Nursing Intervention

NO NURSING DIAGNOSES NOC NIC

1 Ineffective breathing pattern Respiratory status : ventilation - Position the patient to

Definition: Respiratory status : airway patency maximize ventilation

Vital sign status - Perform chest
Inspiration and/or expiration that
physiotherapy if
does not provide ventilation
Result criteria: necessary
- Effective cough and breath - Remove secretions with
sounds

1
 clean, no cyanosis and - cough or suction
dyspnea (able to expel - Auscultate breath sounds,
Characteristic limitation:
sputum, able to breathe easily, note the presence of
- Changes in the depth of no pursed lips) additional sounds
breathing - Shows a patent airway (client - Give a moist gauze air
- Chest excursion changes does not feel suffocated, humidifier nacl moist
- Take a three point breath rhythm, respiratory rate - Adjust intake for optimal
position in the normal range, no fluid balance
- Bradypneu
abnormal breath sounds) - Monitor respiration and
- Decrease in expiratory
- Vital signs within O2 . status
pressure
normal range (blood - Clean the mouth, nose
- Decreased expiratory
pressure, pulse, and tracheal secretions
pressure
respiration) - Maintain a patent airway
- Decreased minute
- Observe for signs of
ventilation
hypoventilation
- Decreased vital capacity
- Monitor the patient's
- Dipsneu
anxiety about
- Increased anterior-
oxygenation
posterior diameter
- Monitor vital signs
- Nasal vuping breathing
- Inform the patient and
- Orthopnea
family about relaxation
- Expiratory phase is
techniques to improve
prolonged
breathing patterns.
- Lip breathing
- Teach how to cough
- Takipneu
effectively
- Use of muscles
- Monitor breathing pattern
accessory for breathing

Related factors:

- Anxiety
- Body position
- Bone deformity
- Chest wall deformity
- Fatigue
- Hyperventilation
 - Hypoventilation
syndrome
- Musculoskeletal disorders
- Neurological damage
- Neurological immaturity
- Neuromuscular
dysfunction
- Obesity
- Painful
Respiratory muscle
fatigue, spinal cord injury
2 Ineffective airway clearance
Definition: Inability to
clear secretions or
obstruction of the airways to
maintain a clear airway
Characteristic limitation:
- Ineffective cough
- Dyspnea
- Nervous
- Difficulty verbalizing
- Eyes wide open
- Orthopnea
- Decreased breath sounds
- Changes in respiratory
rate
- Changes in breathing
pattern
- Cyanosis
- Sputum in excessive
amounts
- Additional breath sounds
- No cough
Respiratory status : ventilation
Respiratory status : airway patency
Aspiration control
Result Criteria
- Demonstrating an effective
cough and clean breath sounds,
no cyanosis and dyspnea (able
to expel sputum, breathe easily,
no pursed lips)
- Shows a patent airway (client
does not feel suffocated, breath
rhythm, respiratory rate in the
normal range, no abnormal
breath sounds)
- Able to identify and prevent
the causative factors.
- O2 saturation within normal
limits
- Chest X-ray within
normal limits
- Ensure oral needs
/ tracheal suctioning
- Instruct the patient to rest
and take deep breaths
- Position the patient to
maximize ventilation
- Perform chest
physiotherapy if necessary
- Remove secretions by
coughing or suction
- Auscultate breath sounds,
note the presence of
additional sounds
- Monitor hemodynamic
status
- Give a moist gauze air
humidifier nacl moist
- Give antibiotics:
1. Ambroxol Syrup
2. Paracetamol Syrup
- Co-trimoxazole 120 mg
- Adjust intake for optimal
fluid balance
- Monitor respiration and
 Related factors:: status o2
- Maintain adequate
Environment
hydration to thin
- Smoker
secretions
- Passive smoker
- Explain to the patient
- Exposure to smoke
and family about the
use of equipment: O2,
Airway obstruction suction, inhalation.

- Presence of an artificial
airway

- Foreign body in the

airway

- Exudate in the alveoli

- Hyperplasia of the
bronchial walls

- Excessive mucus

- Chronic obstructive
pulmonary disease

- Retained secretions

- Airway spasm

Physiological

- Asthma
- Neuromuscular
dysfunction
- Infection

Allergic airway
3 Anxiety Self anxiety control Anxiety reduction
Anxiety level
- Use a calming approach
Definition: - Clearly state expectations
A vague feeling of discomfort or Result Criteria: of client actors
restlessness (source is often - Explain all procedures
- Clients are able to identify and
unspecified or unknown to the and how it feels
express symptoms of anxiety
individual) - during the procedure
- Identify, disclose
feeling of fear caused by
and
anticipation of
dangerous. This is an alert signal demonstrate techniques to - Accompany clients to
that warns the individual of a control anxiety provide security and
danger and enables the individual - Vital signs within normal reduce fear
to act to deal with the threat. limits - Do back/neck rub

- Posture, facial expressions, - Listen attentively

Characteristic Limits: body language and activity - Identify anxiety levels
- Behavior levels show reduced anxiety - Encourage client to

- Decreased productivity express feelings,

strengths, perceptions
- Irrelevant movement
- Instruct the client to
- Nervous use relaxation

- Insomnia techniques
- - Give medicine to
- Looks alert
reduce anxiety
- Affective

