Disturbed Body Image r/t psychological reaction to loss of hair
Imbalanced Nutrition: less than body requirements r/t inability to ingest food because of biological, psychological, economic factors
Anxiety r/t threat to self-concept
Acute Confusion r/t alcohol abuse, delirium, dementia, mental illness, drug abuse
Ineffective Coping r/t distortion and insecurity of life events
Adult Failure to Thrive r/t altered mental status
Risk for Self-Mutilation: Risk factor: command hallucinations
Risk for other-directed Violence: Risk factors: catatonic excitement, manic excitement, rage or panic reactions, response to violent internal stimuli
Risk for self-directed Violence: Risk factors: catatonic excitement, manic excitement, rage or panic reactions, response to violent internal stimuli
Ineffective Breathing Pattern r/t pressure damage to breathing center in brainstem
Acute Confusion r/t increased intracranial pressure
Decreased Intracranial Adaptive Capacity r/t increased intracranial pressure
Risk for ineffective Cerebral tissue perfusion: Risk factors: effects of increased intracranial pressure, trauma to brain
Disturbed Energy Field r/t disharmony
Acute Pain r/t lack of knowledge of pain control techniques or methods to prevent headaches
Ineffective Self-Health Management r/t lack of knowledge, identification, elimination of aggravating factors
Risk-prone Health Behavior: Risk factors: (See Health Behavior, risk-prone, Section III)
Ineffective Health Maintenance (See Health Maintenance, ineffective, Section III)
Ineffective Self-Health Management (See Self-Health Management, ineffective, Section III)
Readiness for enhanced Self-Health Management (See Self-Health Management, readiness for enhanced, Section III)
Hearing Loss r/t (See Hearing Loss, Section III)
Impaired verbal Communication r/t inability to hear own voice
Nausea r/t gastrointestinal irritation
Acute Pain: heartburn r/t inflammation of stomach and esophagus
Risk for imbalanced Nutrition: less than body requirements: Risk factor: pain after eating
Readiness for enhanced Knowledge: expresses an interest in learning
Unilateral Neglect r/t effects of disturbed perceptual abilities
Visual Loss r/t impaired sensory reception, transmission, integration
Anxiety r/t change in health status
Disturbed Body Image r/t functional loss of one side of body
Impaired physical Mobility r/t loss of neurological control of involved extremities
Unilateral Neglect r/t effects of disturbed perceptual abilities
Self-Care deficit: specify: r/t neuromuscular impairment
Impaired Transfer Ability r/t partial paralysis
Impaired Walking r/t loss of neurological control of involved extremities
Risk for Falls: Risk factor: impaired mobility
Risk for impaired Skin Integrity: Risk factors: alteration in sensation, immobility
Ineffective Coping r/t situational crisis
Interrupted Family Processes r/t changes in role responsibilities as a result of therapy regimen
Excess Fluid Volume r/t renal disease with minimal urine output
Powerlessness r/t treatment regimen
Risk for Caregiver Role Strain: Risk factor: complexity of care receiver treatment
Risk for Electrolyte Imbalance: Risk factor: effect of metabolic state on kidney function
Risk for deficient Fluid Volume: Risk factor: excessive removal of fluid during dialysis
Risk for Infection: Risk factors: exposure to blood products, risk for developing hepatitis B or C, impaired immune system
Risk for Injury: Risk factor: clotting of blood access: Risk factor: abnormal surface for blood flow
Readiness for enhanced Knowledge: expresses an interest in learning
See Renal Failure; Renal Failure, Child with Chronic Condition
Risk for Infection: Risk factor: invasive procedure
Risk for Injury: Risk factors: inadvertent wedging of catheter, dislodgement of catheter, disconnection of catheter
Deficient Fluid Volume r/t vomiting, diarrhea
Fear r/t serious condition with unknown outcome
Fatigue r/t decreased red blood cells
Risk for Injury: Risk factors: decreased platelet count, seizure activity
Fear r/t high risk for AIDS infection from contaminated blood products
Impaired physical Mobility r/t pain from acute bleeds, imposed activity restrictions, joint pain
Acute Pain r/t bleeding into body tissues
Risk for Bleeding: Risk factors: deficient clotting factors, child’s developmental level, age-appropriate play, inappropriate use of toys or sports equipment
Readiness for enhanced Knowledge: expresses an interest in learning
See Child with Chronic Condition; Hospitalized Child; Maturational Issues, Adolescent
Fear r/t serious threat to well-being
Risk for ineffective Airway Clearance: Risk factor: obstruction of airway with blood and mucus
Risk for deficient Fluid Volume: Risk factor: excessive loss of blood
Anxiety r/t embarrassment, need for privacy
Constipation r/t fear of pain with defecation
Acute Pain r/t surgical procedure
