Decisional Conflict r/t lack of realistic problem-solving skills
Defensive Coping r/t grandiose sense of self
Interrupted Family Processes r/t taking advantage of others to achieve own goals
Disturbed personal Identity r/t psychological impairment
Ineffective Relationship r/t lack of mutual support/respect between partners
Impaired individual Resilience r/t psychological disorders
Impaired Social Interaction r/t self-concept disturbance
Risk-prone Health behavior r/t low self-efficacy
Risk for Loneliness r/t inability to interact appropriately with others
Anxiety r/t fear of lack of control over falling asleep
Disturbed Sleep Pattern r/t uncontrollable desire to sleep
Risk for Trauma: Risk factor: falling asleep during potentially dangerous activity
Readiness for enhanced Sleep: expression of willingness to enhance sleep
Impaired Oral Mucous Membrane r/t presence of nasogastric tube
Risk for imbalanced Fluid Volume: Risk factor: loss of gastrointestinal fluids without adequate replacement
Risk for dysfunctional Gastrointestinal Motility: Risk factor: blockage in the intestines
Ineffective Airway Clearance r/t aspiration, impaired gas exchange
Aspiration r/t aspiration of fluid into the lungs
Fear: parental r/t possible death of child, possible permanent and debilitating sequelae
Impaired Gas Exchange r/t laryngospasm, holding breath, aspiration
Grieving r/t potential death of child, unknown sequelae, guilt about accident
Ineffective Health Maintenance r/t parental deficient knowledge regarding safety measures appropriate for age
Hypothermia r/t central nervous system injury, prolonged submersion in cold water
Risk for delayed Development/disproportionate Growth: Risk factors: hypoxemia, cerebral anoxia
Risk for complicated Grieving: Risk factors: potential death of child, unknown sequelae, guilt about accident
Risk for Infection: Risk factors: aspiration, invasive monitoring
Risk for ineffective Cerebral tissue perfusion: Risk factor: hypoxia
Readiness for enhanced Spiritual Well-Being: struggle with survival of life-threatening situation
See Child with Chronic Condition; Hospitalized Child; Safety, Childhood; Terminally Ill Child/Death of Child, Parent
Readiness for enhanced Self-Health Management: early diagnosis and appropriate referral for eyeglasses or contact lenses when nearsightedness is suspected; signs that may indicate a vision problem, including sitting close to television, holding books very close when reading, or having difficulty reading the blackboard in school or signs on a wall
Decreased Cardiac Output r/t decreased contractility of heart resulting in increased preload
Excess Fluid Volume r/t excess fluid intake, compromised regulatory mechanisms
Ineffective Breathing Pattern r/t abdominal distention, hypoxia
Disturbed Energy Field r/t illness
Deficient Fluid Volume r/t vomiting, gastrointestinal bleeding
Neonatal Jaundice r/t feeding pattern not well-established
Imbalanced Nutrition: less than body requirements r/t decreased ability to absorb nutrients, decreased perfusion to gastrointestinal tract
Risk for Infection: Risk factors: bacterial invasion of gastrointestinal tract, invasive procedures
Risk for dysfunctional Gastrointestinal Motility: Risk factor: infection
Risk for ineffective Gastrointestinal Perfusion: Risk factors: shunting of blood away from mesenteric circulation and toward vital organs as a result of perinatal stress, hypoxia
Decreased Cardiac Output r/t tachycardia and hypotension
Fear r/t possible fatal outcome of disease
Grieving r/t poor prognosis associated with disease
Hyperthermia r/t presence of infection
Acute Pain r/t toxins interfering with blood flow
Ineffective peripheral Tissue Perfusion r/t thrombosis of the subcutaneous blood vessels, leading to necrosis of nerve fibers
Ineffective Protection r/t cellulites resistant to treatment
Self-Neglect r/t negative feelings
Chronic low Self-esteem r/t long-standing negative self-evaluation
Situational low Self-esteem r/t inappropriate learned negative feelings about self
Readiness for enhanced Self-Concept: expresses willingness to enhance self-concept
Caregiver Role Strain r/t care demands of family member, lack of social or financial support
Disabled family Coping r/t highly ambivalent family relationships, lack of respite care
Interrupted Family Processes r/t situational transition or crisis
Deficient Knowledge r/t care needs
Impaired individual Resilience r/t vulnerability from neglect
Risk for compromised Human Dignity: Risk factor: inadequate participation in decision-making
Readiness for enhanced Childbearing Process: appropriate care of newborn
See Newborn, Normal; Newborn, Postmature; Newborn, Small for Gestational Age (SGA)
Anxiety r/t surgical recovery, prognosis
