Constipation r/t decreased activity, decreased fluid intake, decreased fiber intake, pathological process
Dysfunctional Gastrointestinal Motility r/t decreased perfusion of intestines, medication effect
Nausea r/t irritation of gastrointestinal tract
Imbalanced Nutrition: less than body requirements r/t nausea, vomiting
Acute Pain r/t retention of air, gastrointestinal secretions
Dysfunctional Gastrointestinal Motility r/t decreased perfusion, medication effect
Acute Pain r/t injury, pathological process
See cause of Abdominal Pain
Constipation r/t decreased activity, decreased fluid intake, anesthesia, opioids
Dysfunctional Gastrointestinal Motility r/t medication or anesthesia effect, trauma from surgery
Imbalanced Nutrition: less than body requirements r/t high metabolic needs, decreased ability to ingest or digest food
Acute Pain r/t surgical procedure
Ineffective peripheral Tissue Perfusion r/t immobility, abdominal surgery
Risk for Infection: Risk factor: invasive procedure
Readiness for enhanced Knowledge: expresses an interest in learning
See Surgery, Perioperative Care; Surgery, Postoperative Care; Surgery, Preoperative Care
Disturbed Body Image r/t scarring, change in body function, need for temporary colostomy
Ineffective Breathing Pattern r/t abdominal distention, pain
Deficient Fluid Volume r/t hemorrhage
Dysfunctional Gastrointestinal Motility r/t decreased perfusion
Acute Pain r/t abdominal trauma
Risk for Bleeding: Risk factor: trauma and possible rupture of abdominal organs
Risk for Infection: Risk factor: possible perforation of abdominal structures
Risk for decreased Cardiac tissue perfusion: Risk factor: catheterization of heart
Compromised family Coping r/t unresolved feelings about decision
Acute Pain r/t surgical intervention
Chronic low Self-Esteem r/t feelings of guilt
Chronic Sorrow r/t loss of potential child
Risk for Bleeding: Risk factor: trauma from abortion
Risk for delayed Development: Risk factors: unplanned or unwanted pregnancy
Risk for Infection: Risk factors: open uterine blood vessels, dilated cervix
Risk for Post-Trauma Syndrome: Risk factor: psychological trauma of abortion
Risk for Spiritual Distress: Risk factor: perceived moral implications of decision
Readiness for enhanced Knowledge: expresses an interest in learning
Disturbed Body Image r/t perceived inability to carry pregnancy, produce child
Disabled family Coping r/t unresolved feelings about loss
Ineffective Coping r/t personal vulnerability
Interrupted Family Processes r/t unmet expectations for pregnancy and childbirth
Fear r/t implications for future pregnancies
Acute Pain r/t uterine contractions, surgical intervention
Situational low Self-Esteem r/t feelings about loss of fetus
Chronic Sorrow r/t loss of potential child
Risk for Bleeding: Risk factor: trauma from abortion
Risk for Infection: Risk factors: septic or incomplete abortion of products of conception, open uterine blood vessels, dilated cervix
Risk for Post-Trauma Syndrome: Risk factor: psychological trauma of abortion
Risk for Spiritual Distress: Risk factor: loss of fetus
Readiness for enhanced Knowledge: expresses an interest in learning
Anxiety r/t unknown outcome, change in birth plans
Death Anxiety r/t unknown outcome, hemorrhage, or pain
Interrupted Family Processes r/t unmet expectations for pregnancy and childbirth
Fear r/t threat to well-being of self and fetus
Impaired Gas Exchange: placental r/t decreased uteroplacental area
Acute Pain r/t irritable uterus, hypertonic uterus
Impaired Tissue Integrity: maternal r/t possible uterine rupture
Risk for Bleeding: Risk factor: separation of placenta from uterus causing bleeding
Risk for disproportionate Growth: Risk factor: uteroplacental insufficiency
Risk for Infection: Risk factor: partial separation of placenta
Risk for disturbed Maternal/Fetal Dyad: Risk factors: trauma of process, lack of energy of mother
Risk for Shock: Risk factors: separation of placenta from uterus
Readiness for enhanced Knowledge: expresses an interest in learning
Ineffective Protection r/t inadequate nutrition, abnormal blood profile, drug therapy, depressed immune function
Impaired Tissue Integrity r/t altered circulation, nutritional deficit or excess
Readiness for enhanced Knowledge: expresses an interest in learning
Anxiety r/t threat to self-concept, situational crisis of abuse
Caregiver Role Strain r/t chronic illness, self-care deficits, lack of respite care, extent of caregiving required
Impaired verbal Communication r/t psychological barriers of fear
Compromised family Coping r/t abusive patterns
Defensive Coping r/t low self-esteem
Dysfunctional Family Processes r/t inadequate coping skills
Insomnia r/t psychological stress
Post-Trauma Syndrome r/t history of abuse
Powerlessness r/t lifestyle of helplessness
