Nursing Diagnosis and Intervention

DAFTAR ISI
Activity Intolerence ....................................................................................................
Acute Confusion .........................................................................................................
Acute Pain ..................................................................................................................
Anxiety........................................................................................................................
Bowel Incontinence....................................................................................................
Constipation ...............................................................................................................
Decrease Cardiac Output ..........................................................................................
Deficient fluid volume................................................................................................
10
Diarrhea ......................................................................................................................
11
Disturbed Sleep Pattern .............................................................................................
12
Fatigue ........................................................................................................................
13
Hyperthermia .............................................................................................................
14
Imbalance Nutrition : Less Than Body Requirement ................................................
15
Impaired gas Exchange ..............................................................................................
16
Impaired Memory ......................................................................................................
17
Impaired Physical Mobility ........................................................................................
18
Impaired Skin Integrity ..............................................................................................
19
Impaired Swallowing .................................................................................................
20
Impaired Urinary Elimination ....................................................................................
21
Impaired Verbal Communication ..............................................................................
22
1
Ineffective Airway Clearence .....................................................................................
23
Ineffective Breathing Pattern ....................................................................................
24
Ineffective Thermoregulation ....................................................................................
25
Nausea ........................................................................................................................
26
Risk for Acute Confusion ............................................................................................
27
Risk for Aspiration ......................................................................................................
28
Risk for Bleeding ........................................................................................................
29
Risk for Constipation ..................................................................................................
30
Risk for Decrease Cardiac Tissue Perfusion ...............................................................
31
Risk for Deficient Fluid Volume .................................................................................
32
Risk for Falls................................................................................................................
33
Risk for Imbalance Fluid Volume ...............................................................................
34
Risk for Imbalance Body Temperature ......................................................................
35
Risk for Impaired Skin Integrity .................................................................................
36
Risk for Ineffective Cerebral Tissue Perfusion ..........................................................
37
Risk for Infection ........................................................................................................
38
Risk for Shock ............................................................................................................
39
Risk for Suicide ...........................................................................................................
40
Self-Care Deficit ..........................................................................................................
41
Blank Form .................................................................................................................
42
NURSING DIAGNOSIS AND INTERVENTION

DATE/
NURSING DIAGNOSE
TIME
ACTIVITY INTOLERENCE
Related To :
Bed Rest
Generalized weakness
Imbalance between oxygen
GOAL
INTERVENSION
After Given Nursing care for :

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
The expected outcome are :
Supply/demand
Immobility
Sedentary lifestyle
With Evidenced by:

Abnormal BP Response to
Activity
Abnormal HR Response to
Activity
NURSE
SIGN
Assess patients vital sign before and after activities

Assist with self-care activities
Promote comfort
Monitor Bradens scale
Teach/perform active-passive movement
Ascertain ability to sit, stand and move about
as desired
7. Collaboration with doctor to prevent side effect
of immobilization
1.
2.
3.
4.
5.
6.
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs

DATE/
NURSING DIAGNOSE
TIME
ACUTE CONFUSION
Related To :
Alzheimers disease
Cerebral vascular Attack
Head Injury
Korsakoffs psychosis
Multi infarct dementia
With Evidenced by:

Altered interpretation
Altered personality
Altered response to stimuli
Impaired long term memory
Impaired short term memory
Progressive cognitive
impairment
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
1.
2.
3.
4.
NURSE
SIGN
Monitor patients condition on regular basis

Assess mental status
Evaluate vital sign
Collaboration with DOD to give medication
cautiously to control restlessness, agitation
and hallucination
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs

DATE/
NURSING DIAGNOSE
TIME
ACUTE PAIN
Related To :
Injury agents biological
Injury agents chemical
Injury agents physical
Injury agents phychological
With Evidenced by:

Changes in BP
Changes in HR
Changes in RR
Restlessness Moaning
Grimace
Verbal report of pain
Protective gesture
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NURSE
SIGN
1. Assess patients pain

2. Monitor patients pain scale before and after
medication
3. Provide/promote non pharmacological pain
management e.g., warm compress
4. Monitor patients vital sign during pain
5. Collaboration with doctor to give pain medication
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs

DATE/
TIME
ANXIETY
NURSING DIAGNOSE
GOAL
Related To :
Situational crisis
Stress
Substance Abuse
With Evidenced by:

