Nurseslabs For All Your Nursing Needs

NURSING DIAGNOSIS: Tissue Perfusion, risk for ineffective (specify) Risk factors may include Hypovolemia Reduction/interruption of blood flow: pelvic congestion, postoperative tissue inflammation, venous stasis Intraoperative trauma or pressure on pelvic/calf vessels: lithotomy position during vaginal hysterectomy Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] Desired Outcomes Tissue Perfusion: (Specify) (NOC) Demonstrate adequate perfusion, as evidenced by ...

NURSING DIAGNOSIS: Fatigue May be related to Hypermetabolic state with increased energy requirements Irritability of central nervous system (CNS); altered body chemistry Possibly evidenced by Verbalization of overwhelming lack of energy to maintain usual routine, decreased performance Emotional lability/irritability; nervousness, tension Jittery behavior Impaired ability to concentrate Desired Outcomes Endurance (NOC) Verbalize increase in level of energy. Display improved ability ...

NURSING DIAGNOSIS: Activity intolerance Activity Intolerance — Hypertension Nursing Care Plans May be related to Generalized weakness Imbalance between oxygen supply and demand Possibly evidenced by Verbal report of fatigue or weakness Abnormal heart rate or BP response to activity Exertional discomfort or dyspnea Electrocardiogram (ECG) changes reflecting ischemia; dysrhythmias Desired Outcomes Endurance (NOC) Participate in necessary/desired activities. Report a ...

Excess Fluid Volume — Hemodialysis Nursing Care Plans NURSING DIAGNOSIS: Fluid Volume, risk for excess Risk factors may include Rapid/excessive fluid intake: IV, blood, plasma expanders, saline given to support BP during dialysis Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Fluid Balance (NOC) Maintain “dry weight” within patient’s normal range; be ...

NURSING DIAGNOSIS: Airway Clearance, risk for ineffective Risk factors may include Tracheal obstruction; swelling, bleeding, laryngeal spasms Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] Desired Outcomes Respiratory Status: Airway Patency (NOC) Maintain patent airway, with aspiration prevented. 5 Thyroidectomy Nursing Care Plan (NCP) Acute Pain — Thyroidectomy Nursing Care Plan (NCP) Ineffective Airway ...

NURSING DIAGNOSIS: Fluid Volume excess May be related to Reduced glomerular filtration rate (decreased cardiac output)/increased antidiuretic hormone (ADH) production, and sodium/water retention Possibly evidenced by Orthopnea, S3 heart sound Oliguria, edema, JVD, positive hepatojugular reflex Weight gain Hypertension Respiratory distress, abnormal breath sounds Desired Outcomes Fluid Balance (NOC) Demonstrate stabilized fluid volume with balanced intake and output, breath sounds clear/clearing, ...

Check vital signs before and immediately after activity, especially if patient is receiving vasodilators, diuretics, or beta-blockers. Orthostatic hypotension can occur with activity because of medication effect (vasodilation), fluid shifts (diuresis), or compromised cardiac pumping function.

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, ...