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Nursing Diagnosis for Impaired Oral Mucous Membrane

NANDA Definition: Disruptions of the lips and soft tissues of the oral cavity

Defining Characteristics:

  • Purulent drainage or exudates; 
  • gingival recession, pockets deeper than 4 mm; 
  • enlarged tonsils beyond what is developmentally appropriate; 
  • smooth atrophic, sensitive tongue; 
  • geographic tongue; 
  • mucosal denudation; 
  • presence of pathogens; 
  • difficult speech; 
  • self-report of bad taste; 
  • gingival or mucosal pallor; 
  • oral pain/discomfort; 
  • xerostomia (dry mouth); 
  • vesicles, nodules, or papules; 
  • white patches/plaques, spongy patches, or white curd-like exudate; 
  • oral lesions or ulcers; 
  • halitosis; 
  • edema; 
  • hyperemia; 
  • desquamation; 
  • coated tongue; 
  • stomatitis; 
  • self-report of difficult eating or swallowing; 
  • self-report of diminished or absent taste; 
  • bleeding; macroplasia; gingival hyperplasia; 
  • fissures, cheilitis; 
  • red or bluish masses (e.g., hemangiomas)

Related Factors:
  • Chemotherapy; 
  • chemical (e.g., alcohol, tobacco, acidic foods, regular use of inhalers); 
  • depression; 
  • immunosuppression; 
  • aging-related loss of connective, adipose, or bone tissue; 
  • barriers to professional care; 
  • cleft lip or palate; 
  • medication side effects; 
  • lack of or decreased salivation; 
  • chemical trauma (e.g., acidic foods, drugs, noxious agents, alcohol);
  • pathological conditions—oral cavity (radiation to head or neck); 
  • NPO for more than 24 hours; 
  • mouth breathing; 
  • malnutrition or vitamin deficiency; 
  • dehydration; 
  • infection; 
  • ineffective oral hygiene; 
  • mechanical (e.g., ill-fitting dentures, braces, tubes [endotracheal/nasogastric], surgery in oral cavity); 
  • decreased platelets; 
  • immunocompromised; 
  • impaired salivation; 
  • radiation therapy; 
  • barriers to oral self-care; 
  • diminished hormone levels (women); 
  • stress; 
  • loss of supportive structures

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Oral Health
  • Tissue Integrity: Skin and Mucous Membranes
Client Outcomes
  • Maintains intact, moist oral mucous membranes that are free of ulceration and debris
  • Describes or demonstrates measures to regain or maintain intact oral mucous membranes
NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Oral Health Restoration
Read More : http://nanda-nic-noc.blogspot.com/2013/03/impaired-oral-mucous-membrane-nursing.html

Nursing Diagnosis for Urinary Retention

NANDA Definition: Incomplete emptying of the bladder

Defining Characteristics:

  • Measured urinary residual >150 to 200 ml or 25% of total bladder capacity; 
  • obstructive lower urinary tract symptoms (poor force of stream, intermittency of stream, hesitancy of urination, postvoiding dribbling, feelings of incomplete bladder emptying); 
  • irritative lower urinary tract symptoms (urgency to urinate, diurnal frequency of urination, nocturia); 
  • overflow incontinence (dribbling urine loss caused when intravesical pressure overwhelms the sphincter mechanism)

Related Factors:
  • Bladder outlet obstruction: benign prostatic hyperplasia, prostate cancer, prostatitis, urethral stricture, bladder neck dyssynergia, bladder neck contracture, detrusor striated sphincter dyssynergia, obstructing cystocele or urethral distortion, urethral tumor, urethral polyp, posterior urethral valves, postoperative complication
  • Deficient detrusor contraction strength: sacral level spinal lesions, cauda equina syndrome, peripheral polyneuropathies, herpes zoster or simplex affecting sacral nerve roots, injury or extensive surgery causing denervation of pelvic plexus, medication side effect, complication of illicit drug use, impaction of stool
NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Urinary Elimination
  • Urinary Continence
Client Outcomes
  • Completely and regularly eliminates urine from the bladder; measured urinary residual volume is <150 to 200 ml or 25% of total bladder capacity (voided volume plus urinary residual volume) 
  • Correction or relief from obstructive symptoms 
  • Correction or alleviation of irritative symptoms
  • Client is free of upper urinary tract damage (renal function remains sufficient; absence of febrile urinary infections)
NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Urinary Catheterization
Read More : http://nanda-nic-noc.blogspot.com/2013/04/urinary-retention-nursing-diagnosis.html