Chronic low Self-Esteem r/t negative family interactions
Risk for self-directed Violence: Risk factor: history of abuse
Ineffective Breathing Pattern (See Breathing Pattern, ineffective, Section III)
See Asthma; Bronchitis; COPD (Chronic Obstructive Pulmonary Disease); Respiratory Infections, Acute Childhood
Adult Failure to Thrive r/t fatigue
Acute Confusion r/t altered level of consciousness
Ineffective Coping r/t personal vulnerability, situational crises
Ineffective Impulse Control (See Impulse Control, ineffective, Section III)
Ineffective Coping r/t chronic disease
Acute Pain r/t stasis of food in esophagus
Risk for Electrolyte Imbalance: Risk factors: renal dysfunction, diarrhea, treatment-related side effects (e. g., medications, drains)
Acute Confusion r/t acid-base imbalance, associated electrolyte imbalance
Impaired Memory r/t effect of metabolic acidosis on brain function
Imbalanced Nutrition: less than body requirements r/t inability to ingest, absorb nutrients
Risk for Electrolyte Imbalance: Risk factor: effect of metabolic acidosis on renal function
Risk for Injury: Risk factors: disorientation, weakness, stupor
Risk for decreased Cardiac tissue perfusion: Risk factor: dysrhythmias from hyperkalemia
Risk for Shock: Risk factors: abnormal metabolic state, presence of acid state impairing function
Activity Intolerance r/t imbalance between oxygen supply and demand
Impaired Gas Exchange r/t ventilation-perfusion imbalance
Risk for decreased Cardiac tissue perfusion: Risk factor: dysrhythmias associated with respiratory acidosis
Disturbed Body Image r/t biophysical changes associated with skin disorder
Ineffective Self-Health Management r/t deficient knowledge (medications, personal care, cause)
Impaired Skin Integrity r/t hormonal changes (adolescence, menstrual cycle)
Activity Intolerance (See Activity Intolerance, Section III)
Ineffective Airway Clearance r/t airway obstruction by enlarged tongue
Disturbed Body Image r/t changes in body function and appearance
Impaired physical Mobility r/t joint pain
Risk for decreased Cardiac tissue perfusion: Risk factor: r/t increased atherosclerosis from abnormal health status
Risk for unstable blood Glucose level: Risk factor: abnormal physical health status
Risk for Activity Intolerance (See Activity Intolerance, risk for, Section III)
Deficient Fluid Volume r/t air and fluids trapped in bowel, inability to drink
Acute Pain r/t pathological process
Risk for dysfunctional Gastrointestinal Motility: Risk factor: ineffective gastrointestinal tissue perfusion
See cause of Abdominal Pain
Ineffective Breathing Pattern r/t depression of the respiratory center from excessive alcohol intake
Acute Confusion r/t central nervous system depression
Dysfunctional Family Processes r/t abuse of alcohol
Risk for Aspiration: Risk factor: depressed reflexes with acute vomiting
Risk for Infection: Risk factor: impaired immune system from malnutrition associated with chronic excessive alcohol intake
Anxiety r/t situational crisis, back injury
Constipation r/t decreased activity, effect of pain medication
Ineffective Coping r/t situational crisis, back injury
Impaired physical Mobility r/t pain
Readiness for enhanced Knowledge: expresses an interest in learning
Risk for decreased Cardiac tissue perfusion: Risk factor (See Cardiac tissue perfusion, risk for decreased)
Activity Intolerance r/t weakness, fatigue
Disturbed Body Image r/t increased skin pigmentation
Deficient Fluid Volume r/t failure of regulatory mechanisms
Imbalanced Nutrition: less than body requirements r/t chronic illness
Risk for Injury: Risk factor: weakness
Readiness for enhanced Knowledge: expresses an interest in learning
Acute Pain r/t surgical incision
Ineffective Airway Clearance r/t hesitation or reluctance to cough as a result of pain, fear
Nausea r/t anesthesia effects, drainage from surgery
Acute Pain r/t surgical incision
Risk for Aspiration: Risk factors: postoperative drainage, impaired swallowing
Risk for Bleeding: Risk factors: surgical incision
Risk for deficient Fluid Volume: Risk factors: decreased intake as a result of painful swallowing, effects of anesthesia
Risk for imbalanced Nutrition: less than body requirements: Risk factors: reluctance to swallow
Readiness for enhanced Knowledge: expresses an interest in learning
Anxiety r/t inability to cope with psychosocial stressor
Risk-prone Health Behavior r/t assault to self-esteem
Disturbed personal Identity r/t psychosocial stressor (specific to individual)
Situational low Self-Esteem r/t change in role function
Impaired Social Interaction r/t absence of significant others or peers
Anxiety r/t situational and maturational crisis, pregnancy
Disturbed Body Image r/t pregnancy superimposed on developing body
