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ENGLISH FOR NURSING (Ratna Ning Hanoom 1210322007)

NURSING DIAGNOSES, OUTCOMES, AND INTERVENTION


OF THE CASES

1. MATERNITY NURSING CASE


Harriet, a 33-year-old client at 28 weeks gestasional with her fourth
pregnancy, is being evaluated in the health care providers office. During her
second and third pregnancies, Harriet developed pregnancy-induced hypertension
(PIH) managed with bed rest at home for several weeks. Her obstetric history
(GTPAL) is documented as 41203. My last two babies were born at 34 and 33
weeks because of my blood pressure problems, she reported. Her children are 2,
4, and 7 years old.
Supporting Data : Blood Pressure Rate : 180/100 mmHg, RR : 20x/min, T :
36,5oC, Pulse : 70x/min, Haemoglobin amount : 8,5 gr/dl, has hystory consumed
of Fe tablets.
NANDA (NURSING DIAGNOSE)
Risk for Disturbed Maternal-Fetal Dyad r/t number of blood pressure at this
rate is 180/100 mmHg (hypertension) e/b hystory of pregnancy-induced
hypertension during second and third of pregnancy, and laboratory results of
haemoglobins amount is 8,5 gr/dl.
Data Analysis :
Objective Data
Harriets blood pressure at this rate is 180/100 mmHg (hypertension), she has
hystory of pregnancy-induced hypertension (PIH) during her second and third
pregnancies. Amount of her haemoglobin is 8,5 gr/dl from laboratory result.
Subjective Data
Harriet said that she ever managed with bed rest at home for several weeks
because of pregnancy-induced hypertension (PIH) during her second and third
of pregnancies, and she said that her last two babies were born at 34 and 33
weeks because of her blood pressure problems. She also said that she consumed
Fe tablet because of anemia.
NOC (NURSING OUTCOMES)
Maternal Status : Antepartum
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ENGLISH FOR NURSING (Ratna Ning Hanoom 1210322007)

Indicators :
-

Emotional attachment to fetus


Coping with discomforts of

Urine protein
Urine glucose
Hemoglobin
Blood count
Edema
Headache
Nausea
Vomiting
Abdominal pain
Epigastric pain
Vaginal bleeding/discharge
Heartburn

pregnancy
Mood lability
Weight change
Cognitive status
Visual acuity
Neurological reflexes
Blood pressure
Radial pulse rate
Respiratory rate
Body temperature
NIC (NURSING INTERVENTION)
High Risk Pregnancy Care
-

Activities :
-

Determine the presence of medical factors thatare related to poor

pregnancy outcome (In case : hypertension)


Review obstretrical hystory of pregnancy-related risk factors
Determined clent knowledge of identified risk factors
Discuss fetal risks associated with preterm birth t various gestational

ages
Write guidelines for signs and symptoms that require immediate medical
attention

2. MENTAL HEALTH NURSING


David is a 26-year-old male with an explosive, angry personality. He has
had repeated hospitalizations. This hospitalization was necessary because he was
angry with his parents because of their pending divorce. He become suicidal and
took an overdose of anti depressant. After hospitalization and following a visit
from his mother, he become violently angry, threw a chair in the day room and
threatened the staff when they attempted to subdue him.
NANDA (NURSING DIAGNOSE)
Risk for Other-Directed Violence r/t explosive and angry personality e/b
suicidal behavior and anti depressan-abuse.
Data Analysis :
Objective Data
David violently angry, threw a chair in the day room and threatened the staff
when they attempted to subdue him when his mother come to Davids following

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ENGLISH FOR NURSING (Ratna Ning Hanoom 1210322007)

a visit activity. David had ever tried to suicide his self during hospitalization, he
took an overdose of anti depresan.
Subjective Data
Davids mother said that David become an angry personality and have to
hospitalization because he was angry with her and her husband, this was
happened because of their pending divorce.
NOC (NURSING OUTCOMES)
Aggression Self-Control
Indicators :
-

Identifies when angry


Identifies when frustated
Identifies situations that

precipitate hostility
Identifies responsibility to

maintain control
Identifies when feeling aggressive
Identifies alternatives to

aggressions
Identifies alternatives to verbal

outburst
Use effective conflict resolution

skills
Expresses needs in a non-

Refrains from verbal outburst


Avoid violating others personal

space
Refrains from striking others
Refrains from harming others
Refrains from harming animals
Refrains from destroying property
Controls impulses
Use physical activity to reduce

pent-up energy
Uses technique to control anger
Uses technique to control
frustation
- Maintains self-control without
supervision

destructive manner
NIC (NURSING INTERVENTION)
Anger Control Assistance
Activities :
-

