Readiness for enhanced Resilience: uses SAD lights during winter months
Complicated Grieving r/t actual or perceived loss
Spiritual Distress r/t intense suffering
Risk for Powerlessness: Risk factor: actual or perceived loss
Risk for Spiritual Distress: Risk factor: loss of loved one
Readiness for enhanced Communication: willingness to share feelings and thoughts
Readiness for enhanced Spiritual Well-Being: desire for harmony after actual or perceived loss
See Depression (Major Depressive Disorder); Major Depressive Disorder
Readiness for enhanced Self-Health Management: taking appropriate precautions during sexual activity to keep from contacting a sexually transmitted disease
See Sexuality, Adolescent; STD (Sexually Transmitted Disease)
Deficient Knowledge: potential for enhanced health maintenance r/t parental knowledge and skill acquisition regarding appropriate safety measures
Risk for Aspiration (See Aspiration, risk for, Section III)
Risk for Injury/Trauma: Risk factors: developmental age, altered home maintenance
Risk for impaired Parenting: Risk factors: lack of available and effective role model, lack of knowledge, misinformation from other family members (old wives’ tales)
Risk for Poisoning: Risk factors: use of lead-based paint; presence of asbestos or radon gas; drugs not locked in cabinet; household products left in accessible area (bleach, detergent, drain cleaners, household cleaners); alcohol and perfume within reach of child; presence of poisonous plants; atmospheric pollutants
Risk for Thermal Injury r/t inadequate supervision
Readiness for enhanced Childbearing Process: appropriate knowledge for care of child
Readiness for enhanced Immunization Status: expresses desire to enhance immunization status
Impaired Home Maintenance r/t improper preparation or storage of food, lack of safety measures when caring for pet reptile
Risk for Electrolyte Imbalance: Risk factor: diarrhea
Readiness for enhanced Self-Health Management: avoiding improperly prepared or stored food, wearing gloves when handling pet reptiles or their feces
Decisional Conflict r/t sterilization procedure
Grieving r/t possible loss from tubal pregnancy
Risk for impaired Urinary Elimination: Risk factor: trauma to ureter during surgery
See Hysterectomy; Surgery, Perioperative Care; Surgery, Postoperative Care; Surgery, Preoperative Care
Anxiety r/t change in health status
Impaired Gas Exchange r/t ventilation-perfusion imbalance
Ineffective Health Maintenance r/t deficient knowledge regarding home care and medication regimen
Acute Pain r/t possible disease affecting joints
Ineffective Protection r/t immune disorder
Risk for decreased Cardiac tissue perfusion: Risk factor: dysrhythmias
Risk for impaired Skin Integrity: Risk factor: immunological disorder
Risk for Infection: Risk factor: increased environmental exposure (travelers in close proximity to infected persons, traveling when a fever is present)
Readiness for enhanced Knowledge: information regarding travel and precautions to avoid exposure to SARS
See Pneumonia
Readiness for enhanced Knowledge: self-breast examination
Readiness for enhanced Self-Health Management: desires to have information about SBE
Anxiety r/t threat of death, threat to or change in health status
Death Anxiety r/t unresolved issues surrounding end-of-life decisions
Fear r/t hospitalization, real or imagined threat to own well-being
Impaired individual Resilience r/t violence
Readiness for enhanced Communication: willingness to share thoughts and feelings
Ineffective Activity Planning r/t compromised ability to process information
Anxiety r/t unconscious conflict with reality
Impaired verbal Communication r/t psychosis, disorientation, inaccurate perception, hallucinations, delusions
Ineffective Coping r/t inadequate support systems, unrealistic perceptions, inadequate coping skills, disturbed thought processes, impaired communication
Deficient Diversional Activity r/t social isolation, possible regression
Interrupted Family Processes r/t inability to express feelings, impaired communication
Fear r/t altered contact with reality
Ineffective Health Maintenance r/t cognitive impairment, ineffective individual and family coping, lack of material resources
Impaired Home Maintenance r/t impaired cognitive or emotional functioning, insufficient finances, inadequate support systems
Hopelessness r/t long-term stress from chronic mental illness
Disturbed personal Identity r/t psychiatric disorder
