Appendectomy 1. Risk for infection 2. Acute pain 3.

Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs Peritonitis 1. 2. 3. 4. 5. 6. Risk for infection (septicemia) Deficient fluid volume (mixed) Acute pain Risk for imbalanced nutrition, less than body requirements Anxiety or fear (specify level) Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Cholecystitis with Cholelithiasis 1. 2. 3. 4. Acute pain Risk for deficient fluid volume Risk for imbalanced nutrition, less than body requirements Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Cholecystectomy 1. 2. 3. 4. Ineffective breathing pattern Risk for deficient fluid volume Impaired skin or tissue integrity Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

View Sample NCP for Cholecystectomy Gastritis, acute 1. Acute pain 2. Risk for deficient fluid volume [isotonic] Gastritis, chronic 1. Risk for imbalanced nutrition less than body requirements 2. Knowledge deficient (learning need) regarding pathophysiology, psychologic factors, therapy needs and potential complications.

Hernia, hiatal 1. Chronic pain 2. Knowledge deficient (learning need) regarding disease process/transmission, treatment needs and future expectations. Constipation 1. Constipation 2. Acute pain 3. Knowledge deficient (learning need) regarding dietary needs, bowel function, and medication effect. View Sample NCP for Constipation Irritable Bowel Syndrome 1. Acute pain 2. Constipation 3. Diarrhea Hemorrhoids 1. Acute pain 2. Constipation View Sample NCP for Hemorrhoids Hemorrhoidectomy 1. Acute pain 2. Risk for urinary retention 3. Knowledge deficient (learning need) regarding therapeutic treatment and potential complications. Upper Gastrointestinal/ Esophageal Bleeding 1. 2. 3. 4. 5. Deficient fluid volume (isotonic) Risk for ineffective tissue perfusion Fear or anxiety (specify level) Acute or chronic pain Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Subtotal Gastrectomy/ Gastric Resection

1. Risk for imbalanced nutrition, less than body requirements 2. Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs Inflammatory Bowel Disease: Ulcerative Colitis, Regional Enteritis (Crohns disease, Ileocolitis) 1. 2. 3. 4. 5. 6. 7. Diarrhea Risk for deficient fluid volume Imbalanced nutrition, less than body requirements Anxiety (specify level) Acute pain Ineffective coping Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Fecal Diversions: Post operative Care of Ileostomy and Colostomy 1. Risk for impaired skin integrity 2. Disturbed body image 3. Acute pain 4. Impaired skin or tissue integrity 5. Risk for deficient fluid volume 6. Risk for imbalanced nutrition less than body requirements 7. Disturbed sleeping pattern 8. Risk for diarrhea or constipation 9. Risk for sexual dysfunction 10. Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs POTENTIAL NURSING DIAGNOSIS FOR SEVERE HYPERTENSION: 1. 2. 3. 4. 5. 6. Risk for decreased cardiac output Activity intolerance Acute headache pain Imbalanced nutrition more than body requirements Ineffective coping Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs

VIEW SAMPLE NURSING CARE PLAN FOR HYPERTENSION POTENTIAL NURSING DIAGNOSIS FOR CHRONIC HEART FAILURE (CHF) 1. Decreased Cardiac output 2. Activity intolerance

3. Excess fluid volume 4. Risk for impaired gas exchange 5. Risk for impaired skin integrity 6. Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs VIEW SAMPLE NURSING CARE PLAN FOR CHRONIC HEART FAILURE (CHF) POTENTIAL NURSING DIAGNOSIS FOR ANGINA (CORONARY ARTERY DISEASE) 1. 2. 3. 4. Acute pain Risk for decreased cardiac output Anxiety Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs

POTENTIAL NURSING DIAGNOSIS FOR MYOCARDIAL INFARCTION 1. 2. 3. 4. 5. 6. 7. Acute pain Activity intolerance Anxiety/ Fear Risk for decreased cardiac output Ineffective tissue perfusion Risk for excess fluid volume Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs

VIEW SAMPLE NURSING CARE PLAN FOR MYOCARDIAL INFARCTION POTENTIAL NURSING DIAGNOSIS FOR DYSRHYTHMIAS (INCLUDING DIGITALIS TOXICITY) 1. Risk for decreased cardiac output 2. Risk for poisoning, digitalis toxicity 3. Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs POTENTIAL NURSING DIAGNOSIS FOR CARDIAC SURGERY: POSTOPERATIVE CARE CORONARY ARTERY BYPASS GRAFT (CABG), MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS (MIDCAB), CARDIOMYOPLASTY, VALVE REPLACEMENT 1. Risk for decreased cardiac output 2. Acute pain 3. Ineffective role performance

