Search This Blog

Arterial Blood Gas Analysis

Arterial Blood Gas Analysis (ABG)

Arterial blood gas (ABG) analysis is used to measure the partial pressures of oxygen (PaO2) and carbon dioxide (pacO2)' and the pH of an arterial sample. Oxygen content (O2CT), oxygen saturation (SaO2) and bicarbonate (RCO3 -) values are also measured. A blood sample for ABG analysis may be drawn by percutaneous arterial puncture or from an arterial line.


* To evaluate gas exchange in the lungs.
* To assess integrity of the ventilatory control system.
* To determine the acid-base level of the blood.
* To monitor respiratory therapy.

Patient preparation

* Explain to the patient that this test is used to evaluate how well the lungs are delivering oxygen to blood and eliminating carbon dioxide.
* Tell him that the test requires a blood sample. Explain who will perform the arterial puncture and when and which site - radial, brachial, or femoral artery - has been selected for the puncture.
* Inform him that he needn't restrict food or fluids.
* Instruct the patient to breathe normally during the test, and warn him that he may experience a brief cramping or throbbing pain at the puncture site.

Procedure and posttest care

* Perform an arterial puncture.
* After applying pressure to the puncture site for 3 to 5 minutes, tape a gauze pad firmly over it. (If the puncture site is on the arm, don't tape the entire circumference; this may restrict circulation.)
* If the patient is receiving anticoagulants or has a coagulopathy, hold the puncture site longer than 5 minutes if necessary.
* Monitor vital signs, and observe for signs of circulatory impairment, such as swelling, discoloration, pain, numbness, and tingling in the bandaged arm or leg.
* Watch for bleeding from the puncture site.


* Wait at least 15 minutes before drawing arterial blood when starting, changing, or discontinuing oxygen therapy.
* Before sending the sample to the laboratory, note on the laboratory slip whether the patient was breathing room air or receiving oxygen therapy when the sample was collected.
* If the patient was receiving oxygen therapy, note the flow rate. If he is on a ventilator, note the fraction of inspired oxygen and tidal volume.
* Note the patient's rectal temperature and respiratory rate.

Reference values

Normal ABG values fall within the following ranges:

* PaO2: 75 to 100 mm Hg
* PacO2: 35 to 45 mm Hg
* pH: 7.35 to 7.45
* O2CT: 15% to 22%
* SaO2: 95% to 100%
* HCO3 -: 24 to 28 mEq/L.

Abnormal findings

Low PaO2, O2CT, and SaO2 levels and a high PacO2 may result from conditions that impair respiratory function, such as respiratory muscle weakness or paralysis, respiratory center inhibition (from head injury, brain tumor, or drug abuse, for example), and airway obstruction (possibly from mucus plugs or a tumor). Similarly, low readings may result from bronchiole obstruction caused by asthma or emphysema, from an abnormal ventilation-perfusion ratio due to partially blocked alveoli or pulmonary capillaries, or from alveoli that are damaged or filled with fluid because of disease, hemorrhage, or near-drowning.

When inspired air contains insufficient oxygen, PaO2, O2CT, and SaO2 decrease, but PacO2 may be normal. Such findings are common in pneumothorax, impaired diffusion between alveoli and blood (due to interstitial fibrosis, for example), or an arteriovenous shunt that permits blood to by­pass the lungs.

Low O2CT - with normal PaO2, Sa02 and, possibly, PacO2 values ­may result from severe anemia, de­creased blood volume, and reduced hemoglobin oxygen-carrying capacity.
Interfering factors

* Failure to heparinize syringe, place Rumple in an iced bag, or send the sample to the laboratory immediately (possible altered PaO2 and PacO2 because metabolic processes continue after sample is drawn)
* Exposing the sample to air (increase or decrease in PaO2 and PacO2)
* Venous blood in the sample (possible decrease in Pa02 and increase in PII(02)
* Bicarbonate, ethacrynic acid hydrocortisone, metolazone, prednisone, and Ihlllzides (possible increase in PacO2) . Acetazolamide, methicillin, nitrofurantoin, and tetracycline (possible decrease in PacO2)
* Fever (possible false-high PaO2 and PacO2).

Source :
READ MORE - Arterial Blood Gas Analysis

Adventitious Lung Sound

Adventitious Lung Sound

  1. Crackles
    • Characteristics
      • popping
      • crackling
      • bubbling
      • moist sound on inspiration
    • Lung Problem
      • pneumonia
      • pulmonary edema
      • pulmonary fibrosis
  2. Ronchi
    • Characteristics
      • rubling sound expiration
    • Lung Problem
      • pneumonia
      • emphysema
      • bronchitis
      • bronchectasis
  3. Wheezes
    • Characteristics
      • hight-pitched musicalsound during both inspiration and expiration (louder)
    • Lung Problem
      • emphysema
      • asthma
      • foreign bodies

  4. Pleural Friction Rub
    • Characteristics
      • dry
      • grating sound on both inspiration and expiration
    • Lung Problem
      • pleurisy
      • pneumonia
      • pleural infarct
READ MORE - Adventitious Lung Sound

The Top 10 Qualities of a Good Nurse Manager

By Sandra A. Thompson, RN., BSN., (Case Manager at John C. Lincoln Hospital-North Mountain, in Phoenix, AZ).
References : AMERICAN JOURNAL NURSING, AGUST 2004, VOL. 104, NO. 8.

1. The number-one quality a good nurse manage must have : respect staff as professionals

Nothing is worse than being treated like a child in the work-place. A manager who disrespects her staff, especially in front of others, loses staff respect in return. Nurse managers should refrain from micromanagement; nurses are professionals who can think for themselves. Restraining or limiting nurses because of a lack of trust is deadly to the relationship between staff and manager. Nursing autonomy is promoted at the professional level; it must be promoted at the managerial level as well.

2. Set standards and a clear professional example.

Nurses are expected to behave professionally, and the same holds true for managers. A nurse manager needs to be professional in her appearance, language, and behavior, just as a staff nurse must be. Coming to work disheveled or inappropriately dressed, using improper language, or failing to follow standards for attendance or behavior are a few examples of the do-what-I-say-and-not-what-I-do double standard. What goes for the nurse must go for the manager.

3. Be organized, yet creative and flexible.

Many workers have unusual organizational methods, but employees are effected when a nurse manager can't find an evaluation or forgets a deadline. The manager needs to be organized in a way that her staff can follow. She also needs to establish clear rules that she must be willing to adjust when necessary. For example, if a nurse's child has a school event that conflicts with the posted schedule, the manager must understand its importance and try to resolve the dilemma. Of course, the manager must also recognize when staff members abuse such flexibility and set limits accordingly.

4. Be an effective decision maker, as well as a conflict and crisis manager.

The nursing staff expects the manager to make intelligent decisions when conflicts and problems arise. For example, managers should expect employees to attempt to resolve conflicts among them-selves. But manager needs to realize that she might be asked to assist. No one likes confrontations, but nurse managers who shrink from problems will only create more discord among the staff. When a serious problem arises on the unit, the nurse manager is looked to for leadership and support. If the manager responds by disappearing, crying, or exploding, the staff has diminished resources for handling problems. Timeliness is another factor. If the nurse manager judges too quickly or delays decisions, the entire unit suffers. Nursing staff and administrators agree that the ability to make good decisions is essential for a successful nurse manager.

5. Motivate and empower staff

Change is a necessary part of business, even the business of health care. The nurse manager needs to find ways to motivate and involve staff. If a nurse manager displays a hopeless, cynical, or dispassionate attitude, so will the staff nurses. The effective nurse manager is involved with the nursing staff on all levels, welcomes their input, and works with them to ensure excellence, create autonomy, and increase job satisfaction and opportunities for advancement.

6. Have a good sense of humor

Nursing is one of the toughest and most stressful jobs around. Tension can become so overwhelming that laughing is the only alternative to crying. An affective manager understands this; we are all human, and sometimes appropriate humor can be the healthiest and most compassionate way to help staff and patients cope.

7. Be honest, fair, consistent, and reasonable

Lying is one of the quickest ways to break someone's trust, as is showing favoritism toward particular members of the staff. Deceit of any kind is devastating to the relationship between manager and staff. A good nurse manager knows that consistency matters-working for an unpredictable manager escalates tension and inhibits work. Being unreasonable in expectations and day-to-day dealings can also be harmful. A manager who wants to have an effective and cohesive team needs to be up front, realistic, and fair when it comes to interactions and expectations. Honest, sincere communication is always the best practice.

