Patient Name: Harry Smith

Age: Pneumonia

Nanda Nursing Diagnosis: Deficient Fluid Volume related to diaphoresis as evidenced by fever, hypotension, weakness, and tachycardia

Nanda Definition: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium.

Cues/Defining Characteristics NOC NIC RATIONALE EVALUATION

Subjective: NOC 1: Fluid Balance NIC 1: Fluid Management NOC 1: Fluid Management DAY 1
“Fatigue” [060122] Apical heart rate a. Weigh daily and monitor a. Monitoring weight can Apical heart rate
“Shortness of breath” 1 – Severely compromised trends provide baseline data for 2 – Substantially compromised
Objective: 2 – Substantially compromised b. Maintain accurate intake and comparison after fluid compromised
● Confused 3 – Moderately compromised output record therapy. Pulse rate: 101 bpm
● BP: 90/80 mmHg 4 – Mildly compromised c. Monitor hydration status b. Accurate data can provide
● HR: 101 bpm 5 – Not compromised (e.g., moist mucous for accurate interventions Body temperature elevation
● RR: 28 bpm membranes, adequacy of c. This data is critically used to 3 - moderately compromised
● T: 101.5°F [060107] 24-hour intake and output pulses, and orthostatic blood guide clinical decisions. Temperature: 101.5°F
● Spo2: 85% balance pressure), as appropriate d. Urinalysis can be an
● Lung auscultation reveals 1 – Severely compromised d. Monitor laboratory results indicator if the client is DAY 2
severely diminished 2 – Substantially compromised relevant to fluid retention lacking fluids. Apical heart rate
3 – Moderately compromised (e.g., increased specific e. Vitals gives us a glimpse into 5 – Not compromised
breath sounds in the right
4 – Mildly compromised gravity, increased BUN, our overall wellbeing. Patient maintained a normal pulse
lower lobe 5 – Not compromised decreased hematocrit, and f. IV hydration is indicated rate
● Absence of breath sounds increased urine osmolality when patients are
at the base levels) significantly dehydrated and Body temperature elevation
● The breath sounds in the NOC 2: Hydration e. Monitor vital signs, as unable to orally rehydrate. 5.- None
rest of the lungs are appropriate g. It is vital to increase fluid Patient maintained a normal body
slightly decreased [060227] Body temperature f. Administer IV therapy, as intake to replace fluid lost temperature
● Nail beds and lips turn a elevation prescribed because of fever and
bluish 1 - Severe g. Promote oral intake (e.g., vomiting.
Laboratory/Diagnostic Test: 2 - Substantial provide a drinking straw,
CBC 3 - Moderate offer fluids between meals, NOC 2: Fluid Monitoring
● WBC: 12,500 4 - Mild change ice water routinely, a. To determine the underlying
● Platelets: 350,000 5.- None make freezer pops using cause of the dehydration.
child’s favorite juice, cut b. To determine the extent of
● HCT: 30%
gelatin into fun squares, use the dehydration
● Hgb: 10 g/dL small medicine cups), as c. To assess the degree of
Chest x-ray appropriate dehydration
 ● Right lower lobe
consolidation, presence of
apical bullae
● Flattened diaphragm
● A small pleural effusion in
the right lower lobe
Medication:
d. To assess the degree of
NOC 2: Fluid Monitoring dehydration
a. Determine history of amount e. Urinalysis can be an
and type of fluid intake and indicator if the client is
elimination habits lacking fluids.
b. Determine if patient is f. To determine the extent of
experiencing thirst or the dehydration
symptoms of fluid changes
(e.g., dizziness, change of
mentation, lightheadedness,
apprehension, irritability,
nausea, twitching)
c. Examine capillary refill by
holding the patient’s hand at
the same level as their heart
and pressing on the pad of
their middle finger for five
seconds, releasing pressure
and counting time until color
returns (i.e., should be less
than 2 seconds)
d. Examine skin turgor by
grasping tissue over a bony
area such as the hand or
shin, pinching the skin
gently, holding it for a
second and releasing (i.e.,
skin will fall back quickly if
patient is well hydrated)
e. Monitor color, quantity, and
specific gravity of urine
f. Monitor for signs and
symptoms of ascites
Patient Name: Marie Perez
Medical Diagnosis: Pulmonary Embolism

Nanda Nursing Diagnosis: [00032] Ineffective Breathing Pattern Related to Airway Obstruction as Evidenced by Dyspnea, Tachycardia and Hypoxia.
Nanda Definition: Inspiration and/or expiration that does not provide adequate ventilation.

