Nursing Diagnoses & Interventions PDF

Common Nursing Diagnoses and Interventions Imbalanced Nutrition less than body Requirements (HG, GDM, CPD, Micro, Thalas, CP, IBS, MD, CD, Galact, BA, CH, AGastro) Independent: Ensure proper positioning (reduce risk of aspiration) Small frequent meals (decrease stimulation for vomiting);...

Common Nursing Diagnoses and Interventions Imbalanced Nutrition less than body Requirements (HG, GDM, CPD, Micro, Thalas, CP, IBS, MD, CD, Galact, BA, CH, AGastro) Independent: Ensure proper positioning (reduce risk of aspiration) Small frequent meals (decrease stimulation for vomiting); Give high caloric meal when patient’s peak appetite(More food); Give liquid energy supplements(improve weight);Avoid carbonated drinks(spoil appetite and early Dependent: Administer Parenteral Nutrition (Impaired swallowin/GI problems), Administer NGT/OGT (Impaired swallowing/GI problems), Administer supplements (Increase intake) Collaborative: Consult dietitian for specific diet (nutritional intake and caloric intake) Ineffective Airway Clearance (Tons, Bronch, Pneu, Asth, ARDS) Independent: Monitor Oxygen saturation of SpO2 levels Monitor respiratory status by obtaining respiratory rate Position the client in high fowler's position to allow maximum lung capacity Encourage the client to rest by providing a clean environment Provide pillows to protect patient's extremities Limit the amount of hazards that can cause pain for client Monitor the patient's status including wheezing or stridor sound produced that can reveal signs of obstruction Dependent: Provide ventolin HFA Inhalation for patients Administer bronchodilators such as theophylline or albuterol Collaborative: Collaborate with physicians Ineffective Breathing Pattern (Bonch, Pneu, Asth, ARDS, SIDS) Independent: Monitor the VS: RR and Oxygen saturation levels Observe the client's breathing pattern: bradycardia Observe facial expressions of the patient Assess for breathing difficulties Position the client in supine Position bed into the lowest position preventing fall Reduce hazards that cause irritation or injury to patient Dependent: Administer tracheostomy tube, ventilator breathing tube, or nasal cannula Administer bronchodilators such as theophylline or albuterol Collaborative: N/A Deficient Fluid Volume (HG, EP, HMole, Abort, Previa, Abruptio, PPH,Tons ,DIC, Sickle, HD, IBS, MD, Intus, CAH, AGastro) Independent: Urge patient to drink fluids Assist in drinking oral fluids (patients tend to be weak and need assistance) Provide a cool environment (Increased heat leads to increased thirst) Plan activities (conserve energy) Dependent: Administer IV fluids (impaired swallowing), Administer Anti-diuretics (Increase water retention,[vasopressin]) Administer Blood Products as prescribe (too much fluid loss) Collaborative Educate client’s SO in treating dehydration (Increase fluids, Assist giving fluids, Monitor I&O, medication adherence) Excess Fluid Volume(AGlumerlo) Independent: Limit sodium intake (may increase fluid retention) Reposition client every 2 hrs (prevents fluid accumulation in dependent areas) Elevate areas with edema (helps in venous return and decrease fluid retention) Dependent: Administer diuretics (Promotes fluid loss and prevent fluid retention [Metolazone]) Insert Indwelling catheter (Promotes fluid loss, accurately measures output) Collaborative: Consult with pharmacist to increase concentration of medications (prevent unnecessary fluids) Consult with dietician for low sodium diet (prevents reuptake of fluids) Ineffective Tissue Perfusion (Previa, Abruptio, Oligo, PIH, PPH, DIC, ASD, TOF, CardioM, Hydro, Sickle, Thalas) Independent: Assist change positions (decrease sudden BP change) Do passive ROM exercises (decrease venous stasis and improve circulation)  Position in Fowler’s /High Fowler’s (Improved gas exchange) Keep patient warm (for vasodilation) Dependent: Administer O2 therapy as prescribe (Improve oxygenation) Administer vasodilators (ACE Inhibitors [lisinopril]) Collaborative: Offer exercises (walking, riding a bike to improve circulation) Decreased Cardiac Output (EP, Previa, Abruptio, PPH, ASD, PDA, TOF, EndoC, CardioM) Independent: Decrease fluid intake for those with increased preload (to decrease demand on the heart) Maintain adequate ventilation, Fowler’s position (Improve O2 intake) Use music therapy (to decrease heart rate, blood pressure and anxiety) Educate a healthy lifestyle such as no smoking and alcohol drinking (to reduce health risks) Provide Emotional Support (Listen concerns and provide clear information to reduce anxiety) Advise to use urinal or commode (to prevent immobility and it does not overwork the heart) Dependent: Administer O2 as prescribed (Failing heart may not respond O2 demands) Give Diuretics (Promotes water loss which decreases heart work [Metolazone]) Monitor Cardiac Monitoring (For dysrhythmias) Provide stool softeners (to prevent strain when defecating Collaborative: Educate SO in signs and symptoms and disease process (To give prompt care and contact primary caregiver) Acute Pain (EP, HMole, Abort, IC, Abruptio, Poly, Pre term, PPI, Mast, Tons, OM, Rheu, EndoC, KD, ALL, HD, IBS, MD, CD, Intus, Pku, Burns, UTI) Independent: Use non-pharmacological treatment (Guided Imagery, Distractions, Warm/Cool compress) Do Nursing care at peak analgesic effect (for client’s comfort) Allow client to express feelings of pain (to reduce stress and gives cues of the severity of pain) Use wong-baker scale to assess severity of pain (pediatric) Dependent:  Give Analgesics as prescribed (Non opioids [acetaminophen, ibuprofen, aspirin], Opioids [morphine]) Collaborative: Refer to Massage therapists for Acupressure massages, and massage therapy Impaired Gas Exchange (Previa, Abruptio, Oligo, DIC, Bronch, ARDS, EndoC, CardioM, Sickle) Independent: Place client in high 45 deg Fowler’s position (Improve Lung expansion and diaphragm function) Encourage Controlled coughing inhale,hold,cough 3x (To remove sputum and secretions and decrease cough spasms) Provide reassurance (decreases anxiety and stress and work of breathing) Plan activities with periods of rest (to prevent fatigue and hypoxia to the patient) Dependent: Administer O2 therapy as prescribe (to maintain or increase O2 saturation, by mask or spray) Ambulate patient as prescribe (to improve lung function, and secretion of sputum) Suction as necessary (remove obstruction such as sputum) During ambulation or activity provide portable O2 (Maintain adequate O2) Collaborative: Encourage SO to remove irritants that may impair lung function of the client (to increase oxygen during inspiration) Educate client about disease process (to provide prompt care and contact immediate primary care) Impaired Skin Integrity (PPI, KD, ALL, Pku, AGastro, Burns) Independent: Reposition and support bony prominences (Increase perfusion to the skin especially on bony prominences) Keep skin dry and clean( Change diapers, bed linens, and clothing with bodily fluids, sweat urine and feces cause irritation) Give proper sterile dressing to wound care (Reduces the risk of infection) Increase oral fluid intake (can help improve healing process) Place bed head at lowest degree (to prevent friction on skin) Teach client to not scratch wound, provide gloves or keep nails short (can impair wound healing) Dependent: Administer Antibiotics (Penicillin, to prevent wound infections)  Administer Premedications before wound care (To reduce pain and discomfort) Collaborative: Refer to dietician for high protein diet (can help improve healing process) Impaired Physical Mobility (Micro, Hemo, CP, CH, Burns) Independent: Provide Passive ROM exercises (can improve muscle strength and venous return) Turn patient every 2 hrs (relieve pressure from tissues and improve tissue circulation) Use diversional activities (helps refocus attention and promotes coping) Provide rest periods during activity (can conserve energy and not overwork the patient) Give positive reinforcement during the activity (can improve self esteem) Provide safety in environment, lower bed, side rails up, pad bed (Prevents injury) Dependent: As soon as possible assist patient with ambulation as prescribe (increases self esteem, and prevent injury) Administer antispasmodic (reduce muscle spasms [Anisotropine) Administer analgesics (relieve pain during ambulation[acetaminophen]) Initiate Bowel program, increase fluid intake, laxative [bisacodyl] (prolonged immobility leads to constipation) Collaborative: Demonstrate the use of mobility devices, crutches, walkers (promotes mobility and prevents injury for those with impaired function) If no contradiction encourage high fiber diet and increase oral fluids 2000ml (avoids constipation) Consider home assistance e.g Nurse/Physical Therapist/SO (Check on progression and provide safety) Impaired Urinary Elimination (Spina, UTI) Independent: Encourage adequate oral fluids (can promote adequate hydration and increase output) Discourage the intake of alcohol and caffeine (can irritate the Urinary tract) Give proper perineal care and catheter care (prevents skin breakdown and infection) Promote mobility (Can improve urinary elimination) Dependent: Provide an indwelling catheter to client as prescribed (for patients that cannot eliminate) Administer Antibiotics (do decrease infection [ceftriaxone]) Administer Oxybutynin (For overactive bladder, decreases urgency, frequency and nocturia) Collaborative: N/A Bowel Incontinence (Spina, IBS) Independent: Encourage increased oral fluid intake (for constipation fluids can soften stools, for diarrhea can replace fluid loss) Place a bedside commode (Immediate access for accidents) Assist patient in mobility (can improve peristalsis movement) Create