4. Risk for ineffective breathing pattern 5. Impaired skin integrity 6. Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs POTENTIAL NURSING DIAGNOSIS FOR THROMBOPHLEBITIS: DEEP VEIN THROMBOSIS (INCLUDING PULONARY EMBOLI CONSIDERATIONS) 1. 2. 3. 4. Ineffective tissue perfusion Acute pain Impaired gas exchange (in presence of pulmonary embolus) Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs

POTENTIAL NURSING DIAGNOSIS FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) AND ASTHMA 1. Ineffective airway clearance 2. Impaired gas exchange 3. Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs VIEW NURSING CARE PLAN FOR BRONCHIAL ASTHMA POTENTIAL NURSING DIAGNOSIS FOR PNEUMONIA 1. 2. 3. 4. 5. 6. Ineffective airway clearance Impaired gas exchange Risk for (spread) infection Activity intolerance Acute pain Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs 7. Risk for deficient fluid volume 8. Risk for imbalanced nutrition less than body requirements VIEW NURSING CARE PLAN FOR PNEUMONIA POTENTIAL NURSING DIAGNOSIS FOR LUNG CANCER: POSTOPERATIVE CARE 1. 2. 3. 4. 5. Impaired gas exchange Ineffective airway clearance Acute pain Fear/ Anxiety Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs

POTENTIAL NURSING DIAGNOSIS FOR PNEUMOTHORAX/ HEMOTHORAX 1. Ineffective breathing pattern 2. Trauma/ Suffocation 3. Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs POTENTIAL NURSING DIAGNOSIS FOR RADICAL NECK SURGERY: LARYNGECTOMY (POSTOPERATIVE CARE) 1. 2. 3. 4. 5. 6. 7. 8. 9. Ineffective airway clearance Risk for aspiration Impaired verbal communication Impaired skin or tissue integrity Impaired oral mucus membrane Acute pain Imbalanced nutrition less than body requirements Disturbed body image / Ineffective role performance Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs

POTENTIAL NURSING DIAGNOSIS FOR VENTILATORY ASSISTANCE (MECHANICAL) 1. 2. 3. 4. 5. 6. 7. 8. 9. Ineffective breathing pattern/ Impaired spontaneous ventilation Ineffective airway clearance Impaired verbal communication Fear/ anxiety Impaired oral mucus membrane Imbalanced nutrition less than body requirements Risk for infection Risk for dysfunctional ventilatory weaning response Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs

POTENTIAL NURSING DIAGNOSIS FOR PULMONARY TUBERCULOSIS (PTB) 1. 2. 3. 4. 5. Risk for (spread/ reactivation) infection Ineffective airway clearance Risk for impaired gas exchange Imbalanced nutrition, less than body requirements Deficient knowledge (Learning Need) regarding condition, treatment plan, self-care, and discharge needs

Dermatitis, seborrheic

Impaired skin integrity

Candidiasis

Impaired skin or tissue integrity Acute pain or discomfort Risk for sexual s\dysfunction

Eczema (dermatitis)

Pain or discomfort Risk for infection Social isolation

Frostbite

Impaired tissue integrity Acute pain Risk for infection

Pressure ulcer or sore

Ineffective peripheral tissue perfusion Deficient knowledge (learning need) regarding condition, prognosis, treatment, self-care, and discharge needs.

Fractures

Risk for trauma Acute pain Risk for peripheral neurovascular dysfunction Risk for impaired gas exchange Impaired physical mobility Risk for impaired skin or tissue integrity Risk for infection Deficient knowledge (learning need) regarding condition, prognosis, treatment, self-care, and discharge needs.

View Sample Nursing Care Plan for Fracture Amputation

Low self-esteem Acute pain Risk for ineffective peripheral tissue perfusion Risk for infection

Impaired physical mobility Deficient knowledge (learning need) regarding condition, prognosis, treatment, self-care, and discharge needs.

Total Joint Replacement

Risk for infection Impaired physical mobility Risk for peripheral neurovascular dysfunction Acute pain Risk for constipation Deficient knowledge (learning need) regarding condition, prognosis, treatment, self-care, and discharge needs.

