Hearing Loss r/t alteration in sensory reception, transmission, integration
Impaired verbal Communication r/t impaired hearing
Risk for Sudden Infant Death Syndrome (SIDS) (See death Syndrome, infant, sudden, Risk for, Section III)
Death Anxiety r/t unresolved issues surrounding dying
Compromised family Coping r/t client’s inability to provide support to family
Ineffective Coping r/t personal vulnerability
Grieving r/t loss of significant other
Powerlessness r/t effects of illness, oncoming death
Social Isolation r/t altered state of wellness
Spiritual Distress r/t intense suffering
Readiness for enhanced Spiritual Well-Being: desire of client and family to be in harmony with each other and higher power, God
See 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
Decisional Conflict r/t support system deficit, perceived threat to value system, multiple or divergent sources of information, lack of relevant information, unclear personal values or beliefs
Readiness for enhanced Decision-Making (See Decision-Making, readiness for enhanced, Section III)
Defensive Coping r/t nonacceptance of blame, denial of problems or weakness
Ineffective Denial r/t inability to face situation realistically
Fear r/t threat of death, severe dysfunction
Acute Pain r/t stretching of abdominal wall
Impaired Skin Integrity r/t altered circulation, malnutrition, opening in incision
Delayed Surgical Recovery r/t altered circulation, malnutrition, opening in incision
Impaired Tissue Integrity r/t exposure of abdominal contents to external environment
Risk for deficient Fluid Volume: Risk factor: altered circulation associated with opening of wound and exposure of abdominal contents
Risk for Infection: Risk factor: loss of skin integrity, open surgical wound
Deficient Fluid Volume r/t active fluid volume loss
Impaired Oral Mucous Membrane r/t decreased salivation, fluid deficit
Readiness for enhanced Knowledge: expresses an interest in learning
See cause of Dehydration
Acute Confusion r/t effects of medication, response to hospitalization, alcohol abuse, substance abuse, sensory deprivation or overload, infection, polypharmacy
Adult Failure to Thrive r/t delirium
Sleep deprivation r/t nightmares
Risk for Injury: Risk factor: altered level of consciousness
Impaired verbal Communication r/t psychological impairment, delusional thinking
Acute Confusion r/t alcohol abuse, delirium, dementia, drug abuse
Ineffective Coping r/t distortion and insecurity of life events
Adult Failure to Thrive r/t delusional state
Fear r/t content of intrusive thoughts
Risk for other-directed Violence: Risk factor: delusional thinking
Risk for self-directed Violence: Risk factor: delusional thinking
Chronic Confusion r/t neurological dysfunction
Impaired Environmental Interpretation Syndrome r/t dementia
Adult Failure to Thrive r/t depression, apathy
Interrupted Family Processes r/t disability of family member
Impaired Home Maintenance r/t inadequate support system, neurological dysfunction
Functional urinary Incontinence r/t neurological dysfunction
Insomnia r/t neurological impairment, naps during the day
Impaired physical Mobility r/t neuromuscular impairment
Self-Neglect r/t cognitive impairment
Imbalanced Nutrition: less than body requirements r/t neurological impairment
Self-Care deficit: specify r/t psychological or neuromuscular impairment
Impaired Swallowing r/t neuromuscular changes associated with long-standing dementia
Chronic Sorrow: Significant other r/t chronic long-standing disability, loss of mental function
Risk for Caregiver Role Strain: Risk factors: number of caregiving tasks, duration of caregiving required
Risk for Falls: Risk factor: diminished mental status
Risk for Injury: Risk factors: confusion, decreased muscle coordination
Risk for impaired Skin Integrity: Risk factors: altered nutritional status, immobility
Ineffective Denial r/t lack of perception about the health status effects of illness
Ineffective Self-Health Management r/t denial of seriousness of health situation
Impaired Dentition r/t ineffective oral hygiene, barriers to self-care, economic barriers to professional care, nutritional deficits, dietary habits
Ineffective Self-Health Maintenance r/t lack of knowledge regarding prevention of dental disease
Death Anxiety r/t feelings of lack of self-worth
Constipation r/t inactivity, decreased fluid intake
