Nurseslabs For All Your Nursing Needs

NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs May be related to Lack of exposure/recall information misinterpretation Unfamiliarity with information resources Possibly evidenced by Questions; statement of misconception/misinformation Inaccurate follow-through of instruction/performance of ostomy care Inappropriate or exaggerated behaviors (e.g., hostile, agitated, apathetic, withdrawal) Desired Outcomes Knowledge: Disease Process (NOC) Verbalize understanding of condition/disease ...

NURSING DIAGNOSIS: Cardiac Output, decreased May be related to Altered myocardial contractility/inotropic changes Alterations in rate, rhythm, electrical conduction Structural changes (e.g., valvular defects, ventricular aneurysm) Possibly evidenced by Increased heart rate (tachycardia), dysrhythmias, ECG changes Changes in BP (hypotension/hypertension) Extra heart sounds (S3, S4) Decreased urine output Diminished peripheral pulses Cool, ashen skin; diaphoresis Orthopnea, crackles, JVD, liver engorgement, ...

NURSING DIAGNOSIS: Pain, acute May be related to Physical agent: surgical manipulation, edema, inflammation, harvesting of bone graft Possibly evidenced by Reports of pain Autonomic responses: diaphoresis, changes in vital signs, pallor Alteration in muscle tone Guarding, distraction behaviors/restlessness Desired Outcomes Pain Control (NOC) Report pain is relieved/controlled. Verbalize methods that provide relief. Demonstrate use of relaxation skills and diversional ...

NURSING DIAGNOSIS: Infection, risk for Risk factors may include Inadequate secondary defenses (e.g., leukopenia, suppressed inflammatory response) and immunosuppression Malnutrition Insufficient knowledge to avoid exposure to pathogens Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] Desired Outcomes Risk Control (NOC) Verbalize understanding of individual causative/risk factor(s). Demonstrate techniques; initiate lifestyle changes to avoid reinfection/transmission to others. ...

Disturbed Visual Sensory Perception — Glaucoma Nursing Care Plans

NURSING DIAGNOSIS: Fluid Volume actual or risk for deficient May be related to Inadequate intake of food and liquids Consistent self-induced vomiting Chronic/excessive laxative/diuretic use Possibly evidenced by (actual) Dry skin and mucous membranes, decreased skin turgor Increased pulse rate, body temperature, decreased BP Output greater than input (diuretic use); concentrated urine/decreased urine output (dehydration) Weakness Change in mental state ...

NURSING DIAGNOSIS: Poisoning, risk for digitalis toxicity Risk factors may include Limited range of therapeutic effectiveness, lack of education/proper precautions, reduced vision/cognitive limitations Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] Desired Outcomes Verbalize understanding of individual prescription, how it interacts with other drugs/substances, and importance of maintaining prescribed regimen. Recognize signs of digitalis overdose and ...

NURSING DIAGNOSIS: Cardiac Output, risk for decreased Risk factors may include Altered electrical conduction Reduced myocardial contractility Desired Outcomes Maintain/achieve adequate cardiac output as evidenced by BP/pulse within normal range, adequate urinary output, palpable pulses of equal quality, usual level of mentation. Display reduced frequency/absence of dysrhythmia(s). Participate in activities that reduce myocardial workload. 3 Cardiac Arrhythmia (Digitalis Toxicity) Nursing Care Plan ...