Impaired Gas Exchange NANDA NOC NIC

Impaired Gas Exchange NANDA : NOC, NIC

Impaired Gas Exchange Definition: Excess or lack of oxygenation and or removal of carbon dioxide in the alveolar capillary membrane.

Defining characteristics:

• Impaired vision
• Reduction in CO2
• Tachycardia
• Hypercapnia
• Fatigue
• Somnolence
• Irritability
• Hypoxia
• Confusion
• Dyspnoe
• Nasal pharyngeal
• Normal blood gas analyzer
• Cyanosis
• Abnormal skin color (white, black)
• Hypoxemia
• Hypercarbia
• Headache when waking
• Abnormal breathing frequency and depth

Related factors:

• Ventilation perfusion imbalance
• Alveolar-capillary membrane changes

NOC:

• Respiratory Status: Gas exchange
• Respiratory Status: Ventilation
• Vital Sign Status

Results Criteria:

• Demonstrate improved ventilation and adequate oxygenation
• Maintain cleanliness of the lungs and free of signs of respiratory distress
• Demonstrate effective cough and breath sounds are clean, no cyanosis and dyspnea (capable of removing the sputum, was able to breathe easily, no pursed lips)
• Vital signs within normal range

NIC:
1. Airway Management

• Open the airway, using chin lift technique or jaw thrust if necessary
• Position the patient to maximize ventilation
• Identification of patients need the installation of an artificial airway device
• Replace the mayo if necessary
• Perform chest physiotherapy if necessary
• Remove secretions by coughing or suctioning
• Auscultation of breath sounds, record the presence of additional noise
• Do the suction on the mayo
• Give bronchodilators if necessary
• Give your humidifier
• Adjust fluid intake to optimize the balance
• Monitor respiration and oxygen status

2. Respiratory Monitoring

• Monitor on average, the depth, rhythm and respiratory effort
• Note the movement of the chest, observe the symmetry, the use of additional muscle, supraclavicular and intercostal muscle retraction
• Monitor breath sounds, such as snoring
• Monitor breathing patterns: bradipena, takipenia, Kussmaul, hyperventilation, Cheyne stokes, Biot
• Note the location of the trachea
• Diagfragma monitor muscle fatigue (paradoxical movement)
• Auscultation of breath sounds, noting areas of decreased / no ventilation and additional sound
• Determine the need for suction by mengauskultasi crakles and ronkhi main airway
• Auscultation of lung sounds after the action for the results.

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Imbalanced Nutrition Less Than Body Requirements Nanda Nursing Diagnosis for Hyperemesis Gravidarum

Imbalanced Nutrition Less Than Body Requirements Nanda Nursing Diagnosis for Hyperemesis Gravidarum

Imbalanced Nutrition Less Than Body Requirements Definition: Intake of nutrients insufficient to meet metabolic needs.

Hyperemesis Gravidarum

Hyperemesis Gravidarum (HG) is a very severe form of morning sickness. It is described as extreme vomiting, dehydration, nutritional deficiencies, and electrolyte imbalances combined with a first trimester weight loss of aproximately 10% of normal body weight.

Morning sickness is a normal part of early pregnancy and it can also continue through out the pregnancy in some cases. But extreme pregnancy nausea can cause distressing effects for the mother and can also be harmful for your baby.

There are numerous theories regarding the etiology of HG, however, none are conclusive as of yet. The most commonly held belief is that the increase in HCG and estrogen hormones in early pregnancy is the cause.




Nursing Intervention - Imbalanced Nutrition Less Than Body Requirements - Hyperemesis Gravidarum


1. Restrict oral intake until the vomiting stops.
Rationale: Maintaining electrolyte balance fluid and prevent further vomiting.

2. Give the anti-emetic drugs are prescribed with a low dose.
Rationale: To prevent vomiting and to maintain fluid and electrolyte balance

3. Maintain fluid therapy can be saved.
Rational: Correction of hypovolemia and electrolyte balance.

4. Record intake and output.
Rationale: Determining hydration fluid through vomiting and spending.

5. Encourage to eat small meals but often
Rational: Can adequate intake of nutrients body needs.

6. Advise to avoid fatty foods
Rational: can stimulate nausea and vomiting

7. Recommended to eat a snack such as biscuits
Rational: snack can reduce or prevent nausea, vomiting, excessive excitatory

8. Record intake, if oral intake can not be given within a certain period.
Rational: To maintain a balance of nutrients.

9. Inspection of irritation on the mouth.
Rationale: To determine the integrity of the oral mucosa.

10. Assess oral hygiene and personal hygiene and the use of cleaning fluids mouth as often as possible.
Rational: To maintain the integrity of the oral mucosa

11. Monitor hemoglobin and hematocrit levels.
Rationale: Identify presence of anemia and potential decline in the capacity of oxygen carrier mothers. Clients with Hb levels <12 mg / dl or low hematocrit levels considered anemic in the first trimester.