8. Be reliable resource and staff advocate

A nurse manager needs to have a solid clinical background, preferably in the specialty of the staff. Administrators often feel this is not necessary as long as the manager possesses strong managerial skills. From a staff nurse's perspective, however, respect is lost if the manager is out of touch with what the specialized nursing staff does. The manager also needs to support nursing staff. A manager who does not back up staff loses their respect. A manager who supports staff and is an advocate for them gains loyalty.

9. Be available and accessible to staff

Admittedly, meetings and other managerial responsibilities are important, but the nursing staff needs to know that the manager is available when needed. Acknowledging and incorporating staff suggestions, whenever possible, is also important to nurses.

10. Be a great communicator

Effective communication is one of the most important tools for a leader or manager. Information should be conveyed in a clear manner. Staff should be informed of expectations and upcoming changes (not reprimanded after they've unknowingly done it wrong), be given timely and accurate information and updates, be listened to, and receive positive feedback, one of the most frequent complaints from nurses is that their managers only talk to them when they are in trouble. The nursing professions has a reputation for "eating its young," and breaking this cycle can begin with positive interactions from the nurse manager.

While it's the responsibility of the nurse manager to develop these qualities, staff nurses have a role in fulfillment of the top-10 list as well. What can staff nurses do to support these qualities in their nurse managers?
First, seek educational and practice opportunities to develop these attributes personally.
Second , communicate honestly with the nurse manager about your professional needs. Let the manager know what it is you need to be successful in providing good nursing care.
Third, patiently allow for mistakes and misjudgments, just as you would like manager to do for you. Above all, show respect, support, and appreciation especially when the manager has exhibited or practiced one of the qualities of a great nurse manager.
It's logical that a good nurse manager will attract and retain nurses, and a bad one will drive them away. In light of the current nursing shortage, this issue becomes particularly important. What separates the good from the bad? Nurse managers who want to keep nurses will make it a priority to find out. Staff nurses who want good nurse managers will make it a priority to help them become so.
READ MORE - The Top 10 Qualities of a Good Nurse Manager

Nursing Care Plan for Typhoid Fever

Nursing Care Plan - NCP for Typhoid Fever

Typhoid Fever

Typhoid fever, also known as enteric fever, is a potentially fatal multisystemic illness caused primarily by Salmonella typhi. The protean manifestations of typhoid fever make this disease a true diagnostic challenge. The classic presentation includes fever, malaise, diffuse abdominal pain, and constipation. Untreated, typhoid fever is a grueling illness that may progress to delirium, obtundation, intestinal hemorrhage, bowel perforation, and death within one month of onset. Survivors may be left with long-term or permanent neuropsychiatric complications.


All pathogenic Salmonella species are engulfed by phagocytic cells, which then pass them through the mucosa and present them to the macrophages in the lamina propria. Nontyphoidal salmonellae are phagocytized throughout the distal ilium and colon. With toll-like receptor (TLR)–5 and TLR-4/MD2/CD-14 complex, macrophages recognize pathogen-associated molecular patterns (PAMPs) such as flagella and lipopolysaccharides. Macrophages and intestinal epithelial cells then attract T cells and neutrophils with interleukin 8 (IL-8), causing inflammation and suppressing the infection.

In contrast to the nontyphoidal salmonellae, S typhi enters the host's system primarily through the distal ilium. S typhi has specialized fimbriae that adhere to the epithelium over clusters of lymphoid tissue in the ilium (Peyer patches), the main relay point for macrophages traveling from the gut into the lymphatic system. S typhi has a Vi capsular antigen that masks PAMPs, avoiding neutrophil-based inflammation. The bacteria then induce their host macrophages to attract more macrophages.

It co-opts the macrophages' cellular machinery for their own reproduction as it is carried through the mesenteric lymph nodes to the thoracic duct and the lymphatics and then through to the reticuloendothelial tissues of the liver, spleen, bone marrow, and lymph nodes. Once there, the S typhi bacteria pause and continue to multiply until some critical density is reached. Afterward, the bacteria induce macrophage apoptosis, breaking out into the bloodstream to invade the rest of the body.

The gallbladder is then infected via either bacteremia or direct extension of S typhi –infected bile. The result is that the organism re-enters the gastrointestinal tract in the bile and reinfects Peyer patches. Bacteria that do not reinfect the host are typically shed in the stool and are then available to infect other hosts.

Signs and Symptoms

Typhoid fever is characterized by a slowly progressive fever as high as 40 °C (104 °F), profuse sweating, gastroenteritis, and nonbloody diarrhea. Less commonly, a rash of flat, rose-colored spots may appear.

Classically, the course of untreated typhoid fever is divided into four individual stages, each lasting approximately one week. In the first week, there is a slowly rising temperature with relative bradycardia, malaise, headache and cough. A bloody nose (epistaxis) is seen in a quarter of cases and abdominal pain is also possible. There is leukopenia, a decrease in the number of circulating white blood cells, with eosinopenia and relative lymphocytosis, a positive diazo reaction and blood cultures are positive for Salmonella typhi or paratyphi. The classic Widal test is negative in the first week.

In the second week of the infection, the patient lies prostrate with high fever in plateau around 40 °C (104 °F) and bradycardia (sphygmothermic dissociation), classically with a dicrotic pulse wave. Delirium is frequent, frequently calm, but sometimes agitated. This delirium gives to typhoid the nickname of "nervous fever". Rose spots appear on the lower chest and abdomen in around a third of patients. There are rhonchi in lung bases. The abdomen is distended and painful in the right lower quadrant where borborygmi can be heard. Diarrhea can occur in this stage: six to eight stools in a day, green with a characteristic smell, comparable to pea soup. However, constipation is also frequent. The spleen and liver are enlarged (hepatosplenomegaly) and tender, and there is elevation of liver transaminases. The Widal reaction is strongly positive with antiO and antiH antibodies. Blood cultures are sometimes still positive at this stage. (The major symptom of this fever is the fever usually rises in the afternoon up to the first and second week.)

In the third week of typhoid fever, a number of complications can occur :
  • Intestinal hemorrhage due to bleeding in congested Peyer's patches; this can be very serious but is usually not fatal.
  • Intestinal perforation in the distal ileum: this is a very serious complication and is frequently fatal. It may occur without alarming symptoms until septicaemia or diffuse peritonitis sets in.
  • Encephalitis
  • Metastatic abscesses, cholecystitis, endocarditis and osteitis
The fever is still very high and oscillates very little over 24 hours. Dehydration ensues and the patient is delirious (typhoid state). By the end of third week the fever has started reducing this (defervescence). This carries on into the fourth and final week.

NCP - Nursing Care Plan for Typhoid Fever

  1. Health History Now
    Why patients enter the hospital and what the major complaints of patients, so it can be enforced priority nursing issues that may arise.
  2. Previous Health History
    Does the patient had been ill and treated with the same disease.
  3. Family Health History
    Does anyone in the family of patients, the sick like a patient.
  4. Psychosocial History
    Intrapersonal: the feeling felt client (anxious / sad)
    Interpersonal: relationship with other people.
  5. Patterns of health function
    • The pattern of nutrition and metabolism.
      Usually the client is reduced appetite due to a disruption in the small intestine.
    • Rest and sleep patterns
      During the pain patients feel unable to rest because the patient felt pain in her stomach, nausea, vomiting, sometimes diarrhea.
  6. Physical examination
    • Awareness and patient's general condition
      Patient awareness of the need to study the unconscious - not conscious (composmentis - coma) to assess the severity of the patient's disease prognosis.
    • Vital Signs and physical examination Head to foot
      Blood pressure, pulse, respiration, temperature which is a measure of the general condition of patient / patient's condition and includes examination from head to toe by using the principles of inspection, auscultation, palpation, percussion), in addition to body weight were also aware of any decline weight because of the increased nutritional deficiencies that occur, so it can be calculated nutritional needs required.

