Care Plans

Question 1

Which Nursing Diagnosis might be considered if assigned

Abdominal Assessment?

Answer 1

1. Dysfunctional GI motility

2. Constipation

Question 2

Which Nursing Diagnosis might be considered if assigned:

Respiratory Management?

Answer 2

1. Ineffective Airway Clearance

2. Ineffective Breathing Pattern

Question 3

Which Nursing Diagnosis might be considered if assigned:

Musculoskeletal Management

Answer 3

1. Impaired Physical Mobility

2. Impaired Bed Mobility

Question 4

Which Nursing Diagnosis might be considered if assigned:

Comfort Management

Answer 4

1. Impaired Comfort

2. Anxiety

Question 5

Which Nursing Diagnosis might be considered if assigned:

Oxygen Management

Answer 5

1. Activity Intolerance

2. Impaired Gas Exchange

Question 6

Which Nursing Diagnosis might be considered if assigned:

Skin Management

Answer 6

1. Impaired Skin Integrity

2. Impaired Tissue Integrity

Question 7

Which Nursing Diagnosis might be considered if assigned:

Fluid Management

Answer 7

1. Deficient Fluid Volume

2. Excess Fluid Volume

Question 8

Which Nursing Diagnosis might be considered if assigned:

Enteral Feeding

Answer 8

Imbalanced Nutritional: Less than body requirements

Question 9

Which Nursing Diagnosis might be considered if assigned:

Neurological Assessment

Answer 9

1. Acute/Chronic Confusion
2. Impaired Memory
3. Anxiety

Question 10

Which Nursing Diagnosis might be considered if assigned:

Peripheral Neurovascular Management

Answer 10

1. Ineffective Peripheral Tissue Perfusion

Question 11

Which Nursing Diagnosis might be considered if assigned:

Wound Management

Answer 11

1. Impaired Skin Integrity

2. Impaired Tissue Integrity

Question 12

What can the related factor be?

What can it not be?

Answer 12

It can be a medical diagnosis

It can NOT be: procedure, treatment, or person.

Question 13

What is a good way to start a “rational” for a nursing diagnosis?

Answer 13

1. “Blank” is a basic physiological need. If patient does not have “blank”, patient is at risk for complications …..,

Or

2. Promoting “blank” (clear airway, etc.) will help the patient to heal and prevent complications such as pneumonia.

Question 14

If assigned a device such as an abduction pillow, can “maintaining” this device be used as an intervention?

Answer 14

Yes, but devices must be on the orders.

Question 15

Related factors and potential interventions for ineffective Aires clearance:

Answer 15

Retained secretions

1. Deep breathe/coughing
2. Upright positioning
3. Incentive spirometry

Question 16

Related factors and potential interventions for impaired gas exchange:

Answer 16

Imbalance between oxygen supply and demand.

1. Maintain/apply oxygen
2. Incentive spirometry
3. Deep breathing/coughing
4. Position upright

Question 17

Related factors and potential interventions for ineffective breathing pattern:

Answer 17

Related to: anxiety, pain, musculoskeletal impairment.

1. Upright positioning
2. Maintain/administer oxygen
3. Deep breathing/coughing
4. Rest periods
5. Pain meds

Question 18

Related factors and potential interventions for ineffective peripheral Tissue perfusion:

Answer 18

Related to: Tissue trauma, CHF, diabetes, peripheral vascular disease

1. ROM exercises
2. Anticoagulants
3. SCD’s
4. Anti-embolism socks

Question 19

What the rationale be for the PNVM intervention of administer blood thinner?

Answer 19

Reduces risk of DVT’s thereby promoting circulation in extremities.

Question 20

Related factors and potential interventions for impaired comfort:

Answer 20

R/T: tissue trauma, immobility, disease process, anxiety

1. Reposition
2. Guided imagery
3. Distraction
4. Massage
5. Temp, blankets, TV, book