12. Test urine of acetone, albumin and glucose
Rationale: Establish baseline data; done routinely to detect potential high-risk situations such as inadequate intake of carbohydrate, ketoacidosis diabetic and hypertension due to pregnancy.

13. Measure the enlargement of the uterus
Rational: maternal malnutrition affects fetal growth and aggravate the decline of complement in fetal brain cells, resulting in deterioration of fetal development and the possibilities further.

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Nanda Nursing Diagnosis for Dizziness Vertigo

Dizziness is the Third Most Frequent Reason People Seek Medical Attention

Dizziness is one thing, vertigo is another. Both involve potential feelings of unsteadiness and possible faintness, but vertigo will often also include disorientation. Both conditions can persist to be point of becoming disabling.

There are many reasons for causing dizziness. Infection in viral system is the main cause of dizziness which affects the air flow to the head or the ear. The low blood pressure can also cause dizziness due to reduction of blood supply to the brain. Mental anxiety and panic attacks, can lead to dizzy condition. Sudden low blood sugar is another possible cause, and is easily treated by taking some sugary foods.

The dizziness can be recognized with the following symptoms

• Being fainted at the sight of blood or with emotional upset 
• Fainting in standing up too quickly or standing still too long 
• Weakness during a illness 
• Seasickness or motion sickness 
• Queasiness, nausea, or vomiting 
• Confusion in thinking 
• Fatigue feelings, tiredness or daytime sleepiness 
• Clumsy movement

Vertigo is usually due to an imperfection of the equilibratory apparatus of the semicircular canals of the ear. There may also be associated problems with the vestibule, 8th nerve, the semicircular canals, the eyes, or in the brainstem. Any of these structures can be affected by a variety of diseases and disorders, such as: otitis media, labyrinthitis, osteosclerosis, an obstruction of the Eustachian tube, or external auditory canal. Avery important element that may result in vertigo, is a disease called " Meniere's syndrome.

Nanda Nursing Diagnosis for Dizziness Vertigo

1. Pain (acute / chronic)

related to: stress and tension, irritation / nerve pressure, increased intracranial
characterized by : pain states that are influenced by such factors, changes in position, changes in sleep patterns, anxiety.

2. Ineffective individual coping

related to: inadequate relaxation, coping methods are not adequate, excess workload.

3. Deficient knowledge : (needs to learn) about the condition and treatment needs

related to : cognitive limitations, are not familiar information and less to remember.
characterized by the request information, Inadequate follow the instructions.

Nursing Assessment Nursing Care Plan for Dizziness Vertigo

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Hyperthermia Nanda Nursing Diagnosis - Dengue Fever

Nanda Nursing Diagnosis for Dengue Fever : Hyperthermia

Dengue hemorrhagic fever is an acute infectious disease manifested initially with fever. Dengue fever is one of the contagious viral diseases spread through the mosquito bite. The female Aedes aegypti mosquitoes thrive in stagnant water of surroundings and become the carriers of the virus. The disease is characterized by mild to high fever, headache, joint and muscle pains and rashes.

Signs and Symptoms

• Mild to high fever about 105 F
• Severe pain in the bone joints 
• Intense headache and backache
• Loss of appetite
• Appearance of rashes all over the body
• Nausea followed by vomiting

Home Remedies for Dengue

1. One should reduce the exposure to mosquitoes as far as possible and not venture out in the dawn or dusk, when the mosquitoes are most prevalent.

2. Mosquito nets, mosquito repellant ointments and coils must be regularly used while sleeping at night, to prevent the mosquito bite.

3. Holy basil leaves are very useful in preventing and treating dengue. Drinking a decoction of basil leaves and cardamom powder, adding little salt and milk helps in reducing high fever.

4. Juice extracted from two raw papaya leaves helps in preventing Dengue.

5. Drinking few cups pf herbal tea prepared from basil leaves, ginger and cardamom powder is very effective in reducing the fever.

