Anxiety r/t change in health status, presence of pacemaker
Death Anxiety r/t worry over possible malfunction of pacemaker
Deficient Knowledge r/t self-care program, when to seek medical attention
Acute Pain r/t surgical procedure
Risk for Bleeding: Risk factor: surgery
Risk for Infection: Risk factors: invasive procedure, presence of foreign body (catheter and generator)
Risk for decreased Cardiac tissue perfusion: Risk factor: pacemaker malfunction
Risk for Powerlessness: Risk factor: presence of electronic device to stimulate heart
Readiness for enhanced Self-Health Management: appropriate health care management of pacemaker
Disturbed Body Image r/t possible enlarged head, bowed tibias, kyphosis
Deficient Knowledge r/t appropriate diet high in protein and calcium, mild exercise
Chronic Sorrow r/t chronic condition with altered body image
Risk for Trauma: fracture: Risk factor: excessive bone destruction
Disturbed Energy Field r/t unbalanced energy field
Acute Pain (See Pain, acute, Section III)
Impaired Comfort r/t altered health status
Disturbed Energy Field r/t unbalanced energy field
Chronic Pain (See Pain, chronic, Section III)
Impaired Comfort r/t physical condition
Acute Pain r/t distention of breast tissue
Ineffective Role Performance r/t change in physical capacity to assume role of breastfeeding mother
Impaired Tissue Integrity r/t excessive fluid in breast tissues
Risk for ineffective Breastfeeding: Risk factors: pain, infant’s inability to latch on to engorged breast
Risk for Infection: Risk factor: milk stasis
Risk for disturbed Maternal/Fetal Dyad: Risk factor: discomfort
Ineffective Breastfeeding r/t pain
Insufficient Breast Milk r/t long breastfeeding time/pain response
Impaired Comfort r/t physical condition
Acute Pain r/t cracked nipples
Ineffective Role Performance r/t change in physical capacity to assume role of breastfeeding mother
Impaired Skin Integrity r/t mechanical factors involved in suckling, breastfeeding management
Death Anxiety r/t possible poor prognosis of disease process
Ineffective family Coping r/t poor prognosis
Fear r/t poor prognosis of the disease
Grieving r/t shortened life span
Deficient Knowledge r/t disease-induced diabetes, home management
Spiritual Distress r/t poor prognosis
Risk for impaired Liver Function: Risk factor: complications from underlying disease
See Cancer; Chemotherapy; Radiation Therapy; Surgery, Perioperative; Surgery, Postoperative; Surgery, Preoperative
Ineffective Breathing Pattern r/t splinting from severe pain
Ineffective Denial r/t ineffective coping, alcohol use
Diarrhea r/t decrease in pancreatic secretions resulting in steatorrhea
Adult Failure to Thrive r/t pain
Deficient Fluid Volume r/t vomiting, decreased fluid intake, fever, diaphoresis, fluid shifts
Ineffective Health Maintenance r/t deficient knowledge concerning diet, alcohol use, medication
Nausea r/t irritation of gastrointestinal system
Imbalanced Nutrition: less than body requirements r/t inadequate dietary intake, increased nutritional needs as a result of acute illness, increased metabolic needs caused by increased body temperature
Acute Pain r/t irritation and edema of the inflamed pancreas
Chronic Sorrow r/t chronic illness
Readiness for enhanced Comfort: expresses desire to enhance comfort
Ineffective Activity Planning r/t unrealistic perception of events
Anxiety r/t situational crisis
Risk-prone Health Behavior r/t low self-efficacy
Ineffective Coping r/t personal vulnerability
Disturbed personal Identity r/t situational crisis
Post-Trauma Syndrome r/t previous catastrophic event
Social Isolation r/t fear of lack of control
Risk for Loneliness: Risk factor: inability to socially interact because of fear of losing control
Risk for Post-Trauma Syndrome: Risk factors: perception of the event, diminished ego strength
Risk for Powerlessness: Risk factor: ineffective coping skills
Readiness for enhanced Coping: seeks problem-oriented and emotion-oriented strategies to manage condition
See Anxiety; Anxiety Disorder
Disturbed Body Image r/t biophysical changes, loss of movement, immobility
Impaired Comfort r/t prolonged immobility
Constipation r/t effects of spinal cord disruption, inadequate fiber in diet
Ineffective Health Maintenance r/t deficient knowledge regarding self-care with paralysis
Impaired Home Maintenance r/t physical disability
Reflex urinary Incontinence r/t neurological impairment
Impaired physical Mobility r/t neuromuscular impairment
Impaired wheelchair Mobility r/t neuromuscular impairment
Self-Neglect r/t functional impairment
Powerlessness r/t illness-related regimen
Self-Care deficit: specify r/t neuromuscular impairment
Sexual Dysfunction r/t loss of sensation, biopsychosocial alteration
Chronic Sorrow r/t loss of physical mobility
Impaired Transfer Ability r/t paralysis
Risk for Autonomic Dysreflexia r/t cause of paralysis
Risk for Latex Allergy Response: Risk factor: possible repeated urinary catheterizations
Risk for Disuse Syndrome: Risk factor: paralysis
Risk for Falls: Risk factor: paralysis
Risk for Injury: Risk factors: altered mobility, sensory dysfunction
Risk for Post-Trauma Syndrome: Risk factor: event causing paralysis
Risk for impaired Religiosity: Risk factors: immobility, possible lack of transportation