Insomnia Restlessness
Worried Hand tremors
Distress
Fearful
Irritability
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs

2 X 24 hrs
3 X 24 hrs
INTERVENSION
1 X 24 hrs
NURSE
SIGN
Monitor patients physical response e.g., palpitation

Observe behavior indicate anxiety
Note use of drug, insomnia or restlessness
Provide accurate information about the
situation
5. Provides comfort measure
6. Collaboration with doctor to give medication
1.
2.
3.
4.
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs

DATE/
NURSING DIAGNOSE
TIME
BOWEL INCONTINENCE
Related To :
Chronic diarrhea
General decline in muscle tone
Laxative abuse
Loss of rectal sphincter control
Lower motor nerve damage
Rectal sphincter abnormality
With Evidenced by:

Constant dribbling of soft stool
Inability to delay defecation
Inability to recognize urge to
defecate
Inattention to urge to defecate
Red perianal skin
Self-report of inability to
Recognize rectal fullness
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NURSE
SIGN
1. Ascertain timing and characteristic aspects of

incontinent occurrence
2. Determine stool characteristic
3. Avoid coffee and alcohol
4. Recommend walking and exercise
5. Assist in treatment of underlying factor
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs

DATE/
NURSING DIAGNOSE
TIME
CONSTIPATION
Related To :
Insufficient Physical activity
Recent environmental changes
Emotional Stress
Medication
Neurological impairment
Change in eating pattern
Decrease motility of
gastrointestinal tract
Change in usual food
Insufficient fiber intake
Insufficient fluid intake
Poor eating habit
With Evidenced by:

Abdominal tenderness with
palpable muscle resistance
Abdominal tenderness without
palpable muscle resistance
Distended abdomen
Feeling of rectal fullness
Feeling of rectal pressure
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
1.
2.
3.
4.
5.
6.
NURSE
SIGN
Monitor patients condition

Assist with medical work up
Ascertain presence of associated symptom
Promote adequate diet
Encourage daily activities within limit
Collaboration with doctor to give medication
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs

DATE/
NURSING DIAGNOSE
TIME
DECREASE CARDIAC OUTPUT
Related To :
Altered heart rate
Altered rhythm
Altered stroke volume
Altered afterload
Altered preload
With Evidenced by:

Arrhythmias Bradycardia
EKG changes Palpitation
Tachycardia Edema
Fatigue Clammy skin
Dyspnea Anxiety
Restlessness Oliguria
Prolonged capillary refill
Skin color changes
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NURSE
SIGN
1. Assess for signs of poor ventricular function or

impending cardiac failure/shock
2. Monitor patients vital sign
3. Monitor cardiac rhythm
4. Monitor intake and output
5. Assess hourly or periodic urinary output and weigh
daily
6. Minimize activities that can elicit valsava response
8. Collaboration with doctor to give oxygen
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs

DATE/
NURSING DIAGNOSE
TIME
DEFICIENT FLUID VOLUME
Related To :
Active fluid volume loss
Failure of regulatory
mechanisms
With Evidenced by:

Decrease skin turgor
Decrease urine output
Dry mucous membranes
Dry skin
Increase body temperature
Increase pulse rate
Thirst
Weakness
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NURSE
SIGN
1.
2.
3.
4.
5.
6.
Prepare for/assist with diagnostic evaluation

Monitor patients vital sign
Monitor intake/output and weigh daily
Promote oral intake
Monitor laboratory result relevant to fluid
balance
7. Collaboration with doctor to give fluid
replacement
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
10

DATE/
NURSING DIAGNOSE
TIME
DIARRHEA
Related To :
Anxiety Irritation
Parasites Malabsorbtion
Inflammation
Infectious process
Laxative abuse
Alcohol abuse
Adverse effects of medication
With Evidenced by:

Abdominal pain
Cramping
At least three loose liquid stools
Per day
Hyperactive bowel sound
Urgency
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
1.
2.
3.
4.
5.
NURSE
SIGN

Monitor intake/output
Promote adequate diet
Monitor frequency and characteristic of diarrhea
Collaboration with doctor to give fluid
replacement
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
11