Urinary Retention r/t pain, anesthetic effect
Risk for Bleeding: Risk factors: inadequate clotting, trauma from surgery
Readiness for enhanced Knowledge: expresses an interest in learning
Impaired Comfort r/t itching in rectal area
Constipation r/t painful defecation, poor bowel habits
Readiness for enhanced Knowledge: expresses an interest in learning
Activity Intolerance r/t weakness or fatigue caused by infection
Deficient Diversional Activity r/t isolation
Fatigue r/t infectious process, altered body chemistry
Imbalanced Nutrition: less than body requirements r/t anorexia, impaired use of proteins and carbohydrates
Acute Pain r/t edema of liver, bile irritating skin
Social Isolation r/t treatment-imposed isolation
Risk for deficient Fluid Volume: Risk factor: excessive loss of fluids from vomiting and diarrhea
Readiness for enhanced Knowledge: expresses an interest in learning
Fear r/t threat to fetus, impending surgery
Situational low Self-Esteem r/t threat to fetus as a result of disease process
Risk for Infection (Infant): Risk factors: transplacental transfer during primary herpes, exposure to active herpes during birth process
Ineffective Health Maintenance r/t deficient knowledge regarding treatment, prevention, spread of disease
Acute Pain r/t active herpes lesion
Situational low Self-Esteem r/t expressions of shame or guilt
Sexual Dysfunction r/t disease process
Ineffective Health Maintenance r/t deficient knowledge regarding care of disease
Nausea r/t effects of gastric contents in esophagus
Imbalanced Nutrition: less than body requirements r/t pain after eating
Acute Confusion r/t sensory overload, sensory deprivation, medication side effects, advanced age, pain
Constipation r/t immobility, opioids, anesthesia
Fear r/t outcome of treatment, future mobility, present helplessness
Impaired physical Mobility r/t surgical incision, temporary absence of weight bearing, pain when walking
Acute Pain r/t injury, surgical procedure, movement
Powerlessness r/t health care environment
Self-Care deficit: specify r/t musculoskeletal impairment
Impaired Transfer Ability r/t immobilization of hip
Impaired Walking r/t temporary absence of weight bearing
Risk for Bleeding: Risk factors: postoperative complication, surgical blood loss
Risk for Infection: Risk factor: invasive procedure
Risk for Injury: Risk factors: activities such as greater than 90-degree flexion of hips that can result in dislodged prosthesis, unsteadiness when ambulating
Risk for Perioperative Positioning Injury: Risk factors: immobilization, muscle weakness, emaciation
Risk for Peripheral Neurovascular Dysfunction: Risk factor: trauma, vascular obstruction, fracture
Constipation: bowel obstruction r/t inhibited peristalsis as a result of congenital absence of parasympathetic ganglion cells in distal colon
Grieving r/t loss of perfect child, birth of child with congenital defect even though child expected to be normal within 2 years
Imbalanced Nutrition: less than body requirements r/t anorexia, pain from distended colon
Acute Pain r/t distended colon, incisional postoperative pain
Impaired Skin Integrity r/t stoma, potential skin care problems associated with stoma
Readiness for enhanced Knowledge: expresses an interest in learning
Acute Confusion r/t dementia, alcohol abuse, drug abuse, delirium
Risk for other-directed Violence (See Violence, other-directed, risk for, Section III)
Impaired Home Maintenance r/t impaired cognitive or emotional functioning, inadequate support system, insufficient finances
Impaired Home Maintenance (See Home Maintenance, impaired, Section III)
Self-Neglect r/t mental illness, substance abuse, cognitive impairment
Powerlessness r/t interpersonal interactions
Risk for Trauma: Risk factor: being in high-crime neighborhood
Activity Intolerance r/t fatigue associated with acute illness
Anxiety: separation (child) r/t familiar surroundings and separation from family and friends
Compromised family Coping r/t possible prolonged hospitalization that exhausts supportive capacity of significant people
Ineffective Coping: parent r/t possible guilt regarding hospitalization of child, parental inadequacies
Deficient Diversional Activity r/t immobility, monotonous environment, frequent or lengthy treatments, reluctance to participate, therapeutic isolation, separation from peers
Interrupted Family Processes r/t situational crisis of illness, disease, hospitalization
Fear r/t deficient knowledge or maturational level with fear of unknown, mutilation, painful procedures, surgery
Delayed Growth and Development r/t regression or lack of progression toward developmental milestones as a result of frequent or prolonged hospitalization, inadequate or inappropriate stimulation, cerebral insult, chronic illness, effects of physical disability, prescribed dependence