Risk for compromised Resilience: Risk factor: chronic disability
Risk for situational low Self-Esteem: Risk factor: change in body image and function
Risk for impaired Skin Integrity: Risk factors: altered circulation, altered sensation, immobility
Readiness for enhanced Self-Care: expresses desire to enhance knowledge and responsibility for strategies for self-care
See Child with Chronic Condition; Hemiplegia; Hospitalized Child; Neural Tube Defects; Spinal Cord Injury
Constipation r/t decreased gastric motility
Deficient Fluid Volume r/t loss of fluids from vomiting, retention of fluid in bowel
Dysfunctional Gastrointestinal Motility r/t bowel obstruction
Nausea r/t gastrointestinal irritation
Impaired Oral Mucous Membrane r/t presence of nasogastric tube
Ineffective Activity Planning r/t unrealistic perception of events
Anxiety r/t uncontrollable intrusive, suspicious thoughts
Risk-prone Health Behavior r/t intense emotional state
Disturbed personal Identity r/t difficulty with reality testing
Impaired individual Resilience r/t psychological disorder
Chronic low Self-Esteem r/t inability to trust others
Social Isolation r/t inappropriate social skills
Risk for Loneliness: Risk factor: social isolation
Risk for Post-Trauma Syndrome: Risk factor: exaggerated sense of responsibility
Risk for Suicide: Risk factor: psychiatric illness
Risk for other-directed Violence: Risk factor: being suspicious of others and others’ actions
Risk for ineffective Airway Clearance: Risk factors: edema or hematoma formation, airway obstruction
Risk for Bleeding: Risk factor: surgery
Risk for impaired verbal Communication: Risk factors: possible laryngeal damage, edema
Risk for Infection: Risk factor: surgical procedure
See Hypocalcemia
Risk for impaired Attachment (See Attachment, impaired, risk for, Section III)
Readiness for enhanced Childbearing Process: demonstrates appropriate care of newborn
Parental Role Conflict (See Role Conflict, parental Section III)
Ineffective Relationship r/t unrealistic expectations
Chronic Sorrow r/t difficult parent-child relationship
Risk for Spiritual Distress: Risk factor: altered relationships
Readiness for enhanced Parenting: willingness to enhance parenting
Impaired Parenting (See Parenting, impaired, Section III)
Chronic Sorrow r/t difficult parent-child relationship
Risk for Spiritual Distress: Risk factor: altered relationships
Risk for impaired Parenting (See Parenting, impaired, risk for, Section III)
Risk for Injury r/t inability to feel temperature changes, pain
Impaired verbal Communication r/t decreased speech volume, slowness of speech, impaired facial muscles
Constipation r/t weakness of defecation muscles, lack of exercise, inadequate fluid intake, decreased autonomic nervous system activity
Adult Failure to Thrive r/t depression associated with chronic progressive disease
Imbalanced Nutrition: less than body requirements r/t tremor, slowness in eating, difficulty in chewing and swallowing
Chronic Sorrow r/t loss of physical capacity
Risk for Injury: Risk factors: tremors, slow reactions, altered gait
Deficient Knowledge r/t lack of exposure to information misinterpretation, unfamiliarity with information resources to manage illness
Readiness for enhanced Decision-Making: expresses desire to enhance understanding of choices for decision-making
Deficient Knowledge r/t lack of exposure to information, information misinterpretation
Readiness for enhanced Knowledge (specify): interest in learning
Readiness for enhanced Self-Health Management: expresses desire for information to manage the illness
Readiness for enhanced Spiritual Well-Being: desires to reach harmony with self, others, higher power/God
Impaired Comfort r/t condition requiring PCA, pruritus from medication side effects
Deficient Knowledge r/t self-care of pain control
Nausea r/t side effects of medication
Risk for Injury: Risk factors: possible complications associated with PCA
Risk for Vascular Trauma: Risk factor: insertion site and length of insertion time
Readiness for enhanced Knowledge: appropriate management of PCA
Ineffective Sexuality Pattern r/t use of penile prosthesis
Risk for Infection: Risk factor: invasive surgical procedure
Risk for situational low Self-Esteem: Risk factors: ineffective sexuality pattern
Readiness for enhanced Self-Health Management: seeks information regarding care and use of prosthesis
Acute Pain r/t inflammation, effusion
Delayed Surgical Recovery r/t complications associated with cardiac problems
Risk for decreased Cardiac tissue perfusion: Risk factors: inflammation in pericardial sac, fluid accumulation compressing heart
Activity Intolerance r/t reduced cardiac reserve, prescribed bed rest
Deficient Knowledge r/t unfamiliarity with information sources
Acute Pain r/t biological injury, inflammation
Delayed Surgical Recovery r/t complications associated with cardiac problems
Risk for imbalanced Nutrition: less than body requirements r/t fever, hypermetabolic state associated with fever
Risk for decreased Cardiac tissue perfusion: Risk factor: inflammation in pericardial sac
Risk for Perioperative Positioning Injury (See Perioperative Positioning Injury, risk for, Section III)
