Nursing Diagnoses Taxonomy Pertinent to Problems

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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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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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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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


8/16


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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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..


12/16

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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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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Nursing Diagnoses Taxonomy Pertinent to Problems

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