Rheumatoid Arthritis

Acute or chronic pain Impaired mobility Impaired physical or walking Ineffective body image Disturbed role performance Self-care deficit Risk for impaired home maintenance Deficient knowledge (learning need) regarding condition, prognosis, treatment, self-care, and discharge needs

Potential Nursing Diagnosis for Abortion, elective termination 1. 2. 3. 4. Knowledge deficient regarding reproduction, contraception, self-care Risk for spiritual distress Anxiety [specify level] Acute pain [discomfort]

Potential Nursing Diagnosis for Abortion, spontaneous termination 1. Deficient fluid volume [isotonic] 2. Risk for spiritual distress 3. Knowledge deficient regarding cause of abortion, self-care contraception/future pregnancy 4. Grieving 5. Risk for ineffective sexuality pattern Potential Nursing Diagnosis for Abruptio Placentae 1. Deficient Fluid volume [isotonic] 2. Fear related to threat of death (perceived or actual) to fetus/self

3. Acute pain 4. Impaired fetal gas exchange View Sample NCP for Abruptio Placentae Potential Nursing Diagnosis for Cesarean birth, postpartal 1. 2. 3. 4. 5. Acute pain/discomfort Risk for situational low self-esteem Risk for injury Risk for infection Self-care deficit

View Sample NCP for Cesarean Delivery Potential Nursing Diagnosis for Cesarean birth, unplanned 1. Knowledge deficient regarding underlying procedure, pathophysiology and self-care needs 2. Anxiety [specify level] 3. Powerlessness 4. Risk for impaired fetal gas exchange 5. Risk for infection Potential Nursing Diagnosis for Dilation and Curettage (D and C) 1. Knowledge deficient regarding surgical procedure, possible postprocedural complications, and therapeutic needs View Sample NCP for D and C Potential Nursing Diagnosis for Dilation of cervix, premature 1. Anxiety [specify level] 2. Grieving Potential Nursing Diagnosis for Hysterectomy 1. 2. 3. 4. 5. 6. 7. Situational low, self-esteem Impaired urinary elimination Impaired urinary retention (acute) Risk for constipation or diarrhea Risk for ineffective tissue perfusion Risk for sexual dysfunction Dysfunctional grieving

8. Knowledge deficient regarding condition, prognosis, treatment, self-care, and discharge needs. Potential Nursing Diagnosis for Labor, preterm 1. 2. 3. 4. Activity Intolerance Risk for poisoning Anxiety [specify level] Knowledge deficient regarding preterm labor treatment needs and prognosis

View Sample NCP for Preterm Labor Potential Nursing Diagnosis for Mastectomy 1. 2. 3. 4. 5. 6. Fear or anxiety(specify level) Impaired skin or tissue integrity Acute pain Situation low, self-esteem Impaired physical mobility Knowledge deficient regarding condition, prognosis, treatment, self-care, and discharge needs.

Potential Nursing Diagnosis for Mastitis 1. 2. 3. 4. Acute pain Risk for infection Knowledge deficient regarding pathophysilogy, treatment and prevention Risk for ineffective breastfeeding

Potential Nursing Diagnosis for Pelvic Inflammatory Disease 1. 2. 3. 4. 5. Risk for infection Acute pain Hyperthermia Risk for situational low self-esteem Knowledge deficient regarding cause/complications of condition, therapy needs, and transmission of disease to others

Potential Nursing Diagnosis for Perinatal loss/death of child 1. 2. 3. 4. 5. Grieving Situational low self esteem Risk for ineffective role performance Risk for interrupted family process Risk for spiritual distress

Potential Nursing Diagnosis for Placenta Previa 1. Risk for deficient fluid volume 2. Impaired fetal gas exchange 3. Fear View Sample NCP for Placenta Previa Potential Nursing Diagnosis for Postpartal Period 1. 2. 3. 4. Acute pain [discomfort] Impaired urinary elimination Constipation Insomia

Potential Nursing Diagnosis for Pregnancy-Induced Hypertension (Preeclampsia) 1. 2. 3. 4. Deficient fluid volume [isotonic] Decreased cardiac output Ineffective [uteroplacental] Tissue Perfusion Knowledge deficient regarding pathophysiology of condition, therapy, selfcare/nutritional needs and potential complications

View Sample NCP for Pregnancy Induced Hypertension (Preeclampsia) Potential Nursing Diagnosis for Uterine bleeding, abnormal 1. Anxiety [specify level] 2. Activity intolerance Potential Nursing Diagnosis for Vaginitis 1. Impaired tissue integrity 2. Acute pain 3. Knowledge deficient regarding hygienic/therapy needs and sexual behaviors/transmission of organisms Eating Disorders: Anorexia Nervosa/ Bulimia Nervosa