Decisional Conflict: keeping child versus giving up child versus abortion r/t lack of experience with decision-making, interference with decision-making, multiple or divergent sources of information, lack of support system
Disabled family Coping r/t highly ambivalent family relationships, chronically unresolved feelings of guilt, anger, despair
Ineffective Coping r/t situational and maturational crisis, personal vulnerability
Ineffective Denial r/t fear of consequences of pregnancy becoming known
Interrupted Family Processes r/t unmet expectations for adolescent, situational crisis
Delayed Growth and Development r/t pregnancy
Deficient Knowledge r/t pregnancy, infant growth and development, parenting
Imbalanced Nutrition: less than body requirements r/t lack of knowledge of nutritional needs during pregnancy and as growing adolescent
Ineffective Role Performance r/t pregnancy
Situational low Self-Esteem r/t feelings of shame and guilt about becoming or being pregnant
Impaired Social Interaction r/t self-concept disturbance
Social Isolation r/t absence of supportive significant others
Risk for impaired Attachment: Risk factor: anxiety associated with the parent role
Risk for delayed Development: Risk factor: unplanned or unwanted pregnancy
Risk for urge urinary Incontinence: Risk factor: pressure on bladder by growing uterus
Risk for disturbed Maternal/Fetal Dyad: Risk factors: immaturity, substance use
Risk for impaired Parenting: Risk factors: adolescent parent, unplanned or unwanted pregnancy, single parent
Readiness for enhanced Childbearing Process: reports appropriate prenatal lifestyle
Readiness for enhanced Knowledge: expresses an interest in learning
Decisional Conflict r/t unclear personal values or beliefs, perceived threat to value system, support system deficit
Ineffective Coping r/t stress of loss of child
Interrupted Family Processes r/t conflict within family regarding relinquishment of child
Grieving r/t loss of child, loss of role of parent
Insomnia r/t depression or trauma of relinquishment of child
Social Isolation r/t making choice that goes against values of significant others
Chronic Sorrow r/t loss of relationship with child
Risk for Spiritual Distress: Risk factor: perceived moral implications of decision
Readiness for enhanced Spiritual Well-Being: harmony with self regarding final decision
Deficient Fluid Volume r/t insufficient ability to reabsorb water
Ineffective Protection r/t inability to tolerate stress
Delayed Surgical Recovery r/t inability to respond to stress
Risk for Shock: Risk factor: deficient Fluid Volume, decreased cortisol to initiate stress response to insult to body
Death Anxiety r/t planning for end-of-life health decisions
Decisional Conflict r/t unclear personal values or beliefs, perceived threat to value system, support system deficit
Grieving r/t possible loss of self, significant other
Readiness for enhanced Spiritual Well-Being: harmonious interconnectedness with self, others, higher power, God
See specific disorder: Depression (Major Depressive Disorder); Dysthymic Disorder; Manic Disorder, Bipolar I, Seasonal Affective Disorder
Fear r/t real or imagined threat to own well-being
Risk for other-directed Violence (See Violence, other-directed, risk for, Section III)
Death Anxiety r/t fear of unknown, loss of self, impact on significant others
Impaired Dentition r/t ineffective oral hygiene
Adult Failure to Thrive r/t depression, apathy, fatigue
Grieving r/t multiple losses, impending death
Ineffective Self-Health Management r/t deficient knowledge: medication, nutrition, exercise, coping strategies
Hearing Loss r/t exposure to loud noises, aging
Functional urinary Incontinence r/t impaired vision, impaired cognition, neuromuscular limitations, altered environmental factors
Impaired individual Resilience r/t aging, multiple losses
Sleep deprivation r/t aging-related sleep-stage shifts
Ineffective Thermoregulation r/t aging
Vision Loss r/t aging (see care plan on Evolve)
Risk for Caregiver Role Strain: Risk factor: inability to handle increasing needs of significant other
Risk for Injury: Risk factor: vision loss, hearing loss, decreased balance, decreased sensation in feet
Risk for Loneliness: Risk factors: inadequate support system, role transition, health alterations, depression, fatigue
Readiness for enhanced community Coping: providing social support and other resources identified as needed for elderly client
Readiness for enhanced family Coping: ability to gratify needs, address adaptive tasks
Readiness for enhanced Knowledge: specify need to improve health
Readiness for enhanced Nutrition: need to improve health
Readiness for enhanced Relationship: demonstrates understanding of partner’s insufficient function
Readiness for enhanced Self-Health Management: knowledge about medication, nutrition, exercise, coping strategies
