Nursing diagnosis according to NAND

Sina Institute of Nursing And Allied Health Science Quetta .

Nawab din Bugti( G.BSN,3rd year) ✉

nawabdin0835@gmail.com
✆ :03346653920

I NTRODUCTION OF NURSING:

N ursing is a helping profession that assists individuals and groups in society to

attain ,maintain ,and restore the health.

҉
I'm not telling you its going to be
easy .I'm telling you its going to be
worth it.

Art willims
Nursing diagnosis according to NAND

TABE OF CONTENT
Normal Clinical Values..................................................................................................1

Nursing Diagnosis (Respiratory system).......................................................................2

Nursing diagnosis (GIT system).....................................................................................3

Nursing diagnosis of cardiovascular disorders..............................................................6

Nursing diagnosis of renal and urinary disorders.........................................................7

ENT Nursing diagnosis:*...............................................................................................9

Male reproductive system Nursing diagnosis.............................................................11

Female reproductive nursing diagnosis......................................................................12

Musculoskeletal disorders nursing diagnosis..............................................................13

Intensive and critical care unit (ICU/CCU) role of nurses.............................................14

Nursing diagnosis according to NAND

Normal Clinical Values

Heart rate: 70-80minute(at rest)

Respiration: 16-20/minute(at rest)

Tidal volume of lungs: 500ml

Dead space volume of lung: 150ml

Body temperature: 98.6F

C.S.F. Pressure: 50 to 180mmHg

Intra Cranial Pressure: 5-15mg of Hg

Intra Ocular Pressure: 10 to 20 mm Of Hg

Blood Pressure: 80/120mm of Hg

Urine-Specific Gravity: 1.003-1.030

Blood value

Males: 79ml/kg of body weight

Females: 69ml/kg body weight

Blood Acid Base

(a) pH: 7.35 to 7.45

(b) Oxygen Saturation: 95%

Chemical Constituent of Blood

Blood Sugar (F): 70-100mg/dl

Nursing diagnosis according to NAND

Blood Sugar (PP/Random): 90-140mg/dl

Nursing Diagnosis (Respiratory system)

 a Risk for spread infection related to inadequate primary defenses

mechanism, mal- nutrition, lack of knowledge to avoid exposure to

pathogens.

 Ineffective airway clearance related to thick, bloody sputum, fatigue

 . Imbalanced nutrition related to fatigue, anorexia dyspnea, sputum

production, per- sistent coughing.

 Deficient knowledge related to disease condition, treatment and other self

care needs.

 Anxiety related misconception (T.B. is not curable) and other social stigma.

 Activity intolerance related to fatigue, altered nutrition and fever.

 Impaired gas exchange related to decreased ventilation and mucus plugs.

 Anxiety related to breathing difficulty. Altered nutrition less than body

requirements

 related to reduced appetite, dyspnea and decrease energy level.

 *Sleep pattern disturbance related to dyspnea and external stimuli,

 Airway clearance, ineffective related to coughing and mucus production.

 Ineffective breathing pattern related to collection of fluid in pleural space.

Nursing diagnosis according to NAND

 Imbalanced nutrition less than body requirements related to anorexia,

sputum production, fever, bronchodilators treatment, odour and taste of

sputum

 Deficient knowledge related to disease condition, treatment and other self

care needs.

 Ineffective breathing pattern related to inadequate lung expansion (frozen

chest)

 Risk for infection related to inadequate primary defenses or malnutrition,

disease process

 Pleural pain related to coughing, infectious process in pleural cavity.

 Impaired gas exchange related to causes of disease.

 Ineffective airway clearance related to increase mucous secretion.

 Impaired gas exchange related to ventilation perfusion imbalance (altered O,

car- rying capacity blood altered O, supply, altered blood flow)

 Activity intolerance related to hypoxemia, imbalance O, and CO, exchange.

****

Nursing diagnosis (GIT system)

 Risk for deficient fluid volume related to haemorrhage and bleeding via vomit

and stool.

 Pain related to alteration in the continuity of gastricmucosa.

 Imbalanced nutrition less than body requirement related to changes in

digestiveprocess and altered absorption of nutrient.

Nursing diagnosis according to NAND

 Deficient knowledge related to disease prognosis, treatment self care and

discharge needs.

 Anxiety related to change in health status and disease process.

 Risk for deficient fluid volume related to haemorrhage and bleeding via vomit

andstool.

 Imbalanced nutrition less than body requirement related to changes in

digestive process and altered absorption of nutrient.

 Pain related to alteration in the continuity of gastric mucosa.

 Deficient knowledge related to disease prognosis, treatment self care.

 Diarrhoea related to inflammation of lumen, malabsorption of bowel. Risk for

deficient fluid volume related to diarrhea and vomiting, restricted intake.

 Imbalanced nutrition related to malabsorption of nutrients, diarrhea,

vomiting.