5 Nursing Diagnosis for Angina Pectoris

Angina pectoris is a clinical syndrome characterized by episodes or feelings of distress in the chest due to the lack of coronary blood flow, causing the oxygen supply to the heart is inadequate or in other words, the supply of oxygen demand of the heart increases.

Etiology
  • Arteriosclerosis
  • Coronary artery spasm
  • Severe anemia
  • Arthritis
  • Aortic insufficiency
Factors that may cause attack include:
  • Emotions or the emotions caused by a stressful situation, resulting in increased heart rate, due to the release of adrenaline and increased blood pressure, thereby also increasing the heart's workload.
  • Working too hard can lead to physical attacks by increasing cardiac oxygen demand
  • Eating a heavy meal will increase blood flow to the area mesentrik for digestion, thus decreasing the availability of the supply of blood to the heart. (the heart that has been very severe, blood shortcuts for digestion makes the pain worse angina).
  • Exposure to cold can cause vasoconstriction and increase in blood pressure, accompanied by an increase in oxygen demand.

5 Nursing Diagnosis for Angina Pectoris


1. Acute pain
related to myocardial ischemia

2. Decreased cardiac output
related to changes (transient myocardial ischemia / elongated)

3. Activity intolerance
related to myocardial ischemia, decreased cardiac output.

4. Anxiety
related to pathophysiological responses and threats to health status.

5. Knowledge deficit: (need to learn) about the Events, the need for treatment
related to lack of information.

3 Nursing Diagnosis for Pneumonia

Nursing Diagnosis for Pneumonia and Nursing Interventions for Pneumonia

1. Nursing Diagnosis Deficient Knowledge : about the condition and the need for action

Related to:
  • Less exposed to information
  • Less to remember
  • Misinterpretation
Possible evidenced by:
  • Requests for information
  • Statement of misconception
  • Repeat mistakes
Expected outcomes are:
  • Stated understanding of disease processes and treatment conditions
  • Do changes in lifestyle
Nursing Interventions for Pneumonia :
  • Review of normal lung function
  • Discuss aspects of the inability of the disease, duration of healing and hope of recovery
  • Provide written and verbal form
  • Emphasize the importance of continuing effective cough
  • Emphasize the need to continue antibiotic therapy for the recommended period.

2. Nursing Diagnosis for Pneumonia : Risk for Deficient Fluid Volume

Risk factors:
  • Excessive loss of fluids (fever, sweating, hyperventilation, vomiting)
Expected outcomes are:
  • Balance of fluid balance
  • Moist mucous membranes, normal turgor, capillary filling fast.
Nursing Interventions:
  • Assess changes in vital signs
  • Assess skin turgor, mucous membrane moisture
  • Note the report nausea / vomiting
  • Monitor input and output, note the color, character of urine
  • Calculate the fluid balance
  • Fluid intake of at least 2500 / day
  • Give the drug as an indication: antipyretic, antiemetic
  • Provide additional IV fluids as necessary

3. Nursing Diagnosis : Pain (Acute / Chronic)

Related to:
  • Inflammatory lung parenchyma
  • Cellular reactions against circulating toxins
  • Persistent cough
Possible evidenced by:
  • Chest pain
  • Headache, joint pain
  • Protect an area hospital
  • Distraction behaviors, restlessness
Expected outcomes are:
  • Cause the pain is gone / controlled
  • Show relaxed, rest / sleep and increased activity quickly.
Nursing Interventions:
  • Determine the characteristics of pain
  • Vital Signs Monitor
  • Teach relaxation techniques
  • Advise and assist the patient in the technique of chest compressions during episodes of coughing.