Cues/Defining Characteristics NOC NIC RATIONALE EVALUATION

Subjective: NOC 1: Vital Signs NIC 1: Vital Signs Monitoring NIC 1: Vital Signs Monitoring DAY 1
“Feeling anxious” [060122] Apical heart rate A. Monitor blood pressure, A. Vitals give a glimpse of the Apical heart rate
“Shortness of breath” 1 – Severe deviation from normal pulse, temperature, and patient’s overall well-being, 3 – Moderate deviation from normal
Objective: range respiratory status, as an important component of range
● RR: 30 bpm 2 – Substantial deviation from appropriate monitoring progress. Heart rate: 110 bpm
● HR: 110 bpm normal range B. Note trends and wide B. Accurate blood pressure
● SpO2: 89% 3 – Moderate deviation from normal fluctuations in blood measurement is therefore Respiratory rate
● BP: 90/50 mmHg range pressure vital in the prevention and 2 – Substantial deviation from
Laboratory/Diagnostic Test: 4 – Mild deviation from normal C. Monitor presence and quality treatment of normal range
Medication: range of pulses blood-pressure–related RR: 30 bpm
5 – No deviation from normal range D. Take apical and radial pulses diseases
simultaneously and note the C. Peripheral pulses are Diastolic blood pressure
[080204] Respiratory rate difference, as appropriate clinically useful in identifying 3 – Moderate deviation from normal
1 – Severe deviation from normal E. Monitor lung sounds specific vascular pathologies range
range F. Monitor pulse oximetry D. To ensure accurateness of BP: 90/50 mmHg
2 – Substantial deviation from G. Monitor for abnormal data
normal range respiratory patterns (e.g., E. To monitor the levels of Anxiety
3 – Moderate deviation from normal CheyneStokes, Kussmaul, function and monitor lung 3 - Moderate
range Biot, apneustic, ataxic, and conditions “Feeling anxious”
4 – Mild deviation from normal excessive sighing) F. To see if the patient’s blood
range H. Monitor skin color, is well oxygenated Dyspnea at rest
5 – No deviation from normal range temperature, and moistness G. Respiratory rate is a 3 – Moderate deviation from normal
fundamental vital sign that is range
[080206] Diastolic blood pressure NIC 2: Ventilation Assistance sensitive to different “Shortness of breath”
1 – Severe deviation from normal A. Maintain a patent airway pathological conditions (e.g.,
range B. Position to minimize adverse cardiac events, Oxygen saturation
2 – Substantial deviation from respiratory efforts (e.g., pneumonia, and clinical 2 – Substantial deviation from
normal range elevate the head of the bed deterioration) and stressors, normal range
3 – Moderate deviation from normal and provide overbed table including emotional stress, SpO2: 89%
range for patient to lean on) cognitive load, heat, cold,
4 – Mild deviation from normal
range
5 – No deviation from normal range
NOC 2: Respiratory Status:
Airway Patency
[041002] Anxiety
1 - Severe
2 - Substantial
3 - Moderate
4 - Mild
5 - None
NOC 3: Respiratory Status
[041514] Dyspnea at rest
1 – Severe deviation from normal
range
2 – Substantial deviation from
normal range
3 – Moderate deviation from normal
range
4 – Mild deviation from normal
range
5 – No deviation from normal range
[041508] Oxygen saturation
1 – Severe deviation from normal
range
2 – Substantial deviation from
normal range
3 – Moderate deviation from normal
range
4 – Mild deviation from normal
range
5 – No deviation from normal range
C. Encourage slow deep
breathing, turning, and
coughing
D. Assist with incentive
spirometer, as appropriate
E. Auscultate breath sounds,
noting areas of decreased or
absent ventilation, and
presence of adventitious
sounds
F. Initiate and maintain
supplemental oxygen, as
prescribed
G. Monitor for respiratory
muscle fatigue
NIC 3: Airway Management
A. Remove secretions by
encouraging coughing or
suctioning
B. Regulate fluid intake to
optimize fluid balance
physical effort, and
exercise-induced fatigue.
H. Changes in skin color,
moisture, and temperature
can signal certain diseases.
NIC 2: Ventilation Assistance
A. To allow for oxygenation of
the patient.
B. The change in position can
affect respiratory mechanics
by changing resistance
and/or compliance of the
respiratory system and its
lung and chest wall
components, and by
changing static lung volume
and either its components
and regional distribution.
C. These exercises will help the
breathing, clear the lungs,
and lower your risk of
pneumonia.
D. To monitor lung condition
and check whether a
treatment for a chronic lung
condition is helping the
patient breathe better.
E. Auscultation assesses
airflow through the
trachea-bronchial tree
F. To provide extra oxygen
G. Fatigue in respiratory
muscles can lead to
dyspnea and increased
forced respiration.
NIC 3: Airway Management
A. To maintain a patent airway
B. To maintain homeostasis
DAY 2
Apical heart rate
5 – No deviation from normal range
Patient maintained a normal heart
rate
Respiratory rate
5 – No deviation from normal range
RR: 17 bpm
Patient maintained a normal
respiratory rate
Diastolic blood pressure
5 – No deviation from normal range
BP: 110/80 mmHg
Patient maintained a normal blood
pressure
Anxiety
5 - None
The patient’s anxiety subsided
Dyspnea at rest
5 – No deviation from normal range
The patient’s breathing returned to
normal
Oxygen saturation
5 – No deviation from normal range
SpO2: 96%
Patient maintained a normal oxygen
saturation