Nursing Diagnosis

The increase in body temperature associated with the infection process of salmonella thypii


Objectives : Normal body temperature
Intervention :
  • Observation of the client's body temperature
  • Rational: to know the changes in body temperature.
  • Encourage the family to put on clothing that can absorb sweat like cotton
    Rational: to maintain body hygiene
  • Collaboration with physicians in the provision of anti piretik
    Rational: to reduce the heat to the drug
READ MORE - Nursing Care Plan for Typhoid Fever

Nursing Diagnosis : Application to Clinical Practice

Nursing Diagnosis : Application to Clinical Practice


Lynda Juall Carpenito-Moyet

READ MORE - Nursing Diagnosis : Application to Clinical Practice

Nursing Care Plan for Diabetes Mellitus

NCP - Nursing Care Plan for Diabetes Mellitus

Nursing Care Plan for Diabetes Mellitus

Diabetes Mellitus

Diabetes mellitus, often simply referred to as diabetes—is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced. This high blood sugar produces the classical symptoms of polyuria (frequent urination), polydipsia (increased thirst) and polyphagia (increased hunger).

There are three main types of diabetes :
  • Type 1 diabetes: results from the body's failure to produce insulin, and presently requires the person to inject insulin. (Also referred to as insulin-dependent diabetes mellitus, IDDM for short, and juvenile diabetes.)
  • Type 2 diabetes: results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency.
  • Gestational diabetes: is when pregnant women, who have never had diabetes before, have a high blood glucose level during pregnancy. It may precede development of type 2 DM.

Other forms of diabetes mellitus include congenital diabetes, which is due to genetic defects of insulin secretion, cystic fibrosis-related diabetes, steroid diabetes induced by high doses of glucocorticoids, and several forms of monogenic diabetes.

All forms of diabetes have been treatable since insulin became available in 1921, and type 2 diabetes may be controlled with medications. Both type 1 and 2 are chronic conditions that usually cannot be cured. Pancreas transplants have been tried with limited success in type 1 DM; gastric bypass surgery has been successful in many with morbid obesity and type 2 DM. Gestational diabetes usually resolves after delivery. Diabetes without proper treatments can cause many complications. Acute complications include hypoglycemia, diabetic ketoacidosis, or nonketotic hyperosmolar coma. Serious long-term complications include cardiovascular disease, chronic renal failure, retinal damage. Adequate treatment of diabetes is thus important, as well as blood pressure control and lifestyle factors such as smoking cessation and maintaining a healthy body


The cause of diabetes depends on the type. Type 2 diabetes is due primarily to lifestyle factors and genetics.

Type 1 diabetes is also partly inherited and then triggered by certain infections, with some evidence pointing at Coxsackie B4 virus. There is a genetic element in individual susceptibility to some of these triggers which has been traced to particular HLA genotypes (i.e., the genetic "self" identifiers relied upon by the immune system). However, even in those who have inherited the susceptibility, type 1 diabetes mellitus seems to require an environmental trigger.

Signs and Symptoms

The classical symptoms of diabetes are polyuria (frequent urination), polydipsia (increased thirst) and polyphagia (increased hunger). Symptoms may develop rapidly (weeks or months) in type 1 diabetes while in type 2 diabetes they usually develop much more slowly and may be subtle or absent.

Prolonged high blood glucose causes glucose absorption, which leads to changes in the shape of the lenses of the eyes, resulting in vision changes; sustained sensible glucose control usually returns the lens to its original shape. Blurred vision is a common complaint leading to a diabetes diagnosis; type 1 should always be suspected in cases of rapid vision change, whereas with type 2 change is generally more gradual, but should still be suspected.

People (usually with type 1 diabetes) may also present with diabetic ketoacidosis, a state of metabolic dysregulation characterized by the smell of acetone; a rapid, deep breathing known as Kussmaul breathing; nausea; vomiting and abdominal pain; and an altered states of consciousness.

A rarer but equally severe possibility is hyperosmolar nonketotic state, which is more common in type 2 diabetes and is mainly the result of dehydration. Often, the patient has been drinking extreme amounts of sugar-containing drinks, leading to a vicious circle in regard to the water loss.

A number of skin rashes can occur in diabetes that are collectively known as diabetic dermadromes.

Nursing Care Plan for Diabetes Mellitus

  • Family Health History
    Are there families who suffer from illnesses such as client ?
  • Patient Health History and Previous Treatment
    How long suffered from DM client, how to handle, get what kind of insulin therapy, how to take the medicine whether regular or not, what is done to cope with illness clients.
  • Activity / Rest:
    Tired, weak, hard Moves / walking, muscle cramps, decreased muscle tone.
  • Circulation
    Is there a history of hypertension, AMI, claudication, numbness, tingling in the extremities, ulcers on the feet long healing time, tachycardia, changes in blood pressure
  • Ego Integrity
    Stress, anxiety
  • Elimination
    Changes in the pattern of urination (polyuria, nocturia, anuria), diarrhea
  • Food / Fluids
    Anorexia, nausea, vomiting, do not follow the diet, weight loss, thirst, the use of diuretics.
  • Neurosensori
    Dizziness, headache, numbness, muscle weakness numbness, paraesthesia, visual disturbances.
  • Pain / Leisure
    Abdominal strain, pain (is / weight)
  • Respiratory
    Cough with or without purulent sputum
  • Security
    Dry skin, itching, skin ulcer.

Nursing Diagnosis and Nursing Intervention

Fluid volume deficient related to osmotic diuresis from hyperglycemia


After 8 hours of nursing interventions, the patient will demonstrate adequate hydration.

  • Monitor orthostatic blood pressure changes.
    Rational : Hypovolemia may be manifested by hypotension and tachycardia.
  • Assess peripheral pulses, capillary refill, skin turgor, and mucous membrane.
    Rational : Indicators of level of dehydration, adequacy of circulating volume.
  • Monitor respiratory pattern like Kussmaul’s respirations and acetone breath.
    Rational : Lungs remove carbonic acid through respirations, producing a compensatory respiratory alkalosis for ketoacidosis.
  • Monitor input and output. Note urine specific gravity.
    Rational : Provides ongoing estimate of volume replacement needs, kidney function, and effectiveness of therapy.
  • Promote comfortable environment. Cover patient with light sheets.
    Rational : Avoids overheating, which could promote further fluid loss.
  • Monitor temperature, skin color and moisture.
    Rational : Fever, chills, and diaphoresis are common with infectious process; fever with flushed, dry skin may reflect dehydration.

Read More :

Nursing Interventions for Diabetes Mellitus

NANDA Diabetes

Read More :

Nursing Assessment for Diabetes Mellitus

NANDA Diabetes

12 Nursing Diagnosis for Diabetes Mellitus

Nursing Interventions for Diabetes Mellitus

Nursing Diagnosis and Interventions - Diabetes Mellitus with Gangrene
READ MORE - Nursing Care Plan for Diabetes Mellitus

Nursing Care Plan for COPD (Chronic Obstructive Pulmonary Disease)

NCP - Nursing Care Plan for COPD (Chronic Obstructive Pulmonary Disease)

Chronic Obstructive Pulmonary Disease (COPD)

Chronic obstructive pulmonary disease (COPD) is estimated to affect 32 million persons in the United States and is the fourth leading cause of death in this country. Patients typically have symptoms of both chronic bronchitis and emphysema, but the classic triad also includes asthma. Most of the time COPD is secondary to tobacco abuse, although cystic fibrosis, alpha-1 antitrypsin deficiency, bronchiectasis, and some rare forms of bullous lung diseases may be causes as well.


In general, the vast majority of chronic obstructive pulmonary disease (COPD) cases are the direct result of tobacco abuse. While other causes are known, such as alpha-1 antitrypsin deficiency, cystic fibrosis, air pollution, occupational exposure (eg, firefighters), and bronchiectasis, this is a disease process that is somewhat unique in its direct correlation to a human activity.

Signs and Symptoms

Essentials of diagnosis include:
  • History of cigarette smoking.
  • Chronic cough and sputum production (in chronic bronchitis)
  • Dyspnea (in emphysema)
  • Rhonchi, decreased intensity of breath sounds, and prolonged expiration on physical examination
  • Airflow limitation on pulmonary function testing that is not fully reversible and most often progressive
One of the most common symptoms of COPD is shortness of breath (dyspnea). People with COPD commonly describe this as: "My breathing requires effort," "I feel out of breath," or "I can't get enough air in". People with COPD typically first notice dyspnea during vigorous exercise when the demands on the lungs are greatest. Over the years, dyspnea tends to get gradually worse so that it can occur during milder, everyday activities such as housework. In the advanced stages of COPD, dyspnea can become so bad that it occurs during rest and is constantly present.