Imbalanced nutrition, less than body requirements Actual or risk for deficient fluid volume Disturbed thought process Disturbed body image Low self-esteem Impaired parenting Risk for impaired tissue integrity

Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Eating Disorders: Obesity

Imbalanced nutrition, less than body requirements Actual or risk for deficient fluid volume Disturbed thought process Disturbed body image Chronic low self-esteem Impaired parenting Risk for impaired skin integrity Disturbed thought process Disturbed body image

Obesity: Surgical Interventions (Gastric Partitioning/Gastroplasty, Gastric Bypass)

Ineffective breathing pattern Risk for ineffective tissue perfusion Risk for deficient fluid volume Imbalanced nutrition less than body requirements Risk for impaired tissue integrity Risk for infection Diarrhea Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Diabetes Mellitus/ Diabetic Ketoacidosis

Deficient fluid volume (specify) Imbalanced nutrition less than body requirements Risk for infection (sepsis) Risk for disturbed sensory perception (specify) Fatigue Powerlessness Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

View Sample Nursing Care Plan for Diabetes Mellitus type 1 View Sample Nursing Care Plan for Diabetes Mellitus type 2 Hyperthyroidism (Thyrotoxicosis, Graves Disease)

Risk for decreased cardiac output Fatigue

Risk for imbalanced nutrition, less than body requirements Anxiety (specify level) Risk for disturbed thought process Risk for impaired tissue integrity Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Thyroidectomy

Risk for ineffective airway clearance Impaired verbal communication Risk for injury (tetany) Acute pain Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Hepatitis

Fatigue Imbalanced nutrition less than body requirements Risk for deficient fluid volume Low self-esteem Risk for infection Risk for impaired skin or tissue integrity Imbalanced nutrition less than body requirements

View Sample Nursing Care Plan for Hepatitis A Cirrhosis of the liver

Imbalanced nutrition less than body requirements Excess fluid volume Risk for impaired tissue integrity Risk for ineffective breathing pattern Risk for injury (hemorrhage) Risk for acute confusion Disturbed self-esteem Disturbed body image Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

View Sample Nursing Care Plan for Liver Cirrhosis Pancreatitis

Acute pain

Risk for deficient fluid volume Imbalanced nutrition less than body requirements Risk for infection Risk for ineffective breathing pattern Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Total Nutritional Support: Parenteral/ Enteral Feeding

Imbalanced nutrition less than body requirements Risk for infection Risk for injury (multifactor) Risk for aspiration Risk for imbalance fluid volume Fatigue Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Glaucoma

Disturbed visual sensory perception Anxiety (specify level)

View Sample Nursing Care Plan for Glaucoma Seizure disorders

Risk for trauma or suffocation Risk for ineffective airway clearance or breathing pattern Low self-esteem Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

View Sample Nursing Care Plan for Seizure Craniocerebral trauma (Acute Rehabilitative Phase)

Ineffective cerebral tissue perfusion Risk for ineffective breathing pattern Disturbed sensory perception (specify) Disturbed thought process Impaired physical mobility Risk for infection Risk for imbalanced nutrition, less than body requirements Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Cerebrovascular Accident (CVA) or Stroke

Ineffective cerebral tissue perfusion Impaired physical mobility Impaired verbal or written communication Disturbed sensory perception (specify) Self-care deficit Ineffective coping Risk for impaired swallowing Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

View Sample Nursing Care Plan for CVA Herniated Nucleus Pulposus (Ruptured Intervertebral Disc)

Acute or chronic pain Impaired physical mobility Anxiety (specify level) Ineffective coping Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Disc Surgery

Ineffective tissue perfusion Risk for trauma (spinal) Risk for ineffective airway clearance Risk for ineffective breathing pattern Acute pain Impaired physical mobility Constipation Risk for urinary retention Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

Spinal Cord Injury (Acute Rehabilitative Phase)

Risk for ineffective breathing pattern Risk for injury ( additional spinal injury) Impaired physical mobility Disturbed sensory perception Acute pain Anticipatory grieving Low self-esteem Constipation or bowel incontinence

Impaired urinary elimination Risk for autonomic dysreflexia Risk for skin integrity Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs

View Sample Nursing Care Plan for Spinal Cord Injury (SCI) Multiple Sclerosis

Fatigue Self-care deficit (specify) Chronic low self-esteem (specify situation) Hopelessness or powerlessness ( specify degree) Risk for ineffective coping Disabled family coping Compromised coping Impaired urinary elimination Risk for caregiver role strain Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs