NCP Edema - Fluid Volume Excess NIC NOC

Definition: increased isotonic fluid retention

Defining characteristics:
  • Body weight increased in a short time
  • Excessive intake than output
  • Altered blood pressure, pulmonary artery pressure changes, increased CVP
  • Jugular venous distention
  • Changes in breathing pattern, dyspnoe / shortness of breath, orthopnoe, abnormal breath sounds (Rales or crackles), pulmonary congestion, pleural effusion
  • Decreased hemoglobin and hematocrit, electrolyte changes, particularly changes in density
  • Heart sound SIII
  • Reflex positive hepatojugular
  • Oliguria, azotemia
  • Mental position changes, nervousness, anxiety

Related Factor:
  • Weak regulatory mechanisms
  • Excessive fluid intake
  • Excessive sodium intake

NOC Labels:
  • Electrolit and acid base balance
  • Fluid balance
  • Hydration

Expected outcomes:
  • Free from edema, effusion, anasarca
  • The sound of breathing clean, no dyspnea / orthopnea
  • Free from jugular venous distention, reflexes hepatojugular (+)
  • Maintaining central venous pressure, pulmonary capillary wedge pressure, cardiac output and vital sign within normal limits
  • Free from fatigue, anxiety or confusion
  • Explaining the excess fluid indicator


Fluid management
  • Weigh diapers / pads if needed
  • Maintain a record of intake and output accurately
  • Insert urinary catheter if necessary
  • Monitor lab results that correspond to fluid retention (BUN, Hmt, urine osmolality)
  • Hemodynamic Monitor position including CVP, MAP, PAP, and PCWP
  • Monitor vital sign
  • Monitor indications retention / excess fluid (cracles, CVP, edema, distended neck veins, ascites)
  • Assess the location and size of edema
  • Monitor the input of food / liquid and count daily calorie intake
  • Monitor portion of nutrients
  • Give diuretics as instructed
  • Limit fluid intake on the state of dilution hyponatremia with serum Na less than 130 mEq / l
  • Collaboration doctor if signs of excess fluid appears to deteriorate.

Fluid Monitoring
  • Determine history of the number and type of fluid intake and elimination
  • Determine the possible risk factors of fluid imbalance (Hyperthermia, diuretic therapy, renal disorders, heart failure, diaphoresis, liver dysfunction, etc.)
  • Monitor weight
  • Monitor serum and urine electrolytes
  • Monitor serum and urine osmilalitas
  • Monitor BP, HR, and RR
  • Monitor blood pressure and orthostatic changes in heart rhythm
  • Monitor invasive hemodynamic parameters
  • Record intake and output accurately
  • Monitor the neck distention, peripheral eodem and weight gain
  • Give drugs that can increase urine output
  • Monitor signs and symptoms of edema.

The Benefits Of Iron Tablets for Pregnant Women

Iron supplements are dietary supplements containing iron that can be prescribed by a doctor for a medical reason, or purchased from a vitamin shop, drug store etc. They are primarily used to treat anemia or other iron deficiencies. There are three ways that an iron supplement can be delivered: orally, intravenously or intramuscularly.

This tablet is needed by pregnant women. Many women have an inadequate level of iron in their system to begin with, and the lack becomes more pronounced during pregnancy.

Iron is very vital for the fetus; it is the only nutrient which the fetus depends totally on the mother for the supply. The average woman cannot depend on diet alone. The demand doubles during pregnancy and so iron supplements are added to compensate for the insufficiency.

Iron-deficiency anemia during pregnancy is linked to an increased risk of preterm delivery and low birth weight. It's also associated with a higher risk of stillbirth or newborn death, so it's something to take seriously.

There are two types of iron, heme and nonheme iron, categorized this way because the former is derived from meat and the other from non-meat sources. Heme iron is more readily absorbed than nonheme iron.

Signs and symptoms of iron deficiency may include brittle nails, swelling or soreness of the tongue, cracks in the sides of the mouth, an enlarged spleen, and frequent infections.

People who have iron-deficiency anemia may have an unusual craving for nonfood items, such as ice, dirt, paint, or starch. This craving is called pica (PI-ka or PE-ka).