Readiness for enhanced Sleep: need to improve sleep
Readiness for enhanced Spiritual Well-Being: one’s experience of life’s meaning, harmony with self, others, higher power, God, environment
Readiness for enhanced Urinary Elimination: need to improve health
Acute Confusion r/t side effects of medication, hypoxia, decreased cerebral perfusion, alcohol abuse or withdrawal, substance abuse or withdrawal, sensory deprivation or overload
Sleep deprivation r/t sundown syndrome
See cause of Agitation
Anxiety r/t real or perceived threat to physical integrity
Ineffective Coping r/t inadequate support systems
Fear r/t leaving home, going out in public places
Delayed Surgical Recovery r/t abnormal blood profile
Risk for Infection: Risk factor: abnormal blood profile
Readiness for enhanced Knowledge: expresses an interest in learning
Death Anxiety r/t fear of premature death
Disturbed Body Image r/t chronic contagious illness, cachexia
Caregiver Role Strain r/t unpredictable illness course, presence of situation stressors
Diarrhea r/t inflammatory bowel changes
Disturbed Energy Field r/t chronic illness
Interrupted Family Processes r/t distress about diagnosis of human immunodeficiency virus (HIV) infection
Fatigue r/t disease process, stress, decreased nutritional intake
Fear r/t powerlessness, threat to well-being
Grieving: family/parental r/t potential or impending death of loved one
Grieving: individual r/t loss of physical and psychosocial well-being
Hopelessness r/t deteriorating physical condition
Imbalanced Nutrition: less than body requirements r/t decreased ability to eat and absorb nutrients as a result of anorexia, nausea, diarrhea; oral candidiasis
Chronic Pain r/t tissue inflammation and destruction
Impaired individual Resilience r/t chronic illness
Situational low Self-Esteem r/t crisis of chronic contagious illness
Ineffective Sexuality Pattern r/t possible transmission of disease
Social Isolation r/t self-concept disturbance, therapeutic isolation
Spiritual Distress r/t challenged beliefs or moral system
Risk for deficient Fluid Volume: Risk factors: diarrhea, vomiting, fever, bleeding
Risk for Infection: Risk factor: inadequate immune system
Risk for Loneliness: Risk factor: social isolation
Risk for impaired Oral Mucous Membrane: Risk factor: immunological deficit
Risk for impaired Skin Integrity: Risk factors: immunological deficit, diarrhea
Risk for Spiritual Distress: Risk factor: physical illness
Readiness for enhanced Knowledge: expresses an interest in learning
See AIDS, Child; Cancer; Pneumonia
Impaired Parenting r/t congenital acquisition of infection secondary to intravenous (IV) drug use, multiple sexual partners, history of contaminated blood transfusion
See AIDS (Acquired Immunodeficiency Syndrome); Child with Chronic Condition; Hospitalized Child; Terminally Ill Child, Adolescent; Terminally Ill Child, Infant/Toddler; Terminally Ill Child, Preschool Child; Terminally Ill Child, School-Age Child/Preadolescent; Terminally Ill Child/Death of Child, Parent
Ineffective Airway Clearance (See Airway Clearance, ineffective, Section III)
Anxiety r/t situational crisis, withdrawal
Acute Confusion r/t effects of alcohol withdrawal
Ineffective Coping r/t personal vulnerability
Dysfunctional Family Processes r/t abuse of alcohol
Insomnia r/t effect of alcohol withdrawal, anxiety
Imbalanced Nutrition: less than body requirements r/t poor dietary habits
Chronic low Self-Esteem r/t repeated unmet expectations
Risk for deficient Fluid Volume: Risk factors: excessive diaphoresis, agitation, decreased fluid intake
Risk for other-directed Violence: Risk factor: substance withdrawal
Risk for self-directed Violence: Risk factor: substance withdrawal
Readiness for enhanced Knowledge: expresses an interest in learning
Risk-prone Health Behavior r/t lack of motivation to change behaviors, addiction
Acute Confusion r/t alcohol abuse
Chronic Confusion r/t neurological effects of chronic alcohol intake
Defensive Coping r/t denial of reality of addiction
Disabled family Coping r/t codependency issues due to alcoholism
Ineffective Coping r/t use of alcohol to cope with life events
Ineffective Denial r/t refusal to acknowledge addiction
Dysfunctional Family Process r/t alcohol abuse
Impaired Home Maintenance r/t memory deficits, fatigue
Insomnia r/t irritability, nightmares, tremors
Impaired Memory r/t alcohol abuse
Self-Neglect r/t effects of alcohol abuse
Imbalanced Nutrition: less than body requirements r/t anorexia, inappropriate diet with increased carbohydrates
Powerlessness r/t alcohol addiction
Ineffective Protection r/t malnutrition, sleep deprivation
Chronic low Self-Esteem r/t failure at life events
Social Isolation r/t unacceptable social behavior, values