DATE/
NURSING DIAGNOSE
TIME
DISTURBED SLEEP PATTERN
Related To :
Interruption (e.g., for lab test)
Lighting
Noise
Physical restrain
Unfamiliar sleep furnishings
With Evidenced by:

Change in normal sleep pattern
Verbal complaints of not feeling
Well rested
Dissatisfaction with sleep
Reports being awakened
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
1.
2.
3.
4.
5.
NURSE
SIGN
Assess the underlying problem

Suggest sleep preparatory activities
Schedule all patient therapeutic before 10 pm
Promote comfort
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
12

DATE/
TIME
FATIGUE
NURSING DIAGNOSE
GOAL
Related To :
Anxiety Noise
Sleep Deprivation
Temperature Anemia
Disease states
Poor Physical condition
With Evidenced by:

Decrease performance
Drowsy
Increase in rest requirement
Tired
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs

2 X 24 hrs
3 X 24 hrs
INTERVENSION
1 X 24 hrs
1.
2.
3.
4.
5.
6.
NURSE
SIGN

Encourage patient to do whatever activity possible
Encourage patient to have a nutritional food
Collaboration with nutritionist to provide a
nutritional food
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
13

DATE/
NURSING DIAGNOSE
TIME
HYPERTHERMIA
Related To :
Dehydration
Exposure to hot environment
Illness
Medications
Trauma
Vigorous activity
With Evidenced by:

Flushed skin
Increase in body temperature
Above normal range
Tachycardia
Tachypnea
Warm to touch
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
1.
2.
3.
4.
5.
6.
7.
8.
NURSE
SIGN

Monitor skin color and temperature
Monitor neurological response
Encourage patient to drink a lot of water
Monitor intake and output
Provide compress as needed
Adjust environmental temperature to patient need
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs
2 X 24 hrs
3 X 24 hrs
1 X 12 hrs
1 X 24 hrs
14

DATE/
NURSING DIAGNOSE
GOAL
TIME
IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENT
Related To :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
Biological factors
Inability to absorb nutrients
Inability to Ingest Food
Psychological Factors
Economic Factors
With Evidenced by:

Abdominal cramping
Aversion to eating Diarrhea
Reported altered taste sensation
Sore Buccal Cavity
Abdominal pain
2 X 24 hrs
INTERVENSION
1 X 24 hrs
3 X 24 hrs
1.
2.
3.
4.
5.
NURSE
SIGN
Weight patient at everyday

Monitor for nausea and vomiting
Monitor recorded intake for nutritional content
Provide nutritional food and fluid as appropriate
Collaboration with doctor to give parenteral
nutrition
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
15

DATE/
NURSING DIAGNOSE
TIME
IMPAIRED GAS EXCHANGE
Related To :
Alveolar-capillary membrane
changes
Ventilation-perfusion
With Evidenced by:

Abnormal Arterial blood gas
Abnormal arterial pH
Dyspnea
Cyanosis
Diaphoresis
Nasal flaring
Restlessness
Tachycardia
Somnolence
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NURSE
SIGN

Review pertinent diagnostic data
Position patient in head up position
Teach and encourage patient to do breathing
exercises
6. Collaboration with doctor to give oxygen
1.
2.
3.
4.
5.
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
16

DATE/
NURSING DIAGNOSE
TIME
IMPAIRED MEMORY
Related To :
Decrease cardiac output
Excessive environmental
disturbance
Fluid and electrolyte imbalance
Neurological disturbances
Hypoxia
With Evidenced by:

Experience of forgetting
Inability to determine if a
Behavior was performed
Inability to recall events
Inability to recall factual
information
Inability to retain new skill
Inability to retain new
information
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
1.
2.
3.
4.
NURSE
SIGN
Assist with cognitive testing

Monitor patients behavior
Assist patient with activities to meet needs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
17

DATE/
NURSING DIAGNOSE
TIME
IMPAIRED PHYSICAL MOBILITY
Related To :
Cognitive impairment
Contracture
Discomfort
Joint stiffness
Musculoskeletal impairment
Neuromuscular impairment
Pain
Prescribed movement restriction
Sensoriperceptual impairment
With Evidenced by:

difficulty turning
Limited range of motion
Slowed movement
Uncoordinated movement
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
1.
2.
3.
4.
5.
6.
NURSE
SIGN
Assist with self-care activities as needed