 Deficient knowledge related to disease prognosis, treatment self care and

dischargeneeds.

 Anxiety related to change in health status and disease process.

 Disturbed body image related to colostomy, presence of stoma, loss of

control of bowel elimination, colitis.

 Pain related to appendicitis and after surgery.

 Knowledge deficit related to procedure of surgery.

 Anxiety related to fear of death during operation.

 -Risk for infection related to perforation or rupture or appendix. -

Nursing diagnosis according to NAND

 Risk for deficient fluid volume related to excessive vomiting and restricted

intake.

 Acute pain and discomfort related to surgical incision

 Ineffective breathing pattern related to pain abdomen surgical incision and

decrease energy.

 * Impaired skin integrity related to altered biliary drainage after surgical

incision. Imbalanced nutrition, less than body requirements related to

inadequate bile secretion.

 Deficient knowledge about self-care activities related to incisional care,

disease condition.

 Abdomen pain and tenderness related to accumulation of fluid in peritoneum

 Impaired skin integrity related to edema.

 Ineffective breathing pattern related to abdominal distention.

 Fear related to life threatening symptoms of disease..

 Deficient knowledge related to disease prognosis, treatment self care and

discharge needs.

 Excess fluid volume related to ascites and edema.

 Ineffective breathing pattern related to abdominal distension or ascites.

 Altered nutrition less than body requirements related to Nausea and

vomiting." nasogastric vomiting.

 Risk for injury related to malfunction of pancreatic drains.

Nursing diagnosis according to NAND

 Knowledge deficit related to causes of pancreatitis, treatment, possible

complications.

****

Nursing diagnosis of cardiovascular disorders

 Risk for decreased cardiac output related to increasesvascular

resistance,vasoconstriction.

 Acute headache related to increases cerebral vascular pressure.

 Activity intolerance related to generalized weakness or imbalance between

CO2 supply and demand.

 Ineffective coping related to multiple life style changes, situational crisis, and

diseasecondition.

 Deficient knowledge related to disease condition, treatments, self care.

 Imbalanced nutrition more than body requirements related excessive intake

in relation to metabolic need, sedentary life style.

 Anxiety related disease process, and life time treatment plan.

 Acute pain related to myocardial ischemia.

 Risk for decrease cardiac output related to prolonged myocardial ischemia,

alteration in electrical conductivity.

 Anxiety related to disease process, altered image; threat to change health

status.

 Deficient knowledge related to disease condition, treatments, self care.

Nursing diagnosis according to NAND

 Risk for decreased cardiac output related to reduced preload, dysrrhythmias,

decreasecontracture ability of cardiac muscles.

 Ineffective tissue perfusion related to infarction, obstruction in blood flow.

 Risk for digitalis toxicity (poisoning) related to lack of education, improper

precautions.

 Risk for ineffective breathing pattern related to inadequate ventilation,

decreases O2 ,carrying capacity.

 Hyperthermia related to disease process.

 Decreased cardiac output related to decreased cardiac contractility.

 Activity intolerance related to joint pain and easy fatigability.

 Anxiety related to chest pain, prognosis and treating environment.

 Activity intolerance related to decrease O2 supply.

 Altered cardiac output related to ventricular fibrillation.

 Pain related to inflammation, abnormal dilated, tortuous veins or surgical

incisions.

****

Nursing diagnosis of renal and urinary disorders

 Excess fluid volume related to compromised renal function.

 Ineffective (ranal) tissue perfusion related to glomerulus damage.

 Imbalanced nutrition less than body requirement related to anorexia and

altered renal function.

Nursing diagnosis according to NAND

 Risk for impaired skin integrity related to edema and decrease activity.

Deficient knowledge related prognosis, treatment, self-care, and discharge

needs.

 Risk for infection related to immunosuppressive drugs.

 Excess fluid volume related to edema.

 Impaired skin integrity related to disease process

 Altered nutrition related to Anorexia.

 Deficient knowledge related prognosis, treatment, self-care, and discharge

needs

 Knowledge deficit related to disease process.

 Pain related to irritation from stone movement.

 Risk for injury related to possible obstruction.

 Knowledge deficit related to dietary restrictions, and medications.

 Impaired urinary elimination related to urinary retention due to stone

blockage...

 Risk for infection related to obstruction and instrumentation during

movement.

 Excess fluid volume related to decreased GFR and sodium retention.

 Imbalanced nutrition, less than body requirements related to catabolic state,

Anorexia, malnutrition associated with acute renal failure.

 Anxiety related to unknown outcome of disease process.

 Risk for injury related to lowered resistance.

Nursing diagnosis according to NAND

 Fluid and electrolyte imbalance related to kidney failure. Altered nutrition

related to Anorexia malnutrition.

 Risk for infection related to prolonged on immuno suppressive therapy.

 Altered skin integrity related to dermatologic changes.