Establish basic trust and rapport with patient


Use a calm, reassuring approach
Assist patient in identiying the source of anger
Identify the function that anger, frustation, and rage serve for the patient
Assist patient in planning strategies to prevent inapropriate expression

of anger
Instruct on use of calming measures
Establish expectation that patient can control his/her beavior
Support patient in implementing anger control strategies and in the
appropriate expression of anger

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ENGLISH FOR NURSING (Ratna Ning Hanoom 1210322007)

3. CHILD HEALTH NURSING


Barry is a 2 year old diagnosed with celiac disease that you see at
birthday party. His abdomen is protuberant, yet his arms and legs seem thin and
wasted. He refuses to eat a piece of birthday cake even though his mother sits
beside him insisting on it. See the problem I have with him?, she asks you. He
eats nothing. When he does, he gets diarrhea.
NANDA (NURSING DIAGNOSE)
Imbalanced Nutrition : Less Than Body Requirement r/t anorexia and
gastrointestinal impairment e/b malabsorpsion of nutrient because of the
reaction autoimun that make worse the absorption proccess in the intestinal
tract.
Data Analysis :
Objective Data
Barry was diagnosed with celiac disease, from physical assesment his abdoment
is protuberant, yet his arms and legs seem thin and wasted. Bodys image poor,
anorexia, when eat something, he gets diarrhea.
Subjective Data
Barrys mother said that Barry refuses to eat a piece of birthday cake even
though she was sit beside him insisting on it. She also said that Barry eats
nothing, but when he did, he got diarrhea.
NOC (NURSING OUTCOMES)
Nutritional Status
Nuritional Status :
Child Development : 2
Indicators :
-

Nutrient Intake
Food intake
Fluid intake
Energy
Weight/height

Nutrient Intake

Years

Indicators :

Indicators :

Caloric intake
Protein intake
Fat intake
Carbohydrate

ratio
Hematocrit
Muscle tone
Hydration

intake
- Fiber intake
- Vitamin intake
- Mineral intake
- Iron intake
- Calcium intake
NIC (NURSING INTERVENTION)
Nutrition Management
-

Activities :

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Walks quickly
Stoops well
Walks backwards
Kicks a ball
Feeds self with
spoon and fork

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ENGLISH FOR NURSING (Ratna Ning Hanoom 1210322007)

Inquiry the patients food that make allergy (from this case the food that

compose from cereal can make the digestive proccess worse)


Determine, in collaboration with dietican number of callories and type

of nutrients needed to meet nutrition requirement


Provide food selection
Weight patient at appropriate intervals

4. MEDICAL SURGICAL NURSING


Mrs. Sheryl, age 58 years, is seen in the clinic for her yearly physical
examination. She says, I hardly have energy to get up and dress in the morning.
Cleaning the house and doing the laundry make me exhausted. She does not work
and she is not involved in the community activities. Her daily routine involves
cooking for her husband, reading and watching TV for 6 to 8 hours. She loves to
bake fresh breads and pastry. She had history of being overweight and does not
exercise. She says, I eat because I have nothing to else to do. Assesment reveal :
height : 53, weight 166 pounds, weigh gains 14 pounds in the past year.
Sedentary lifestyle, eat in response to having nothing to do.
NANDA (NURSING DIAGNOSE)
Imbalanced Nutrition : More Than Body Requirements r/t weight 20% over
ideal for height and frame, as well as sedentary lifestyle (supporting by BMIs
data) e/b her weight now is 166 pounds, and weigh gains 14 pounds in past
year.
Data Analysis :
Objective Data
Mrs. Sheryl (58 y), has hystory of being overweight and does not exercise. Her
weigh is 166 pounds (74,7 kg) and her height is 53 feet (161,5 cm). Mrs.
Sheryl does not work, not involved in the community activities.
Mrs. Sheryls BMI is :
=

74,7 kg
( 1,615 m )2
74,7
=28,73 kg/m2 (overweight)
2,6

Subjective Data
Mrs. Sheryl said that she hardly have energy to get up & dress in the morning,
cleaning house & doing laundry make her exhausted. She also said that she ate
in response because theres nothing to do, her daily activities involves cooking

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ENGLISH FOR NURSING (Ratna Ning Hanoom 1210322007)

for her husband, reading and watching TV for 6 to 8 hours.


