MEXICAN SOCIAL SECURITY INSTITUTE

DIRECTORATE OF MEDICAL BENEFITS

MEDICAL CARE UNIT
COORDINATION OF HIGH SPECIALTY MEDICAL UNITS

LEVEL: SPECIALTY: NURSING CARE PLAN

Emergencies
Diarrhea
NURSING DIAGNOSIS (NANDA) (ED. FR.CD) CLASSIFICATION OF NURSING OUTCOMES (NOC)
DOMAIN 3: Elimination and exchange CLASS 2: RESULT INDICATORS MEASUREMENT SCALE TARGET SCORE
Gastrointestinal Function
DOMAIN: 2 050101 – elimination 1- Seriously Maintain A: 12
PATTERN: 2 intestinal elimination Physiological Health pattern. compromised
CLASS: elimination 050102 – control of 2- Substantially Increase To: 20?
Intestinal elimination: related to infectious RESULT: bowel movements committed
processes 501– Intestinal
050103- Color of feces. 3- Moderately engaged
Manifested by: elimination
050129- Abdominal 4- Slightly
Abdominal pain
noises compromised
Cramps
050111 – diarrhea 5- Uncommitted
Elimination of at least three liquid stools a
_______________________
day
1. Serious
Hyper active bowel sounds
2. Substantial
urge to defecate
3. Moderate
4. Mild
5. None

CLASSIFICATION OF NURSING INTERVENTIONS (NIC)

FIELD: 02 Physiological: Low CLASS: B Elimination control FIELD: 02 Basic physiological CLASS: b Elimination control

INTERVENTION: Management of diarrhea INTERVENTION: Management of diarrhea

Activities: Activities:
o Determine the history of diarrhea
o Obtain a stool sample for culture and antibiogram if diarrhea
continues.
o Evaluate the medication profile for gastrointestinal side
effects.
o Teach the correct use of anti-diarrheal medications.
o Ask the patient/family members to record the color, volume,
frequency and consistency of the stools.
PREPARATION: COORDINATION: PREPARATION DATE
REVIEW: REVISION DATE
 MEXICAN SOCIAL SECURITY INSTITUTE
DIRECTORATE OF MEDICAL BENEFITS
MEDICAL CARE UNIT
COORDINATION OF HIGH SPECIALTY MEDICAL UNITS

LEVEL: SPECIALTY: NURSING CARE PLAN

CARDIOLOGY
Fatigue
NURSING DIAGNOSIS (NANDA) (ED. FR.CD) CLASSIFICATION OF NURSING OUTCOMES (NOC)
DOMAIN: 04 Activity/Rest CLASS: 03 Energy RESULT INDICATORS MEASUREMENT SCALE TARGET SCORE
balance
PATTERN: 04 Activity and Exercise DOMAIN: 01 301 – Rest time 1- Serious A first assessment will be made
Functional health prior to the nursing intervention
302 – Pattern of rest 2- Substantial and a second assessment
Fatigue related to Poor physical condition, stress CLASS: A Energy 303 – Quality of rest 3- Moderate based on what was obtained
and occupation manifested by Increase in physical maintenance 310 – Appearance of 4- Mild after the nursing intervention,
complaints, expresses tiredness, Expresses PATTERN: 05 recorded in the response and
inability to maintain usual activities and lack of being rested 5- None
Sleep/Rest evolution section of the clinical
energy. RESULT: record sheet.
0003 - Rest

CLASSIFICATION OF NURSING INTERVENTIONS (NIC)

FIELD: 01 Physiological: Basic CLASS: E Promotion of comfort FIELD: 03 Behavioral CLASS: T Promotion of psychological comfort
Physical
INTERVENTION: Aromatherapy INTERVENTION: Relaxation therapy
Activities: Activities:
° Obtain verbal consent to use aromatherapy. ° Explain the basis of relaxation and its benefits, limits and types of relaxation
° Before using a scent, determine the patient's response to the available (music, meditation. Rhythmic breathing, jaw relaxation and progressive
chosen scent (e.g., likes or dislikes). muscle relaxation).
° Choose the appropriate essential oil or essential oil blend to
° Provide a detailed description of the chosen relaxation intervention.
achieve the desired result.
° Observe if the patient experiences discomfort or nausea before ° Suggest the person adopt a comfortable position without restrictive clothing and
and after administration. with their eyes closed.
PREPARATION: COORDINATION: PREPARATION DATE
REVIEW: REVISION DATE
 MEXICAN SOCIAL SECURITY INSTITUTE
DIRECTORATE OF MEDICAL BENEFITS
MEDICAL CARE UNIT
COORDINATION OF HIGH SPECIALTY MEDICAL UNITS