Some people who have iron-deficiency anemia develop restless legs syndrome (RLS). RLS is a disorder that causes a strong urge to move the legs. This urge to move often occurs with strange and unpleasant feelings in the legs. People who have RLS often have a hard time sleeping.

Within a week or so after starting treatment, you should be producing a lot of new red blood cells and your hemoglobin level will begin to rise. It usually takes just a couple of months for the anemia to resolve, but your caregiver will likely advise you to continue taking iron supplements for several more months so you can replenish your iron stores.

One more important thing to note: Be vigilant about keeping any pills containing iron in childproof containers and away from children. More kids die from iron overdose each year than from any other kind of accidental drug poisoning. In fact, a single adult dose can poison a small child.

Take your prenatal vitamin and eat a healthy diet that includes plenty of iron-rich foods. Red meat is your best bet, although poultry (dark meat), other meats, and shellfish are good sources, too. Non-animal iron-rich foods include beans, lentils, tofu, raisins, dates, prunes, figs, apricots, potatoes (leave the skin on), broccoli, beets, leafy green vegetables, whole grain breads, nuts and seeds, blackstrap molasses, oatmeal, and iron-fortified cereals. Keep in mind that your body absorbs the iron from animal sources (heme iron) much more readily than the iron from non-animal sources (non-heme iron).

Diet for Patients With Hepatitis

The word hepatitis comes from the Ancient Greek word hepar (root word hepat) meaning 'liver', and the Latin itis meaning inflammation. Hepatitis is a term used to describe inflammation (swelling) of the liver. It can occur as a result of a viral infection or because the liver is exposed to harmful substances such as alcohol.

Someone with hepatitis may:
  • have one of several disorders, including a viral or bacterial infection of the liver
  • have a liver injury caused by a toxin (poison)
  • have liver damage caused by interruption of the organ's normal blood supply
  • be experiencing an attack by his or her own immune system through an autoimmune disorder
  • have experienced abdominal trauma in the area of the liver

Most liver damage is caused by 3 hepatitis viruses, called hepatitis A, B and C. However, hepatitis can also be caused by alcohol and some other toxins and infections, as well as from our own autoimmune process (the body attacks itself).

Initial symptoms of hepatitis caused by infection are similar to the flu and include:
  • muscle and joint pain
  • a high temperature (fever) of 38C (100.4F) or above
  • feeling sick
  • being sick
  • headache
  • occasionally yellowing of the eyes and skin (jaundice)

Symptoms of chronic hepatitis can include:
  • feeling unusually tired all the time
  • depression
  • jaundice
  • a general sense of feeling unwell

Some restrictions to avoid hepatitis patients include:
  • All meals are high in fat like mutton and pork, offal, brains, ice cream, whole milk, cheese, butter / margarine, coconut oil and foods like goulash.
  • Canned food such as sardines and korned.
  • Cake or fatty snacks, such as cake, fried foods, fast food.
  • Raw foods that cause gas, such as sweet potatoes, beans, cabbage, radishes, cucumbers, durian, jackfruit.
  • Stimulating condiments, such as chili, onion, pepper, vinegar, ginger.
  • Beverages containing alcohol and soda.

While good food consumed hepatitis patients:
  • Source of carbohydrate, such as rice, oatmeal, white bread, tubers.
  • Sources of protein include eggs, fish, meat, chicken, tempeh, tofu, green beans, vegetables and fruits that do not cause gas.
  • Foods that contain high carbohydrate and easy to digest such as confectionery, fruit juice, jam, syrup, preserves, and honey.

Activity Intolerance - NCP Pneumonia

Pneumonia is a general term that refers to an infection of the lungs, which can be caused by a variety of microorganisms, including viruses, bacteria, fungi, and parasites.

Risk factors that increase your chances of getting pneumonia include:
  • Chronic lung disease (COPD, bronchiectasis, cystic fibrosis)
  • Cigarette smoking
  • Dementia, stroke, brain injury, cerebral palsy, or other brain disorders
  • Immune system problem (during cancer treatment or due to HIV/AIDS or organ transplant)
  • Other serious illnesses, such as heart disease, liver cirrhosis, or diabetes mellitus
  • Recent surgery or trauma
  • Surgery to treat cancer of the mouth, throat, or neck.

