Constipation r/t low-residue diet, stress
Diarrhea r/t increased motility of intestines associated with disease process, stress
Ineffective Self-Health Management r/t deficient knowledge, powerlessness
Chronic Pain r/t spasms, increased motility of bowel
Readiness for enhanced Self-Health Management: expressed desire to manage illness and prevent onset of symptoms
Decreased Cardiac Output r/t possible dysrhythmia
Readiness for enhanced Knowledge: expresses an interest in learning
Disturbed personal Identity r/t situational crisis, psychological impairment, chronic illness, pain
Risk for disturbed personal Identity (See Identity, personal, risk for disturbed in Section III)
Disturbed Body Image r/t presence of stoma
Ineffective Self-Health Management r/t new skills required to care for appliance and self
Ineffective Sexuality Pattern r/t altered body function and structure
Social Isolation r/t alteration in physical appearance, fear of accidental spill of urine
Risk for Latex Allergy Response: Risk factor: repeated exposures to latex associated with treatment and management of disease
Risk for impaired Skin Integrity: Risk factor: difficulty obtaining tight seal of appliance
Readiness for enhanced Knowledge: expresses an interest in learning
Disturbed Body Image r/t presence of stoma
Diarrhea r/t dietary changes, alteration in intestinal motility
Deficient Knowledge r/t limited practice of stoma care, dietary modifications
Ineffective Sexuality Pattern r/t altered body function and structure
Social Isolation r/t alteration in physical appearance, fear of accidental spill of ostomy contents
Risk for impaired Skin Integrity: Risk factors: difficulty obtaining tight seal of appliance, caustic drainage
Readiness for enhanced Knowledge: expresses an interest in learning
Deficient Fluid Volume r/t loss of fluids from vomiting, fluids trapped in bowel
Dysfunctional Gastrointestinal Motility r/t effects of surgery, decreased perfusion of intestines, medication effect, immobility
Nausea r/t gastrointestinal irritation
Acute Pain r/t pressure, abdominal distention
Readiness for enhanced Knowledge: expresses an interest in learning
Ineffective Breathing Pattern r/t inability to deep breathe in supine position
Acute Confusion: elderly r/t sensory deprivation from immobility
Adult Failure to Thrive r/t limited physical mobility
Impaired physical Mobility r/t medically imposed bed rest
Ineffective peripheral Tissue Perfusion r/t interruption of venous flow
Powerlessness r/t forced immobility from health care environment
Impaired Walking r/t limited physical mobility, deconditioning of body
Risk for Disuse Syndrome: Risk factor: immobilization
Risk for impaired Skin Integrity: Risk factors: pressure on immobile parts, shearing forces when moved
Readiness for enhanced Knowledge: expresses an interest in learning
Readiness for enhanced Immunization Status (See Immunization Status, readiness for enhanced, Section III)
Constipation r/t decreased fluid intake, less than adequate amounts of fiber and bulk-forming foods in diet, medication effect, or immobility
Anxiety r/t ability to care for newborn
Impaired Skin Integrity r/t infectious disease
Readiness for enhanced Knowledge: expresses an interest in learning
Situational low Self-Esteem r/t physiological crisis, inability to practice usual sexual activity
Sexual Dysfunction r/t altered body function
Readiness for enhanced Knowledge: treatment information for erectile dysfunction
Activity Intolerance r/t imbalance between oxygen supply and demand, sedentary lifestyle, weakness, immobility
Hopelessness r/t deteriorating physiological condition, long-term stress, social isolation
Impaired physical Mobility r/t intolerance to activity, decreased strength and endurance, depression, severe anxiety, musculoskeletal impairment, perceptual or cognitive impairment, neuromuscular impairment, pain, discomfort
Risk for Constipation: Risk factor: insufficient physical activity
Disturbed Body Image r/t inability to control elimination of stool
Bowel Incontinence r/t decreased awareness of need to defecate, loss of sphincter control
Toileting Self-Care deficit r/t cognitive impairment, neuromuscular impairment, perceptual impairment, weakness.