Promote comfort
Monitor Bradens scale
Assist patient in changing position
Teach/perform active-passive movement
Collaboration with doctor to prevent side effect
of immobilization
7. Collaboration with rehabilitation specialist
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
18

DATE/
NURSING DIAGNOSE
TIME
IMPAIRED SKIN INTEGRITY
Related To :
Chemical substance
Mechanical factors (e.g.,
Restraint)
Physical immobilization
Impaired circulation
Impaired sensation
With Evidenced by:

Destruction of skin layer
Disruption of skin surface
Invasion of body structure
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NURSE
SIGN
Monitor patients skin

Do wound dressing daily or if needed
Monitor patients Braden scale
Monitor patients Neuro Vascular supply
Collaboration with nutritionist to provide nutritional
meal
1.
2.
3.
4.
5.
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
19

DATE/
NURSING DIAGNOSE
TIME
IMPAIRED SWALLOWING
Related To :
Mechanical obstruction
Respiratory disorder
Trauma
With Evidenced by:

Vomiting
Choking before a swallow
Coughing before a swallow
Food falls from mouth
Choking
Coughing
Delayed swallowing
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NURSE
SIGN
1. Monitor patient condition

2. Ascertain presence and strength of cough and gag
reflex
3. Monitor intake and output
4. Positioning patient when take food (45-90 degree)
5. Provide mouth care as needed
6. Collaboration with nutritionist to provide adequate
meal (solid/soft/thickened food)
8. Collaboration with doctor to give enteral feeding
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
20

DATE/
NURSING DIAGNOSE
TIME
IMPAIRED URINARY ELEMINATION
Related To :
Anatomic obstruction
Sensory motor impairment
Urinary tract infection
With Evidenced by:

Dysuria
Frequency
Hesitancy
Incontinence
Nocturia
Urgency
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
1.
2.
3.
4.
5.
NURSE
SIGN

Ascertain patients previous pattern of elimination
Assist in diagnostic test
Encourage patient to drink a lot of water
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
21

DATE/
NURSING DIAGNOSE
TIME
IMPAIRED VERBAL COMMUNICATION
Related To :
Alteration of central nervous
system
Cultural difference
Decrease in circulation to brain
Physical barrier
With Evidenced by:

Cannot speak
Difficulty expressing thoughts
Verbally (e.g., aphasia, etc.)
Difficulty forming sentence
Difficulty forming words (e.g.,
Dysarthria, etc)
Does not speak
Inability to speak language of
Caregiver
Slurring
Speak with difficulty
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NURSE
SIGN
1. Provide devices as needed for communication

2. Determine meaning of words used by patient and
congruency of communication and nonverbal
massage
3. Point to objects or demonstrate desired action
4. Obtain interpreter
5. Collaboration with rehabilitation specialist (speech)
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs
2 X 24 hrs
3 X 24 hrs
1 X 12 hrs
1 X 24 hrs
22

DATE/
NURSING DIAGNOSE
TIME
INEFFECTIVE AIRWAY CLEARANCE
Related To :
Airway spasm
Excessive mucus
Exudate in the alveoli
Retained secretion
Secretions in the bronchi
Asthma
COPD
Infection
Neuromuscular dysfunction
With Evidenced by:

Change in RR
Cyanosis
Difficulty vocalizing
Dyspnea
Excessive sputum
Ineffective cough
Orthopnea
Restlessness
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NURSE
SIGN

2. Position patient to maximize ventilation
3. Monitor type and amount of secretion being
produced
4. Teach/encourage patient to do effective cough
and breathing exercise
5. Assist with diagnostic testing
6. Perform chest percussion/vibration/postural
drainage
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
23

DATE/
NURSING DIAGNOSE
TIME
INEFFECTIVE BREATHING PATTERN
Related To :
Anxiety
Chest wall deformity
Fatigue
Hyperventilation
Neuromuscular dysfunction
Pain
Respiratory muscle fatigue
Spinal cord injury
With Evidenced by:

Alteration in depth breathing
Bradypnea
Dyspnea
Nasal flaring
Orthopnea
Purse-lip breathing
Tachypnea
Use of accessory muscle to
breath
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
1.
2.
3.
4.
5.
6.
7.
NURSE
SIGN