Ineffective Breathing Pattern r/t location of surgical incision
Constipation r/t lack of return of peristalsis
Acute Pain r/t incisional discomfort
Spiritual Distress r/t chronic illness
Impaired Urinary Elimination r/t loss of kidney
Risk for Bleeding: Risk factor: surgery
Risk for Electrolyte Imbalance: Risk factor: renal dysfunction
Risk for imbalanced Fluid Volume: Risk factors: vascular losses, decreased intake
Risk for Infection: Risk factors: invasive procedure, lack of deep breathing because of location of surgical incision
Risk for ineffective Renal Perfusion: Risk factor: renal disease
Acute Pain r/t invasive procedure
Activity Intolerance r/t generalized edema
Disturbed Body Image r/t edematous appearance and side effects of steroid therapy
Excess Fluid Volume r/t edema resulting from oncotic fluid shift caused by serum protein loss and renal retention of salt and water
Imbalanced Nutrition: less than body requirements r/t anorexia, protein loss
Imbalanced Nutrition: more than body requirements r/t increased appetite attributable to steroid therapy
Social Isolation r/t edematous appearance
Risk for Infection: Risk factor: altered immune mechanisms caused by disease and effects of steroids
Risk for ineffective Renal Perfusion: Risk factor: renal disease
Constipation r/t immobility or less than adequate mobility
Grieving r/t loss of perfect child, birth of child with congenital defect
Delayed Growth and Development r/t physical impairments, possible cognitive impairment
Reflex urinary Incontinence r/t neurogenic impairment
Total urinary Incontinence r/t neurogenic impairment
Urge urinary Incontinence r/t neurogenic impairment
Impaired Mobility r/t neuromuscular impairment
Chronic low Self-Esteem r/t perceived differences, decreased ability to participate in physical and social activities at school
Impaired Skin Integrity r/t incontinence
Risk for Latex Allergy Response: Risk factor: multiple exposures to latex products
Risk for imbalanced Nutrition: more than body requirements: Risk factors: diminished, limited, or impaired physical activity
Risk for Powerlessness: Risk factor: debilitating disease
Risk for impaired Skin Integrity: lower extremities: Risk factor: decreased sensory perception
Readiness for enhanced family Coping: effective adaptive response by family members
Readiness for enhanced Family Processes: family supports each other
Activity Intolerance r/t pain with movement
Ineffective Health Maintenance r/t deficient knowledge regarding self-care with neuritis
Acute Pain r/t stimulation of affected nerve endings, inflammation of sensory nerves
Disturbed Energy Field r/t disease
Compromised Family coping r/t cost and emotional needs of disease
Impaired Skin Integrity r/t café-au-lait spots
Risk for delayed Development: learning disorders including attention deficit hyperactivity disorder, low intelligent quotient scores, and developmental delay: Risk factor: genetic disorder
Risk for disproportionate Growth: short stature, precocious puberty, delayed maturation, thyroid disorders: Risk factor: genetic disorder
Risk for Injury: Risk factor: possible problems with balance
Risk for decreased Cardiac tissue perfusion: Risk factor: hypertension
Risk for compromised Resilience: Risk factor: presence of chronic disease
Risk for Spiritual Distress: Risk factor: possible severity of disease
Readiness for enhanced Decision-Making: expresses desire to enhance understanding of choices and meaning of choices, genetic counseling
Readiness for enhanced Self-Health Management: seeks cancer screening, education and genetic counseling
See Abdominal Distention; Surgery, Perioperative; Surgery, Post-operative; Surgery, Preoperative
Overflow urinary Incontinence r/t detrusor external sphincter dyssynergia
Reflex urinary Incontinence r/t neurological impairment
Urinary Retention r/t interruption in the lateral spinal tracts
Risk for Latex Allergy Response: Risk factors: repeated exposures to latex associated with possible repeated catheterizations
Ineffective Airway Clearance r/t perceptual or cognitive impairment, decreased energy, fatigue
Acute Confusion r/t dementia, alcohol abuse, drug abuse, delirium
Ineffective Coping r/t disability requiring change in lifestyle
Risk for dry Eye r/t lagophthalmos (lack of spontaneous blink reflex)
Disturbed Energy Field r/t illness
Interrupted Family Processes r/t situational crisis, illness, or disability of family member
Grieving r/t loss of usual body functioning
Impaired Home Maintenance r/t client’s or family member’s disease
Impaired Memory r/t neurological disturbance
Impaired physical Mobility r/t neuromuscular impairment
Imbalanced Nutrition: less than body requirements r/t impaired swallowing, depression, difficulty feeding self
Powerlessness r/t progressive nature of disease