 Altered thought process related to progressive uraemia.

 Altered rest related to disease condition.

 Impaired urinary elimination related to frequency, urgency, dysuria, nocturia.

 Ineffective coping related to changes in life style and chronic symptoms.

 Deficient knowledge related prognosis, treatment, self-care, and discharge

needs

 Acute pain related to irritation of bladder and urethral mucosa.

 Altered urinary pattern related to irritation of bladder mucosa.

 Risk of infection related to urinary stasis, pregnancy and risk factors.

 Knowledge deficit related to prevention, medications, hygiene and fluid

intake.

 Hyperthermia related to infection.

 Risk for infection related to sexual activity.

****

ENT Nursing diagnosis:*

 Ear: 👂

 Risk for infection related to Eustachian tube dysfunction.

Nursing diagnosis according to NAND

 Altered auditory sensation perception related to fluid accumulation in middle

ear

 Otalgia (pain) related to disease condition.

 Impaired communication related to otalgia and hearing loss.

 High risk for infection related to tissue destruction and chronic disease.

 Pain related to physical factors.

 Altered auditory sensory perception related to partial/total perforation of

tympanic membrane.

 Impaired verbal communication related to hearing deficit.

 Risk for trauma related to hearing difficulty.

 Risk for injury related to vertigo, imbalance endolymphatic system.

 Nose 👃:

 Ineffective breathing pattern related tonasal obstruction.

 Risk for infection related to Rhinitis.

 Imbalanced nutrition less than body requirement related to anorexia, nasa

obstruction.

 Anxiety related to disease process.

 Hyperthermia/pyrexia related to infammation or infection process .

 Throat :*

 Impaired verbal communication related to vocal cord abnormality.

 Altered nutrition pattern related to vocal cord abnormality.

 Altered breathing pattern related to disease condition.

 Altered sleeping pattern related to pain in throat and irritability.

Nursing diagnosis according to NAND

 Altered body temperature related to infection.

 Fluid volume deficit related to edema,.

 Sleep pattern disturbed related to pain in throat.

 Eye :

 Acute pain related to increase in IOP.

 Impaired visual sensory perception related to disease status

 Anxiety/fear related to potential loss of vision, changes due to health status.

 Knowledge deficit related to disease prognosis, progression, and treatment.

 Acute pain related to inflammation of conjunctiva.

 Anxiety related to lack of knowledge about disease process. Self care

disturbance related to changes in the eyelids swelling, edema.

 Risk for injury related to limits of vision..

 Pain related to blepharitis.

 Disturbed visual sensory perception related to infammation.

****

Male reproductive system Nursing diagnosis

 Hyperthermia related to infectious process.

 Acute pain related to prostatic infection.

 Chronic pain related to chronic prostatitis.

 Impaired urinary elimination related to obstruction of urethra.

 Acute pain related to surgical process

Nursing diagnosis according to NAND

 Risk for fluid volume deficit

 Anxiety related to incontinence.

 Fear/anxiety related to incontinence, surgery, changes life threatening.

 Risk for sexual dysfunction related to change in health status, urinary

incontinen

 Knowledge deficient related to disease condition, prognosis, and treatment.

****

Female reproductive nursing diagnosis

 Acute pain related to increase uterine contractility

 Imbalanced nutrition less than body requirement related to nausea/vomiting,

discomfort.

 Ineffective individual coping related to emotional excess.

 Anxiety related to symptoms and lack of control over condition.

 Sleeping pattern disturbance related to discomfort, depression.

 Disturbed body image related to disease condition.

 Fatigue related to excessive blood loss.

 Disturbed daily activities related to disease condition.

 Acute pain related to pelvic pressure.

 Stress urinary incontinence related to relaxed pelvic muscles, displaced

organs.

 Urinary retention related to displaced of organs.

Nursing diagnosis according to NAND

 Acute pain related to downward pressure and exposed tissue.

 Impaired tissue integrity related to exposed cervix and uterus.

 Sexual dysfunction related to loss of vaginal cavity.

 Stress urinary incontinence related to degenerative changes in pelvic

musculaturo and structural supports, atrophic vaginitis.

****

Musculoskeletal disorders nursing diagnosis

 Risk for haemorrhage and shock related to Open Fracture

 Pain and swelling related to Fracture

 Risk for infection related to open wound.

 Risk for peripheral neurovascular dysfunction related to interruption of blood

flow, direct vascular injury, trauma to tissue.

 Impaired skin integrity related to immobilization.

 Impaired physical mobility related to pain, discomfort, restrictive, therapies,

and limb immobilization.

 Knowledge deficient related to disease condition, prognosis, and treatment

modalities.

 Chronic pain related to disease process.

 Impaired physical mobility related to pain and limited joint motion. Ineffective

coping related to pain, physical limitations and chronicity of RA

 Chronic pain related to chronic joint disease.