Observe characteristic of breathing pattern
Assist with diagnostic testing
Position patient in semi-fowler
Teach/encourage patient to do breathing exercise
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
24

DATE/
NURSING DIAGNOSE
TIME
INEFFECTIVE THERMOREGULATION
Related To :
Aging
Fluctuating environmental
Temperature
Illness
Trauma
With Evidenced by:

Cool skin
Fluctuation in body temperature
above and below the normal
range
Mild shivering
Flushed skin
Increase RR
Seizure
Slow capillary refill
Tachycardia
Warm to touch
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
1.
2.
3.
4.
5.
6.
7.
NURSE
SIGN

Monitor patients temperature
Provide compress as needed
Adjust environmental temperature to patient need
Collaboration with doctor to give mediation
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
25

DATE/
TIME
NAUSEA
NURSING DIAGNOSE
GOAL
Related To :
Biochemical disorder (e.g.,

Uremia, DKA)
Gastric distention
Gastric Irritation
Increase intracranial pressure
With Evidenced by:

Abdominal cramping
Aversion to eating Diarrhea
Reported altered taste sensation
Sore Buccal Cavity
Abdominal pain
Reported nausea feeling
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs

2 X 24 hrs
3 X 24 hrs
INTERVENSION
1 X 24 hrs
NURSE
SIGN

Monitor nausea feeling
Monitor intake every meal time
Manage food and fluid, small amount but
frequent
5. Collaboration with nutritionist to provide non
Irritate food
7. Collaboration with doctor to give parenteral food
1.
2.
3.
4.
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
26

DATE/
NURSING DIAGNOSE
TIME
RISK FOR ACUTE CONFUSION
Related To :
Alcohol use
Dementia
Fluctuation in sleep-wake cycle
History of stroke
Impaired cognition
Infection
Medication
Substance abuse
Over 60 years of age
Pain
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
1.
2.
3.
4.
NURSE
SIGN

Assess mental status
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
27

DATE/
NURSING DIAGNOSE
TIME
RISK FOR ASPIRATION
Related To :
Depressed gag reflex
Facial surgery
Facial trauma
Impaired swallowing
Neck surgery
Neck trauma
Oral Surgery
Oral trauma
Reduced level of consciousness
Situation hindering elevation
Of upper body
Tube feeding
Wired jaw
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NURSE
SIGN
1. Monitor patients condition (e.g., ability to

swallow, etc)
2. Monitor the use of oxygen mask if patient at risk
for vomiting
3. Keep wire cutter/scissors with patient at all times
when jaw are wired
4. Keep suction with patient at all times
5. Elevated head of bed 30 degrees during meal and
at least 30 minutes after meal
6. Collaboration with doctor to give mediation
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
28

DATE/
NURSING DIAGNOSE
TIME
RISK FOR BLEEDING
Related To :
History of falls
Gastrointestinal disorders (e.g.,
gastric ulcer, etc)
Impaired liver function
Inherent coagulopathies (e.g.,
Thrombocytopenia)
Pregnancy-related complication
Trauma
Treatment-related side effects
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
1.
2.
3.
4.
NURSE
SIGN

Monitor laboratory value
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
29

DATE/
NURSING DIAGNOSE
TIME
RISK FOR CONTIPATION
Related To :
Insufficient physical activity
Decrease motility of
gastrointestinal tract
Insufficient fiber intake
Insufficient fluid intake
Poor eating habit
Medication (e.g,. opioids)
Neurological impairment
Hemorrhoids
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NURSE
SIGN
1. Encourage patient to take a lot of fluid and high

fiber food
2. Encourage daily activity/exercise within limit of
individual ability
3. Collaboration with nutritionist to provide high fiber
diet
NEXT Review :
1 X 30 mnt. 1 X 6 hrs
2 X 24 hrs
3 X 24 hrs
1 X 12 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
30

DATE/
NURSING DIAGNOSE
GOAL
TIME
RISK FOR DECREASED CARDIAC TISSUE PERFUSION
Related To :
Family history of coronary
Artery disease
Diabetes mellitus
Hyperlipidemia
Hypertension
Hypoxemia
Hypoxia
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs

2 X 24 hrs
3 X 24 hrs
INTERVENSION
1 X 24 hrs
1.
2.
3.
4.
5.
NURSE
SIGN

Monitor cardiac rhythm
Assist in diagnostic test
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
31

DATE/
NURSING DIAGNOSE
TIME
RISK FOR DEFICIENT FLUID VOLUME
Related To :
Excessive losses through
Normal route
Loss of fluid through abnormal
Route
Medication (e.g., deuretics)
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
1.
2.
3.
4.
5.
NURSE
SIGN

Encourage patient to drink lot of water
Collaboration with doctor to give intravenous fluid
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
32

DATE/
NURSING DIAGNOSE
TIME
RISK FOR FALLS
Related To :
Age 65 or over
History of falls
Use of assistive device
Wheelchair use
Diminished mental status
Dimly lit room
Medication (e.g., opiates )
Orthostatic hypotension
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NURSE
SIGN

Assess and document patients fall risk everyday
Assist with transfer and ambulation
Clear environment of hazard
Put patients bed in lowest position and raise the
side rails of the bed
7. Ensure call bell within reach
8. Instruct patient to call for assistance with out-ofbed activities
1.
2.
3.
4.
5.
6.
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
33

DATE/
NURSING DIAGNOSE
TIME
RISK FOR IMBALANCE FLUID VOLUME
Related To :
Abdominal surgery
Ascites
Burns
Intestinal obstruction
Pancreatitis
Sepsis
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
1.
2.
3.
4.
5.
NURSE
SIGN

NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
34

DATE/
NURSING DIAGNOSE
GOAL
TIME
RISK FOR IMBALANCED BODY TEMPERATURE
Related To :
Altered metabolic rate
Illness affecting temperature
regulation
Trauma affecting temperature
regulation
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs

2 X 24 hrs
3 X 24 hrs
INTERVENSION
1 X 24 hrs
NURSE
SIGN

2. Monitor patients temperature regularly
3. Maintain comfortable ambient environmental
temperature
4. Provide compress
5. Maintain adequate fluid intake
6. Collaboration with doctor to give intravenous fluid
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
35

DATE/
NURSING DIAGNOSE
TIME
RISK FOR IMPAIRED SKIN INTEGRITY
Related To :
Physical immobilization
Mechanical factors
Moisture
Impaired circulation
Impaired sensation
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NURSE
SIGN
1.
2.
3.
4.
5.
Monitor patients skin

Delegative to do wound dressing daily or if needed
Monitor patients Braden scale
Monitor patients Neuro Vascular supply
Collaboration with nutritionist to provide nutritional
meal
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
36

DATE/
NURSING DIAGNOSE
GOAL
TIME
RISK FOR INEFFECTIVE CEREBRAL TISSUE PERFUSION
Related To :
Abnormal Partial tromboplastin
time
Abnormal prothrombin time
Atrial fibrillation
Head Trauma
Substance abuse
Hypercholesterolemia
Hypertension
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs

2 X 24 hrs
3 X 24 hrs
INTERVENSION
1 X 24 hrs
1.
2.
3.
4.
NURSE
SIGN

Assess mental status (e.g., GCS)
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
37

DATE/
NURSING DIAGNOSE
TIME
RISK FOR INFECTION
Related To :
Chronic Disease
Inadequate Primary defense
(e.g., broken skin, etc)
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
Inadequate secondary defense
(e.g., Leukopenia, etc)

Immunosuppression
Invasive procedure
Trauma
Tissue destruction
NURSE
SIGN

2. Monitor phlebitis score
3. Delegative to do wound dressing everyday or if
needed
4. Change IV site dressing @ 72 hrs or if needed
5. Change IV cannula @ 72 hrs or if needed
6. Monitor patients Neuro Vascular supply
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
38

DATE/
NURSING DIAGNOSE
TIME
RISK FOR SHOCK
Related To :
Hypotension
Hypovolemia
Hypoxemia
Hypoxia
Infection
Sepsis
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
1.
2.
3.
4.
5.
NURSE
SIGN

Position patient so the head is lower
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
39

DATE/
NURSING DIAGNOSE
TIME
RISK FOR SUICIDE
Related To :
History of prior suicide attempt
Psychiatric disorder
Psychiatric illness
Substance abuse
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NURSE
SIGN
1. Provide ongoing monitoring of patient and

environment
2. Remove dangerous item from patient environment
3. Place patient in more protective environment
4. Collaboration with psychiatrist to give medication
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
40

DATE/
NURSING DIAGNOSE
TIME
SELF-CARE DEFICIT
Related To :
Cognitive impairment
Musculoskeletal impairment
Pain
Weakness
Fatigue
With Evidenced by:

Inability to access bathroom
Inability to wash body
Inability to bring food from
Receptacle to the mouth
Inability to put cloth on
GOAL
INTERVENSION

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NURSE
SIGN

Assist patient to do self-care
Perform/assist with meeting patients need
Encourage patient to do daily activity living as
possible
5. Collaboration with nutritionist to provide
adequate diet
6. Collaboration with rehabilitation specialist
1.
2.
3.
4.
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
41

DATE/
TIME
NURSING DIAGNOSE
GOAL
Related To :
With Evidenced by:
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs

2 X 24 hrs
3 X 24 hrs
INTERVENSION
NURSE
SIGN
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
42

DATE/
TIME
NURSING DIAGNOSE
GOAL
Related To :
With Evidenced by:
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs

2 X 24 hrs
3 X 24 hrs
INTERVENSION
NURSE
SIGN
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
43

DATE/
TIME
NURSING DIAGNOSE
GOAL
Related To :
With Evidenced by:
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs

2 X 24 hrs
3 X 24 hrs
INTERVENSION
NURSE
SIGN
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
NEXT Review :
1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs
2 X 24 hrs
3 X 24 hrs
1 X 24 hrs
44
45

Nursing Diagnosis and Intervention

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Nursing Diagnosis and Intervention

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DAFTAR ISI

Activity Intolerence ....................................................................................................

Acute Confusion .........................................................................................................

Acute Pain ..................................................................................................................

Decrease Cardiac Output ..........................................................................................

Deficient fluid volume................................................................................................

Disturbed Sleep Pattern .............................................................................................

Imbalance Nutrition : Less Than Body Requirement ................................................

Impaired gas Exchange ..............................................................................................

Impaired Memory ......................................................................................................

Impaired Physical Mobility ........................................................................................

Impaired Skin Integrity ..............................................................................................

Impaired Swallowing .................................................................................................

Impaired Urinary Elimination ....................................................................................

Impaired Verbal Communication ..............................................................................

Ineffective Airway Clearence .....................................................................................

Ineffective Breathing Pattern ....................................................................................

Ineffective Thermoregulation ....................................................................................

Risk for Acute Confusion ............................................................................................

Risk for Aspiration ......................................................................................................

Risk for Bleeding ........................................................................................................

Risk for Constipation ..................................................................................................

Risk for Decrease Cardiac Tissue Perfusion ...............................................................

Risk for Deficient Fluid Volume .................................................................................

Risk for Falls................................................................................................................

Risk for Imbalance Fluid Volume ...............................................................................

Risk for Imbalance Body Temperature ......................................................................

Risk for Impaired Skin Integrity .................................................................................

Risk for Ineffective Cerebral Tissue Perfusion ..........................................................

Risk for Infection ........................................................................................................

Risk for Shock ............................................................................................................

Risk for Suicide ...........................................................................................................

Self-Care Deficit ..........................................................................................................

Blank Form .................................................................................................................

NURSING DIAGNOSIS AND INTERVENTION

After Given Nursing care for :

The expected outcome are :

With Evidenced by:

Assess patients vital sign before and after activities

The expected outcome are :

The expected outcome are :

NURSING DIAGNOSIS AND INTERVENTION

With Evidenced by:

After Given Nursing care for :

The expected outcome are :

Monitor patients condition on regular basis

The expected outcome are :

The expected outcome are :

NURSING DIAGNOSIS AND INTERVENTION

With Evidenced by:

After Given Nursing care for :

The expected outcome are :

1. Assess patients pain

The expected outcome are :

The expected outcome are :

NURSING DIAGNOSIS AND INTERVENTION

After Given Nursing care for :

With Evidenced by:

1 X 30 mnt. 1 X 6 hrs 1 X 12 hrs

The expected outcome are :

Monitor patients physical response e.g., palpitation

The expected outcome are :

The expected outcome are :