a bowel program (time on when the patient needs to defecate) Clean area after elimination (prevents skin irritation and provide comfort) Dependent: Remove fecal impaction, manually, enema (removal can relieve discomfort and may return bowel routine Administer antidiarrheal drugs (bulks stools [loperamide]) Administer laxatives (can help stimulate GI tract [bisacodyl]) Collaborative: Include a high fiber diet in patient’s meal (Stimulates peristalsis) Educate SO in increasing fiber and increase oral intake (soften stools and stimulates peristalsis) Ineffective Breastfeeding (Mast, Galact) Independent: Pump breast in between feedings (to reduce breast engorgement and supply milk) Apply warm compress on breast (prevent inflammation and pain) Teach mom to do proper latching (This helps infant to get adequate nutrition) Dependent: Administer Antibiotics (reduce infection on the breast [Cloxacillin]) Administer anti-inflammatory (reduce inflammation on the breast [Ibuprofen]) Collaborative: N/A Constipation (HyperB, HD, IBS, MD) Independent: Increase oral fluid intake by 1.5-2L per day (makes stool soft) Educate on contradicting alcohol,coffee and tea (has a diuretic effect) Schedule a time for toilet use preferably morning (gastrocolic reflex is most active during the morning) Provide warm sitz bath (relaxes anal sphincter muscles) Provide safe environment, close doors/curtains (promotes privacy) Dependent: Administer Probiotics (can help soften stools with bacteria [erceflora {bacillus clausii}]) Administer laxatives (can help stimulate GI tract [bisacodyl]) Perform enema or rectal irrigation as indicated (to flush out fecal matter) Refer to surgery and assist in surgery (for severe constipation or unresponsive GIT) Collaborative: Increase diet to 30g of fiber and offer prune juice (Provides bulk and soften stools) Do isometric and glute exercises (enhances muscle coordination, relaxes lower abdomen muscles, pelvic floor and external anal sphincter muscles) Diarrhea (IBS, CD, Galact) Independent: Encourage client to have a stool diary (records, consistency, frequency and time of defecation) Monitor signs of dehydration skin turgor, thirst, dizziness, hypotension (give prompt care when severe dehydration occurs) Increase fluid intake (replenish fluid loss after defecation) Give oral rehydration solution (replenish electrolyte loss[children - breastfeeding]) Promote perineal care (provides comfort and prevents impaired tissue integrity) Monitor urine I&O (take note of oliguria, dark yellow urine, and specific gravity) Dependent: Give Antidiarrheal Medications (prevents diarrhea [loperamide]) Initiate Tube feeding (feeding at room temp, feeding slowly) Collaborative: Diet should be bland first rice, bread (prevents stomach irritation) Hyperthermia (PPI, Mast, Tons, Pneu, Rheu, EndoC, ALL, BA) Independent: Remove excess clothing or covers (decreases heat and increase evaporative cooling) Provide tepid or sponge bath (promotes evaporative cooling) Apply Ice packs to the patient (can cool and lower core body temp) Encourage oral fluid intake (Can help cool body temp) Dependent: Administer Diazepam (prevents excess shivering that leads to overheating) Administer antipyretics (reduces high temperature) Collaborative: Consult with patient in planning meals with dietician that is appealing to patient (can help reduce loss of appetite, and high metabolic rate) Activity Intolerance (IC, Poly, Asth, ASD, PDA, TOF, CardioM, Thalas, Acute Glomerulo) Independent: Encourage the client to do the activity slowly and and with more rest (this helps client’s activity intolerance) Gradual progression of activity with range of motion exercises (prevents overexertion) Provide bedside commode (allows ambulation in using the bathroom with little energy expenditure) Provide Physical activity that matches client’s energy level (promotes sense of autonomy with being realistic of capabilities) Encourage verbalization of feelings and provide a positive environment (minimizes frustration and promotes nurse-client relation) Assist ADLs (Can conserve energy) Dependent: Assist client in ambulation if prescribed (can help client improve physical strength) Collaborative: Plan with SO on goals for the client (can enhance patient’s adherence to activity) Anxiety (IC, Pre term, CPD, Asth, ARDS, SIDS, CD) Independent Use therapeutic communication, touch, answering to questions, verbalization (allows client to feel that they’re are not alone) Educate client in anxiety reducing skills, guided imagery, deep breathing (divert attention, allows positive thinking) Use past and effective coping strategies to the client (can make the client feel independent and promote self mastery) Provide client with a journal to record anxiety logs (recognizes the problem and take essential steps in recovery) Provide a peaceful environment (decreasing noise, triggers