Risk for Peripheral Neurovascular Dysfunction (See Peripheral Neurovascular Dysfunction, risk for, Section III)
See Neuropathy, Peripheral; Peripheral Vascular Disease (PVD)
Activity Intolerance r/t imbalance between peripheral oxygen supply and demand
Ineffective Health Maintenance r/t deficient knowledge regarding self-care and treatment of disease
Chronic Pain: intermittent claudication r/t ischemia
Ineffective peripheral Tissue Perfusion r/t disease process
Risk for Falls: Risk factor: altered mobility
Risk for Injury: Risk factors: tissue hypoxia, altered mobility, altered sensation
Risk for Peripheral Neurovascular Dysfunction: Risk factor: possible vascular obstruction
Risk for impaired Skin Integrity: Risk factor: altered circulation or sensation
Readiness for enhanced Self-Health Management: self-care and treatment of disease
See Neuropathy, Peripheral; Peripheral Neurovascular Dysfunction
Ineffective Breathing Pattern r/t pressure from dialysate
Impaired Home Maintenance r/t complex home treatment of client
Deficient Knowledge r/t treatment procedure, self-care with peritoneal dialysis
Acute Pain r/t instillation of dialysate, temperature of dialysate
Chronic Sorrow r/t chronic disability
Risk for unstable blood Glucose level r/t increased concentrations of glucose dialysate
Risk for ineffective Coping: Risk factor: disability requiring change in lifestyle
Risk for imbalanced Fluid Volume: Risk factor: medical procedure
Risk for Infection: peritoneal: Risk factor: invasive procedure, presence of catheter, dialysate
Risk for Powerlessness: Risk factor: chronic condition and care involved
See Child with Chronic Condition; Hemodialysis; Hospitalized Child; Renal Failure; Renal Failure, Acute/Chronic, Child
Ineffective Breathing Pattern r/t pain, increased abdominal pressure
Constipation r/t decreased oral intake, decrease of peristalsis
Deficient Fluid Volume r/t retention of fluid in bowel with loss of circulating blood volume
Nausea r/t gastrointestinal irritation
Imbalanced Nutrition: less than body requirements r/t nausea, vomiting
Acute Pain r/t inflammation, stimulation of somatic nerves
Risk for dysfunctional Gastrointestinal Motility: Risk factor: gastrointestinal disease
Diarrhea r/t malabsorption of nutrients
Fatigue r/t imbalanced nutrition: less than body requirements
Impaired Memory r/t anemia; lack of adequate red blood cells
Nausea r/t altered oral mucous membrane; sore tongue, bleeding gums
Imbalanced Nutrition: less than body requirements r/t lack of appetite associated with nausea and altered oral mucous membrane
Impaired Oral Mucous Membrane r/t vitamin deficiency; inability to absorb vitamin B12 associated with lack of intrinsic factor
Risk for Falls: Risk factors: dizziness, lightheadedness
Risk for Peripheral Neurovascular Dysfunction: Risk factor: anemia
Disturbed personal Identity (See Identity, personal, disturbed, Section III)
Ineffective Activity Planning r/t unrealistic perception of events
Impaired individual Resilience r/t psychological disorder
See specific disorder Antisocial Personality Disorder; Borderline Personality Disorder; OCD (Obsessive-Compulsive Disorder); Paranoid Personality Disorder
Contamination r/t use of environmental contaminants; pesticides
Risk for Allergy Response r/t repeated exposure to pesticides
Risk for disproportionate Growth: Risk factor: environmental contamination
See Anticoagulant Therapy; Clotting Disorder; DIC (Disseminated Intravascular Coagulation); Hemophilia
Readiness for enhanced Self-Health Management: wears medical alert bracelet; limits hazardous activities such as driving, swimming, working at heights, operating equipment
See Epilepsy
Anxiety r/t symptoms from increased catecholamines—headache, palpitations, sweating, nervousness, nausea, vomiting, syncope
Ineffective Health Maintenance r/t deficient knowledge regarding treatment and self-care
Insomnia r/t high levels of catecholamines
Nausea r/t increased catecholamines
Risk for adverse reaction to iodinated Contrast media r/t pheochromocytoma
Risk for decreased Cardiac tissue perfusion: Risk factor: hypertension
See Surgery, Perioperative; Surgery, Postoperative; Surgery, Preoperative
Fear r/t presence or anticipation of specific object or situation
Powerlessness r/t anxiety about encountering unknown or known entity
Impaired individual Resilience r/t psychological disorder
Readiness for enhanced Power: expresses readiness to enhance identification of choices that can be made for change
See Anxiety; Anxiety Disorder; Panic Disorder (Panic Attacks)
Ineffective Health Maintenance r/t deficient knowledge regarding medications inducing photosensitivity
Risk for dry Eye r/t pharmaceutical agents/sunlight exposure
Risk for impaired Skin Integrity: Risk factor: exposure to sun
Anxiety r/t stress from urge to eat nonnutritive substances
Imbalanced Nutrition: less than body requirements r/t eating nonnutritive substances
Impaired Parenting r/t lack of supervision, food deprivation
Risk for Constipation: Risk factor: presence of undigestible materials in gastrointestinal tract
Risk for Infection: Risk factor: ingestion of infectious agents via contaminated substances
Risk for Gastrointestinal Motility: Risk factor: abnormal eating behavior
Risk for Poisoning: Risk factor: ingestion of substances containing lead