Self-Care deficit: specify r/t neuromuscular dysfunction
Sexual Dysfunction r/t biopsychosocial alteration of sexuality
Social Isolation r/t altered state of wellness
Impaired Swallowing r/t neuromuscular dysfunction
Wandering r/t cognitive impairment
Risk for Disuse Syndrome: Risk factors: physical immobility, neuromuscular dysfunction
Risk for Injury: Risk factors: altered mobility, sensory dysfunction, cognitive impairment
Risk for ineffective Cerebral tissue perfusion: Risk factor: cerebral disease/injury
Risk for impaired Religiosity: Risk factor: life transition
Risk for impaired Skin Integrity: Risk factors: altered sensation, altered mental status, paralysis
See specific condition: Alcohol Withdrawal; Amyotrophic Lateral Sclerosis (ALS); CVA (Cerebrovascular Accident); Delirium; Dementia; Guillain-Barré Syndrome; Head Injury; Huntington’s Disease; Multiple Sclerosis (MS); Myasthenia Gravis; Muscular Dystrophy; Parkinson’s Disease
Chronic Pain r/t damage to nerves in the peripheral nervous system as a result of medication side effects, vitamin deficiency, or diabetes
Ineffective Thermoregulation r/t decreased ability to regulate body temperature
Risk for Injury: Risk factors: lack of muscle control, decreased sensation
Breastfeeding r/t normal oral structure and gestational age greater than 34 weeks
Ineffective Protection r/t immature immune system
Ineffective Thermoregulation r/t immaturity of neuroendocrine system
Risk for Sudden Infant Death Syndrome: Risk factors: lack of knowledge regarding infant sleeping in prone or side-lying position, prenatal or postnatal infant smoke exposure, infant overheating or overwrapping, loose articles in the sleep environment
Risk for Infection: Risk factor: open umbilical stump
Risk for Injury: Risk factors: immaturity, need for caretaking
Readiness for enhanced Childbearing Process: appropriate care of newborn
Readiness for enhanced organized Infant behavior: demonstrates adaptive response to pain
Readiness for enhanced Parenting: providing emotional and physical needs of infant
Hypothermia r/t depleted stores of subcutaneous fat
Impaired Skin Integrity r/t cracked and peeling skin as a result of decreased vernix
Risk for ineffective Airway Clearance: Risk factor: meconium aspiration
Risk for unstable blood Glucose level: Risk factor: depleted glycogen stores
Risk for Injury: Risk factor: hypoglycemia caused by depleted glycogen stores
Neonatal Jaundice r/t neonate age and difficulty feeding
Imbalanced Nutrition: less than body requirements r/t history of placental insufficiency
Ineffective Thermoregulation r/t decreased brown fat, subcutaneous fat
Risk for Sudden Infant Death Syndrome: Risk factor: low birth weight
Risk for delayed Development: Risk factor: history of placental insufficiency
Risk for disproportionate Growth: Risk factor: history of placental insufficiency
Risk for Injury: Risk factors: hypoglycemia, perinatal asphyxia, meconium aspiration
Risk-prone Health Behavior r/t smoking
Ineffective Health Maintenance r/t lack of ability to make a judgment about smoking cessation
Powerlessness r/t perceived lack of control over ability to give up nicotine
Readiness for enhanced Decision-Making: expresses desire to enhance understanding and meaning of choices
Readiness for enhanced Self-Health Management: expresses desire to learn measures to stop smoking
Readiness for enhanced Self-Health Management: expresses desire for information on exercise and diet to manage diabetes
Disturbed Energy Field r/t disharmony of body and mind
Post-Trauma Syndrome r/t disaster, war, epidemic, rape, assault, torture, catastrophic illness, or accident
Urge urinary Incontinence r/t decreased bladder capacity, irritation of bladder stretch receptors causing spasm, alcohol, caffeine, increased fluids, increased urine concentration, overdistention of bladder
Impaired Urinary Elimination r/t sensory motor impairment, urinary tract infection
Risk for Powerlessness: Risk factor: inability to control nighttime voiding
Impaired verbal Communication r/t obstruction of flow of cerebrospinal fluid
Acute Confusion r/t dementia caused by obstruction to flow of cerebrospinal fluid
Impaired Memory r/t neurological disturbance
Risk for Falls: Risk factor: unsteady gait as a result of obstruction of cerebrospinal fluid
Risk for ineffective Cerebral tissue perfusion: Risk factor: fluid pressing on the brain
Imbalanced Nutrition: less than body requirements (See Nutrition: less than body requirements, imbalanced, Section III)
Imbalanced Nutrition: more than body requirements (See Nutrition: more than body requirements, imbalanced, Section III)
Risk for imbalanced Nutrition: more than body requirements (See Nutrition: more than body requirements, imbalanced, risk for, Section III)