and harmful equipment can make the client calm) Approach client in a peaceful manner (may prevent additional anxiety to the client) Use brief, simple language (can make the client understand the situation better and remember better) Dependent: Refer client to a psychiatrist (for severe anxiety and diagnosis and drug prescription) Administer Anti-anxiety drugs (Can control mood and decrease anxiety [Buspirone HCl, Alprazolam]) Collaborative: Refer client to a Psychologist (to initiate talk therapy with the client) Refer client to a support group (to share similar experiences and provide empowerment) Fatigue (CPD, Bronch, HyperB, ALL) Independent: Decrease environmental stimuli especially during rest/sleep (can promote relaxation) Assist patient in developing activities with rest periods (can help the patient complete activities with adequate rest) Provide comfort measures such as therapeutic touch, massage, cool shower (decreases anxiety) Encourage to verbalize feelings of fatigue (decreases anxiety by acknowledging it) Offer diversional activities (decreases anxiety and keeps patient in a positive mood) Dependent: Assist client during ambulation as prescribe (reduces risk of injury) Collaborative: Refer to occupational therapist (offer assistive devices for ADLs) Refer to dietician for sufficient nutritional intake (increase energy) Ineffective Health Management (GDM) Grieving (EP, HMole, Abort, SIDS) Independent: Communicate therapeutically with patient/SO and allow to verbalize feelings (decreases stress) Share similar feelings and experiences (can better understand their feelings and allow expression of feelings) Encourage rest, adequate nutrition and self care needs (to start emotional reconstruction) Allow patient’s/SO to review experience (integrate the event into their experience) Dependent: Refer to Psychiatrist (for severe complications such as depression) Collaborative Refer to a support group (people can share similar experiences and promotes support) Risk for Bleeding (Abort, DIC, Hemo) Independent: Educate prevent tissue trauma (soft bristle toothbrush, Avoid rectal suppositories, limit forceful bowel movement, forceful nose blowing, careful in sharp objects [prevent mucosal membrane breaking]) Ask client to save pads and weigh them (to check amount of blood loss) Edu cate the client to check stool (black stool - Upper GI bleeding, red stool - lower GI bleeding) Dependent: Provide Antidotes for excessive Anti-coagulants (promotes coagulation [Vit K, heparin]) Administer Blood products as prescribe (replenish blood loss and increase blood with O2) Collaborative: Increase dietary fiber to prevent constipation (constipation may cause trauma in mucous membrane) Risk for Infection (Abort, PROM, PPH, OM, Rheu, Hydro, ALL, CP, HD, Intus, AGlumerelo) Independent: Do hand washing before and after doing procedures (reduce pathogens and microorganisms [IV, Catheter, NGT]) Sanitize Articles before use (reduce pathogens and organisms) Use soft bristle Toothbrush (Prevents breaks in mucous membranes) Educate SO in preventing infections (Prevents infection) Reduce stressful stimulants (Stress predisposes to infection) Dependent: Encourage fluids if tolerated (To increase fluid output and decrease urine stasis) Give prescribed antibiotics or antiinfectives and emphasize medication adherence(To decrease infections) Collaborative: Refer Dietitian for high protein and caloric diet (Improve immune function) Risk for Injury (Oligo, Poly, Pre term, , GDM, CPD, OM, HyperB, SIDS, Hydro, Hemo, Intus, Pku, AGlumerlo) Independent: Guide patient with surroundings (patient should be familiar with surroundings) Use alternatives to restraints to prevent falls (Alarams, Lower Bed, Constant Monitoring, Door Locked) Avoid extreme temperatures (to prevent burns, pain and discomfort) Allow client to express feelings about the environment (promotes nurse-client relation) Dependent: Use alternatives to chemical restraints, needs prescribed order (for restraints not to be coercive, comfort) Collaborative: Ask SO to monitor patient for risk for falls, and removing of IV lines Risk for F&E imbalance (BA, CAH) Independent: Educate Client and SO to report signs of electrolyte imbalance (to give prompt care and contact primary care provider) Encourage client to verbalize feelings on treatment (allows to reduce stress) Educate client on sodium found in diet (to be aware on amount of salt is being taken) Dependent: Give balanced electrolytes through IV as prescribed (Maintains balance of electrolytes and fluids) Prepare measures for excess electrolytes e.g Potassium (excess potassium can lead to cardiac arrest administer [Kayexalate] to reduce potassium) Collaborative: Refer to dietician to change diet that can maintain balance in electrolytes (electrolytes are found in food and increasing or decreasing certain foods may maintain balance)