Hopelessness: child r/t prolonged activity restriction, uncertain prognosis
Insomnia: child or parent r/t 24-hour care needs of hospitalization
Acute Pain r/t treatments, diagnostic or therapeutic procedures, disease process
Powerlessness: child r/t health care environment, illness-related regimen
Risk for impaired Attachment: Risk factor: separation
Risk for delayed Growth and Development: regression: Risk factors: disruption of normal routine, unfamiliar environment or caregivers, developmental vulnerability of young children
Risk for Injury: Risk factors: unfamiliar environment, developmental age, lack of parental knowledge regarding safety (e.g., side rails, IV site/pole)
Risk for imbalanced Nutrition: less than body requirements: Risk factors: anorexia, absence of familiar foods, cultural preferences
Readiness for enhanced family Coping: impact of crisis on family values, priorities, goals, relationships in family
Ineffective Self-Health Management (See Self-Health Management, ineffective, Section III)
Imbalanced Nutrition: more than body requirements r/t lack of knowledge of relationship between diet and disease process
Readiness for enhanced Self-Health Management (See Self-Health Management, readiness for enhanced, Section III)
See AIDS (Acquired Immunodeficiency Syndrome); HIV (Human Immunodeficiency Virus)
Risk for compromised Human Dignity (See Human Dignity, compromised, risk for, Section III)
Acute Pain r/t severely enlarged hydrocele
Ineffective Sexuality Pattern r/t recent surgery on area of scrotum
Decisional Conflict r/t unclear or conflicting values regarding selection of treatment modality
Interrupted Family Processes r/t situational crisis
Delayed Growth and development r/t sequelae of increased intracranial pressure
Imbalanced Nutrition: less than body requirements r/t inadequate intake as a result of anorexia, nausea, vomiting, feeding difficulties
Risk for delayed Development: Risk factor: sequelae of increased intracranial pressure
Risk for disproportionate Growth: Risk factor: sequelae of increased intracranial pressure
Risk for Infection: Risk factor: sequelae of invasive procedure (shunt placement)
Risk for ineffective Cerebral tissue perfusion: Risk factors: interrupted flow, hypervolemia of cerebral ventricles
See Normal Pressure Hydrocephalus (NPH); Child with Chronic Condition; Hospitalized Child; Mental Retardation (if appropriate); Premature Infant (Child); Premature Infant (Parent)
Adult Failure to Thrive r/t depression, apathy as evidenced by inability to perform self-care
Self-Neglect (See Self-Neglect, Section III)
Bathing Self-Care deficit (See Self-Care deficit, bathing, Section III)
Decisional Conflict r/t multiple or divergent sources of information regarding education, nutrition, medication regimens; willingness to change own food habits; limited resources
Parental Role Conflict: when siblings present r/t increased attention toward hyperactive child
Compromised family Coping r/t unsuccessful strategies to control excessive activity, behaviors, frustration, anger
Ineffective Impulse Control r/t disorder of development, environment that might cause frustration or irritation
Ineffective Role Performance: parent r/t stressors associated with dealing with hyperactive child, perceived or projected blame for causes of child’s behavior, unmet needs for support or care, lack of energy to provide for those needs
Chronic low Self-Esteem r/t inability to achieve socially acceptable behaviors; frustration; frequent reprimands, punishment, or scolding for uncontrolled activity and behaviors; mood fluctuations and restlessness; inability to succeed academically; lack of peer support
Impaired Social Interaction r/t impulsive and overactive behaviors, concomitant emotional difficulties, distractibility and excitability
Risk for delayed Development: Risk factor: behavior disorders
Risk for impaired Parenting: Risk factor: disruptive or uncontrollable behaviors of child
Risk for other-directed Violence: parent or child: Risk factors: frustration with disruptive behavior, anger, unsuccessful relationships
Anxiety: parent r/t threat to infant, unknown future
Parental Role Conflict r/t interruption of family life because of care regimen
Neonatal Jaundice r/t abnormal breakdown of red blood cells following birth
Imbalanced Nutrition: less than body requirements (infant) r/t disinterest in feeding because of jaundice-related lethargy
Risk for disproportionate Growth: infant: Risk factor: disinterest in feeding because of jaundice-related lethargy
Risk for imbalanced body Temperature: infant: Risk factor: phototherapy
Risk for Injury: infant: Risk factors: kernicterus, phototherapy lights
Decreased Cardiac Output r/t bradydysrhythmia
Impaired physical Mobility r/t decreased muscle tone
Imbalanced Nutrition: less than body requirements r/t gastrointestinal manifestations of hypercalcemia (nausea, anorexia, ileus)