Other symptoms of COPD are a persistent cough, sputum or mucus production, wheezing, chest tightness, and tiredness.

People with advanced (very severe) COPD sometimes develop respiratory failure. When this happens, cyanosis, a bluish discoloration of the lips caused by a lack of oxygen in the blood, can occur. An excess of carbon dioxide in the blood can cause headaches, drowsiness or twitching (asterixis). A complication of advanced COPD is cor pulmonale, a strain on the heart due to the extra work required by the heart to pump blood through the affected lungs. Symptoms of cor pulmonale are peripheral edema, seen as swelling of the ankles, and dyspnea.

There are a few signs of COPD that a healthcare worker may detect although they can be seen in other diseases. Some people have COPD and have none of these signs. Common signs are :
  • tachypnea, a rapid breathing rate
  • wheezing sounds or crackles in the lungs heard through a stethoscope
  • breathing out taking a longer time than breathing in
  • enlargement of the chest, particularly the front-to-back distance (hyperaeration)
  • active use of muscles in the neck to help with breathing
  • breathing through pursed lips
  • increased anteroposterior to lateral ratio of the chest (i.e. barrel chest).

Nursing Care Plan for Chronic Obstructive Pulmonary Disease (COPD)

  1. The identity of the client
    Name, place of birth date, age, gender, religion / tribe, the people of the State, the language used, the responsible include: name, address, relationship with the client.
  2. Patterns of health perception
    Review the status of a medical history of having experienced the client, what efforts and where clients get medical help, then what makes the client's health status declined.
  3. The pattern of metabolic nutrients.
    Ask the client about the type, frequency, and amount of eating and drinking in a day. Assess client's excessive appetite or reduced, assess nausea or vomiting or any intravenous therapy, use of enteric tube, also measuring weight, measure height, upper arm circle and calculate the ideal weight client to obtain nutritional status.
  4. The pattern of elimination :
    • Review of rekuensi, characteristics, difficulties / problems and also the use of assistive devices such as catheters Folly, also measuring intake and output every shift.
    • Elimination of the process, review the frequency, characteristics, difficulties / problems defecation.
  5. The pattern of activity and exercise
    Assess the ability of activities both before illness or condition now and also the use of aids such as canes, wheel chairs and others. Ask the client about the use of leisure time. Does the client complain of breathing, such as pounding heart, chest pain, weak body.
  6. The pattern of sleep and rest
    Ask the client's daily sleep habits, how long sleep, a nap. How sleep the client whether in light or dark. Often wake up during sleep caused by pain, itching, urination, difficulty and others.
  7. The pattern of cognitive perception
    Ask the client whether to use tool for seeing, hearing. Is there any client trouble remembering things, how clients cope with discomfort: pain. Is there a perception of sensory disturbances such as blurred to see, hearing impaired. Assess the level of orientation to time place and person.
  8. Patterns of perception and self-concept
    Review about his behavior, whether the client has experienced despair / frustration / stress.
  9. The pattern of role relationships
    What is the role of clients in the community and family, how client relationships in society and family and coworkers. Assess whether there is disruption and disturbance of verbal communication in interactions with family members and others.
  10. The pattern of sexual production
    Ask the client about the use of contraception and the problems that arise. How many children of clients and client's marital status.
  11. The pattern of sexual production
    Ask the client about the use of contraception and the problems that arise. How many children of clients and client's marital status. The pattern of coping mechanisms and tolerance to stress.
    Assess the factors that make the client angry, where clients exchange opinions and coping mechanisms that are used for this. Assess client's current situation against conformity, expression, denial / rejection of self.
  12. he pattern of belief system
    Assess whether the client is often worship, clients follow a religion?. Assess whether there are values on which clients embrace religion contrary to health.

Nursing Diagnosis and Nursing Intervention

Ineffective airway clearance related to the disruption of production increased secretions, retained secretions

Goal : Ventilation / oxygenation to the needs of clients.

Outcome : Maintain a patent airway and breath sounds clean

  • Review / monitor respiratory frequency, record the ratio of inspiration / expiration.
  • Assess the patient to a comfortable position, such as raising the head of the bed, seat and backrest of the bed.
  • Auscultation for breath sounds, record the sound of breath for example: wheezing, and rhonchi krokels.
  • Note the presence disepnea, for example: complaints restlessness, anxiety, respiratory distress
  • Help the abdominal breathing exercises or lip.
  • Observation of the characteristic cough, for example: persistent, hacking cough, wet, auxiliary measures to improve the effectiveness of the airway.
  • Increase fluid intake to 3000 ml / day according to tolerance of the heart.
  • Bronchodilators, eg, β-agonists, efinefrin (adrenaline, vavonefrin), albuterol (Proventil, Ventolin), terbutaline (brethine, brethaire), isoeetrain (brokosol, bronkometer).
  • (Doenges, 1999. P. 156).

Related Articles About COPD


Physical Assessment for COPD

Ineffective Airway Clearance related to - COPD

Activity Intolerance related to - COPD

Nursing Care Plan for Chronic Obstructive Pulmonary Disease
READ MORE - Nursing Care Plan for COPD (Chronic Obstructive Pulmonary Disease)

Nanda Nursing Diagnosis By Gordon’s Functional Health Patterns

Download :
Nanda Nursing Diagnosis By Gordon’s Functional Health Patterns

Click Here

READ MORE - Nanda Nursing Diagnosis By Gordon’s Functional Health Patterns

Nursing Care Plan for Stroke

Nursing Care Plan - NCP for Stroke


A stroke, previously known medically as a cerebrovascular accident (CVA), is the rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a hemorrhage (leakage of blood). As a result, the affected area of the brain is unable to function, leading to inability to move one or more limbs on one side of the body, inability to understand or formulate speech, or an inability to see one side of the visual field.

A stroke is a medical emergency and can cause permanent neurological damage, complications, and even death. It is the leading cause of adult disability in the United States and Europe and it is the number two cause of death worldwide. Risk factors for stroke include advanced age, hypertension (high blood pressure), previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, cigarette smoking and atrial fibrillation. High blood pressure is the most important modifiable risk factor of stroke.

A stroke is occasionally treated in a hospital with thrombolysis (also known as a "clot buster"). Post-stroke prevention may involve the administration of antiplatelet drugs such as aspirin and dipyridamole, control and reduction of hypertension, the use of statins, and in selected patients with carotid endarterectomy, the use of anticoagulants. Treatment to recover any lost function is stroke rehabilitation, involving health professions such as speech and language therapy, physical therapy and occupational therapy.

Causes of Stroke

Blockage of an artery

The blockage of an artery in the brain by a clot (thrombosis) is the most common cause of a stroke. The part of the brain that is supplied by the clotted blood vessel is then deprived of blood and oxygen. As a result of the deprived blood and oxygen, the cells of that part of the brain die and the part of the body that it controls stops working. Typically, a cholesterol plaque in a small blood vessel within the brain that has gradually caused blood vessel narrowing ruptures and starts the process of forming a small blood clot.

Risk factors for narrowed blood vessels in the brain are the same as those that cause narrowing blood vessels in the heart and heart attack (myocardial infarction). These risk factors include :
  • high blood pressure (hypertension),
  • high cholesterol,
  • diabetes, and
  • smoking.

Embolic stroke

Another type of stroke may occur when a blood clot or a piece of atherosclerotic plaque (cholesterol and calcium deposits on the wall of the inside of the heart or artery) breaks loose, travels through the bloodstream and lodges in an artery in the brain. When blood flow stops, brain cells do not receive the oxygen and glucose they require to function and a stroke occurs. This type of stroke is referred to as an embolic stroke. For example, a blood clot might originally form in the heart chamber as a result of an irregular heart rhythm, such as occurs in atrial fibrillation. Usually, these clots remain attached to the inner lining of the heart, but occasionally they can break off, travel through the blood stream, form a plug (embolism) in a brain artery, and cause a stroke. An embolism can also originate in a large artery (for example, the carotid artery, a major artery in the neck that supplies blood to the brain) and then travel downstream to clog a small artery within the brain.