Risk for Injury: Risk factor: alteration in sensory or perceptual function
Risk for Loneliness: Risk factor: unacceptable social behavior
Risk for other-directed Violence: Risk factors: reactions to substances used, impulsive behavior, disorientation, impaired judgment
Risk for self-directed Violence: Risk factors: reactions to substances used, impulsive behavior, disorientation, impaired judgment
Dysfunctional Family Processes (See Family Processes, dysfunctional, Section III)
Latex Allergy Response r/t hypersensitivity to natural rubber latex
Risk for Allergy Response: Risk factor: chemical factors, dander, environmental substances, foods, insect stings, medications
Risk for Latex Allergy Response: Risk factor: repeated exposure to products containing latex
Readiness for enhanced Knowledge: expresses an interest in learning
Disturbed Body Image r/t loss of hair, change in appearance
Readiness for enhanced Knowledge: expresses an interest in learning
Caregiver Role Strain r/t duration and extent of caregiving required
Chronic Confusion r/t loss of cognitive function
Compromised family Coping r/t interrupted family processes
Adult Failure to Thrive r/t difficulty in reasoning, judgment, memory, concentration
Impaired Home Maintenance r/t impaired cognitive function, inadequate support systems
Hopelessness r/t deteriorating condition
Insomnia r/t neurological impairment, daytime naps
Impaired Memory r/t neurological disturbance
Impaired physical Mobility r/t severe neurological dysfunction
Self-Neglect r/t loss of cognitive function
Powerlessness r/t deteriorating condition
Self-Care deficit: specify r/t loss of cognitive function, psychological impairment
Social Isolation r/t fear of disclosure of memory loss
Wandering r/t cognitive impairment, frustration, physiological state
Risk for Injury: Risk factor: confusion
Risk for Loneliness: Risk factor: potential social isolation
Risk for Relocation Stress Syndrome: Risk factors: impaired psychosocial health, decreased health status
Risk for other-directed Violence: Risk factors: frustration, fear, anger, loss of cognitive function
Readiness for enhanced Knowledge: Caregiver: expresses an interest in learning
See Dementia
Acute Confusion r/t alcohol abuse, delirium, dementia, drug abuse
Dysfunctional Family Processes r/t alcohol abuse, inadequate coping skills
Impaired Memory r/t excessive environmental disturbance, neurological disturbance
Post-Trauma Syndrome r/t history of abuse, catastrophic illness, disaster, accident
Anxiety r/t threat to self and fetus, unknown future
Decisional Conflict r/t choice of treatment pending results of test
Disturbed Body Image r/t negative effects of amputation, response from others
Grieving r/t loss of body part, future lifestyle changes
Impaired physical Mobility r/t musculoskeletal impairment, limited movement
Acute Pain r/t surgery, phantom limb sensation
Chronic Pain r/t surgery, phantom limb sensation
Ineffective peripheral Tissue Perfusion r/t impaired arterial circulation
Impaired Skin integrity r/t poor healing, prosthesis rubbing
Risk for Bleeding: Risk factor: vulnerable surgical site
Readiness for enhanced Knowledge: expresses an interest in learning
Death Anxiety r/t impending progressive loss of function leading to death
Ineffective Breathing Pattern r/t compromised muscles of respiration
Impaired verbal Communication r/t weakness of muscles of speech, deficient knowledge of ways to compensate and alternative communication devices
Decisional Conflict: ventilator therapy r/t unclear personal values or beliefs, lack of relevant information
Impaired individual Resilience r/t chronic debilitating illness
Chronic Sorrow r/t chronic illness
Impaired Swallowing r/t weakness of muscles involved in swallowing
Impaired Spontaneous Ventilation r/t weakness of muscles of respiration
Risk for Aspiration: Risk factor: impaired swallowing
Risk for Spiritual Distress: Risk factor: chronic debilitating condition
Ineffective Airway Clearance r/t laryngeal edema, bronchospasm
Latex Allergy Response r/t abnormal immune mechanism response
Impaired Spontaneous Ventilation r/t acute airway obstruction from anaphylaxis process
Excess Fluid Volume r/t excessive fluid intake, cardiac/renal dysfunction, loss of plasma proteins
Risk for impaired Skin Integrity: Risk factor: impaired circulation to skin from edema
See cause of Anasarca
Impaired Comfort r/t feelings of always being cold from decreased hemoglobin and decreased metabolism
Fatigue r/t decreased oxygen supply to the body, increased cardiac workload
Impaired Memory r/t change in cognition from decreased oxygen supply to the body
Delayed Surgical Recovery r/t decreased oxygen supply to body, increased cardiac workload
Risk for Bleeding (See Bleeding, risk for, Section III)
Risk for Injury: Risk factor: alteration in peripheral sensory perception