LEVEL: SPECIALTY: NURSING CARE PLAN

CARDIOLOGY Lack of oxygen
NURSING DIAGNOSIS (NANDA) (ED. FR.CD) CLASSIFICATION OF NURSING OUTCOMES (NOC)
DOMAIN: 4 Activity/Rest CLASS: 4 RESULT INDICATORS MEASUREMENT SCALE TARGET SCORE
Cardiovascular/Respiratory Responses
PATTERN: 04 Activity and Exercise DOMAIN: 02 40203 – Dyspnea at rest 1- Serious A first assessment will be made
Physiological health prior to the nursing intervention
40204 - Dyspnea on 2- Substantial and a second assessment
Activity intolerance related to imbalance between CLASS: E exertion 3- Moderate based on what was obtained
oxygen supply and demand and bed rest Cardiopulmonary 40211 – O₂ 4- Mild after the nursing intervention,
manifested by electrocardiographic changes PATTERN: 04 recorded in the response and
indicative of arrhythmias, dyspnea on exertion, saturation. 5- None
Activity/Exercise evolution section of the clinical
expresses weakness, expresses fatigue, abnormal RESULT: 40213 – Findings on chest record sheet.
heart rate in response to activity and abnormal 402 – Respiratory x-ray
blood pressure in response to activity. status: Gas exchange

CLASSIFICATION OF NURSING INTERVENTIONS (NIC)

FIELD: 02 Physiological: Complex CLASS: K Respiratory Control FIELD: 04 Safety CLASS: V Risk control

INTERVENTION: Oxygen therapy INTERVENTION: Surveillance

Activities:
° Restrict smoking.
° Prepare oxygen equipment and administer through a heated and
humidifying system.
° Monitor the flow of liters of oxygen.
° Periodically check the oxygen delivery device to ensure that the
prescribed concentration is delivered.
Activities:
° Determine the patient's health risks, as appropriate.
° Obtain information about normal behavior and routines.
° Ask the patient about their perception of their health status.
° Contact the doctor. As appropriate.
° Explain the results of diagnostic tests to the patient and family.

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MEXICAN SOCIAL SECURITY INSTITUTE

DIRECTORATE OF MEDICAL BENEFITS
MEDICAL CARE UNIT
COORDINATION OF HIGH SPECIALTY MEDICAL UNITS
LEVEL: SPECIALTY: NURSING CARE PLAN
CARDIOLOGY Respiratory insufficiency
NURSING DIAGNOSIS (NANDA) (ED. FR.CD) CLASSIFICATION OF NURSING OUTCOMES (NOC)
DOMAIN: 04 Activity/Rest CLASS: 04 RESULT INDICATORS MEASUREMENT SCALE TARGET SCORE
Cardiovascular/pulmonary response
PATTERN: 04 Activity/Exercise DOMAIN: 2 41501 – Respiratory rate 1- Serious A first assessment will be made
Physiological Health prior to the nursing intervention
41502 – Heart rate 2- Substantial and a second assessment
Ineffective respiratory pattern related to pain, CLASS: E 41504 – Auscultated 3- Moderate based on what was obtained
respiratory muscle fatigue, fatigue and obedience Cardiopulmonary respiratory sounds 4- Mild after the nursing intervention,
manifested by nasal flaring, bradypnea, dyspnea PATTERN :01 Health recorded in the response and
and decreased respiratory pressure. 41508 – Oxygen 5- None
Perception/Manageme evolution section of the clinical
nt saturation record sheet.
RESULT: 41514 – Dyspnea at rest
415 – Respiratory
status

CLASSIFICATION OF NURSING INTERVENTIONS (NIC)

FIELD: 02 Physiological: Complex CLASS: K Respiratory Control FIELD: 02 Physiological: Complete CLASS: K Respiratory Control

INTERVENTION: Helps ventilation INTERVENTION: Respiratory Monitoring

Activities:
° Maintain a patent airway.
° Position the patient in a way that relieves dyspnea.
° Assist with frequent position changes, as appropriate
° Auscultate respiratory sounds, observing areas of decreased or
absence of ventilation and the presence of adventitious sounds.
Activities:
° Monitor the frequency, rhythm, depth and effort of breathing.
° Observe if noisy breathing occurs, such as stridor or snoring.
° Monitor breathing patterns; bradypnea, tachypnea, hyperventilation, Kussmaul
respirations, Cheyne-Stokes respirations, apneustic respiration, Biot and ataxic
patterns.

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MEXICAN SOCIAL SECURITY INSTITUTE

DIRECTORATE OF MEDICAL BENEFITS
MEDICAL CARE UNIT
COORDINATION OF HIGH SPECIALTY MEDICAL UNITS
LEVEL: SPECIALTY: NURSING CARE PLAN
CARDIOLOGY Pyrexia
NURSING DIAGNOSIS (NANDA) (ED. FR.CD) CLASSIFICATION OF NURSING OUTCOMES (NOC)
DOMAIN: 4 CLASS: 4 RESULT INDICATORS MEASUREMENT SCALE TARGET SCORE
PATTERN: 04
DOMAIN: 02 230101 - Expected 1- Serious A first assessment will be made
Hyperthermia related to increased metabolic rate, Physiological Health prior to the nursing intervention
therapeutic effects 2- Substantial and a second assessment
illness and medications manifested by CLASS: AA Therapeuticpresent 3- Moderate based on what was obtained
tachycardia, tachypnea, seizures and increase in Response 230102 – Expected 4- Mild after the nursing intervention,
body temperature above the normal limit. PATTERN: 01 Health recorded in the response and
changes in blood 5- None
Perception/Manageme evolution section of the clinical
nt biochemistry record sheet.
RESULT: 230103 – Expected
2301 – Response to changes in symptoms
Medication 230105 – Allergic
reactions
CLASSIFICATION OF NURSING INTERVENTIONS (NIC)
FIELD: 02 Physiological: Complex CLASS: H Drug Control FIELD: 02 Physiological: Complete CLASS: H Drug Control

INTERVENTION: Medication Administration INTERVENTION: Medication Control

Activities: Activities:
° Maintain facility policy and procedures for accurate and safe ° Check the medication list with indications and medical history to ensure that the list
medication administration. is accurate and complete.
° Follow the five rules of correct medication administration. ° Control medications with changes in the patient's condition or with medication
° Verify the prescription or medication order before administering changes.
the drug. ° Control medications at all transition points, such as admission, transfer and
discharge.

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REVIEW: REVISION DATE

MEXICAN SOCIAL SECURITY INSTITUTE

DIRECTORATE OF MEDICAL BENEFITS
MEDICAL CARE UNIT
COORDINATION OF HIGH SPECIALTY MEDICAL UNITS
LEVEL: SPECIALTY: NURSING CARE PLAN
CARDIOLOGY IRC
NURSING DIAGNOSIS (NANDA) (ED. FR.CD) CLASSIFICATION OF NURSING OUTCOMES (NOC)
DOMAIN: 11 Safety/Protection CLASS: 02 Physical RESULT INDICATORS MEASUREMENT SCALE TARGET SCORE
Injury
PATTERN: 01 Health Perception/Management DOMAIN: 02 110502 – Local skin 1- Serious A first assessment will be made
Physiological Health prior to the nursing intervention
coloring 2- Substantial and a second assessment
Risk of vascular trauma related to catheter caliber, CLASS: L Tissue 110503 – Local 3- Moderate based on what was obtained
inadequate catheter fixation, catheter type, Integrity suppuration 4- Mild after the nursing intervention,
insertion site, and solution composition (e.g., PATTERN: NA recorded in the response and
concentration, chemical irritant, temperature, 110506 – Tremor 5- None
RESULT: evolution section of the clinical
pH). 1105 – Integrity of 110508 – Local record sheet.
Access for hemorrhage
Hemodialysis 110514 – Clotting time
110515 - Local
hypersensitivity
CLASSIFICATION OF NURSING INTERVENTIONS (NIC)
FIELD: 04 Safety CLASS: V Risk Control FIELD: 02 Physiological: Complex CLASS: L Skin/wound control

INTERVENTION: Protection Against Infections INTERVENTION: Insertion Site Care

Activities:
° Observe signs and symptoms of systemic and localized infection
° Observe the patient's vulnerability to infections
° Follow proper precautions in patients with neutropenia, if
applicable.
° Maintain asepsis for the at-risk patient
° Apply isolation techniques, if necessary.
PREPARATION: COORDINATION: PREPARATION DATE
REVIEW: REVISION DATE
Activities:
° Explain the procedure to the patient through sensory preparation.
° Inspect the insertion site for erythema, inflammation, or signs of dehiscence or
evisceration.
° Observe the characteristics of any drainage.
° Clean the area surrounding the incision with an appropriate antiseptic solution.
° Observe if there are signs and symptoms of infection in the incision.