See Anemia
Ineffective Health Maintenance r/t deficient knowledge regarding self-care, treatment of disease
Acute Pain r/t biological injury; inflammation, edema, congestion of pelvic tissues
Ineffective Sexuality Pattern r/t medically imposed abstinence from sexual activities until acute infection subsides, change in reproductive potential
Risk for urge urinary Incontinence: Risk factors: inflammation, edema, congestion of pelvic tissues
Risk for Infection: Risk factors: insufficient knowledge to avoid exposure to pathogens; proper hygiene, nutrition, other health habits
See Maturational Issues, Adolescent; STD (Sexually Transmitted Disease)
Anxiety r/t fear of the unknown, threat to self and infant, change in role functioning
Death Anxiety r/t threat of preeclampsia
Deficient Diversional Activity r/t bed rest
Interrupted Family Processes r/t situational crisis
Impaired Home Maintenance r/t bed rest
Deficient Knowledge r/t lack of experience with situation
Impaired physical Mobility r/t medically prescribed limitations
Impaired Parenting r/t bed rest
Powerlessness r/t complication threatening pregnancy, medically prescribed limitations
Ineffective Role Performance r/t change in physical capacity to assume role of pregnant woman or resume other roles
Situational low Self-Esteem r/t loss of idealized pregnancy
Impaired Social Interaction r/t imposed bed rest
Risk for imbalanced Fluid Volume: Risk factors: hypertension, altered renal function
Risk for Injury: fetal: Risk factors: decreased uteroplacental perfusion, seizures
Risk for Injury: maternal: Risk factors: vasospasm, high blood pressure
Readiness for enhanced Knowledge: desire for information on managing condition
Impaired Home Maintenance r/t inadequate cleaning of bed linen and toilet seats
Readiness for enhanced Self-Health Management: proper handwashing; short, clean fingernails; avoiding hand, mouth, nose contact with unwashed hands; appropriate cleaning of bed linen and toilet seats
Risk for delayed Development: Risk factors: not following strict dietary program; eating foods extremely low in phenylalanine; avoiding eggs, milk, any foods containing aspartame (NutraSweet)
Readiness for enhanced Self-Health Management: testing for PKU and following prescribed dietary regimen
Death Anxiety r/t threat of mortality associated with bleeding
Fear r/t threat to self and fetus
Ineffective Health Maintenance r/t deficient knowledge regarding treatment and control of hypertension associated with placenta abruptio
Acute Pain: abdominal/back r/t premature separation of placenta before delivery
Risk for Bleeding: Risk factor: placenta abruptio
Risk for deficient Fluid Volume: Risk factor: maternal blood loss
Risk for disturbed Maternal/Fetal Dyad: Risk factor: complication of pregnancy
Risk for Powerlessness: Risk factors: complications of pregnancy and unknown outcome
Risk for Shock: Risk factor: hypovolemia
Risk for Spiritual Distress: Risk factor: fear from unknown outcome of pregnancy
Death Anxiety r/t threat of mortality associated with bleeding
Disturbed Body Image r/t negative feelings about body and reproductive ability, feelings of helplessness
Ineffective Coping r/t threat to self and fetus
Deficient Diversional Activity r/t long-term hospitalization
Interrupted Family Processes r/t maternal bed rest, hospitalization
Fear r/t threat to self and fetus, unknown future
Impaired Home Maintenance r/t maternal bed rest, hospitalization
Impaired physical Mobility r/t medical protocol, maternal bed rest
Ineffective Role Performance r/t maternal bed rest, hospitalization
Situational low Self-Esteem r/t situational crisis
Spiritual Distress r/t inability to participate in usual religious rituals, situational crisis
Risk for Bleeding: Risk factor: placenta previa
Risk for Constipation: Risk factor: bed rest, pregnancy
Risk for deficient Fluid Volume: Risk factor: maternal blood loss
Risk for imbalanced Fluid Volume: Risk factor: maternal blood loss
Risk for Injury: fetal and maternal: Risk factors: threat to uteroplacental perfusion, hemorrhage
Risk for disturbed Maternal/Fetal Dyad: Risk factor: complication of pregnancy
Risk for impaired Parenting: Risk factors: maternal bed rest, hospitalization
Risk for ineffective peripheral Tissue Perfusion: placental: Risk factors: dilation of cervix, loss of placental implantation site
Risk for Powerlessness: Risk factors: complications of pregnancy and unknown outcome
Ineffective Breathing Pattern r/t pain
Excess Fluid Volume r/t compromised regulatory mechanisms; heart, liver, or kidney failure
Hyperthermia r/t increased metabolic rate secondary to infection
Ineffective Breathing Pattern r/t pain
Acute Pain r/t inflammation, fluid accumulation
See cause of Pleural Friction Rub
Ineffective Breathing Pattern r/t pain
Impaired Gas Exchange r/t ventilation perfusion imbalance
Acute Pain r/t pressure on pleural nerve endings associated with fluid accumulation or inflammation
Risk for ineffective Airway Clearance: Risk factors: increased secretions, ineffective cough because of pain
Risk for Infection: Risk factor: exposure to pathogens
Risk for impaired physical Mobility: Risk factors: activity intolerance, inability to “catch breath”