Situational low Self-Esteem r/t inability to control elimination of stool
Risk for impaired Skin Integrity: Risk factor: presence of stool
Functional urinary Incontinence r/t altered environment; sensory, cognitive, or mobility deficits
Overflow urinary Incontinence r/t relaxation of pelvic muscles and changes in urinary structures
Reflex urinary Incontinence r/t neurological impairment
Stress urinary Incontinence (See Incontinence, urinary, stress, Section III)
Urge urinary Incontinence (See Incontinence, urinary, urge, Section III)
Toileting Self-Care deficit r/t cognitive impairment
Situational low Self-Esteem r/t inability to control passage of urine
Risk for impaired Skin Integrity: Risk factor: presence of urine on perineal skin
Nausea r/t gastrointestinal irritation
Imbalanced Nutrition: less than body requirements r/t discomfort when eating
Anxiety r/t medical interventions, powerlessness
Decisional Conflict r/t perceived threat to idealized birth
Ineffective Coping r/t situational crisis of medical intervention in birthing process
Situational low Self-Esteem r/t inability to carry out normal labor
Risk for Injury: maternal and fetal: Risk factors: hypertonic uterus, potential prematurity of newborn
Readiness for enhanced Family Processes: family support during induction of labor
See Premature Infant (Child); Respiratory Conditions of the Neonate; SIDS (Sudden Infant Death Syndrome)
Disorganized Infant behavior r/t pain, oral/motor problems, feeding intolerance, environmental overstimulation, lack of containment or boundaries, prematurity, invasive or painful procedures
Risk for disorganized Infant behavior: Risk factors: pain, oral/motor problems, environmental overstimulation, lack of containment or boundaries
Readiness for enhanced organized Infant behavior: stable physiologic measures, use of some self-regulatory measures
Readiness for enhanced Childbearing Process: a pattern of preparing for, maintaining, and strengthening care of newborn infant
Ineffective infant Feeding Pattern r/t prematurity, neurological impairment or delay, oral hypersensitivity, prolonged nothing-by-mouth order
Decreased Cardiac Output r/t cardiomegaly
Deficient Fluid Volume r/t increased urinary excretion and osmotic diuresis
Delayed Growth and Development r/t prolonged and severe postnatal hypoglycemia
Imbalanced Nutrition: less than body requirements r/t hypotonia, lethargy, poor sucking, postnatal metabolic changes from hyperglycemia to hypoglycemia and hyperinsulinism
Risk for delayed Development: Risk factors: prolonged and severe postnatal hypoglycemia
Risk for impaired Gas Exchange: Risk factors: increased incidence of cardiomegaly, prematurity
Risk for unstable blood Glucose level: Risk factor: metabolic change from hyperglycemia to hypoglycemia and hyperinsulinism
Risk for disproportionate Growth: Risk factors: prolonged and severe postnatal hypoglycemia
Risk for disturbed Maternal-Fetal Dyad: Risk factor: impaired glucose metabolism
See Premature Infant (Child); Respiratory Conditions of the Neonate
Ineffective Airway Clearance r/t pooling of secretions from the lack of adequate cough reflex, effects of viral or bacterial lower airway infection as a result of altered protective state
Interrupted Breastfeeding r/t use of drugs or alcohol by mother
Diarrhea r/t effects of withdrawal, increased peristalsis from hyperirritability
Ineffective infant Feeding Pattern r/t uncoordinated or ineffective sucking reflex
Delayed Growth and Development r/t effects of maternal use of drugs, effects of neurological impairment, decreased attentiveness to environmental stimuli or inadequate stimuli
Disorganized Infant behavior r/t exposure and or withdrawal from toxic substances (alcohol and drugs)
Ineffective Childbearing Process r/t inconsistent prenatal health visits, suboptimal maternal nutrition, substance abuse
Insomnia r/t hyperirritability or hypersensitivity to environmental stimuli
Imbalanced Nutrition: less than body requirements r/t feeding problems; uncoordinated or ineffective suck and swallow; effects of diarrhea, vomiting, or colic associated with maternal substance abuse
Impaired Parenting r/t impaired or absent attachment behaviors, inadequate support systems
Risk for delayed Development: Risk factor: substance abuse
Risk for disproportionate Growth: Risk factor: substance abuse
Risk for Infection: skin, meningeal, respiratory: Risk factor: stress effects of withdrawal
See Cerebral Palsy; Child with Chronic Condition; Crack Baby; Failure to Thrive, Nonorganic; Hospitalized Child; Hyperactive Syndrome; Premature Infant (Child); SIDS (Sudden Infant Death Syndrome)
Hyperthermia r/t increased metabolic rate