Cerebral hemorrhage

A cerebral hemorrhage occurs when a blood vessel in the brain ruptures and bleeds into the surrounding brain tissue. A cerebral hemorrhage (bleeding in the brain) causes stroke symptoms by depriving blood and oxygen to parts of the brain in a variety of ways. Blood flow is lost to some cells. As well, blood is very irritating and can cause swelling of brain tissue (cerebral edema). Edema and the accumulation of blood from a cerebral hemorrhage increases pressure within the skull and causes further damage by squeezing the brain against the bony skull further decreasing blood flow to brain tissue and cells.

Subarachnoid hemorrhage

In a subarachnoid hemorrhage, blood accumulates in the space beneath the arachnoid membrane that lines the brain. The blood originates from an abnormal blood vessel that leaks or ruptures. Often this is from an aneurysm (an abnormal ballooning out of the wall of the vessel). Subarachnoid hemorrhages usually cause a sudden, severe headache, nausea, vomiting, light intolerance, and a stiff neck. If not recognized and treated, major neurological consequences, such as coma, and brain death may occur.


Another rare cause of stroke is vasculitis, a condition in which the blood vessels become inflamed causing decreased blood flow to brain tissue.

Migraine headache

There appears to be a very slight increased occurrence of stroke in people with migraine headache. The mechanism for migraine or vascular headaches includes narrowing of the brain blood vessels. Some migraine headache episodes can even mimic stroke with loss of function of one side of the body or vision or speech problems. Usually, the symptoms resolve as the headache resolves.

Treatment of a Stroke

Tissue plasminogen activator (TPA)

There is opportunity to use alteplase (TPA) as a clot-buster drug to dissolve the blood clot that is causing the stroke. There is a narrow window of opportunity to use this drug. The earlier that it is given, the better the result and the less potential for the complication of bleeding into the brain.

Present American Heart Association guidelines recommend that if used, TPA must be given within 4 1/2 hours after the onset of symptoms. for patients who waken from sleep with symptoms of stroke, the clock starts when they were last seen in a normal state.

TPA is injected into a vein in the arm but, the time frame for its use may be extended to six hours if it is dripped directly into the blood vessel that is blocked requiring angiography, which is performed by an interventional radiologist. Not all hospitals have access to this technology.

TPA may reverse stroke symptoms in more than one-third of patients, but may also cause bleeding in 6% patients, potentially making the stroke worse.

For posterior circulation strokes that involve the vertebrobasilar system, the time frame for treatment with TPA may be extended even further to 18 hours.

Heparin and aspirin

Drugs to thin the blood (anticoagulation; for example, heparin) are also sometimes used in treating stroke patients in the hopes of improving the patient's recovery. It is unclear, however, whether the use of anticoagulation improves the outcome from the current stroke or simply helps to prevent subsequent strokes (see below). In certain patients, aspirin given after the onset of a stroke does have a small, but measurable effect on recovery. The treating doctor will determine the medications to be used based upon a patient's specific needs.

Managing other Medical Problems

Blood pressure will be tightly controlled often using intravenous medication to prevent stroke symptoms from progressing. This is true whether the stroke is ischemic or hemorrhagic.

Supplemental oxygen is often provided.

In patients with diabetes, the blood sugar (glucose) level is often elevated after a stroke. Controlling the glucose level in these patients may minimize the size of a stroke.

Patients who have suffered a transient ischemic attacks, the patient may be discharged with blood pressure and cholesterol medications even if the blood pressure and cholesterol levels are within acceptable levels. Smoking cessation is mandatory.


When a patient is no longer acutely ill after a stroke, the health care staff focuses on maximizing the individuals functional abilities. This is most often done in an inpatient rehabilitation hospital or in a special area of a general hospital. Rehabilitation can also take place at a nursing facility.

The rehabilitation process can include some or all of the following :
  1. speech therapy to relearn talking and swallowing;
  2. occupational therapy to regain as much function dexterity in the arms and hands as possible;
  3. physical therapy to improve strength and walking; and
  4. family education to orient them in caring for their loved one at home and the challenges they will face.
The goal is for the patient to resume as many, if not all, of their pre-stroke activities and functions. Since a stroke involves the permanent loss of brain cells, a total return to the patient's pre-stroke status is not necessarily a realistic goal in many cases. However, many stroke patients can return to vibrant independent lives.

Depending upon the severity of the stroke, some patients are transferred from the acute care hospital setting to a skilled nursing facility to be monitored and continue physical and occupational therapy.

Many times, home health providers can assess the home living situation and make recommendations to ease the transition home. Unfortunately, some stroke patients have such significant nursing needs that they cannot be met by relatives and friends and long-term nursing home care may be required. ( Diagnosis for Stroke1. Ineffective Airway Clearance

2. Ineffective Cerebral Tissue Perfusion

3. Impaired Physical Mobility

4. Impaired Verbal Communication

5. Disturbed Sensory Perception

6. Imbalanced Nutrition Less Than Body Requirements

7. Self-Care Deficit

8. Risk of Injury

9. Deficient Knowledge

10. Disturbed Sleep Pattern
READ MORE - Nursing Care Plan for Stroke

Nursing Care Plan for Congestive Heart Failure - CHF

Nursing Care Plan for Congestive Heart Failure - CHF

Congestive Heart Failure (CHF)

Congestive heart failure (CHF), or heart failure, is a condition in which the heart can't pump enough blood to the body's other organs. This can result from :
  • narrowed arteries that supply blood to the heart muscle — coronary artery disease
  • past heart attack, or myocardial infarction, with scar tissue that interferes with the heart muscle's normal work
  • high blood pressure
  • heart valve disease due to past rheumatic fever or other causes
  • primary disease of the heart muscle itself, called cardiomyopathy.
  • heart defects present at birth — congenital heart defects.
  • infection of the heart valves and/or heart muscle itself — endocarditis and/or myocarditis
The "failing" heart keeps working but not as efficiently as it should. People with heart failure can't exert themselves because they become short of breath and tired.

As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing congestion in the tissues. Often swelling (edema) results. Most often there's swelling in the legs and ankles, but it can happen in other parts of the body, too. Sometimes fluid collects in the lungs and interferes with breathing, causing shortness of breath, especially when a person is lying down.

Heart failure also affects the kidneys' ability to dispose of sodium and water. The retained water increases the edema.

Nursing Care Plan for Congestive Heart Failure - CHF

Congestive Heart Failure Symptoms and Signs

The symptoms of congestive heart failure vary among individuals according to the particular organ systems involved and depending on the degree to which the rest of the body has "compensated" for the heart muscle weakness.

The early symptoms are often shortness of breath, cough, or a feeling of not being able to get a deep breath.

In addition, the three major symptoms of congestive heart failure are :
  1. exercise intolerance (a person may be unable to tolerate exercise or even mild physical exertion that he or she may have been able to do in the past);
  2. shortness of breath (you may have difficulty breathing (dyspnea), especially when active, or even at rest); and
  3. fluid retention and swelling (edema in the legs, feet, and ankles).

Nursing Diagnosis
  1. Decreased cardiac out put related to structural defect, myocardial dysfunction.
  2. Ineffective breathing pattern related to pulmonary congestion.
  3. Anxiety related to threat to or change in health status resulting in inability to manage feelings of uncertainty and apprehension regarding the life-style changes.
  4. Disturbance of sleep pattern related to illness resulting in interrupted sleep caused by nocturnal dyspnea.

Nursing Intervention
  • Monitor vital signs every two to four hours including apical pulse, peripheral pulses, capillary refill, CVP and PAP if appropriate. Indicates change in cardiac status and potential for arrhythmias, compromised systemic venous flow.
  • Monitor for heart sounds and breath sounds. Indications of recuced cardiac output caused by mechanical failure, pulmonary edema.
  • Monitor electrolyte level of sodium increases and potassium decreases. Diuretic therapy may induce hypokalemia; decreased glomerular filtration rate (GFR) may cause hypernatremia; arrhythmias may be induced by potassium imbalances.
  • Administer diuretic (hydrochlorothiazide, furosemide) while monitoring for electrolyte imbalances. Acts on distal tubule to increase water and potassium excretion or loop of Henle to promote excretion of sodium and chloride.
  • Administer bronchodilator (theophylline). Dilates airways to facilitate breathing if dyspneic.
  • Administer inotropic agents (digoxin, dopamine) while monitoring hemodynamic status. Increases cardiac output by increasing cardiac contractility.
  • Administer oxygen therapy by cannula. Provides oxygen if hypoxic from decreased cardiac output or with ventilation perfusion imbalance from fluid in alveoli.
  • Provide quite environment limiting stimuli. Stimuli and stress stimulate catecholamines and cardiac workload.
  • Provide small meals six times per day. Reduces pressure on diaphragm and enhances chest expansion.
  • Provide bed rest with head of bed elevated 30 to 60 degrees. Promotes lung expansion and decreases venous return.
  • Perform deep breathing exercises, incentive spirometry ever two hours. Improves breathing and oxygen intake.
Read More :

NANDA Congestive Heart Failure CHF

READ MORE - Nursing Care Plan for Congestive Heart Failure - CHF

Nursing Diagnosis 2009 - 2011 - NANDA Approved

NANDA Nursing Diagnoses 2009-2011 : Definitions and Classification

NANDA Approved Nursing Diagnosis 2007-2008 contains 188 nursing diagnosis, latest NANDA-I Approved Nursing Diagnosis 2009-2011 contains an additional 21 new nursing diagnosis, 9 revisions diagnosis and some of diagnosis are not used again. Total nursing diagnosis at this time is 205 nursing diagnosis.