6. Orange juice is widely used for treating Dengue fever. Drinking orange juice helps in proper digestion to fight against the disease.

7. Plenty of water or diluted fruit juice must be administered to the patient to maintain the required water balance of the body.


Nursing Diagnosis and Interventions for Dengue Fever 

Nursing Diagnosis Hyperthermia

related to :

the disease (viremia)

Goal :

• Normal body temperature (36-37 C).
• Patients were free from fever.

Nursing Interventions and Rational for DHF :

1. Assess the onset of fever.
Rational: to identify patterns of fever patients.

2. Observation of vital signs (temperature, pulse, blood pressure, respiration) every 3 hours.
Rational: vital signs is a reference to determine the patient's general condition.

3. Instruct patient to drink plenty
Rationale: Increased body temperature resulting in increased evaporation of the body so it needs to be balanced with a lot of fluid intake.

4. Give a warm compress.
Rational: With vasodilation can increase evaporation which accelerate the decline in body temperature.

5. Advise not to wear a thick blanket and clothing.
Rational: thin clothing helps reduce the evaporation of the body.

6. Give intravenous fluid therapy and medications according to physician programs.
Rational: infusion of fluids is very important for patients with a high temperature.

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Impaired Skin Integrity Nanda Nursing Diagnosis - Stevens-Johnson Syndrome (SJS)

Stevens Johnsons Syndrome is a dangerous problem of the skin. It is thought to be a hypersensitivity complex affecting the skin and the mucous membranes.

Stevens Johnson Syndrome (SJS) is a severe and deadly allergic reaction to certain drugs, some proscription and some over the counter, which causes the severe burning of skin and mucosal membranes from the inside out. 15% of people who develop Stevens Johnson Syndrome will die as a direct result. Many drugs which have been known to cause SJS do not have warning labels notifying users about the very real danger of Stevens Johnson Syndrome.

The skin rash of SJS consists of erythematous (red) papules, vesicles, bullae. There may also be iris lesions. The mucosal lesions include conjunctivitis as well as oral and genital ulcers. The most frequent complications of SJS are keratitis, uveitis, and perforation of the globe of the eye all of which may result in permanent visual impairment.

Nanda Nursing Diagnosis : Impaired skin integrity related to inflammatory dermal and epidermal

Expected Outcomes:

Shows the skin and skin tissue intact.

Intervention:

1. Observation of skin turgor circulation daily notes and sensory as well as other changes that occur.
Rational: determining a baseline by which changes in status can be compared and appropriate intervention

2. Use a thin clothing and soft loom.
Rational: reduce irritation and pressure from the suture line of clothes, leave the incision open to air increases the healing process and reduce the risk of infection

3. Keep loom is used.
Rationale: to prevent infection

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Self-Care Deficit Nanda Nursing Diagnosis

Self-care deficits

When an individual is very unable to meet their own self-care requisites, a "self-care deficit" occurs. It is the job of the Registered Nurse to determine these deficits, and define a support modality.

Self-care deficit nursing theory is a grand nursing theory that was developed between 1959 and 2001 by Dorothea Orem. It is also known as the Orem model of nursing. It is particularly used in rehabilitation and primary care settings where the patient is encouraged to be as independent as possible.

Self-Care Deficit

Bathing/Hygiene; Dressing/Grooming; Feeding; Toileting

Defining Characteristics:

• Inability to feed self independently
• Inability to dress self independently
• Inability to bathe and groom self independently
• Inability to perform toileting tasks independently
• Inability to transfer from bed to wheelchair
• Inability to ambulate independently
• Inability to perform miscellaneous common tasks such as telephoning and writing

Related Factors :

• Neuromuscular impairment, secondary to cerebrovascular accident (CVA)
• Musculoskeletal disorder such as rheumatoid arthritis
• Cognitive impairment
• Energy deficit
• Pain
• Severe anxiety
• Decreased motivation
• Environmental barriers
• Impaired mobility or transfer ability

Expected Outcomes

• Patient safely performs (to maximum ability) self-care activities.
• Resources are identified which are useful in optimizing the autonomy and independence of the patient.

