Patient condition
Pneumonia, COPD, Asthma, ARDS
What is Impaired Gas Exchange
Advanced age, Weakness, Sedation, Gait imbalance
What is Risk for falls?
Productive cough with thick secretions with audible wheezes
What is Ineffective Breathing Pattern?
Impaired Skin Integrity
What is Reposition every 2hrs, Keep skin dry, Use Pressure-relieving devices
Based on Maslow’s Hierarchy, which need must be met first: Nutrition, Love & Belonging, or Self-Esteem?
What is Nutrition (Physiological Need)
Surgery, Trauma and Burns
What is Acute Pain
Bed rest, incontinence, Malnutrition
What is Risk For impaired Skin Integrity?
Post-surgical incision with redness and purulent draining
What is Impaired Skin Integrity?
Ineffective breathing Pattern
What is Position in high Fowlers, Encourage incentive spirometer use, Teach pursed lip breathing
A patient with a new colostomy states, “I feel disgusting, and I don’t want to look at it.” What is the nursing diagnosis?
What is Disturbed Body Image?
Pressure Ulcers, Burns, Surgical Wounds
What is Impaired Skin Integrity?
Indwelling Catheters, Surgery, Immunosuppression
What is Risk For Infection?
Peripheral edema, Crackles in Lungs, hypertension
What is Excess Fluid volume?
Deficient Fluid Volume
What is Monitor I&O's, Encourage oral fluids, Administer IV fluids as ordered?
A patient in a long-term care facility is withdrawn and refuses to participate in activities. What is a possible nursing diagnosis?
What is Social Isolation
Congestive heart failure, Renal Failure, Cirrhosis
What is Excess Fluid Volume?
Stroke, Dysphagia, NG Tube placement
What is Risk For Aspiration?
Malnutrition, Weight loss, Muscle wasting
What is Imbalanced Nutrition: Less than Body Requirements?
Self-Care Deficit
What is Assist with ADL's, Encourage independence, provide adaptive Equipment
A confused patient is trying to pull out their IV. What intervention should the nurse use first?
What is Provide a distraction or reorient the patient (Least restrictive intervention first)
Obesity, Diabetes
What is Imbalanced Nutrition; More than body requirements
Kidney disease, Diarrhea, diuretic use
Dry Skin, Poor Skin Turgor, Hypotension, Decreased Urinary Output
What is Deficient Fluid Volume?
Risk For Infection
What is Maintain aseptic technique, Monitor WBC'S, Educate on hand hygeine
A newly diagnosed cancer patient is refusing visitors and appears sad. What is a nursing concern?
What is Risk for Social Isolation or Ineffective Coping