Nanda I usually revised every 2 years, but this time NANDA I publish a list of NANDA Nursing Diagnosis for period of three years.

for complete list of NANDA Approved Nursing Diagnosis 2009-2011
Nursing Diagnosis List – NANDA 2009 – 2011
READ MORE - Nursing Diagnosis 2009 - 2011 - NANDA Approved

Travel Nurse in NYC! RN - Emergency Room - ER - Registered Nurse

Travel Nurse in NYC! RN - Emergency Room - ER - Registered Nurse

White Glove Placement, Inc

Location: New York, New York 10003 United States

Last Updated: 10/18/2010

Job Type: Contract, Temporary

Job Status: Full Time, Seasonal

Shift: 1st Shift, 2nd Shift, 3rd Shift

Job Description

RN - Registered Nurse
Are you looking for a rewarding position? Join White Glove!! White Glove is the premier provider of the highest quality nurses to many of the nation's best rated hospitals and healthcare networks. We provide travel nurse jobs and per diem employment opportunities in most major hospitals nationwide. Apply now or give us a call to see what we have available for you.
Fantastic Travel assignments for ER - Emergency Room  nurses available in Manhattan, New York! 
 Join our team of White Glove Nurses today and get the best pay and selection of nursing opportunities!!
We have assignments available all over New Jersey and New York including: 
Med/Surg / Medical/Surgical
Telemetry / Stepdown
ICU / Intensive Care Unit / Critical Care
ER / Emergency Room / Emergency Department
L&D / Labor & Delivery
MotherBaby / PostPartum
Nursery / NICU / Neonatal ICU
OR / Operating Room
PACU / Post Anesthesia Care Unit/ Recovery Room
Case Management
Cath Lab
All Shifts 
You Choose: Full Time, Part Time, or Per Diem
13 week assignments


We have highest rates, competitive plans, and best terms. During your nursing assignment, enjoy the benefits that we offer:
  • Extraordinarily high pay and a variety of bonuses
  • Instant dental and health coverage
  • Cash for hours program
  • 401K retirement plan
  • Direct deposit for your convenience  
Ask about the lucrative nursing jobs we have right now all over NY and NJ
 Refer a friend... Earn a CASH BONUS!!

Related terms: Nurse, Registered Nurse, Travel RN, Travel Nurse - Full Time Nurse, Part Time Nurse, Temporary/ Contract/Project Shifts: First Shift (Day), Second Shift (Afternoon), Third Shift (Night), Rotating, Travel Nurse, RN, R.N., Hemo,  Hematology, telemetry, Nursing, Nurses, Traveler, biotelemetry, CCU, cardiac, CVICU, Cardiovascular Intensive Care Unit, CV, cardiac care nurse, er, emergency room nurse, ECU, emergency care unit, trauma center, ER RN, intensive care unit, icu, critical care, CCRN, postpartum, OB, OB/GYN, obstetrics nurse, dialysis, hemodialysis, acute care nurse, L & D, labor & delivery nurse, obstetrics, medsurg, medical surgical, medical/surgical, MS, NICU, neonatal intensive care unit, RN NICU, or, o.r., operating room, OR RN, surgery, PCU, Progressive Care Unit, pedi, pedi er, peds, pediatric care unit, PCU, pedi trauma center, pediatric intensive care unit, PICU, pediatric nurse, peds, rehab, rehabilitation, acute rehabilitation nurse, Rehab RN, Cardiac Thoracic ICU, Open heart, Radiology, Cardiac Cath Lab, medical, surgical, ortho orthopedic, orthopedics, lpn, licensed practical nurse, lvn, licensed vocational nurse, long term care, ltc, rehab, rehabilitation, nursing home, endoscopy, travel assignment, travel contract

  • Current and unrestricted RN nursing license in NY

  • Two years clinical experience as an RN in specialty

  • Must be eligible to work in the United States

  • Contact Information
    Contact: Recruitment
    Phone: 866-387-8100 Ext 149
    Address: 85 Bartlett Street
    Brooklyn, New York 11206
    United States

    Read More
    READ MORE - Travel Nurse in NYC! RN - Emergency Room - ER - Registered Nurse

    Nursing Care Plan for Schizophrenia

    Nursing Care Plan for Schizophrenia

    Schizophrenia is a severe, lifelong brain disorder. People who have it may hear voices, see things that aren't there or believe that others are reading or controlling their minds. In men, symptoms usually start in the late teens and early 20s. They include hallucinations, or seeing things, and delusions such as hearing voices. For women, they start in the mid-20s to early 30s. Other symptoms include
    • Unusual thoughts or perceptions
    • Disorders of movement
    • Difficulty speaking and expressing emotion
    • Problems with attention, memory and organization
    No one is sure what causes schizophrenia, but your genetic makeup and brain chemistry probably play a role. Medicines can relieve many of the symptoms, but it can take several tries before you find the right drug. You can reduce relapses by staying on your medicine for as long as your doctor recommends. With treatment, many people improve enough to lead satisfying lives.
    NIH: National Institute of Mental Health

    Causes For Schizophrenia

    Schizophrenia may result from a combination of genetic, biological, cultural, and psychological factors with genetic and environmental insults most associated. For example, some evidence supports a genetic predisposition to this disorder. Close relatives of schizophrenic patients are up to 50 times more likely to develop schizophrenia; the closer the degree of biological relatedness, the higher the risk.

    The most widely accepted biochemical hypothesis holds that schizophrenia results from excessive activity at dopaminergic synapses. Other neurotransmitter alterations may also contribute to schizophrenic symptoms.

    Numerous psychological and sociocultural causes, such as disturbed family and interpersonal patterns, also have been proposed as possible causes. Schizophrenia has a higher incidence among lower socioeconomic groups, possibly related to downward social drift or lack of upward socioeconomic mobility, and to high stress levels, possibly induced by poverty, social failure, illness, and inadequate social resources. Gestational and birth complications, such as Rh factor incompatibility, prenatal exposure to influenza during the second trimester, and prenatal nutritional deficiencies, have been associated.

    Assessment Nursing Care Plans For Schizophrenia

    Schizophrenia is associated with a wide variety of abnormal behaviors; therefore, assessment findings vary greatly, depending on both the type and phase of the illness. The individual may exhibit a decreased emotional expression, impaired concentration, and decreased social functioning, loss of function, or anhedonia. Individuals with these particular symptoms (present in one-third of the schizophrenic population) are associated with poor response to drug treatment and poor outcome.

    Although behaviors and functional deficiencies can vary widely among patients and even in the same patient at different times, watch for the following characteristic signs and symptoms during the assessment interview:

    1. ambivalence coexisting strong positive and negative feelings, leading to emotional conflict
    2. apathy
    3. clang associations words that rhyme or sound alike used in an illogical, nonsensical manner; for instance, It's the rain, train, pain.
    4. concrete thinking inability to form or understand abstract thoughts
    5. delusions false ideas or beliefs accepted as real by the patient. Delusions of grandeur, persecution, and reference (distorted belief regarding the relation between events and one's self; for example, a belief that television programs address the patient on a personal level) are common in schizophrenia. Also common are feelings of being controlled, somatic illness, and depersonalization.
    6. echolalia meaningless repetition of words or phrases
    7. echopraxia involuntary repetition of movements observed in others
    8. flight of ideas rapid succession of incomplete and poorly connected ideas
    9. hallucinations false sensory perceptions with no basis in reality. Usually visual or auditory, hallucinations may also be olfactory (smell), gustatory (taste), or tactile (touch).
    10. illusions—false sensory perceptions with some basis in reality; for example, a car backfiring might be mistaken for a gunshot.
    11. loose associations not connected or related by logic or rationality
    12. magical thinking belief that thoughts or wishes can control other people or events
    13. neologisms bizarre words that have meaning only for the patient
    14. poor interpersonal relationships
    15. regression return to an earlier developmental stage
    16. thought blocking sudden interruption in the patient's train of thought
    17. withdrawal disinterest in objects, people, or surroundings
    18. word salad illogical word groupings; for example, She had a star, barn, plant. It's the extreme form of loose associations.