Excess Fluid Volume r/t alterations of hormonal levels inducing fluid retention
Deficient Knowledge r/t methods to deal with and prevent syndrome
Acute Pain r/t hormonal stimulation of gastrointestinal structures
Risk for Powerlessness: Risk factors: lack of knowledge and ability to deal with symptoms
Risk for compromised Resilience: Risk factor: PMS symptoms
Readiness for enhanced Communication: willingness to express thoughts and feelings about PMS
Readiness for enhanced Self-Health Management: desire for information to manage and prevent symptoms
Anxiety r/t inability to breathe during sleep
Ineffective Breathing Pattern r/t increase in carbon dioxide levels, decrease in oxygen levels
Insomnia r/t suffocating feeling from fluid in lungs on awakening from sleep
Sleep deprivation r/t inability to breathe during sleep
Risk for decreased Cardiac tissue perfusion: Risk factor: hypoxia
Risk for Powerlessness: Risk factor: inability to control nocturnal dyspnea
Readiness for enhanced Sleep: expresses willingness to learn measures to enhance sleep
Activity Intolerance r/t imbalance between oxygen supply and demand
Ineffective Airway Clearance r/t inflammation and presence of secretions
Impaired Gas Exchange r/t decreased functional lung tissue
Ineffective Self-Health Management r/t deficient knowledge regarding self-care and treatment of disease
Hyperthermia r/t dehydration, increased metabolic rate, illness
Deficient Knowledge r/t risk factors predisposing person to pneumonia, treatment
Imbalanced Nutrition: less than body requirements r/t loss of appetite
Impaired Oral Mucous Membrane r/t dry mouth from mouth breathing, decreased fluid intake
Risk for acute Confusion: Risk factor: underlying illness
Risk for deficient Fluid Volume: Risk factor: inadequate intake of fluids
Risk for Vascular Trauma: Risk factor: irritation from IV antibiotics
Readiness for enhanced Immunization Status: expresses desire to increase immunization status
Fear r/t threat to own well-being, difficulty breathing
Impaired Gas Exchange r/t ventilation-perfusion imbalance
Acute Pain r/t recent injury, coughing, deep breathing
Risk for Injury: Risk factor: possible complications associated with closed chest drainage system
See Chest Tubes
Readiness for enhanced Immunization Status: expresses desire to increase immunization status
See Paralysis
Readiness for enhanced Urinary Elimination: willingness to learn measures to enhance urinary elimination
Anxiety r/t new responsibilities of parenting
Disturbed Body Image r/t normal postpartum recovery
Ineffective Childbearing Process r/t depression/lack of support system
Ineffective Coping r/t hormonal changes, maturational crisis
Fatigue r/t childbirth, postpartum state
Risk-prone Health Behavior r/t lack of support systems
Impaired Home Maintenance r/t fatigue, care of newborn
Deficient Knowledge r/t lifestyle changes
Impaired Parenting r/t hormone-induced depression
Ineffective Role Performance r/t new responsibilities of parenting
Sexual Dysfunction r/t fear of another pregnancy, postpartum pain, lochia flow
Sleep deprivation r/t environmental stimulation of newborn
Impaired Social Interaction r/t change in role functioning
Risk for disturbed personal Identity r/t role change/depression/inability to cope
Risk for Post-Trauma Syndrome: Risk factors: trauma or violence associated with labor and birth process, medical/surgical interventions, history of sexual abuse
Risk for situational low Self-Esteem: Risk factor: decreased power over feelings of sadness
Risk for Spiritual Distress: Risk factors: altered relationships, social isolation
Readiness for enhanced Hope: expresses desire to enhance hope and interconnectedness with others
Activity intolerance r/t anemia from loss of blood
Death Anxiety r/t threat of mortality associated with bleeding
Disturbed Body Image r/t loss of ideal childbirth
Interrupted Breastfeeding r/t separation from infant for medical treatment
Insufficient Breast Milk r/t fluid volume depletion
Decreased Cardiac Output r/t hypovolemia
Fear r/t threat to self, unknown future
Deficient Fluid Volume r/t uterine atony, loss of blood
Impaired Home Maintenance r/t lack of stamina
Deficient Knowledge r/t lack of exposure to situation
Acute Pain r/t nursing and medical interventions to control bleeding
Ineffective peripheral Tissue Perfusion r/t hypovolemia
Risk for Bleeding: Risk factor: postpartum complications
Risk for imbalanced Fluid Volume: Risk factor: maternal blood loss
Risk for Infection: Risk factors: loss of blood, depressed immunity
Risk for disturbed Maternal/Fetal Dyad: Risk factor: complication of pregnancy
Risk for impaired Parenting: Risk factor: weakened maternal condition
Anxiety r/t change in role functioning, parenting
Effective Breastfeeding r/t basic breastfeeding knowledge, support of partner and health care provider
Constipation r/t hormonal effects on smooth muscles, fear of straining with defecation, effects of anesthesia
Fatigue r/t childbirth, new responsibilities of parenting, body changes
Acute Pain r/t episiotomy, lacerations, bruising, breast engorgement, headache, sore nipples, epidural or intravenous (IV) site, hemorrhoids
Sexual Dysfunction r/t recent childbirth
Impaired Skin Integrity r/t episiotomy, lacerations