MEXICAN SOCIAL SECURITY INSTITUTE

DIRECTORATE OF MEDICAL BENEFITS
MEDICAL CARE UNIT
COORDINATION OF HIGH SPECIALTY MEDICAL UNITS
LEVEL: SPECIALTY: NURSING CARE PLAN
CARDIOLOGY
Blood Infection
NURSING DIAGNOSIS (NANDA) (ED. FR.CD) CLASSIFICATION OF NURSING OUTCOMES (NOC)
DOMAIN: 11 Safety/Protection CLASS: 02 Physical RESULT INDICATORS MEASUREMENT SCALE TARGET SCORE
Injury
PATTERN: 04 Activity/Exercise DOMAIN: 02 40101 - Systolic blood 1- Serious A first assessment will be made
Physiological Health prior to the nursing intervention
pressure 2- Substantial and a second assessment
Risk of shock related to hypotension, hypoxia and CLASS: E 40102 – Diastolic blood 3- Moderate based on what was obtained
infection. Cardiopulmonary pressure 4- Mild after the nursing intervention,
RESULT: recorded in the response and
40103 – Pulse pressure 5- None
401 – Circulatory State evolution section of the clinical
40105 - PVC record sheet.
40121 – Ascites
40123 – Fatigue
40137 – Oxygen
saturation
CLASSIFICATION OF NURSING INTERVENTIONS (NIC)
FIELD: 02 Physiological: Complex CLASS: N Control of Tissue Perfusion FIELD: 02 Physiological: Complete CLASS: N Control of Tissue Perfusion

INTERVENTION: Cardiac Care: Acute INTERVENTION: Circulatory Care: Arterial Insufficiency

Activities: Activities:
° Monitor heart rate and rhythm. ° Perform a thorough assessment of peripheral circulation (e.g., check peripheral
° Auscultate heart sounds. pulses, edema, capillary refill, color, and temperature).
° Monitor intake and output, diuresis and daily weight, if ° Inspect the skin for arterial ulcers or tissue continuity.
applicable.
° Monitor water status, including inputs and outputs.
° Obtain a 12-lead ECG, as appropriate.
° Perform a chest x-ray, if appropriate.

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REVIEW: REVISION DATE

MEXICAN SOCIAL SECURITY INSTITUTE

DIRECTORATE OF MEDICAL BENEFITS
MEDICAL CARE UNIT
COORDINATION OF HIGH SPECIALTY MEDICAL UNITS
LEVEL: SPECIALTY: NURSING CARE PLAN
CARDIOLOGY Fluid retention
NURSING DIAGNOSIS (NANDA) (ED. FR.CD) CLASSIFICATION OF NURSING OUTCOMES (NOC)
DOMAIN: 02 Nutrition CLASS: 05 Hydration RESULT INDICATORS MEASUREMENT SCALE TARGET SCORE
PATTERN: 02 Nutritional/Metabolic
DOMAIN: 04 Health 183501 – Causes and 1- Serious A first assessment will be made
Excess fluid volume related to compromise of Knowledge and prior to the nursing intervention
contributing factors 2- Substantial and a second assessment
regulatory mechanisms, excess fluid intake and Behavior 183502 – Signs and 3- Moderate based on what was obtained
excess sodium intake manifested by agitation, CLASS: S Health symptoms of early disease 4- Mild after the nursing intervention,
intake greater than loss, weight gain in a short Knowledge recorded in the response and
period of time, changes in blood pressure, 183503 – Benefits of 5- None
RESULT: evolution section of the clinical
changes in respiratory pattern, electrolyte 1835 – Knowledge: disease control record sheet.
imbalance, dyspnea and edema. Management of Heart 183504 – Basic actions of
Failure the heart

CLASSIFICATION OF NURSING INTERVENTIONS (NIC)

FIELD: 03 Behavioral CLASS: S Patient education FIELD: 01 Physiological: Basic CLASS: D Nutritional Support

INTERVENTION: Teaching: Disease Process INTERVENTION: Teaching: Prescribed Diet

Activities:
° Explain the pathophysiology of the disease and its relationship
with anatomy and physiology, according to each case.
° Describe the common signs and symptoms of the disease, as
appropriate.
° Describe the disease process, as appropriate.
° Identify changes in the patient's physical status.
Activities:
° Indicate to the patient the proper name of the prescribed diet.
° Explain the purpose of following the diet for general health.
° Inform the patient about how long the diet should be followed.
° Inform the patient about allowed and prohibited foods.
° Reinforce the importance of continuous monitoring and changing needs that may
require additional modifications to the dietary care plan.

