pneumonic inflammation of the lungs occurs due to collection of cellular wastes and blood cells within the air sacs within the lungs.

Other viruses, such as respiratory syncytial virus (RSV), are common causes of pneumonia in young children and infants. Bacteria such asStreptococcus pneumoniae can cause pneumonia, too.

There are many symptoms of pneumonia, and some of them, like a cough or a sore throat, are associated with many other common infections. Often, people get pneumonia after they’ve had an upper respiratory tract infection like a cold.

Symptoms of pneumonia can include: Cough with a yellow or greenish mucus or Phlegm, Fever often with chills and the shakes, Soreness or pain in the chest, worsened by breathing deeply or coughing, Shallow breathing, Shortness of breath, Bloody mucus or phlegm, Headache, Sweating and sometimes clammy skin, Fatigue and weakness, Decreased appetite.

Other symptoms of pneumonia are coughing up blood, vomiting, nausea, joint and muscle pain, getting the chills and having blueness of the skin.
When pneumonia is caused by bacteria, the person tends to become sick quickly and develops a high fever and has difficulty breathing. When it’s caused by a virus, symptoms generally appear more gradually and may be less severe.

Pneumonia diagnosed after a series of x-rays, MRIs and tests done on the mucus or phlegm from the throat. It can also be detected with a blood count test. If there is a high number of white blood cells then that means there is an infection present in the body.
Pneumonia can be treated without hospitalization but severe cases sometimes call for hospitalization.  

Pneumonia home care that involves rest, antibiotics and lots of fluids can help to rid the body of pneumonia. If patients do not heal within a specified amount of time by the doctor then they will have to be admitted into a hospital.

8 Nursing Diagnosis for Pneumonia
  1. Ineffective Airway Clearance
  2. Impaired Gas Exchange
  3. Ineffective Breathing Pattern
  4. Increased Body Temperature
  5. Risk for Infection
  6. Activity Intolerance
  7. Pain
  8. Imbalanced Nutrition Less Than Body Requirements
Nursing Interventions for Pneumonia
1. Maintain patent airway.
2. Adequate oxygenation.
3. Obtain sputum specimens as needed.
4. Control the spread of infection.
5. Give high calorie and high protein diets.
6. Use suction if the patient can’t produce a specimen.
7. Provide a quiet environment.
8. Monitor ABG levels, especially if he’s hypoxic.
9. Assess respiratory status.
10. Auscultate breath sounds at least every 4 hours.
11. Monitor fluid intake and output.
12. Evaluate the effectiveness of administered medications.
13. Explain all procedures to the patient and family.

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