    Diagnoses Nursing Care Plans For Schizophrenia

    • Anxiety
    • Bathing or hygiene self-care deficit
    • Disabled family coping
    • Disturbed body image
    • Disturbed personal identity
    • Disturbed sensory perception (auditory, visual, kinesthetic)
    • Disturbed sleep pattern
    • Disturbed thought processes
    • Dressing or grooming self-care deficit
    • Fear
    • Hopelessness
    • Imbalanced nutrition: Less than body requirements
    • Impaired home maintenance
    • Impaired social interaction
    • Impaired verbal communication
    • Ineffective coping
    • Ineffective role performance
    • Powerlessness
    • Risk for injury
    • Risk for other-directed violence
    • Risk for self-directed violence
    • Social isolation

    Interventions Nursing Care Plans For Schizophrenia

    1. Assess the patient's ability to carry out the activities of daily living, paying special attention to his nutritional status. Monitor his weight if he isn't eating. If he thinks that his food is poisoned, allow him to fix his own food when possible, or offer him foods in closed containers that he can open. If you give liquid medication in a unit-dose container, allow the patient to open the container.
    2. Maintain a safe environment, minimizing stimuli. Administer medication to decrease symptoms and anxiety. Use physical restraints according to your facility's policy to ensure the patient's safety and that of others.
    3. Adopt an accepting and consistent approach with the patient. Don't avoid or overwhelm him. Keep in mind that short, repeated contacts are best until trust has been established.
    4. Avoid promoting dependence. Meet the patient's needs, but only do for the patient what he can't do for himself.
    5. Reward positive behavior to help the patient improve his level of functioning.
    6. Engage the patient in reality-oriented activities that involve human contact: inpatient social skills training groups, outpatient day care, and sheltered workshops. Provide reality-based explanations for distorted body images or hypochondriacal complaints. Clarify private language, autistic inventions, or neologisms, explaining to the patient that what he says isn't understood by others. If necessary, set limits on inappropriate behavior.
    7. If the patient is hallucinating, explore the content of the hallucinations. If he has auditory hallucinations, determine if they're command hallucinations that place the patient or others at risk. Tell the patient you don't hear the voices but you know they're real to him. Avoid arguing about the hallucinations; if possible, change the subject.
    8. Don't tease or joke with the patient. Choose words and phrases that are unambiguous and clearly understood. For instance, a patient who's told, That procedure will be done on the floor, may become frightened, thinking he is being told to lie down on the floor.
    9. Don't touch the patient without telling him first exactly what you're going to do. For example, clearly explain to him, I'm going to put this cuff on your arm so I can take your blood pressure. If necessary, postpone procedures that require physical contact with facility personnel until the patient is less suspicious or agitated.
    10. Remember, institutionalization may produce new symptoms and handicaps in the patient that aren't part of his diagnosed illness, so evaluate symptoms carefully.
    11. Mobilize community resources to provide a support system for the patient and reduce his vulnerability to stress. Ongoing support is essential to his mastery of social skills.
    12. Encourage compliance with the medication regimen to prevent relapse. Also monitor the patient carefully for adverse effects of drug therapy, including drug-induced parkinsonism, acute dystonia, akathisia, tardive dyskinesia, and malignant neuroleptic syndrome. Make sure you document and report such effects promptly.
    READ MORE - Nursing Care Plan for Schizophrenia

    NANDA List : Activity / Rest

    NANDA List : Activity / Rest


    Activity intolerance (specify level)
    Activity intolerance, for
    Disuse syndrome, risk for
    Diversional activity deficit
    Sleep pattern disturbance
    READ MORE - NANDA List : Activity / Rest

    NANDA List : Ego Integrity

    NANDA List : Ego Integrity

    Ego Integrity

    Adjustment, impaired
    Anxiety (mild, moderate, severe, panic)
    Body image disturbance
    Coping, defensive
    Coping, individual, ineffective
    Decisional conflict
    Denial, ineffective
    Energy field disturbance
    Grieving, anticipatory
    Grieving, dysfunctional
    Personal identity disurbance
    Post-trauma response (specify stage)
    Rape-trauma syndrome (specify)
    Rape-trauma syndrome: compound reaction
    Rape-trauma syndrome: silent reaction
    Relocaction stress syndrome
    Self-esteem, chronic low
    Self-esteem disturbance
    Self-esteem, situational low
    Spiritual distress (distress of the human spirit)
    Spiritual well being, enhanced, potential for
    READ MORE - NANDA List : Ego Integrity

    NANDA List : Elimination

    NANDA List : Elimination


    Bowel incontinence
    Constipation, colonic
    Constipation, perceived
    Incontinence, functional
    Incontinence, reflex
    Incontinence, stress
    Incontinence, total
    Incontinence, urge
    Urinary elimination, altered
    Urinary retention, (acute/chronic)
    READ MORE - NANDA List : Elimination

    NANDA List : Food / Fluid

    NANDA List :  Food / Fluid

    Food / Fluid

    Breastfeeding, effective
    Breastfeeding, ineffective
    Breastfeeding, interrupted
    Fluid volume deficit (active loss)
    Fluid volume deficit (regulatory failure)
    Fluid volume deficit, risk for
    Fluid volume excess
    Infant feeding pattern, ineffective
    Nutrition: altered, less than body requirements
    Nutrition: altered, more than body requirements
    Nutrition: altered, risk for more than body requirements
    Oral mucous membrane, altered
    Swallowing, impaired
    READ MORE - NANDA List : Food / Fluid

    NANDA List : Circulation

    1NANDA List : Circulation


    Adative capacity: intracranial, decreased
    Cardiac output, decreased
    Tissue perfusion, altered (specify): cerebral, cardiopulmonary, renal, pastrointestinal, peripheral
    READ MORE - NANDA List : Circulation

    NANDA List : Hygiene

    NANDA List : Hygiene


    Self-care deficit (specify level): feeding, bathing/hygiene, dressing/ grooming, toileting
    READ MORE - NANDA List : Hygiene

    NANDA List : Neurosensory

    NANDA List : Neurosensory


    Confusion, aacute
    Confusion, chronic
    Infant behavior, disorganized
    Infant behavior, disorganized, risk for
    Infant behavior, organized, potential for enhanced
    Memory, impaired
    Peripheral neurovascular dysfunction, risk for
    Sensory perception alterations (specify): visual, auditory, kinesthetic, gustatory, tactile, olfactory
    Thought processes, altered
    Unilateral neglect
    READ MORE - NANDA List : Neurosensory

    NANDA List : Pain / Discomfort

    NANDA List : Pain / Discomfort


    Pain, acute
    Pain, chronic
    READ MORE - NANDA List : Pain / Discomfort

    NANDA List : Respiration

    NANDA List : Respiration


    Airway clearance, ineffective
    Aspiration, risk for
    Breathing pattern, ineffective
    Gas exchange, impaired
    Spontaneous ventilation, inability to sustain
    Ventilatory weaning response, dysfunctional (DVWR)
    READ MORE - NANDA List : Respiration

    Nursing Diagnoses 2007–2008 - NANDA Approved

    Source: NANDA Nursing Diagnoses: Definitions and Classification, 2007–2008. Philadelphia: North American Nursing Diagnosis Association. Used with permission.