NOC (NURSING OUTCOMES)
Nuritional Status :
Nutritional Status

Nutrient Intake

Weight Loss Behavior

Indicators :

Indicators :

Indicators :

Nutrient Intake
Food intake
Fluid intake
Energy
Weight/height

Caloric intake
Protein intake
Fat intake
Carbohydrate

ratio
Hematocrit
Muscle tone
Hydration

intake
Fiber intake
Vitamin intake
Mineral intake
Iron intake
Calcium intake

Obtains information
on

weight

loss

strategies

from

health professional
Selects a healthy

target weight
Commits
to
healthy

target

weight
Establish an exercise

routine
NIC (NURSING INTERVENTION)
Weight Management
Weight Reduction Assistance
Activities :
-

Activities :

Discuss with individual the


relationship

between

food

motivation to reduce weight or

intake, exercise, weight gain,


-

and weight loss


Discuss with individual the
habits

and

customs

and

body fat
Assist with adjusting diets to

lifestyle and activity level


Plan an exercise program,
taking into consideration the

cultural and heredity factors


-

that influence weight


Determine individuals ideal

body weight
Inform
individual

Determine patients desire and

patients limitation
Developed a daily meal plan
with

well-balanced

diet,

about

reduced calories, and reduced

whether support groups are

fat
Refer to a community weight

avaible for assistance


Encourage individual to chart

control program

weekly weights
5. MEDICAL SURGICAL NURSING

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ENGLISH FOR NURSING (Ratna Ning Hanoom 1210322007)

Mrs. Shiva, a 48-year-old woman, injured her back 3 years ago while
lifting some boxes of paper at work. Since that time she has had four epidural
steroidal injections for the pain associated with two ruptured discs. Her pain has
been intermittent, with some elevation from the epidural injections. Her last
epidural was 3 months ago. She arrive at the clinic stating, I just do not know I
can go on like this. The pain has been tolerable until last night. I am hurting so
bad. She is tearful and facing saying. It is hurt too much when I sit down.
Verbalize pain is 9 on 1 to 10 pain intensity scale. Blood pressure is 148/90. Pulse
is strong and regular at 92. She has guarded movements.

NANDA (NURSING DIAGNOSE)


Acute Pain r/t intermittent pain e/b that because of her hystory of rupture discs
that happened 3 years ago that injured when lifting some boxes of paper at work
and her last epidural was 3 months ago.
Data Analysis :
Objective Data
Mrs. Shiva arrive at the clinic, came with back pain, she was tearful and facing
saying. Her verbalize pain is 9 on 1 to 10 pain intensity scale. Blood pressure is
148/90 mmHg, pulse is strong and regular at 92.
Subjective Data
Mrs. Shiva said that she ever injured her back 3 years ago while lifting some
boxes of paper at work. Since that time she has had four epidural steroidal
injections for the pain associated with two ruptured discs. Her pain has been
intermittent, with some elevation from the epidural injections. Her last epidural
was 3 months ago. Mrs. Shiva said that she just do not know she can go on with
her pain, and the pain has been tolerable until last night, she hurted so bad.
NOC (NURSING OUTCOMES)
Pain Control
Pain Level
Indicators :
-

Recognizes pain onset


Describes causal factors
Uses diary to monitor symptoms

over time
Uses non-analgesic relief

measures
Uses analgesic relief
merecommended

Indicators :
-

Reported pain
Length of pain episodes
Rubbing affected area
Moaning and crying
Facial expressions of pain
Restlessness
Agitation
Irritability
Wincing

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ENGLISH FOR NURSING (Ratna Ning Hanoom 1210322007)

Reports changes in pain

Tearing
Blood pressure
Radial pulse rate

symptoms to health professional


Reports pain controlled
NIC (NURSING INTERVENTION)
Analgesic Administration
Pain Management
-

Activities :
-

Activities :

Determine

pain

characteristic,
severity
-

location,

quality,

before

and

and

medicating

frequency

comprehensive

assesment of pain to include


location,

patient
Check medical order for drug,
dose,

Perform

characteristics,

onset/duration,

frequency,

quality, intensity or severity of

of
-

pain, and precipating factors


Assure
patient
attentive

analgesic prescibed
Check history for

allergies
Monitor vital signs before and

analgesic care
Explore patients knowledge

after

and belief about pain


Teach
the
use

drug

of

nonpharmacological
-

techniques
Encourage

patient

to

adequate pain medication

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