- Restless, distress

- Deep sadness

- Fear of feeling inadequate

- Focus on yourself

- Increased alertness

- Irritability

- Nervous happy too much

- Pain that increases

helplessness

- Doubt/not confident

- Worried

Relevant factors:
- Changes in (economic
status, environment,
health status, pattern
interaction, role function,
 role status)
- Related to family
- Hereditary
4 Hyperthermia
Definition : Result criteria:
Increased body temperature above
the normal range
Characteristic Limits:
- Convulsions
- Reddish skin
- Increased body
temperature above the
normal range
- Seizures
- Tachycardia
- Takipneu
- Skin feels warm
Relevant factors:
- Anesthesia
- Decreased respiration
- Dehydration
- Exposure to hot
environment
- Wearing clothes that are
not in accordance with the
ambient temperature
- Increased metabolic rate
- Trauma
- Excessive activity
5 Activity intolerance
Definition :
Insufficient psychological and
physiological energy to
Thermoregulation
- body temperature within
normal limits.
- Pulse and rr within
normal range
- No skin discoloration and
no there is dizziness, feel
comfortable
Energy conservation
Tolerance to activity
Self care: activities of daily living
(ADL)
Fever treatment
- Monitor the temperature
as often as possible
- Monitor IWL
- Monitor blood pressure,
pulse and RR
- Monitor decreased level
of consciousness
- Monitor WBC, Hb and
Hct
- Monitor intake and
output
- Give antipyretics
- Give treatment to
overcome the cause of
fever
- Cover the client
- Do tapid sponge
- Collaboration
intravenous fluid
administration
- Compress on groin and
axial
- Improve air circulation
- - Give medication to
prevent shivering
Activity therapy
- Collaboration with medical
rehabilitation personnel in
planning the program the
right therapy
 continue or complete activities of
daily living that must or want to be
done.
Characteristic Limitations:
- Abnormal blood pressure
response to activity
- Abnormal heart rate
response to activity
- Discomfort after activities
- Dyspnea after activity
- Expresses feeling tired
and weak
6 Risk of infection
Definition:
Vulnerable to invasion and
multiplication of pathogenic
organisms that can interfere with
health
Risk factors:
- Lack of knowledge
to avoid exposure to
pathogens
- Malnutrition
Result Criteria: - Help clients to
- Participate in physical activity identify activities that
without increasing blood can be done
pressure, pulse and RR - Help to get activity
- Able to perform daily activities aids such as
- Normal vital signs wheelchairs, crutches
- Help to identify
- Able to move with or without
preferred activities
the help of tools
- Help the client or
- - Good status circulation
family to identify
deficiencies in
activities
- Help clients to
develop self-
motivation and
knowledge
- Monitor physical,
emotional, social and
response spiritual
Infection Severity Indicator:
Infection Control
- Redness - Clean the environment
- Vesicles that do not harden the well after use for each
patient
surface
- Change treatment
- foul-smelling liquid (wound) equipment per patient
- Purulent sputum according to
institutional protocol
- Purulent drainage
- Isolation of people
- Pyuria / pus in the urine affected by infectious
diseases
- Fever
- Place isolation
- Hypothermia according to appropriate
- Temperature instability precautions
- - Maintain technique
- Painful
- Soft network
- Obesity
- Chronic disease (eg,
diabetes mellitus) -
Invasive procedure
Inadequate Primary Body
Defense
- Impaired skin integrity
- Peristalsis disorders
- Smoking
- Premature rupture of
membranes
- Slow rupture of
membranes
- Decreased ciliary work
- Changes in the pH of
secretions
- Stasis of body fluids
Inadequate Secondary Body
Defense
- Immunosuppressants
- Leukopenia
- Decreased hemoglobin
- Suppression of
inflammatory response
(eg, interleukin 6 [IL-6],
C-reactive protein [CRP])
- Inadequate Vaccination
Increased Exposure to
Environmental
Pathogens
- Gastrointestinal symptoms
- Lymphadenopathy
- Malaise
- Shivering
- Unexplained cognitive
impairment
- Lethargy
- Loss of appetite
- Chest x-ray infiltration
- Colonization of blood cultures
- Colonization of vascular access
devices
- Sputum culture colonization
- Colonization of cerebrospinal
fluid cultures
- Culture colonization of the
wound area
- Colonization of urine culture
- Colonization of faecal culture
- - Increased white blood cell
count
suitable insulation
- Limit the number of
visitors
- Advise how to wash
hands for health workers
- Instruct the patient to
know the technique of
washing hands properly
- Advise visitors to wash
their hands when entering
and leaving the patient's
room
- Use antimicrobial soap
for proper hand washing
- Wash hands before and
after patient care
activities
- Wear gloves as
recommended by the
Universal Precautions
- Wear a change of clothes
or a robe when handling
infectious materials
- Wear sterile gloves
properly
- Ensure proper wound
care technique
- Use intermittent
catheterization to
- reduce incidence
- bladder infection
- Appropriate level of fluid
intake
- Encourage to rest
- Give appropriate
antibiotic therapy
- Advise the patient
- take antibiotics as
prescribed
- Teach patient and family
about signs and
symptoms of infection
and when to report it to
health care provider
- Teach patients and family
members how to avoid
infection Infection
Protection
- Monitor for signs and
symptoms of systemic
and local infection
- Monitor susceptibility to
infection
- Maintain asepsis for at-
risk patients
- Maintain isolation
techniques, as
appropriate
- Provide proper skin care
for edema area
- Check the skin and
mucous membranes for
the presence of redness,
extreme warmth, or
drainage
- Check the condition of
each surgical incision or
wound
- Increase intake of
adequate nutrition
- Advise rest
- Advise fluid intake,
appropriately
- Advise increased
 mobility and exercise,
appropriately
- Encourage deep
breathing and coughing,
appropriately
- Instruct patient to take
prescribed antibiotics
- Teach the patient and the
patient's family about the
differences between viral
and bacterial infections
- Teach patient and family
about signs and
symptoms of infection
and when to report it to
health care providers
- Teach patients and
families how to
- avoid infection