The most common symptoms of pneumonia are:
  • Cough (with some pneumonias you may cough up greenish or yellow mucus, or even bloody mucus)
  • Fever, which may be mild or high
  • Shaking chills
  • Shortness of breath, which may only occur when you climb stairs

Additional symptoms include:

  • Sharp or stabbing chest pain that gets worse when you breathe deeply or cough
  • Headache
  • Excessive sweating and clammy skin
  • Loss of appetite, low energy, and fatigue
  • Confusion, especially in older people.

Nursing Diagnosis for Pneumonia : Activity Intolerance

May be related to Imbalance between oxygen supply and demand. General weakness. Exhaustion associated with interruption in usual sleep pattern because of discomfort, excessive coughing, and dyspnea.

Desired Outcomes Report/demonstrate a measurable increase in tolerance to activity with absence of dyspnea and excessive fatigue, and vital signs within patient’s acceptable range.

1. Assist with self-care activities as necessary. Provide for progressive increase in activities during recovery phase and demand.
Rational : Minimizes exhaustion and helps balance oxygen supply and demand.

2. Assist patient to assume comfortable position for rest/sleep.
Rational : Patient may be comfortable with head of bed elevated, sleeping in a chair, or leaning forward on overbed table with pillow support.

3. Provide a quiet environment and limit visitors during acute phase as indicated. Encourage use of stress management and diversional activities as appropriate.
Rational : Reduces stress and excess stimulation, promoting rest.

4. Explain importance of rest in treatment plan and necessity for balancing activities with rest.
Rational : Bedrest is maintained during acute phase to decrease metabolic demands, thus conserving energy for healing. Activity restrictions thereafter are determined by individual patient response to activity and resolution of respiratory insufficiency.

5. Evaluate patient’s response to activity. Note reports of dyspnea, increased weakness/fatigue, and changes in vital signs during and after activities.
Rational : Establishes patient’s capabilities/needs and facilitates choice of interventions.

Nursing Interventions for Hyperthermia

Nursing Care Plan for Hyperthermia

The normal human body temperature in health can be as high as 37.7 °C (99.9 °F) in the late afternoon. Hyperthermia is defined as a temperature greater than 37.5–38.3 °C (100–101 °F), depending on the reference used, that occurs without a change in the body's temperature set point. (wikipedia)

Hyperthermia is elevated body temperature due to failed thermoregulation that occurs when a body produces or absorbs more heat than it dissipates.

Hyperthermia: Hyperthermia is an increase in body temperature in the context of an unchanged thermoregulatory point in the brain.

Common causes include heat stroke and adverse reactions to drugs. The former is an acute hyperthermia caused by exposure to excessive heat, or combination of heat and humidity, that overwhelms the heat-regulating mechanisms of the body causing uncontrolled elevation of body temperature.

Both one's general health and/or lifestyle may increase a person's chance of suffering a heat-related illness.

Symptoms of Hyperthermia
  • Dry skin and mucus membranes
  • Dehydration
  • Meiosis
  • Hallucinations or delirium
  • Signs of heat exposure

Nursing Diagnosis : Hyperthermia 
related to :
  • Infection
  • Inflammation
  • CNS Pathology
  • Dehydration
  • Impaired physical environment
  • Exposure to heat/sun
  • Vigorous activity

Evidenced by :
  • Temperature over 38.8 C (101 F) rectally, or 37.8 C (100 F) orally.
  • Loss of appetite
  • Malaise/weakness
  • Shivering/goose pimples
  • Tachycardia
  • Dehydration
  • Warm to touch
  • Flushed skin
  • Increased respiratory rate

Goal :
  • The patient will maintian normal body temperature.

Nursing Interventions :
  • Administer antipyretics per physician's order.
  • Assess possible etiology of increased temperature.
  • Remove excess clothing or blankets.
  • Assess temperature q ___ hours.
  • Encourage fluids when indicated.
  • Provide air condition/fan if appropriate.

Angina Pectoris - 4 Nursing Diagnosis

Angina pectoris is the result of myocardial ischemia caused by an imbalance between myocardial blood supply and oxygen demand.

Angina pectoris is the medical term for chest pain or discomfort due to coronary heart disease. It occurs when the heart muscle doesn't get as much anginablood as it needs. This usually happens because one or more of the heart's arteries is narrowed or blocked, also called ischemia.