Risk for Disuse Syndrome: Risk factor: comatose state impairing mobility
Impaired Gas Exchange r/t ventilation-perfusion imbalance, retention of carbon dioxide
See cause of Hypercapnia
Anxiety r/t threat to self and infant, hospitalization
Deficient Fluid Volume r/t excessive vomiting
Impaired Home Maintenance r/t chronic nausea, inability to function
Nausea r/t hormonal changes of pregnancy
Imbalanced Nutrition: less than body requirements r/t excessive vomiting
Ineffective Self-Health Management r/t complexity of therapeutic regimen, decisional conflicts, economic difficulties, unsupportive family, insufficient cues to action, deficient knowledge, mistrust, lack of acknowledgment of seriousness of condition
Risk for unstable blood Glucose level (See Glucose level, blood, unstable, risk for, Section III)
Risk for Activity Intolerance: Risk factor: muscle weakness
Risk for excess Fluid Volume: Risk factor: untreated renal failure
Risk for decreased Cardiac tissue perfusion: Risk factor: abnormal electrolyte level affecting heart electrical conduction
Risk for deficient Fluid Volume: Risk factors: abnormal water loss, inadequate water intake
Acute Confusion r/t dehydration, electrolyte imbalance
Deficient Fluid Volume r/t polyuria, inadequate fluid intake
Risk for Electrolyte Imbalance: Risk factors: effect of metabolic state on kidney function
Risk for Injury: seizures: Risk factors: hyperosmolar state, electrolyte imbalance
Deficient Knowledge r/t dietary changes needed to control phosphate levels
See Renal Failure
Defensive Coping r/t situational crisis, psychological impairment, substance abuse
Anxiety r/t increased stimulation, loss of control
Diarrhea r/t increased gastric motility
Insomnia r/t anxiety, excessive sympathetic discharge
Imbalanced Nutrition: less than body requirements r/t increased metabolic rate, increased gastrointestinal activity
Risk for Injury: eye damage: Risk factor: protruding eyes without sufficient lubrication
Readiness for enhanced Knowledge: expresses an interest in learning
Ineffective Breathing Pattern r/t anxiety, acid-base imbalance
See cause of Hyperventilation
Activity Intolerance r/t neuromuscular irritability
Ineffective Breathing Pattern r/t laryngospasm
Imbalanced Nutrition: less than body requirements r/t effects of vitamin D deficiency, renal failure, malabsorption, laxative use
Acute Confusion r/t insufficient blood glucose to brain
Ineffective Self-Health Management r/t deficient knowledge regarding disease process, self-care
Imbalanced Nutrition: less than body requirements r/t imbalance of glucose and insulin level
Risk for unstable blood Glucose level (See Glucose level, blood, unstable, risk for, Section III)
Activity Intolerance r/t muscle weakness
Risk for decreased Cardiac tissue perfusion: Risk factor: possible dysrhythmia from electrolyte imbalance
Imbalanced Nutrition: less than body requirements r/t deficient knowledge of nutrition, alcoholism
See Alcoholism
Acute Confusion r/t electrolyte imbalance
Excess Fluid Volume r/t excessive intake of hypotonic fluids
Risk for Injury: Risk factors: seizures, new onset of confusion
Decreased Cardiac Output r/t decreased preload, decreased contractility
Risk for deficient Fluid Volume: Risk factor: excessive fluid loss
Risk for ineffective Cerebral tissue perfusion: Risk factors: hypovolemia, decreased contractility, decreased afterload
Risk for ineffective Gastrointestinal Perfusion (See Gastrointestinal Perfusion, ineffective, risk for, Section III)
Risk for ineffective Renal Perfusion: Risk factor: prolonged ischemia of kidneys
Risk for Shock (See Shock, risk for, Section III)
See cause of Hypotension
Activity Intolerance r/t muscular stiffness, shortness of breath on exertion
Constipation r/t decreased gastric motility
Impaired Gas Exchange r/t respiratory depression
Imbalanced Nutrition: more than body requirements r/t decreased metabolic process
Acute Confusion r/t decreased oxygen supply to brain
Impaired Gas Exchange r/t altered oxygen supply, inability to transport oxygen
Risk for Shock (See Shock, risk for, Section III)
Constipation r/t opioids, anesthesia, bowel manipulation during surgery
Ineffective Coping r/t situational crisis of surgery
Grieving r/t change in body image, loss of reproductive status
Acute Pain r/t surgical injury
Sexual Dysfunction r/t disturbance in self-concept
Urinary Retention r/t edema in area, anesthesia, opioids, pain
Risk for Bleeding: Risk factor: surgical procedure
Risk for Constipation: Risk factors: opioids, anesthesia, bowel manipulation during surgery
Risk for ineffective peripheral Tissue Perfusion: Risk factor: deficient knowledge of aggravating factors
Readiness for enhanced Knowledge: Expresses an interest in learning
See Surgery, Perioperative; Surgery, Preoperative; Surgery, Postoperative