Disturbed Energy Field r/t disharmony
Impaired Environmental Interpretation Syndrome r/t severe mental functional impairment
Adult Failure to Thrive r/t depression
Fatigue r/t psychological demands
Ineffective Health Maintenance r/t lack of ability to make good judgments regarding ways to obtain help
Hopelessness r/t feeling of abandonment, long-term stress
Self-Neglect r/t depression, cognitive impairment
Powerlessness r/t pattern of helplessness
Chronic low Self-Esteem r/t repeated unmet expectations
Sexual Dysfunction r/t loss of sexual desire
Social Isolation r/t ineffective coping
Chronic Sorrow r/t unresolved grief
Risk for complicated Grieving: Risk factor: lack of previous resolution of former grieving response
Anxiety r/t situational crisis imposed by illness
Impaired Skin Integrity r/t side effect of medication, allergic reaction
Readiness for enhanced Knowledge: expresses an interest in learning
See Itching
Risk-prone Health Behavior r/t intense emotional state
Ineffective Coping r/t situational crises, maturational crises, disturbance in pattern of appraisal of threat
Risk for other-directed Violence (See Violence, other-directed, risk for, Section III)
Delayed Growth and Development (See Growth and Development, delayed, Section III)
Risk for delayed Development (See Development, delayed, risk for, Section III)
Deficient Fluid Volume r/t inability to conserve fluid
Ineffective Health Maintenance r/t deficient knowledge regarding care of disease, importance of medications
Adult Failure to Thrive r/t undetected disease process
Ineffective Health Maintenance r/t complexity of therapeutic regimen
Ineffective Self-Health Management (See Self-Health Management, ineffective, Section III)
Imbalanced Nutrition: less than body requirements r/t inability to use glucose (type 1 [insulin-dependent] diabetes)
Imbalanced Nutrition: more than body requirements r/t excessive intake of nutrients (type 2 diabetes)
Ineffective peripheral Tissue Perfusion r/t impaired arterial circulation
Powerlessness r/t perceived lack of personal control
Sexual Dysfunction r/t neuropathy associated with disease
Vision Loss r/t ineffective tissue perfusion of retina
Risk for unstable blood Glucose level (See Glucose level, blood, unstable, risk for, Section III)
Risk for Infection: Risk factors: hyperglycemia, impaired healing, circulatory changes
Risk for Injury: Risk factors: hypoglycemia or hyperglycemia from failure to consume adequate calories, failure to take insulin
Risk for dysfunctional Gastrointestinal Motility: Risk factor: complication of diabetes
Risk for impaired Skin Integrity: Risk factor: loss of pain perception in extremities
Readiness for enhanced Self-Health Management (See Self-Health Management, readiness for enhanced, Section III)
Readiness for enhanced Knowledge: expresses an interest in learning
Risk-prone Health Behavior r/t inadequate comprehension, inadequate social support, low self-efficacy, impaired adjustment attributable to adolescent maturational crises
Disturbed Body Image r/t imposed deviations from biophysical and psychosocial norm, perceived differences from peers
Impaired Comfort r/t insulin injections, peripheral blood glucose testing
Ineffective Health Maintenance r/t (See Health Maintenance, ineffective, Section III)
Imbalanced Nutrition: less than body requirements r/t inability of body to adequately metabolize and use glucose and nutrients, increased caloric needs of child to promote growth and physical activity participation with peers
Readiness for enhanced Knowledge: expresses an interest in learning
See Diabetes Mellitus; Child with Chronic Condition; Hospitalized Child
Acute Confusion r/t hyperglycemia, presence of excessive metabolic acids
Deficient Fluid Volume r/t hyperglycemia resulting in polyuria
Ineffective Self-Health Management r/t lack of understanding of preventive measures, adequate blood sugar control
Risk for unstable blood Glucose level (See Glucose level, blood, unstable, risk for, Section III)
Risk for Infection: Risk factors: hyperglycemia, changes in vascular system
Ineffective Health Maintenance r/t deficient knowledge regarding preserving vision with treatment if possible, use of low-vision aids
Diarrhea r/t infection, change in diet, gastrointestinal disorders, stress, medication effect, impaction
Deficient Fluid Volume r/t excessive loss of fluids in liquid stools.