Ineffective Protection r/t inadequate nutrition, abnormal blood profiles, drug therapies, treatments
Risk for Vascular Trauma: Risk factor: infusion of antibiotics
Ineffective Self-Health Management r/t deficient knowledge about infertility
Ineffective Coping r/t repeated episodes of diarrhea
Diarrhea r/t effects of inflammatory changes of the bowel
Deficient Fluid Volume r/t frequent and loose stools
Imbalanced Nutrition: less than body requirements r/t anorexia, decreased absorption of nutrients from gastrointestinal tract
Acute Pain r/t abdominal cramping and anal irritation
Impaired Skin Integrity r/t frequent stools, development of anal fissures
See Child with Chronic Condition; Crohn’s Disease; Hospitalized Child; Maturational Issues, Adolescent
Deficient Fluid Volume r/t inadequate fluid intake
Ineffective Self-Health Management r/t lack of knowledge regarding preventive immunizations
Ineffective Thermoregulation r/t infectious process
Acute Pain r/t inflammatory changes in joints
Readiness for enhanced Knowledge: about information to prevent or treat influenza
Impaired physical Mobility r/t pain at surgical site and fear of causing hernia to rupture
Acute Pain r/t surgical procedure
Risk for Falls: Risk factors: orthostatic hypotension, impaired physical mobility, diminished mental status
Risk for Injury: Risk factor: environmental conditions interacting with client’s adaptive and defensive resources
Risk for Thermal Injury: Risk factor: cognitive impairment, inadequate supervision, developmental level
Deficient Knowledge r/t lack of knowledge of cause and treatment of peripheral vascular diseases
Acute Pain r/t decreased circulation to extremities with activity
Ineffective peripheral Tissue Perfusion r/t interruption of arterial flow
Risk for Injury: Risk factor: tissue hypoxia
Readiness for enhanced Knowledge: prevention of pain and impaired circulation
Impaired Walking r/t repair of fracture
Risk for Infection: Risk factors: traumatized tissue, broken skin
See Fracture
Acute Pain r/t inflammatory process
Impaired Urinary Elimination r/t inflammation of bladder
Risk for Infection: Risk factor: suppressed inflammatory response
Readiness for enhanced Knowledge: expresses an interest in learning
Anxiety r/t loss of control of actions
Acute Confusion r/t alcohol abuse
Ineffective Coping r/t use of mind-altering substances as a means of coping
Impaired Memory r/t effects of alcohol on mind
Risk for Aspiration: Risk factors: diminished mental status, vomiting
Risk for Falls: Risk factor: diminished mental status
Risk for other-directed Violence: Risk factor: inability to control thoughts and actions
Anxiety r/t device providing cardiovascular assistance
Decreased Cardiac Output r/t failing heart needing counterpulsation
Compromised family Coping r/t seriousness of significant other’s medical condition
Impaired physical Mobility r/t restriction of movement because of mechanical device
Risk for Peripheral Neurovascular Dysfunction: Risk factors: vascular obstruction of balloon catheter, thrombus formation, emboli, edema
Ineffective Breathing Pattern r/t pressure damage to breathing center in brainstem
Acute Confusion r/t increased intracranial pressure
Adult Failure to Thrive r/t undetected changes from increased intracranial pressure
Decreased Intracranial Adaptive Capacity r/t sustained increase in intracranial pressure
Impaired Memory r/t neurological disturbance
Vision Loss r/t pressure damage to sensory centers in brain
Risk for ineffective Cerebral tissue perfusion: Risk factors: body position, cerebral vessel circulation deficits
See cause of Increased Intracranial Pressure
Anxiety: maternal r/t threat to fetus
Ineffective Coping: maternal r/t situational crisis, threat to fetus
Impaired Gas exchange r/t insufficient placental perfusion
Delayed Growth and Development r/t insufficient supply of oxygen and nutrients
Imbalanced Nutrition: less than body requirements r/t insufficient placenta
Situational low Self-Esteem: maternal r/t guilt about threat to fetus
Spiritual Distress r/t unknown outcome of fetus
Risk for Powerlessness: Risk factor: unknown outcome of fetus
Disturbed Body Image r/t altered appearance with mechanical devices
Impaired verbal Communication r/t endotracheal tube
Imbalanced Nutrition: less than body requirements r/t inability to ingest food because of the presence of tubes
Risk for adverse reaction to iodinated Contrast media: Risk factor (See reaction to iodinated Contrast media, risk for adverse, Section III)
Impaired individual Resilience (See Resilience, individual, impaired, Section III)
Social Isolation (See Social Isolation, Section III)
Impaired Comfort r/t inflammation of skin causing itching
Risk for impaired Skin Integrity: Risk factor: scratching, dry skin