Readiness for enhanced Knowledge: expresses an interest in learning
Anxiety r/t concerns about health of self and fetus
Fatigue r/t decreased oxygen supply to the body, increased cardiac workload
Risk for delayed Development: Risk factor: reduction in the oxygen-carrying capacity of blood
Risk for Infection: Risk factor: reduction in oxygen-carrying capacity of blood
Risk for disturbed Maternal/Fetal Dyad: Risk factor: compromised oxygen transport
Readiness for enhanced Knowledge: expresses an interest in learning
Risk for deficient Fluid Volume: Risk factor: hemorrhage r/t potential abnormal blood loss
Risk for Infection: Risk factor: invasive procedure
Risk for ineffective Gastrointestinal Perfusion (See Gastrointestinal Perfusion, ineffective, risk for, Section III)
Risk for ineffective Renal Perfusion: Risk factor: prolonged ischemia of kidneys
Anxiety r/t situational crisis
Risk-prone Health Behavior r/t assault to self-esteem, disability requiring change in lifestyle, inadequate support system
Defensive Coping r/t inability to acknowledge responsibility for actions and results of actions
Fear r/t environmental stressor, hospitalization
Powerlessness r/t health care environment
Risk for compromised Human Dignity: Risk factors: inadequate participation in decision-making, perceived dehumanizing treatment, perceived humiliation, exposure of the body, cultural incongruity
Risk for Post-Trauma Syndrome: Risk factor: inadequate social support
Risk for other-directed Violence: Risk factors: history of violence, rage reaction
Risk for self-directed Violence: Risk factors: history of violence, history of abuse, rage reaction
Activity Intolerance r/t acute pain, dysrhythmias
Anxiety r/t situational crisis
Decreased Cardiac Output r/t myocardial ischemia, medication effect, dysrhythmia
Ineffective Coping r/t personal vulnerability to situational crisis of new diagnosis, deteriorating health
Ineffective Denial r/t deficient knowledge of need to seek help with symptoms
Grieving r/t pain, loss of health
Acute Pain r/t myocardial ischemia
Ineffective Sexuality Pattern r/t disease process, medications, loss of libido
Readiness for enhanced Knowledge: expresses an interest in learning
Fear r/t possible outcome of interventional procedure
Ineffective peripheral Tissue Perfusion r/t vasospasm, hematoma formation
Risk for Bleeding: Risk factors: possible damage to coronary artery, hematoma formation
Risk for decreased Cardiac tissue perfusion: Risk factors: ventricular ischemia, dysrhythmias
Readiness for enhanced Knowledge: expresses an interest in learning
Anxiety r/t threat to role functioning, situational crisis
Decisional Conflict: interventions for fetus or newborn r/t lack of relevant information, spiritual distress, threat to value system
Parental Role Conflict r/t separation from newborn, intimidation with invasive or restrictive modalities, specialized care center policies
Disabled family Coping r/t chronically unresolved feelings about loss of perfect baby
Ineffective Coping r/t personal vulnerability in situational crisis
Interrupted Family Processes r/t unmet expectations for perfect baby, lack of adequate support systems
Fear r/t real or imagined threat to baby, implications for future pregnancies, powerlessness
Grieving r/t loss of ideal child
Hopelessness r/t long-term stress, deteriorating physical condition of child, lost spiritual belief
Deficient Knowledge r/t limited exposure to situation
Impaired Parenting r/t interruption of bonding process
Powerlessness r/t complication threatening fetus or newborn
Situational low Self-Esteem r/t perceived inability to produce a perfect child
Social Isolation r/t alterations in child’s physical appearance, altered state of wellness
Chronic Sorrow r/t loss of ideal child, inadequate bereavement support
Spiritual Distress r/t test of spiritual beliefs
Risk for impaired Attachment: Risk factor: ill infant unable to effectively initiate parental contact as result of altered behavioral organization
Risk for disorganized Infant behavior: Risk factor: congenital disorder
Risk for impaired Parenting: Risk factors: interruption of bonding process; unrealistic expectations for self, infant, or partner; perceived threat to own emotional survival; severe stress; lack of knowledge
Risk for Spiritual Distress: Risk factor: lack of normal child to raise and carry on family name
Disturbed Body Image r/t odor and drainage from rectal area
Acute Pain r/t inflammation of perirectal area
Risk for Constipation: Risk factor: fear of painful elimination
Readiness for enhanced Knowledge: expresses an interest in learning
Deficient Fluid Volume r/t inability to drink
Imbalanced Nutrition: less than body requirements r/t loss of appetite, nausea, vomiting, laxative abuse.