Angina often occurs when the heart muscle itself needs more blood than it is getting, for example, during times of physical activity or strong emotions.

There are many risk factors for coronary heart disease. Some include:
  • Diabetes
  • High blood pressure
  • High LDL cholesterol and low HDL cholesterol
  • Smoking

Other causes of angina include:
  • Abnormal heart rhythms (usually ones that cause your heart to beat quickly)
  • Anemia
  • Coronary artery spasm (also called Prinzmetal's angina)
  • Heart failure
  • Heart valve disease
  • Hyperthyroidism (overactive thyroid)

Angina is usually felt as:
  • pressure,
  • heaviness,
  • tightening,
  • squeezing, or
  • aching across the chest, particularly behind the breastbone.

Patients may also suffer:
  • indigestion,
  • heartburn,
  • weakness,
  • sweating,
  • nausea,
  • cramping, and
  • shortness of breath.

People with angina pectoris or sometimes referred to as stable angina have episodes of chest discomfort that are usually predictable and manageable. You might experience it while running or if you’re dealing with stress.

Normally this type of chest discomfort is relieved with rest, nitroglycerin or both. Nitroglycerin relaxes the coronary arteries and other blood vessels, reducing the amount of blood that returns to the heart and easing the heart's workload. By relaxing the coronary arteries, it increases the heart's blood supply.

If you experience chest discomfort, be sure and visit your doctor for a complete evaluation and, possibly, tests. If you have stable angina and start getting chest pain more easily and more often, see your doctor immediately as you may be experiencing early signs of unstable angina.

Angina Pectoris - 4 Nursing Diagnosis

1. Acute Pain

2. Activity Intolerance

3. Anxiety

4. Knowledge Deficit

NCP COPD - Ineffective Airway Clearance

Chronic obstructive pulmonary disease (COPD) also known as emphysema and chronic bronchitis is a very serious disease. COPD is one of the most common lung diseases.

There are two main forms of COPD:
Chronic bronchitis, which involves a long-term cough with mucus
Emphysema, which involves destruction of the lungs over time

Symptoms of COPD
Cough, with or without mucus
Many respiratory infections
Shortness of breath (dyspnea) that gets worse with mild activity
Trouble catching one's breath

In COPD, less air flows in and out of the airways because of one or more of the following:

The airways and air sacs lose their elastic quality.
The walls between many of the air sacs are destroyed.
The walls of the airways become thick and inflamed.
The airways make more mucus than usual, which can clog them.

Nursing Care Plan for COPD

Nursing Diagnosis : Ineffective Airway Clearance related to the disruption of production increased secretions, retained secretions

Goal : Ventilation / oxygenation to the needs of clients.

Expected outcome : Maintain a patent airway and breath sounds clean

Interventions :

Assess the patient to a comfortable position, such as raising the head of the bed, seat and backrest of the bed.
Review / monitor respiratory frequency, record the ratio of inspiration / expiration.
Auscultation for breath sounds, record the sound of breath for example: wheezing, and rhonchi krokels.
Observation of the characteristic cough, for example: persistent, hacking cough, wet, auxiliary measures to improve the effectiveness of the airway.
Note the presence disepnea, for example: complaints restlessness, anxiety, respiratory distress.
Help the abdominal breathing exercises or lip.
Bronchodilators, eg, β-agonists, efinefrin (adrenaline, vavonefrin), albuterol (Proventil, Ventolin), terbutaline (brethine, brethaire), isoeetrain (brokosol, bronkometer).
Increase fluid intake to 3000 ml / day according to tolerance of the heart.

Risk for Infection - NCP Anemia

Risk for Infection related to inadequate secondary defenses (decreased hemoglobin, leukopenia, or a decrease in granulocytes (inflammatory response depressed)).

Goal: Infection does not occur.
Expected outcomes:
  • identify behaviors to prevent / reduce the risk of infection.
  • improve wound healing, free purulent drainage or erythema, and fever.

Intervention and Rational:

1. Maintain strict aseptic technique on the procedure / treatment of wounds.
Rational: to reduce the risk of colonization / infection of bacterial

2. Increase good hand washing; by the care givers and patients.
Rational: to prevent cross contamination / bacterial colonization.

.3. Give skin care, oral and perianal carefully.
Rational: reducing the risk of damage to the skin / tissue and infection.