Risk for Electrolyte Imbalance: Risk factor: effect of loss of electrolytes from frequent stools
Deficient Fluid Volume: hemorrhage r/t depletion of clotting factors
Risk for Bleeding: Risk factors: microclotting within vascular system, depleted clotting factors
Risk for ineffective Gastrointestinal Perfusion (See Gastrointestinal Perfusion, ineffective, risk for, Section III)
Decreased Cardiac Output r/t drug toxicity affecting cardiac rhythm, rate
Ineffective Self-Health Management r/t deficient knowledge regarding action, appropriate method of administration of digitalis
Risk for compromised Human Dignity (See Human Dignity, compromised, risk for, Section III)
Acute Pain r/t uterine contractions
Risk for Bleeding: Risk factor: surgical procedure
Risk for Infection: Risk factor: surgical procedure
Risk for ineffective Sexuality Pattern: Risk factors: painful coitus, fear associated with surgery on genital area
Readiness for enhanced Knowledge: expresses an interest in learning
Self-Neglect r/t mental illness, substance abuse, cognitive impairment
Impaired Home Maintenance r/t family member’s disease or injury interfering with home maintenance
Deficient Knowledge r/t lack of exposure to information for home care
Readiness for enhanced Knowledge: expresses an interest in learning
Disturbed Body Image r/t pregnancy-induced body changes
Impaired Comfort r/t enlarged abdomen, swollen feet
Fatigue r/t hormonal, metabolic, body changes
Stress urinary Incontinence r/t enlarged uterus, fetal movement
Insomnia r/t psychological stress, fetal movement, muscular cramping, urinary frequency, shortness of breath
Acute Pain: headache r/t hormonal changes of pregnancy
Acute Pain: leg cramps r/t nerve compression, calcium/phosphorus/potassium imbalance
Risk for Constipation: Risk factors: decreased intestinal motility, inadequate fiber in diet
Risk for Injury: Risk factors: faintness and/or syncope caused by vasomotor lability or postural hypotension, venous stasis in lower extremities
Acute Pain r/t dislocation of a joint
Anxiety r/t psychosocial stress
Ineffective Coping r/t personal vulnerability in crisis of accurate self-perception
Disturbed personal Identity r/t inability to distinguish self caused by multiple personality disorder, depersonalization, disturbance in memory
Impaired Memory r/t altered state of consciousness
See Multiple Personality Disorder (Dissociative Identity Disorder)
Anxiety r/t situational crises, maturational crises
Death Anxiety r/t denial of one’s own mortality or impending death
Disturbed Energy Field r/t disruption in flow of energy as result of pain, depression, fatigue, anxiety, stress
Risk for Disuse Syndrome: Risk factors: paralysis, mechanical immobilization, prescribed immobilization, severe pain, altered level of consciousness
Deficient Diversional Activity r/t environmental lack of diversional activity as in frequent hospitalizations, lengthy treatments
Constipation r/t dietary deficiency of fiber and roughage
Diarrhea r/t increased intestinal motility caused by inflammation
Deficient Knowledge r/t diet needed to control disease, medication regimen
Imbalanced Nutrition: less than body requirements r/t loss of appetite
Decreased Cardiac Output r/t dysfunctional electrical conduction
Deficient Knowledge r/t actions to take to prevent or modify dizziness and prevent falls
Impaired physical Mobility r/t dizziness
Risk for Falls: Risk factor: difficulty maintaining balance
Risk for ineffective Cerebral tissue perfusion: Risk factor: interruption of cerebral arterial blood flow
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
Fear r/t threat to self-concept, situational crisis of abuse
Insomnia r/t psychological stress
Post-Trauma Syndrome r/t history of abuse
Powerlessness r/t lifestyle of helplessness
Situational low Self-Esteem r/t negative family interactions
Risk for compromised Resilience: Risk factor: effects of abuse
Risk for other-directed Violence: Risk factor: history of abuse
Dressing Self-Care deficit r/t intolerance to activity, decreased strength and endurance, pain, discomfort, perceptual or cognitive impairment, neuromuscular impairment, musculoskeletal impairment, depression, severe anxiety
Overflow urinary Incontinence r/t degenerative changes in pelvic muscles and urinary structures
Stress urinary Incontinence r/t degenerative changes in pelvic muscles and urinary structures
Impaired individual Resilience (See Resilience, individual, impaired, Section III)
