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NANDA-Nursing Plan 00128 Acute confusion
In acute confusion, we intervene in delirium caused by metabolic disorders in the brain.
In acute confusion, we intervene in delirium caused by metabolic disorders in the brain.
Hemi-neglect (hemi-spatial neglect) focuses on hemi-neglect in agnosia, a type of higher brain dysfunction.
Self-neglect proposes factor-based interventions for patients who are unable to self-care due to factors such as isolation or personal factors.
In the self-care promotion readiness state, we confirm from the definition of self-care. In line with Orem’s theory of self-care, we are also planning interventions for lack of self-care.
In terms of lack of self-care for eating, we will consider interventions for those who have decreased food intake due to impaired swallowing function or difficulty recognizing food due to dementia.
In the lack of dressing self-care, we will intervene for the lack of self-care due to paralysis and cognitive impairment. While using self-help tools, etc., we are planning to maintain the remaining functions.
In the case of lack of self-care in bathing, we are investigating the causes of lack of self-care from individual factors such as cognitive impairment and paralysis, and environmental factors such as bathroom equipment and location, and are exploring ways to maintain self-care while maintaining residual functions.
The difficult reaction to weaning from mechanical ventilation deals with cases in which the patient who was ventilated with a mechanical respirator during intubation or tracheostomy does not proceed smoothly during the process of weaning (weaning).
In the ineffective peripheral tissue circulation risk state, the causes of peripheral circulation disorders such as lifestyle habits, trauma, and treatment (cast fixation and drug treatment) are listed, and a nursing plan is drawn up for the areas that can be dealt with.
For ineffective peripheral tissue circulation, we consider the causes of peripheral tissue circulation disorders that cause Raynaud’s phenomenon, etc., and formulate countermeasures as nursing plans. I would appreciate it if you could refer to it.
In the ineffective cerebral tissue circulation risk state, a plan for stroke (cerebral infarction, cerebral hemorrhage, transient ischemic attack) is made.
For conditions at risk of decreased cardiac tissue circulation, we formulate nursing care plans focusing on arteriosclerosis, which is the cause of coronary artery disease, and hyperlipidemia, diabetes, etc., which are the causes of arteriosclerosis.
In the thrombosis risk state, the risk of thromboembolism due to abnormality of the blood coagulation system (fibrinolytic system, anticoagulant factors, coagulation factors, platelets) and arteriosclerosis is listed. We formulate nursing care plans for progression prevention and thrombosis prevention.
In blood pressure instability risk conditions, we intervene in situations where blood pressure fluctuations are likely to occur due to the effects of disease, drugs, or surgery.
For spontaneous ventilation disorders, we review the physiology of breathing and formulate a plan for the causes, symptoms, and treatment of ventilation disorders → respiratory failure.
Ineffective lymphedema self-management risk state is a risk-type diagnosis, so we will intervene in advance to explain to patients who are expected to need self-management of lymphedema and promote their understanding.
Ineffective Lymphoedema Self-Management provides support through the process of understanding the pathology of lymphedema and becoming able to self-manage it. We aim not only to acquire skills, but also to provide mental support for changing body image.
In low cardiac output risk conditions, causes of decreased cardiac output such as heart failure, hemorrhage, and anemia are listed, and a plan for early detection of abnormalities and relief of pain is developed.
“Cardiac output reduction” focuses on low-output conditions due to heart failure, anemia, and hemorrhage. In particular, the causes of heart failure are diverse and the symptoms are complex. I am reviewing and planning for heart failure.