Post on 03-Jun-2018
8/12/2019 Nursing Diagnoses Taxonomy Pertinent to Problems
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Nursing Diagnoses Taxonomy
Pertinent To Problems/ Alteration In
Perception And Coordination
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Assessment Diagnosis Planning Intervention Evaluation
Subjective:
nagsusugat
sugat ako, ang
dame dame
Objective:
Disruption of
skin surface
Wound is 5mm in
diameter
Erythema
(localized)
Impaired skin
integrity
related to
Immunologic
deficit: (AIDS-
related derma
titis; viral,
bacterial,
and fungal
infections (e.g.,
herpes, Pseud
omonas,
Candida);)
Be free
of/display
improvement
in
wound/lesion
healing.
Assess skin
daily. Note
color, turgor,
circulation,
and
sensation.
Describe/mea
sure lesions
and observe
changes.
Maintain/instr
uct in good
skin hygiene,
Repositionfrequently.
Maintain
clean, dry,
wrinkle-free
linen,preferably
Reposition
frequently
Maintain
clean, dry
wrinkle free
linen
Ecourage
ambulation
File nails
regularly
Cover
ulcerated KSlesions with
wet-to-wet
dressings or
antibiotic
ointment and
nonstickdressing (e.g.,
After 2 weeks
of nursing
intervention,
patient shows
improvement
in wound
healing and
lesions.
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Assessment Diagnosis Planning Intervention Evaluation
Subjective:
"hindi
akomakagala
w ng maayos
dahil pag
gumalaw ako
sumasakit
O- slow
movement-
needs support
in moving-
experience
difficulty in
doing certainactions becau
se of pain
Rate of pain
from 0-10 is 9
Activity
intolerance
After
the interventi
on the patient
will be able to
verbalize and
utilize energy
conservation
techniques
Establish
rapport
Monitor vita
signs
Establish
guidelines
and goals of
activity with
the patient
and caregiver.
Encourage
adequate rest
Give meds as
ordered
The patient
was able to
verbalize and
utilize energy
conservation
techniques
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Assessment Diagnosis Planning Intervention Evaluation
Subjective:
Kaninang
umaga lang
ako na
operahan;asverbalized by
the patient.
Objective:
T-36.3C
Weak
inappearance
Clean
andintactabd
ominaldressin
Risk for
infection
Make the
patient free
from signs
and
symptoms ofinfection
Assess signs
and
symptoms
of infection
especiallytemperature
Emphasize
the
importance
of handwashi
ng
Technique
Maintain
aseptic
technique
when
changing
dressing of
wounds
Keep area
clean and dry
Take
antibiotics
Patient was
free from sign
and
symptoms of
infection
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Neural Regulation
A. Altered cerebral tissue perfusion
B. Impaired verbal communication
C. Impaired swallowing D. Potential for Injury
E. Activity Intolerance
F. Ineffective individual coping G. Knowledge deficit
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Assessment Diagnosis Planning Intervention Evaluation
Subjective:
Pt stated that
she was
nauseous.
Objective:
Pt took a long
time to chew
and swallow
food andcontinued to
pocket food in
cheeks even
after
attempting to
swallow.
Impaired
swallowing
related to
neuromuscula
r disturbances
Patient will
demonstrate
effective
swallowing
techniques by
the end of the
shift
Watch for
uncoordinate
d chewing or
swallowing,
or coughing
immediately
after
swallowing.
Have suctionmaterial
ready at
bedside and
during
feeding in
case chockingoccurs and
suctioning is
necessary to
clear airway
Praise the
patient for
successfully
following
directions and
swallowing
appropriately
because
positive
reinforcementhelps the
patient want
to learn
Goal met
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Assessment Diagnosis Planning Intervention Evaluation
Subjective:
Hind sya
makapagsalita
-as verbalizedby daughter
Objective:
Cant speak
Difficulty in
expressing
thoughts
verbally
Impaired
verbal
communicatio
n related toneuromuscula
r impairment
After 4 days
of nursing
intervention
the client willbe able to
improve his
communicatio
n skills
Review
history
for neurologic
al condition
Encourage
the patient to
communicate
Adviseother healthc
are providers
of the client
tocommunica
te using a
writing pad
Give the
necessary
medications
for the client
After the
nursing
diagnoses the
clients skillsin
communicatio
n had
improve by
expressing
thoughtsusing non-
verbal actions
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Visual and Auditory Perception
A. Alteration in sensory perception:
visual/auditory
B. Potential for infection
C. Self Esteem Disturbance
D. Potential for injury
E. Knowledge Deficit
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Assessment Diagnosis Planning Intervention Evaluation
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Assessment Diagnosis Planning Intervention Evaluation
Subjective:
nahihirapan
ako
makakineg
as verbalized
by patient
Objective:
Difficulty in
hearing
disoriented
time place
Disturbed
Sensory
Perception
(Sensory
Overload)rela
ted to
change in
environment,
and
hearing loss(as evidenced
by
disorientation
to time and
place;
restlessness;and altered
behavior)
Patient should
become
oriented and
hearing must
be
compensated.
Provide a
consistent
physical
environment
and a daily
routine.
Provide for
adequate
rest, sleep,and daytime
naps
Use a calm
and unhurried
approachwhen
interacting
Speak to the
client in a
slow, distinctmanner with
Facilitate
use of hearing
aids, as
appropriate.
Use simple
words and
short
sentences, as
appropriate.
Goal met..
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Locomotion
A. Alteration in comfort: pain/ pruritus
B. Knowledge Deficit
C. Impaired Physical Mobility D. Disturbance in self concept
E. Altered Nutrition
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Assessment Diagnosis Planning Intervention Evaluation
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Assessment Diagnosis Planning Intervention Evaluation
Subjective:
Nahihirapan
ako gumalaw
As verbalized
by patient
Objective:
Inablitiy to
move
purposively
Reluctant to
attempt
movement
Limited ROM
Decrease
muscle
strength
Impaired
Physical
mobility
After 2 weeks
of nursing
intervention ,
patiet will
show sign ofmobility.
Exercise Thera
py:
Ambulation
Joint Mobility
Fall
Precautions
Positioning
Bed Rest Care
Patient
performs
physical
activity
independently or with
assistive
devices as
needed.
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Assessment Diagnosis Planning Intervention Evaluation