Sleep deprivation r/t care of infant
Impaired Urinary Elimination r/t effects of anesthesia, tissue trauma
Risk for Constipation: Risk factors: hormonal effects on smooth muscles, fear of straining with defecation, effects of anesthesia
Risk for imbalanced Fluid Volume: Risk factors: shift in blood volume, edema
Risk for urge urinary Incontinence: Risk factors: effects of anesthesia or tissue trauma
Risk for Infection: Risk factors: tissue trauma, blood loss
Readiness for enhanced family Coping: adaptation to new family member
Readiness for enhanced Hope: desire to increase hope
Readiness for enhanced Parenting: expressing willingness to enhance parenting skills
Risk for Post-Trauma Syndrome (See Post-Trauma Syndrome, risk for, Section III)
Powerlessness (See Powerlessness, Section III)
Risk for ineffective Childbearing Process r/t maternal powerlessness
Risk for Powerlessness (See Powerlessness, risk for, Section III)
Readiness for enhanced Power (See Power, readiness for enhanced, Section III)
Anxiety r/t threat to role functioning, health status, situational crisis
Compromised family Coping r/t lack of support by significant other because of personal suffering
Ineffective Coping r/t situational crisis
Grieving r/t loss of pregnancy, fetus, or child
Complicated Grieving r/t sudden loss of pregnancy, fetus, or child
Acute Pain r/t surgical intervention
Ineffective Role Performance r/t inability to assume parenting role
Ineffective Sexuality Pattern r/t self-esteem disturbance resulting from pregnancy loss and anxiety about future pregnancies
Chronic Sorrow r/t loss of a fetus or child
Spiritual Distress r/t intense suffering
Risk for Bleeding: Risk factor: pregnancy complication
Risk for deficient Fluid Volume: Risk factor: blood loss
Risk for complicated Grieving: Risk factor: loss of pregnancy
Risk for Infection: Risk factor: retained products of conception
Risk for Powerlessness: Risk factor: situational crisis
Risk for Ineffective Relationship r/t poor communication skills in dealing with the loss
Risk for Spiritual Distress: Risk factor: intense suffering
Readiness for enhanced Communication: willingness to express feelings and thoughts about loss
Readiness for enhanced Hope: expresses desire to enhance hope
Readiness for enhanced Spiritual Well-Being: desire for acceptance of loss
Anxiety r/t unknown future, threat to self secondary to pain of labor
Disturbed Body Image r/t altered body function and appearance
Interrupted Family Processes r/t developmental transition of pregnancy
Fatigue r/t increased energy demands
Deficient Knowledge r/t primiparity
Nausea r/t hormonal changes of pregnancy
Imbalanced Nutrition: less than body requirements r/t growing fetus, nausea
Imbalanced Nutrition: more than body requirements r/t deficient knowledge regarding nutritional needs of pregnancy
Sleep deprivation r/t uncomfortable pregnancy state
Impaired Urinary Elimination r/t frequency caused by increased pelvic pressure and hormonal stimulation
Risk for Constipation: Risk factor: pregnancy
Risk for Sexual Dysfunction: Risk factors: altered body function, self-concept, body image with pregnancy
Readiness for enhanced Childbearing Process: appropriate prenatal care
Readiness for enhanced family Coping: satisfying partner relationship, attention to gratification of needs, effective adaptation to developmental tasks of pregnancy
Readiness for enhanced Family Processes: family adapts to change
Readiness for enhanced Nutrition: desire for knowledge of appropriate nutrition during pregnancy
Readiness for enhanced Parenting: expresses willingness to enhance parenting skills
Readiness for enhanced Relationship: meeting developmental goals associated with pregnancy
Readiness for enhanced Self-Health Management: seeks information for prenatal self care
Readiness for enhanced Spiritual Well-Being: new role as parent
Ineffective Activity Planning r/t unrealistic perception of events
Ineffective Coping r/t bed rest, threat to fetus
Deficient Diversional Activity r/t bed rest
Fear r/t potential loss of infant
Grieving r/t potential loss of infant
Deficient Knowledge r/t treatment regimen, prognosis for pregnancy
Impaired physical Mobility r/t imposed bed rest to prevent preterm birth
Powerlessness r/t inability to control outcome of pregnancy
Ineffective Role Performance r/t inability to continue usual patterns of responsibility
Situational low Self-Esteem r/t inability to complete normal pregnancy
Sexual Dysfunction r/t fear of harm to fetus
Impaired Social Interaction r/t bed rest
Risk for Infection: Risk factors: invasive procedures to prevent preterm birth
Risk for Injury: fetal: Risk factors: preterm birth, use of anesthetics
Risk for Injury: maternal: Risk factors: surgical procedures to prevent preterm birth (e.g., cerclage)
Risk for compromised Resilience: Risk factor: complication of pregnancy
Risk for Spiritual Distress: Risk factors: physical/psychological stress
Insufficient Breast Milk r/t ineffective sucking, latching on of the infant
Impaired Gas Exchange r/t effects of cardiopulmonary insufficiency
Delayed Growth and Development: developmental lag r/t prematurity, environmental and stimulation deficiencies, multiple caretakers
Disorganized Infant behavior r/t prematurity