PREPARATION: COORDINATION: PREPARATION DATE

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MEXICAN SOCIAL SECURITY INSTITUTE

DIRECTORATE OF MEDICAL BENEFITS
MEDICAL CARE UNIT
COORDINATION OF HIGH SPECIALTY MEDICAL UNITS
LEVEL: SPECIALTY: NURSING CARE PLAN
CARDIOLOGY Obesity
NURSING DIAGNOSIS (NANDA) (ED. FR.CD) CLASSIFICATION OF NURSING OUTCOMES (NOC)
DOMAIN: 02 Nutrition RESULT INDICATORS MEASUREMENT SCALE TARGET SCORE
CLASS: 01 Ingestion
PATTERN: 04 Activity and Exercise DOMAIN: 02 100801 – Oral food 1- Serious A first assessment will be made
Physiological Health prior to the nursing intervention
ingestion 2- Substantial and a second assessment
Nutritional imbalance: intake higher than needs CLASS: K Digestion and 100803 – Ingestion of oral 3- Moderate based on what was obtained
related to excessive intake in relation to metabolic Nutrition liquids 4- Mild after the nursing intervention,
needs manifested by eating in response to internal RESULT: recorded in the response and
cues other than hunger (such as anxiety), 100804 – Administration 5- None
1008 – Nutritional evolution section of the clinical
sedentary lifestyle and body weight 20% higher Status: Food and Liquid of IV fluids record sheet.
than the ideal according to body size and Intake
constitution.

CLASSIFICATION OF NURSING INTERVENTIONS (NIC)

FIELD: 02 Physiological: Basic CLASS: D Nutritional Support FIELD: 01 Physiological: Basic CLASS: D Nutritional Support

INTERVENTION: Food INTERVENTION: Nutritional Counseling

Activities: Activities:
° Identify the prescribed diet. ° Establish a therapeutic relationship based on trust and respect.
° Facilitate oral hygiene after meals. ° Establish the duration of the advisory relationship.
° Give the opportunity to smell food to stimulate appetite. ° Establish realistic short- and long-term goals for changing nutritional status.
° Accompany the food with water, if necessary.
° Discuss nutritional needs and the patient's perception of the
° Record intake, if appropriate.
° Eat without haste, slowly. prescribed/recommended diet.
° Wash your face and hands after eating.
PREPARATION: COORDINATION: PREPARATION DATE
REVIEW: REVISION DATE

MEXICAN SOCIAL SECURITY INSTITUTE

DIRECTORATE OF MEDICAL BENEFITS
MEDICAL CARE UNIT
COORDINATION OF HIGH SPECIALTY MEDICAL UNITS
LEVEL: SPECIALTY: NURSING CARE PLAN
CARDIOLOGY Stress
NURSING DIAGNOSIS (NANDA) (ED. FR.CD) CLASSIFICATION OF NURSING OUTCOMES (NOC)
DOMAIN: 02 Nutrition RESULT INDICATORS MEASUREMENT SCALE TARGET SCORE
CLASS: 01 Ingestion
PATTERN: 04 Activity and Exercise DOMAIN: 03 121201 – Increased blood 1- Serious A first assessment will be made
Psychosocial Health prior to the nursing intervention
pressure 2- Substantial and a second assessment
Overload stress related to repeated stressors CLASS: M Psychological 121206 – Tension 3- Moderate based on what was obtained
(Chronic Renal Failure) manifested by Wellbeing headache 4- Mild after the nursing intervention,
demonstrating increasing feelings of impatience, RESULT: recorded in the response and
expressing problems with decision making, 121207 – Sweaty palms 5- None
1212 – Stress Levels evolution section of the clinical
expressing a feeling of pressure, and expressing a 121212 – Upset stomach record sheet.
feeling of tension. 121214 – Sleep disorders

CLASSIFICATION OF NURSING INTERVENTIONS (NIC)

FIELD: 03 Behavioral CLASS: R Coping Help FIELD: 03 Behavioral CLASS: R Coping Help

INTERVENTION: Emotional Support INTERVENTION: Mood Control

Activities:
° Support the use of appropriate defense mechanisms.
° Help the patient recognize feelings such as anxiety, anger or
sadness.
° Listen to expressions of feelings and beliefs.
° Provide support during denial, anger, negotiation and acceptance
of the stages of grief.
Activities:
° Assess mood (signs, symptoms, personal history) initially and safely, as treatment
progresses.
° Determine if the patient poses a risk to the safety of himself or others.
° Monitor the patient's physical condition (body weight and hydration).

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