1. Ineffective Airway Clearance
Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway
Defining Characteristics:
- Dyspnea;
- diminished breath sounds;
- orthopnea;
- adventitious breath sounds (crackles, wheezes);
- cough, ineffective or absent;
- sputum production;
- cyanosis;
- difficulty vocalizing;
- wide-eyed;
- changes in respiratory rate and rhythm;
- restlessness
Related Factors:
Environmental
- Smoking;
- smoke inhalation;
- second-hand smoke
- Airway spasm;
- retained secretions;
- excessive mucus;
- presence of artificial airway;
- foreign body in airway;
- secretions in bronchi;
- exudate in alveoli
Physiological
- Neuromuscular dysfunction;
- hyperplasia of bronchial walls;
- chronic obstructive pulmonary disease;
- infection;
- asthma;
- allergic airways
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
- Respiratory Status: Ventilation
- Respiratory Status: Airway Patency
- Respiratory Status: Gas Exchange
- Aspiration Control
Client Outcomes
- Demonstrates effective coughing and clear breath sounds; is free of cyanosis and dyspnea
- Maintains a patent airway at all times
- Relates methods to enhance secretion removal
- Relates the significance of changes in sputum to include color, character, amount, and odor
- Identifies and avoids specific factors that inhibit effective airway clearance
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
- Airway Management
- Airway Suctioning
- Cough Enhancement
https://nanda-nic-noc.blogspot.com/2013/03/ineffective-airway-clearance-nursing.html
2. Impaired Gas Exchange
Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane
Defining Characteristics:
- Visual disturbances;
- decreased carbon dioxide;
- dyspnea;
- abnormal arterial blood gases;
- hypoxia;
- irritability;
- somnolence;
- restlessness;
- hypercapnia;
- tachycardia;
- cyanosis (in neonates only);
- abnormal skin color (pale, dusky);
- hypoxemia;
- hypercarbia;
- headache on awakening;
- abnormal rate, rhythm, depth of breathing;
- diaphoresis;
- abnormal arterial pH;
- nasal flaring
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
- Respiratory Status: Gas Exchange
- Respiratory Status: Ventilation
- Tissue Perfusion: Pulmonary
- Vital Signs Status
- Electrolyte and Acid-Base Balance
Client Outcomes
- Demonstrates improved ventilation and adequate oxygenation as evidenced by blood gases within client's normal parameters
- Maintains clear lung fields and remains free of signs of respiratory distress
- Verbalizes understanding of oxygen and other therapeutic interventions
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
- Airway Management
- Oxygen Therapy
- Respiratory Monitoring
- Acid-Base Management
https://nanda-nic-noc.blogspot.com/2013/03/impaired-gas-exchange-nursing-diagnosis.html
3. Imbalanced Nutrition: less than body requirements
Intake of nutrients insufficient to meet metabolic needs
Defining Characteristics:
- Body weight greater than or equal to20% under ideal weight;
- pale conjunctival and mucus membranes;
- weakness of muscles required for swallowing or mastication;
- sore, inflamed buccal cavity;
- satiety immediately after ingesting food;
- reported or evidence of lack of food;
- reported inadequate food intake less than RDA (Recommended Dietary Allowance);
- reported altered taste sensation;
- perceived inability to ingest food;
- misconceptions;
- loss of weight with adequate food intake;
- aversion to eating;
- abdominal cramping;
- poor muscle tone;
- abdominal pain with or without pathology;
- lack of interest in food;
- capillary fragility;
- diarrhea and/or steatorrhea;
- excessive loss of hair;
- hyperactive bowel sounds;
- lack of information;
- misinformation
Related Factors:
Inability to ingest or digest food or absorb nutrients because of biological, psychological, or economic factors
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
- Nutritional Status
- Nutritional Status: Food and Fluid Intake
- Nutritional Status: Nutrient Intake
- Weight Control
Client Outcomes
- Progressively gains weight toward desired goal
- Weight is within normal range for height and age
- Recognizes factors contributing to underweight
- Identifies nutritional requirements
- Consumes adequate nourishment
- Free of signs of malnutrition
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
- Nutrition Management
- Eating Disorders Management
- Electrolyte Management: Hypophosphatemia
- Enteral Tube Feeding
- Feeding
- Nutrition Therapy
- Nutritional Counseling
- Nutritional Monitoring
- Swallowing Therapy
- Weight Gain Assistance
- Weight Management
https://nanda-nic-noc.blogspot.com/2013/04/imbalanced-nutrition-less-than-body.html
4. Deficient Knowledge
Absence or deficiency of cognitive information related to a specific topic
Defining Characteristics:
- Verbalization of the problem;
- inaccurate follow-through of instruction;
- inaccurate performance of test;
- inappropriate or exaggerated behaviors (e.g., hysterical, hostile, agitated, apathetic)
Related Factors:
- Lack of exposure;
- lack of recall;
- information misinterpretation;
- cognitive limitation;
- lack of interest in learning;
- unfamiliarity with information resources
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
- Knowledge of: Diet
- Disease Process
- Energy Conservation
- Health Behaviors
- Health Resources
- Infection Control
- Medication
- Personal Safety
- Prescribed Activity
- Substance Use Control
- Treatment Procedure(s)
- Treatment Regimen
Client Outcomes
- Explains disease state, recognizes need for medications, understands treatments
- Explains how to incorporate new health regimen into lifestyle
- States an ability to deal with health situation and remain in control of life
- Demonstrates how to perform procedure(s) satisfactorily
- Lists resources that can be used for more information or support after discharge
https://nursing-nic-noc.blogspot.com/2013/10/deficient-knowledge.html