4. Increase enter adequate fluids.
Rational: to assist in the dilution secret breathing to ease spending and prevent stasis of body fluids such as respiratory and kidney.

5. Motivation changes in position / ambulation often, coughing and deep breathing exercises.
Rationale: increased pulmonary ventilation all segments and help mobilize secretions to prevent pneumonia.

6. Monitor body temperature. Note the chills and tachycardia with or without fever.
Rational: the process of inflammation / infection require evaluation / treatment.

7. Monitor / limit visitors. Provide insulation where possible.
Rational: limiting exposure to bacteria / infection. Protection of insulation required in aplastic anemia, when the immune response is very disturbed.

8. Observe erythema / wound fluid.
Rational: indicators of local infection. Note: the formation of pus may not exist when granulocytes depressed.

9. Take a specimen for culture / sensitivity as indicated (collaboration)
Rational: to distinguish the presence of infection, identify specific pathogens and influence the choice of treatment.

10. Leave a topical antiseptic; systemic antibiotics (collaboration).
Rational: may be used to reduce colonization or prophylactic treatment for local infection process.

Postoperative Care for Otosclerosis

Otosclerosis is a disease of the bone surrounding the inner ear. It can cause hearing loss when abnormal bone forms around the stapes, reducing the sound that reaches the inner ear. This is called conductive hearing loss. Less frequently, otosclerosis can interfere with the inner ear nerve cells and affect the production of the nerve signal. This is called sensorineural hearing loss.

Causes of Otosclerosis

There is a specific gene, which if present in the patient’s genetic make up, can result in the development of otosclerosis. Some medical studies have implicated the measles virus as a factor in causing otosclerosis. In some women with otosclerosis, pregnancy can accelerate the process.

Symptoms of Otosclerosis

Otosclerosis tends to target one ear at first, but both ears are eventually affected. The condition doesn’t cause total deafness. The symptoms of otosclerosis include:
  • Gradual but progressive loss of hearing
  • Hearing may improve in noisy conditions
  • Sensations of ringing in the ears (tinnitus)
  • Dizziness.

Treatment of Otosclerosis

There is no known cure for otosclerosis. The individual with otosclerosis has several options: do nothing, be fitted with hearing aids, or surgery. No treatment is needed if the hearing impairment is mild. 
Hearing aids amplify sounds so that the user can hear better. The advantage of hearing aids is that they carry no risk to the patient. An audiologist can discuss the various types of hearing aids available and make a recommendation based on the specific needs of an individual.

As hearing aids work well and are completely safe, many patients with otosclerosis decide not to undergo surgery. However, surgery does offer the chance of returning the hearing to normal so that a hearing aid is not required. Surgery can also have a stabilising effect on the otosclerotic process and can offer some degree of protection against otosclerosis advancing to the inner ear.

Postoperative Care of Otosclerosis

  1. Do not blow your nose for three weeks following surgery. If you sneeze or cough keep your mouth open.
  2. Avoid any heavy lifting (over 4 kg), straining or bending for three weeks following surgery
  3. Keep your head elevated as much as possible. Sleep and rest on 2-3 pillows if possible.
  4. Do not get water in your ear. If showering/washing your hair, place a cotton wool ball coated in Vaseline in the car canal to seal it. If there is a separate incision keep this dry until your first post-operative visits.
  5. If you wear glasses either remove the arm on the operated side, or make certain that it does not rest on the incision behind your ear for one week.
  6. Replace the cotton wool ball daily until your first post-operative visit.
  7. Take your oral antibiotic as prescribed.
  8. You may use Panadol, Panadeine or Panadeine Forte for pain. Do NOT use Aspirin or other analgesics.
  9. If there is a separate incision a small amount of drainage may occur from this area also. If the drainage is profuse or develops a foul odour contact us.
  10. Popping sounds, a plugged sensation, ringing or fluctuating hearing may be occur during healing.
  11. Avoid travel by air for three weeks following surgery.
  12. If you should notice any swelling, redness or excessive pain, contact us.
  13. Some dizziness may occur after surgery. If severe or is associated with nausea or vomiting, contact us.
  14. Please contact our office to make an appointment to be seen 7-10 days after the time of your surgery unless stated otherwise by your physician.

Reference :

NANDA Nursing

Nursing Care Plan