    Activity Intolerance
    Activity Intolerance,
    Risk for Airway Clearance,
    Ineffective Anxiety
    Anxiety, Death
    Aspiration, Risk for
    Attachment, Parent/Infant/Child, Risk for Impaired
    Autonomic Dysreflexia Autonomic Dysreflexia, Risk for Blood Glucose, Risk for Unstable Body Image, Disturbed
    Body Temperature: Imbalanced, Risk for
    Bowel Incontinence Breastfeeding, Effective Breastfeeding, Ineffective Breastfeeding, Interrupted Breathing Pattern, Ineffective Cardiac Output, Decreased Caregiver Role Strain Caregiver Role Strain, Risk for
    Comfort, Readiness for Enhanced Communication: Impaired, Verbal Communication, Readiness for Enhanced Confusion, Acute
    Confusion, Acute, Risk for Confusion, Chronic Constipation
    Constipation, Perceived Constipation, Risk for Contamination Contamination, Risk for
    Coping: Community, Ineffective
    Coping: Community, Readiness for Enhanced
    Coping, Defensive
    Coping: Family, Compromised
    Coping: Family, Disabled
    Coping: Family, Readiness for Enhanced Coping (Individual), Readiness for Enhanced Coping, Ineffective
    Decisional Conflict
    Decision Making, Readiness for Enhanced
    Denial, Ineffective
    Dentition, Impaired Development: Delayed, Risk for Diarrhea
    Disuse Syndrome, Risk for Diversional Activity, Deficient Energy Field, Disturbed
    Environmental Interpretation Syndrome, Impaired
    Failure to Thrive, Adult
    Falls, Risk for
    Family Processes, Dysfunctional: Alcoholism
    Family Processes, Interrupted
    Family Processes, Readiness for Enhanced
    Fluid Balance, Readiness for Enhanced
    Fluid Volume, Deficient
    Fluid Volume, Deficient, Risk for
    Fluid Volume, Excess
    Fluid Volume, Imbalanced, Risk for
    Gas Exchange, Impaired
    Grieving, Complicated
    Grieving, Risk for Complicated Growth, Disproportionate, Risk for Growth and Development, Delayed Health Behavior, Risk-Prone
    Health Maintenance, Ineffective Health-Seeking Behaviors (Specify) Home Maintenance, Impaired
    Hope, Readiness for Enhanced
    Human Dignity, Risk for Compromised
    Immunization Status, Readiness for Enhanced
    Infant Behavior, Disorganized
    Infant Behavior: Disorganized, Risk for
    Infant Behavior: Organized, Readiness for
    Infant Feeding Pattern, Ineffective
    Infection, Risk for Injury, Risk for Insomnia
    Intracranial Adaptive Capacity, Decreased
    Knowledge, Deficient (Specify)
    Knowledge (Specify), Readiness for Enhanced
    Latex Allergy Response
    Latex Allergy Response, Risk for Liver Function, Impaired, Risk for Loneliness, Risk for
    Memory, Impaired
    Mobility: Bed, Impaired Mobility: Physical, Impaired Mobility: Wheelchair, Impaired Moral Distress
    Neurovascular Dysfunction: Peripheral, Risk for
    Noncompliance (Specify)
    Nutrition, Imbalanced: Less than Body
    Nutrition, Imbalanced: More than Body Requirements
    Nutrition, Imbalanced: More than Body
    Requirements, Risk for Nutrition, Readiness for Enhanced Oral Mucous Membrane, Impaired Pain, Acute
    Pain, Chronic
    Parenting, Impaired
    Parenting, Readiness for Enhanced Parenting, Risk for Impaired Perioperative Positioning Injury, Risk for Personal Identity, Disturbed
    Poisoning, Risk for
    Post-Trauma Syndrome
    Post-Trauma Syndrome, Risk for
    Power, Readiness for Enhanced
    Powerlessness Powerlessness, Risk for Protection, Ineffective Rape-Trauma Syndrome
    Rape-Trauma Syndrome: Compound Reaction Rape-Trauma Syndrome: Silent Reaction Religiosity, Impaired
    Religiosity, Readiness for Enhanced Religiosity, Risk for Impaired Relocation Stress Syndrome Relocation Stress Syndrome, Risk for Role Conflict, Parental
    Role Performance, Ineffective
    Sedentary Lifestyle
    Self-Care, Readiness for Enhanced Self-Care Deficit: Bathing/Hygiene Self-Care Deficit: Dressing/Grooming Self-Care Deficit: Feeding
    Self-Care Deficit: Toileting
    Self-Concept, Readiness for Enhanced
    Self-Esteem, Chronic Low
    Self-Esteem, Situational Low
    Self-Esteem, Risk for Situational Low
    Self-Mutilation, Risk for
    Sensory Perception, Disturbed (Specify: Auditory, Gustatory, Kinesthetic, Olfactory Tactile, Visual)
    Sexual Dysfunction Sexuality Pattern, Ineffective Skin Integrity, Impaired
    Skin Integrity, Risk for Impaired
    Sleep Deprivation
    Sleep, Readiness for Enhanced Social Interaction, Impaired Social Isolation
    Sorrow, Chronic
    Spiritual Distress
    Spiritual Distress, Risk for
    Spiritual Well-Being, Readiness for Enhanced
    Spontaneous Ventilation, Impaired
    Stress, Overload
    Sudden Infant Death Syndrome, Risk for
    Suffocation, Risk for
    Suicide, Risk for
    Surgical Recovery, Delayed
    Swallowing, Impaired
    Therapeutic Regimen Management: Community, Ineffective
    Therapeutic Regimen Management, Effective
    Therapeutic Regimen Management: Family, Ineffective
    Therapeutic Regimen Management, Ineffective
    Therapeutic Regimen Management, Readiness for
    Enhanced Thermoregulation, Ineffective Thought Processes, Disturbed Tissue Integrity, Impaired
    Tissue Perfusion, Ineffective (Specify: Cerebral, Cardiopulmonary, Gastrointestinal, Renal)
    Tissue Perfusion, Ineffective, Peripheral
    Transfer Ability, Impaired Trauma, Risk for Unilateral Neglect
    Urinary Elimination, Impaired
    Urinary Elimination, Readiness for Enhanced
    Urinary Incontinence, Functional
    Urinary Incontinence, Overflow Urinary Incontinence, Reflex Urinary Incontinence, Stress Urinary Incontinence, Total Urinary Incontinence, Urge
    Urinary Incontinence, Risk for Urge
    Urinary Retention
    Ventilatory Weaning Response, Dysfunctional
    Violence: Other-Directed, Risk for Violence: Self-Directed, Risk for Walking, Impaired
    READ MORE - Nursing Diagnoses 2007–2008 - NANDA Approved

    NANDA List : Safety

    NANDA List : Safety

    Body tempurature, altered, risk for
    Environmental interpretation syndrome, impaired
    Health maintenance, altered
    Home maintenance management, impaired
    Infection, risk for
    Injury, risk for
    Perioperative positioning injury, risk for
    Physical mobility, impaired
    Poisoning, risk for
    Protection, altered
    Self-mutilation, risk for
    Skin integrity, impaired
    Skin integrity, impaired, risk for
    Suffocation, risk for
    Thermoregulation, ineffective
    Tissue integrity, impaired
    Trauma, risk for
    Violence, (actual)/risk for:
    directed at self/others
    READ MORE - NANDA List : Safety

    NANDA List : Sexuality

    NANDA List : Sexuality

    Sexuality (component of ego integrity and social interaction)

    Sexual dysfunction
    Sexuality patterns, altered
    READ MORE - NANDA List : Sexuality

    NANDA List : Social Interaction

    NANDA List : Social Interaction

    Social Interaction

    Caregiver role strain
    Caregiver role strain, risk for
    Communication, impaired verbal
    Community coping, enhanced, potential for
    Community coping, ineffective
    Family coping, ineffective
    Family coping, potential for growth
    Family processes, altered: alcoholism (substance abuse)
    Family processes, altered
    Loneliness, risk for
    Parental role conflict
    Parent/infant/child attachment, altered, risk for
    Parenting, altered
    Parenting, altered, risk for
    Role performance, altered
    Socical interaction, impaired
    Social isolation
    READ MORE - NANDA List : Social Interaction

    NANDA List : Teaching / Learning

    NANDA List : Teaching / Learning

    Teaching / Learning

    Growth and development, altered
    Health-seeking behaviors (specify)
    Knowledge deficit (learning need) (specify)
    Noncompliance (compliance, altered) (specify)
    Therapeutic regimen: community, ineffective management
    Therapeutic regimen: families, ineffective management
    Therapeutic regimen: individual, effective management
    Therapeutic regimen: individual, ineffective management
    READ MORE - NANDA List : Teaching / Learning



    Nanda Books