Anxiety r/t threat to self-concept, lack of control of drug use
Risk-prone Health Behavior r/t addiction
Ineffective Coping r/t situational crisis
Ineffective Denial r/t use of drugs affecting quality of own life and that of significant others
Imbalanced Nutrition: less than body requirements r/t poor eating habits
Powerlessness r/t feeling unable to change patterns of drug abuse
Impaired individual Resilience (See Resilience, individual, impaired, Section III)
Sexual Dysfunction r/t actions and side effects of drug abuse
Sleep deprivation r/t prolonged psychological discomfort
Impaired Social Interaction r/t disturbed thought processes from drug abuse
Spiritual Distress r/t separation from religious, cultural ties
Risk for Injury: Risk factors: hallucinations, drug effects
Risk for other-directed Violence: Risk factor: poor impulse control
Anxiety r/t physiological withdrawal
Acute Confusion r/t effects of substance withdrawal
Ineffective Coping r/t situational crisis, withdrawal
Insomnia r/t effects of medication withdrawal
Imbalanced Nutrition: less than body requirements r/t poor eating habits
Risk for other-directed Violence: Risk factors: poor impulse control, hallucinations
Risk for self-directed Violence: Risk factors: poor impulse control, hallucinations
See Drug Abuse
Risk for dry Eye: Risk factors: (See dry Eye, risk for, Section III)
Readiness for enhanced Knowledge: expresses an interest in learning
Constipation r/t inactivity, bed rest
Impaired physical Mobility r/t pain in extremity
Acute Pain r/t vascular inflammation, edema
Ineffective peripheral Tissue Perfusion r/t deficient knowledge of aggravating factors
Delayed Surgical Recovery r/t impaired physical mobility
Readiness for enhanced Knowledge: expresses an interest in learning
See Terminally Ill Adult; Terminally Ill 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
Imbalanced Nutrition: less than body requirements r/t psychological factors
Imbalanced Nutrition: more than body requirements r/t psychological factors
See Anorexia Nervosa; Bulimia; Maturational Issues, Adolescent; Obesity
Dysfunctional Ventilatory Weaning Response r/t physical, psychological, situational factors
Nausea r/t prostaglandin effect
Acute Pain r/t cramping from hormonal effects
Readiness for enhanced Knowledge: expresses an interest in learning
Sexual Dysfunction r/t lack of lubrication during intercourse, alteration in reproductive organ function
Anxiety r/t pressures of personal role
Acute Pain r/t gastrointestinal disease, consumption of irritating foods
Readiness for enhanced Knowledge: expresses an interest in learning
Impaired Swallowing r/t neuromuscular impairment
Risk for Aspiration: Risk factor: loss of gag or cough reflex
Activity Intolerance r/t imbalance between oxygen supply and demand
Ineffective Breathing Pattern r/t compromised cardiac or pulmonary function, decreased lung expansion, neurological impairment affecting respiratory center, extreme anxiety
Fear r/t threat to state of well-being, potential death
Impaired Gas Exchange r/t alveolar-capillary damage
Insomnia r/t difficulty breathing, positioning required for effective breathing
Activity Intolerance r/t decreased cardiac output
Decreased Cardiac Output r/t altered electrical conduction
Fear r/t threat of death, change in health status
Risk for ineffective Cerebral tissue perfusion: Risk factor: decreased blood supply to the brain from dysrhythmia
Readiness for enhanced Knowledge: expresses an interest in learning
Ineffective Coping r/t impaired social interaction
Ineffective Health Maintenance r/t inability to make good judgments regarding ways to obtain help
Chronic low Self-Esteem r/t repeated unmet expectations
Ineffective Sexuality Pattern r/t loss of sexual desire
Anxiety r/t difficult labor, deficient knowledge regarding normal labor pattern
Ineffective Coping r/t situational crisis
Grieving r/t loss of ideal labor experience
Acute Pain r/t difficult labor, medical interventions
Powerlessness r/t perceived inability to control outcome of labor
Risk for Bleeding: Risk factor: hemorrhage secondary to uterine atony
Risk for delayed Development (Infant): Risk factor: difficult labor and birth
Risk for disproportionate Growth: Risk factor: difficult labor and birth
Risk for Infection: Risk factor: prolonged rupture of membranes
Risk for ineffective Cerebral tissue perfusion (fetal): Risk factor: difficult labor and birth
Risk for impaired Tissue Integrity (maternal and fetal): Risk factor: difficult labor