Activity Intolerance r/t fatigue, weakness
Disturbed Body Image r/t misconception of actual body appearance
Constipation r/t lack of adequate food, fiber, and fluid intake
Defensive Coping r/t psychological impairment, eating disorder
Disabled family Coping r/t highly ambivalent family relationships
Ineffective Denial r/t fear of consequences of therapy, possible weight gain
Interrupted Family Processes r/t situational crisis
Imbalanced Nutrition: less than body requirements r/t inadequate food intake, excessive exercise
Chronic low Self-Esteem r/t repeated unmet expectations
Ineffective Sexuality Pattern r/t loss of libido from malnutrition
Ineffective family Therapeutic Regimen Management r/t family conflict, excessive demands on family associated with complexity of condition and treatment
Risk for Infection: Risk factor: malnutrition resulting in depressed immune system
Imbalanced Nutrition: less than body requirements r/t loss of appetite associated with loss of smell
Urinary Retention r/t edema of urinary structures
Risk for urge urinary Incontinence: Risk factor: trauma to bladder
Readiness for enhanced Knowledge: expresses an interest in learning
Risk for Bleeding: Risk factors: altered clotting function from anticoagulant
Risk for deficient Fluid Volume: hemorrhage: Risk factor: altered clotting mechanism
Readiness for enhanced Knowledge: expresses an interest in learning
Defensive Coping r/t excessive use of projection
Ineffective Coping r/t frequently violating the norms and rules of society
Impaired Social Interaction r/t sociocultural conflict, chemical dependence, inability to form relationships
Spiritual Distress r/t separation from religious or cultural ties
Ineffective family Therapeutic Regimen Management r/t excessive demands on family
Risk for Loneliness: Risk factor: inability to interact appropriately with others
Risk for impaired Parenting: Risk factors: inability to function as parent or guardian, emotional instability
Risk for Self-Mutilation: Risk factors: self-hatred, depersonalization
Risk for other-directed Violence: Risk factor: history of violence, altered thought patterns
Ineffective Activity Planning r/t unrealistic perception of events
Anxiety r/t unmet security and safety needs
Death Anxiety r/t fears of unknown, powerlessness
Decisional Conflict r/t low self-esteem, fear of making a mistake
Defensive Coping r/t overwhelming feelings of dread
Disabled family Coping r/t ritualistic behavior, actions
Ineffective Coping r/t inability to express feelings appropriately
Ineffective Denial r/t overwhelming feelings of hopelessness, fear, threat to self
Disturbed Energy Field r/t hopelessness, helplessness
Insomnia r/t psychological impairment, emotional instability
Powerlessness r/t lifestyle of helplessness
Self-Care deficit r/t ritualistic behavior, activities
Sleep deprivation r/t prolonged psychological discomfort
Risk for Spiritual Distress: Risk factor: psychological distress
Readiness for enhanced Knowledge: expresses an interest in learning
Anxiety r/t situational crisis of aphasia
Impaired verbal Communication r/t decrease in circulation to brain
Ineffective Coping r/t loss of speech
Ineffective Health Maintenance r/t deficient knowledge regarding information on aphasia and alternative communication techniques
Activity Intolerance r/t imbalance between oxygen supply and demand
Fear r/t ability to live with serious disease
Risk for Bleeding: Risk factor: inadequate clotting factors
Risk for Infection: Risk factor: inadequate immune function
Readiness for enhanced Knowledge: expresses an interest in learning
See Premature Infant (Child); Premature Infant (Parent); SIDS (Sudden Infant Death Syndrome)
Ineffective Breathing Pattern r/t perception or cognitive impairment, neurological impairment
See cause of Apneustic Respirations
Deficient Fluid Volume r/t fluid restriction, hypermetabolic state, nausea, vomiting
Acute Pain r/t surgical incision
Delayed Surgical Recovery r/t rupture of appendix
Risk for Infection: Risk factors: perforation or rupture of appendix, surgical incision, peritonitis
Readiness for enhanced Knowledge: expresses an interest in learning
Deficient Fluid Volume r/t anorexia, nausea, vomiting
Risk for Infection: Risk factor: possible perforation of appendix
Readiness for enhanced Knowledge: expresses an interest in learning
Anxiety r/t threat to self-concept, threat to health status, situational crisis
Death Anxiety r/t apprehension over loss of self, consequences to significant others
Ineffective Airway Clearance r/t excessive tracheobronchial secretions
Death Anxiety r/t seriousness of physical disease
Impaired Gas Exchange r/t damage to alveolar capillary membrane, change in lung compliance
Impaired Spontaneous Ventilation r/t damage to alveolar capillary membrane
Activity Intolerance r/t chronic pain, fatigue, weakness
Disturbed Body Image r/t ineffective coping with joint abnormalities
Impaired physical Mobility r/t joint impairment
Chronic Pain r/t progression of joint deterioration
Self-Care deficit: specify r/t pain with movement, damage to joints
Readiness for enhanced Knowledge: expresses an interest in learning
See Total Joint Replacement (Total Knee, Total Hip, Shoulder); Surgery, Perioperative; Surgery, Postoperative; Surgery, Preoperative
Impaired physical Mobility r/t surgical trauma of knee