Insomnia r/t noisy and noxious intensive care environment
Neonatal Jaundice r/t infant experiences difficulty making transition to extrauterine life
Imbalanced Nutrition: less than body requirements r/t delayed or understimulated rooting reflex, easy fatigue during feeding, diminished endurance
Impaired Swallowing r/t decreased or absent gag reflex, fatigue
Ineffective Thermoregulation r/t large body surface/weight ratio, immaturity of thermal regulation, state of prematurity
Risk for delayed Development: Risk factor: prematurity
Risk for disproportionate Growth: Risk factor: prematurity
Risk for Infection: Risk factors: inadequate, immature, or undeveloped acquired immune response
Risk for Injury: Risk factor: prolonged mechanical ventilation, retinopathy of prematurity (ROP) secondary to 100% oxygen environment
Risk for Neonatal Jaundice r/t to late preterm birth
Readiness for enhanced organized Infant behavior: use of some self-regulatory measures
Ineffective Breastfeeding r/t disrupted establishment of effective pattern secondary to prematurity or insufficient opportunities
Decisional Conflict r/t support system deficit, multiple sources of information
Parental Role Conflict r/t expressed concerns, expressed inability to care for child’s physical, emotional, or developmental needs
Compromised family Coping r/t disrupted family roles and disorganization, prolonged condition exhausting supportive capacity of significant persons
Grieving r/t loss of perfect child possibly leading to complicated grieving
Complicated Grieving (prolonged) r/t unresolved conflicts
Chronic Sorrow r/t threat of loss of a child, prolonged hospitalization
Spiritual Distress r/t challenged belief or value systems regarding moral or ethical implications of treatment plans
Risk for impaired Attachment: Risk factors: separation, physical barriers, lack of privacy
Risk for disturbed Maternal/Fetal Dyad: Risk factor: complication of pregnancy
Risk for Powerlessness: Risk factor: inability to control situation
Risk for compromised Resilience: Risk factor: premature infant
Risk for Spiritual Distress: Risk factors: challenged belief or value systems regarding moral or ethical implications of treatment plans
Readiness for enhanced Family Process: adaptation to change associated with premature infant
Anxiety r/t threat to infant’s health status
Disturbed Body Image r/t inability to carry pregnancy to term
Ineffective Coping r/t situational crisis
Grieving r/t potential loss of infant
Situational low Self-Esteem r/t inability to carry pregnancy to term
Risk for Infection: Risk factor: rupture of membranes
Risk for Injury: fetal: Risk factor: risk of premature birth
Risk for disturbed Maternal/Fetal Dyad: Risk factor: complication of pregnancy
Readiness for enhanced Childbearing Process: appropriate prenatal lifestyle
Readiness for enhanced Knowledge: appropriate prenatal care
Readiness for enhanced Spiritual Well-Being: new role as parent
Anxiety r/t unknown outcome, delayed test results
Acute Pain r/t invasive procedures
Risk for Infection r/t invasive procedures during amniocentesis or chorionic villus sampling
Impaired Comfort r/t pressure ulcer
Impaired bed Mobility r/t intolerance to activity, pain, cognitive impairment, depression, severe anxiety
Imbalanced Nutrition: less than body requirements r/t limited access to food, inability to absorb nutrients because of biological factors, anorexia
Acute Pain r/t tissue destruction, exposure of nerves
Impaired Skin Integrity: stage I or II pressure ulcer r/t physical immobility, mechanical factors, altered circulation, skin irritants
Impaired Tissue Integrity: stage III or IV pressure ulcer r/t altered circulation, impaired physical mobility
Risk for Infection: Risk factors: physical immobility, mechanical factors (shearing forces, pressure, restraint, altered circulation, skin irritants)
Anxiety r/t threat to fetus, change in role functioning, change in environment and interaction patterns, use of tocolytic drugs
Ineffective Coping r/t situational crisis, preterm labor
Deficient Diversional Activity r/t long-term hospitalization
Grieving r/t loss of idealized pregnancy, potential loss of fetus
Impaired Home Maintenance r/t medical restrictions
Impaired physical Mobility r/t medically imposed restrictions
Ineffective Role Performance r/t inability to carry out normal roles secondary to bed rest or hospitalization, change in expected course of pregnancy
Situational low Self-Esteem r/t threatened ability to carry pregnancy to term
Sexual Dysfunction r/t actual or perceived limitation imposed by preterm labor and/or prescribed treatment, separation from partner because of hospitalization
Sleep deprivation r/t change in usual pattern secondary to contractions, hospitalization, treatment regimen
Impaired Social Interaction r/t prolonged bed rest or hospitalization
Risk for Injury: fetal: Risk factors: premature birth, immature body systems
Risk for Injury: maternal: Risk factor: use of tocolytic drugs
Risk for Powerlessness: Risk factor: lack of control over preterm labor
Risk for Vascular Trauma: Risk factor: IV medication
Readiness for enhanced Childbearing Process: appropriate prenatal lifestyle
Readiness for enhanced Comfort: expresses desire to enhance relaxation