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

• Self-Care: Eating
• Self-Care: Bathing
• Self-Care: Dressing
• Self-Care: Grooming
• Self-Care: Hygiene
• Self-Care: Toileting

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

• Self-Care Assistance: Bathing/Hygiene
• Self-Care Assistance
• Dressing/Grooming
• Self-Care Assistance: Feeding
• Self-Care Assistance: Toileting
• Environment Management

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Impaired Physical Mobility Nanda Nursing Diagnosis

Nanda Definition:

Impaired physical mobility a nursing diagnosis approved by the North American Nursing Diagnosis Association, defined as the state in which an individual has a limitation in independent, purposeful physical movement of the body or of one or more extremities.


Alteration in mobility may be a temporary or more permanent problem. Most disease and rehabilitative states involve some degree of immobility (e.g., as seen in strokes, leg fracture, trauma, morbid obesity, and multiple sclerosis). With the longer life expectancy for most Americans, the incidence of disease and disability continues to grow. And with shorter hospital stays, patients are being transferred to rehabilitation facilities or sent home for physical therapy in the home environment.

Mobility is also related to body changes from aging. Loss of muscle mass, reduction in muscle strength and function, stiffer and less mobile joints, and gait changes affecting balance can significantly compromise the mobility of elderly patients. Mobility is paramount if elderly patients are to maintain any independent living. Restricted movement affects the performance of most activities of daily living (ADLs). Elderly patients are also at increased risk for the complications of immobility. Nursing goals are to maintain functional ability, prevent additional impairment of physical activity, and ensure a safe environment.

Impaired physical mobility - Related factors arising from within the person include pain or fear of discomfort, anxiety or depression, and physical limitations due to neuromuscular or musculoskeletal impairment. External factors include enforced rest for therapeutic purposes, as in the case of immobilization of a fractured limb. The human body is designed for motion; hence, any restriction of movement will take its toll on every major anatomic system.

Defining Characteristics:

• Inability to move purposefully within physical environment, including bed mobility, transfers, and ambulation
• Reluctance to attempt movement
• Limited range of motion (ROM)
• Decreased muscle endurance, strength, control, or mass
• Imposed restrictions of movement including mechanical, medical protocol, and impaired coordination
• Inability to perform action as instructed

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

• Ambulation: Walking
• Joint Movement: Active
• Mobility Level

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

• Exercise Therapy: Ambulation
• Joint Mobility
• Fall Precautions
• Positioning
• Bed Rest Care

Expected Outcomes

• Patient performs physical activity independently or with assistive devices as needed.
• Patient is free of complications of immobility, as evidenced by intact skin, absence of thrombophlebitis, and normal bowel pattern.

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Imbalanced Nutrition More than Body Requirements Nanda Nursing Diagnosis

Imbalanced Nutrition More than Body Requirements Definition :


Imbalanced nutrition : more than body requirements refers to a caloric intake / excess of daily energy requirements, resulting in storage of energy in the form of adipose tissue. As the amount of stored fat increases, the individual becomes overweight or obese. A person is said to be overweight when BMI is between 25 and 29.9 kg/m2 and obese when BMI is >30 kg/m2 . Factors that affect weight gain include genetics, sedentary lifestyle, and emotional factors associated with dysfunctional eating. Medical conditions associated with this problem are as follows: diabetes mellitus, severe hypertension, and Cushing’s syndrome. Cultural or ethnic background also influences eating habits. Overall nutritional requirements of geriatric patients are similar to those of younger patients, except that calories should be reduced because of their leaner body mass. The major goals for this problem is to maintain or restore optimal nutrition status, promote healthy nutritional practices, prevent complication associated with malnutrition and decrease weight.


Related Factors :

• Cultural preferences
• Excessive intake in relation to metabolic need
• Lack of knowledge of nutritional needs, food intake, and/or appropriate food preparation
• Metabolic disorders
• Poor dietary habits
• Psychosocial factors
• Sedentary lifestyle
• Socioeconomic status
• Use of food as coping mechanism

Nursing Interventions Classification (NIC)

• Nutrition Counseling
• Nutritional Monitoring
• Weight Reduction Assistance

Nursing Outcomes Classification (NOC)

• Nutritional Status: Food and Fluid Intake
• Weight Control
• Knowledge: Diet

Goal and Objectives

• Patient will articulate actions essential to attain weight reduction.
  
  • Patient will cemonstrate change in eating patterns and participation in individual exercise program.
• Patient will commence an appropriate program of exercise.
  
• Patient will demonstrate proper selection of meals or menu planning toward the goal of weight reduction.
  
• Patient will exhibit weight loss with optimal continuation of health.
  
• Patient will recognize inappropriate behaviors and consequences related with overeating or weight gain.

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