Readiness for enhanced Knowledge: expresses an interest in learning
Ineffective Breathing Pattern r/t increased abdominal girth
Imbalanced Nutrition: less than body requirements r/t loss of appetite
Chronic Pain r/t altered body function
Readiness for enhanced Knowledge: expresses an interest in learning
Ineffective Relationship r/t poor communication skills, lack of empathy
See Autism
Ineffective Breathing Pattern r/t depression of breathing reflex secondary to anoxia
Ineffective Coping r/t uncertainty of child outcome
Fear (parental) r/t concern over safety of infant
Impaired Gas Exchange r/t poor placental perfusion, lack of initiation of breathing by newborn
Grieving r/t loss of “perfect” child, concern of loss of future abilities
Impaired Spontaneous Ventilation r/t brain injury
Risk for impaired Attachment: Risk factors: ill infant who is unable to initiate parental contact, hospitalization in critical care environment
Risk for delayed Development: Risk factor: lack of oxygen to brain
Risk for disproportionate Growth: Risk factor: lack of oxygen to brain
Risk for disorganized Infant behavior: Risk factor: lack of oxygen to brain
Risk for Injury: Risk factor: lack of oxygen to brain
Risk for ineffective Cerebral tissue perfusion: Risk factor: poor placental perfusion or cord compression resulting in lack of oxygen to brain
Post-Trauma Syndrome r/t assault
Impaired individual Resilience r/t frightening experience, post-trauma stress response
Risk for Post-Trauma Syndrome: Risk factors: perception of event, inadequate social support, unsupportive environment, diminished ego strength, duration of event
Risk for Spiritual Distress: Risk factors: physical, psychological stress
Risk for Injury: Risk factors: confused thought process, impaired judgment
Risk for other-directed Violence: Risk factors: paranoid ideation, anger
Activity Intolerance r/t fatigue, energy shift to meet muscle needs for breathing to overcome airway obstruction
Ineffective Airway Clearance r/t tracheobronchial narrowing, excessive secretions
Anxiety r/t inability to breathe effectively, fear of suffocation
Disturbed Body Image r/t decreased participation in physical activities
Ineffective Breathing Pattern r/t anxiety
Ineffective Coping r/t personal vulnerability to situational crisis
Ineffective Self-Health Management (See Self-Health Management, ineffective, in Section III)
Impaired Home Maintenance r/t deficient knowledge regarding control of environmental triggers
Sleep deprivation r/t ineffective breathing pattern, cough
Readiness for enhanced Self-Health Management (See Self-Health Management, readiness for enhanced, in Section III)
Readiness for enhanced Knowledge: expresses an interest in learning
Anxiety r/t change in health status
Disturbed Body Image r/t staggering gait
Ineffective Breathing Pattern r/t loss of functional lung tissue, depression of respiratory function or hypoventilation because of pain
Impaired Gas Exchange r/t decreased alveolar-capillary surface
See MI (Myocardial Infarction); CVA (Cerebrovascular Accident); Peripheral Vascular Disease (PVD)
Impaired Skin Integrity r/t effects of fungal agent
Readiness for enhanced Knowledge: expresses an interest in learning
Risk-prone Health Behavior r/t intense emotional state
Disabled family Coping r/t significant person with chronically unexpressed feelings of guilt, anxiety, hostility, and despair
Ineffective Impulse Control r/t (See Impulse Control, ineffective, Section III)
Chronic low Self-Esteem r/t difficulty in participating in expected activities, poor school performance
Social Isolation r/t unacceptable social behavior
Risk for delayed Development: Risk factor: behavior disorders
Risk for Falls: Risk factor: rapid non-thinking behavior
Risk for Loneliness: Risk factor: social isolation
Risk for impaired Parenting: Risk factor: lack of knowledge of factors contributing to child’s behavior
Risk for Spiritual Distress: Risk factor: poor relationships
Impaired verbal Communication r/t speech and language delays
Compromised family Coping r/t parental guilt over etiology of disease, inability to accept or adapt to child’s condition, inability to help child and other family members seek treatment
Delayed Growth and Development r/t difficulty developing relationships with other human beings, inability to identify own body as separate from those of other people, inability to integrate concept of self
Disturbed personal Identity r/t inability to distinguish between self and environment, inability to identify own body as separate from those of other people, inability to integrate concept of self
Self-Neglect r/t impaired socialization
Impaired Social Interaction r/t communication barriers, inability to relate to others, failure to develop peer relationships
Risk for delayed Development: Risk factor: autism
Risk for Loneliness: Risk factors: difficulty developing relationships with other people
Risk for Self-Mutilation: Risk factor: autistic state
Risk for other-directed Violence: Risk factors: frequent destructive rages toward others secondary to extreme response to changes in routine, fear of harmless things
Risk for self-directed Violence: Risk factors: frequent destructive rages toward self, secondary to extreme response to changes in routine, fear of harmless things