Readiness for enhanced Communication: willingness to discuss thoughts and feelings about situation
Defensive Coping r/t situational crisis
Risk for chronic low Self-Esteem r/t repeated failures
Readiness for enhanced Communication: willing to share ideas with others
Readiness for enhanced Relationship: shares information and ideas between partners
Readiness for enhanced Resilience: identifies available resources
Readiness for enhanced Spiritual Well-Being: desires to draw on inner strength and find meaning and purpose to life
Anxiety r/t threat to self-concept
Defensive Coping r/t inability to acknowledge that own behavior may be a problem, blaming others
Chronic low Self-Esteem r/t failure
Impaired Social Interaction r/t self-concept disturbance, confrontational communication style
Risk for Loneliness: Risk factor: blaming others for problems
Risk for Post-Trauma Syndrome: Risk factor: diminished ego strength
Fear r/t threat to fetus, impending surgery
Ineffective peripheral Tissue Perfusion: fetal r/t interruption in umbilical blood flow
Risk for Injury: fetal: Risk factors: cord compression, ineffective tissue perfusion
Ineffective Health Maintenance r/t deficient knowledge regarding self-care and prevention of complications
Urinary Retention r/t obstruction
Risk for urge urinary Incontinence: Risk factor: small bladder capacity
Risk for Infection: Risk factors: urinary residual after voiding, bacterial invasion of bladder
Impaired Comfort r/t inflammation
Ineffective Health Maintenance r/t deficient knowledge regarding treatment
Deficient Knowledge r/t methods to treat and prevent itching
Risk for impaired Skin Integrity: Risk factor: scratching from pruritus
Disturbed Body Image r/t lesions on body
Impaired Comfort r/t irritated skin
Ineffective Health Maintenance r/t deficient knowledge regarding treatment modalities
Powerlessness r/t lack of control over condition with frequent exacerbations and remissions
Ineffective Activity Planning r/t compromised ability to process information
Ineffective Health Maintenance r/t cognitive impairment, ineffective individual and family coping
Self-Neglect r/t mental disorder
Impaired individual Resilience r/t psychological disorder
Situational low Self-Esteem r/t excessive use of defense mechanisms (e.g., projection, denial, rationalization)
Risk for disturbed personal Identity r/t psychosis
Risk for Post-Trauma Syndrome: Risk factor: diminished ego strength
See Schizophrenia
Anxiety r/t exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
Death Anxiety r/t psychological stress associated with traumatic event
Ineffective Breathing Pattern r/t hyperventilation associated with anxiety
Ineffective Coping r/t extreme anxiety
Disturbed Energy Field r/t disharmony of mind, body, spirit
Ineffective Impulse Control r/t re-experience of initial trauma
Insomnia r/t recurring nightmares
Post-Trauma Syndrome r/t exposure to a traumatic event
Sleep deprivation r/t nightmares associated with traumatic event
Spiritual Distress r/t feelings of detachment or estrangement from others
Risk for Powerlessness: Risk factors: flashbacks, reliving event
Risk for ineffective Relationship r/t stressful life events
Risk for self- or other-directed Violence: Risk factors: fear of self or others
Readiness for enhanced Comfort: expresses desire to enhance relaxation
Readiness for enhanced Communication: willingness to express feelings and thoughts
Readiness for enhanced Spiritual Well-Being: desire for harmony after stressful event
Anxiety r/t fear of suffocation
Ineffective Breathing Pattern r/t presence of tracheobronchial secretions
Impaired Gas Exchange r/t extravasation of extravascular fluid in lung tissues and alveoli
Ineffective Health Maintenance r/t deficient knowledge regarding treatment regimen
Sleep deprivation r/t inability to breathe
Risk for decreased Cardiac tissue perfusion: Risk factor: heart failure
Decreased Cardiac Output r/t right ventricular failure secondary to obstructed pulmonary artery
Fear r/t severe pain, possible death
Impaired Gas Exchange r/t altered blood flow to alveoli secondary to lodged embolus
Deficient Knowledge r/t activities to prevent embolism, self-care after diagnosis of embolism
Acute Pain r/t biological injury, lack of oxygen to cells
Ineffective peripheral Tissue Perfusion: r/t deep vein thrombus formation
Delayed Surgical Recovery r/t complications associated with respiratory difficulty
Readiness for enhanced Knowledge: information associated with treatment regimen
See Hypoxia
Ineffective peripheral Tissue Perfusion r/t interruption of arterial flow
Risk for Peripheral Neurovascular Dysfunction: Risk factors: fractures, mechanical compression, orthopedic surgery trauma, immobilization, burns, vascular obstruction
See cause of Absent or Diminished Peripheral Pulses
Ineffective Health Maintenance r/t deficient knowledge regarding self-care, treatment of disease, prevention of further urinary tract infections
Insomnia r/t urinary frequency
Acute Pain r/t inflammation and irritation of urinary tract
Impaired Urinary Elimination r/t irritation of urinary tract
Risk for urge urinary Incontinence: Risk factor: irritation of urinary tract
Risk for ineffective Renal Perfusion: Risk factor: infection