Nursing Diagnoses Taxonomy

Pertinent To Problems/ Alteration In

Perception And Coordination
Inflammatory and Immunologic
Reaction
A. Impaired skin integrity
B. Activity intolerance
C. Potential for infection
D. Disturbances in self concept
E. Ineffective family coping
F. Social Isolation
Assessment Diagnosis Planning Intervention Evaluation
Subjective:
nagsusugat
sugat ako, ang
dame dame

Objective:
Disruption of
skin surface

Wound is 5
mm in
diameter

Erythema
(localized)


Impaired skin
integrity
related to
Immunologic
deficit: (AIDS-
related derma
titis; viral,
bacterial,
and fungal
infections (e.g
.,
herpes, Pseud
omonas,
Candida);)

Be free
of/display
improvement
in
wound/lesion
healing.

Assess skin
daily. Note
color, turgor,
circulation,
and
sensation.
Describe/mea
sure lesions
and observe
changes.

Maintain/instr
uct in good
skin hygiene,

Reposition
frequently.

Maintain
clean, dry,
wrinkle-free
linen,
preferably
soft cotton
fabric.

Reposition
frequently

Maintain
clean, dry
wrinkle free
linen

Ecourage
ambulation

File nails
regularly

Cover
ulcerated KS
lesions with
wet-to-wet
dressings or
antibiotic
ointment and
nonstick
dressing (e.g.,
Telfa), as
indicated.
After 2 weeks
of nursing
intervention,
patient shows
improvement
in wound
healing and
lesions.
Assessment Diagnosis Planning Intervention Evaluation
Subjective:

"hindi
akomakagala
w ng maayos
dahil pag
gumalaw ako
sumasakit

O- slow
movement-
needs support
in moving-
experience
difficulty in
doing certain
actions becau
se of pain

Rate of pain
from 0-10 is 9
Activity
intolerance
After
the interventi
on the patient
will be able to
verbalize and
utilize energy
conservation
techniques
Establish
rapport

Monitor vita
signs

Establish
guidelines
and goals of
activity with
the patient
and caregiver.

Encourage
adequate rest

Give meds as
ordered

The patient
was able to
verbalize and
utilize energy
conservation
techniques
Assessment Diagnosis Planning Intervention Evaluation
Subjective:
Kaninang
umaga lang
ako na
operahan; as
verbalized by
the patient.

Objective:

T-36.3C

Weak
inappearance

Clean
andintactabd
ominaldressin

Risk for
infection
Make the
patient free
from signs
and
symptoms of
infection
Assess signs
and
symptoms
of infection
especially
temperature

Emphasize
the
importance
of handwashi
ng
Technique

Maintain
aseptic
technique
when
changing
dressing of
wounds

Keep area
clean and dry

Take
antibiotics
Patient was
free from sign
and
symptoms of
infection
Neural Regulation
A. Altered cerebral tissue perfusion
B. Impaired verbal communication
C. Impaired swallowing
D. Potential for Injury
E. Activity Intolerance
F. Ineffective individual coping
G. Knowledge deficit
Assessment Diagnosis Planning Intervention Evaluation
Subjective:
Pt stated that
she was
nauseous.

Objective:
Pt took a long
time to chew
and swallow
food and
continued to
pocket food in
cheeks even
after
attempting to
swallow.
Impaired
swallowing
related to
neuromuscula
r disturbances
Patient will
demonstrate
effective
swallowing
techniques by
the end of the
shift
Watch for
uncoordinate
d chewing or
swallowing,
or coughing
immediately
after
swallowing.

Have suction
material
ready at
bedside and
during
feeding in
case chocking
occurs and
suctioning is
necessary to
clear airway
Praise the
patient for
successfully
following
directions and
swallowing
appropriately
because
positive
reinforcement
helps the
patient want
to learn
Goal met
Assessment Diagnosis Planning Intervention Evaluation
Subjective:
Hind sya
makapagsalita
-as verbalized
by daughter

Objective:

Cant speak

Difficulty in
expressing
thoughts
verbally


Impaired
verbal
communicatio
n related to
neuromuscula
r impairment
After 4 days
of nursing
intervention
the client will
be able to
improve his
communicatio
n skills
Review
history
for neurologic
al condition

Encourage
the patient to
communicate

Advise
other healthc
are providers
of the client
tocommunica
te using a
writing pad

Give the
necessary
medications
for the client

After the
nursing
diagnoses the
clients skills
in
communicatio
n had
improve by
expressing
thoughts
using non-
verbal actions
Visual and Auditory Perception
A. Alteration in sensory perception:
visual/auditory
B. Potential for infection
C. Self Esteem Disturbance
D. Potential for injury
E. Knowledge Deficit
Assessment Diagnosis Planning Intervention Evaluation
Assessment Diagnosis Planning Intervention Evaluation
Subjective:
nahihirapan
ako
makakineg
as verbalized
by patient


Objective:

Difficulty in
hearing

disoriented
time place

Disturbed
Sensory
Perception
(Sensory
Overload)rela
ted to
change in
environment,
and
hearing loss
(as evidenced
by
disorientation
to time and
place;
restlessness;
and altered
behavior)
Patient should
become
oriented and
hearing must
be
compensated.
Provide a
consistent
physical
environment
and a daily
routine.

Provide for
adequate
rest, sleep,
and daytime
naps

Use a calm
and unhurried
approach
when
interacting

Speak to the
client in a
slow, distinct
manner with
appropriate
volume
Facilitate
use of hearing
aids, as
appropriate.

Use simple
words and
short
sentences, as
appropriate.
Goal met..
Locomotion
A. Alteration in comfort: pain/ pruritus
B. Knowledge Deficit
C. Impaired Physical Mobility
D. Disturbance in self concept
E. Altered Nutrition
Assessment Diagnosis Planning Intervention Evaluation
Assessment Diagnosis Planning Intervention Evaluation
Subjective:
Nahihirapan
ako gumalaw
As verbalized
by patient

Objective:
Inablitiy to
move
purposively

Reluctant to
attempt
movement

Limited ROM

Decrease
muscle
strength
Impaired
Physical
mobility
After 2 weeks
of nursing
intervention ,
patiet will
show sign of
mobility.
Exercise Thera
py:
Ambulation

Joint Mobility

Fall
Precautions

Positioning

Bed Rest Care

Patient
performs
physical
activity
independentl
y or with
assistive
devices as
needed.


Assessment Diagnosis Planning Intervention Evaluation