Insomnia r/t sensory alterations contributing to fear and anxiety
Impaired Memory r/t psychosocial condition
Imbalanced Nutrition: less than body requirements r/t fear of eating, lack of awareness of hunger, disinterest toward food
Impaired individual Resilience r/t psychological disorder
Self-Care deficit: specify r/t loss of contact with reality, impairment of perception
Sleep deprivation r/t intrusive thoughts, nightmares
Impaired Social Interaction r/t impaired communication patterns, self-concept disturbance, disturbed thought processes
Social Isolation r/t lack of trust, regression, delusional thinking, repressed fears
Chronic Sorrow r/t chronic mental illness
Spiritual Distress r/t loneliness, social alienation
Ineffective family Therapeutic Regimen Management r/t chronicity and unpredictability of condition
Risk for Caregiver Role Strain: Risk factors: bizarre behavior of client, chronicity of condition
Risk for compromised Human Dignity: Risk factor: stigmatizing label
Risk for Loneliness: Risk factor: inability to interact socially
Risk for Post-Trauma Syndrome: Risk factor: diminished ego strength
Risk for Powerlessness: Risk factor: intrusive, distorted thinking
Risk for impaired Religiosity: Risk factors: ineffective coping, lack of security
Risk for Suicide: Risk factor: psychiatric illness
Risk for self- and other-directed Violence: Risk factors: lack of trust, panic, hallucinations, delusional thinking
Readiness for enhanced Hope: expresses desire to enhance interconnectedness with others and problem-solve to meet goals
Readiness for enhanced Power: expresses willingness to enhance participation in choices for daily living and health and enhance knowledge for participation in change
Risk-prone Health Behavior r/t lack of developmental maturity to comprehend long-term consequences of noncompliance with treatment procedures
Disturbed Body Image r/t use of therapeutic braces, postsurgery scars, restricted physical activity
Ineffective Breathing Pattern r/t restricted lung expansion caused by severe curvature of spine
Impaired Comfort r/t altered health status and body image
Impaired Gas Exchange r/t restricted lung expansion as a result of severe presurgery curvature of spine, immobilization
Impaired physical Mobility r/t restricted movement, dyspnea caused by severe curvature of spine
Acute Pain r/t musculoskeletal restrictions, surgery, reambulation with cast or spinal rod
Impaired Skin Integrity r/t braces, casts, surgical correction
Chronic Sorrow r/t chronic disability
Ineffective Health Maintenance r/t deficient knowledge regarding treatment modalities, restrictions, home care, postoperative activities
Risk for Infection: Risk factor: surgical incision
Risk for Perioperative Positioning Injury: Risk factor: prone position
Risk for compromised Resilience: Risk factor: chronic condition
Readiness for enhanced Self-Health Management: desires knowledge regarding treatment for condition
Activity Intolerance r/t sedentary lifestyle
Sedentary lifestyle (See Sedentary lifestyle, Section III)
Risk for ineffective peripheral Tissue Perfusion r/t lack of exercise/movement
Readiness for enhanced Coping: seeking knowledge of new strategies to adjust to sedentary lifestyle
Acute Confusion r/t postseizure state
Social Isolation r/t unpredictability of seizures, community-imposed stigma
Risk for ineffective Airway Clearance: Risk factor: accumulation of secretions during seizure
Risk for Falls: Risk factor: uncontrolled seizure activity
Risk for unstable blood Glucose level (hypoglycemia)
Risk for Powerlessness: Risk factor: possible seizure
Risk for compromised Resilience: Risk factor: chronic illness
Readiness for enhanced Knowledge: anticonvulsive therapy
Readiness for enhanced Self-Care: expresses desire to enhance knowledge and responsibility for self-care
See Epilepsy
Ineffective Health Maintenance r/t lack of knowledge regarding anticonvulsive therapy, fever reduction (febrile seizures)
Social Isolation r/t unpredictability of seizures, community-imposed stigma
Risk for ineffective Airway Clearance: Risk factor: accumulation of secretions during seizure
Risk for delayed Development and disproportionate Growth: Risk factors: effects of seizure disorder, parental overprotection
Risk for Falls: Risk factor: possible seizure
Risk for Injury: Risk factors: uncontrolled movements during seizure, falls, drowsiness caused by anticonvulsants
See Epilepsy
Dressing Self-Care deficit (See Self-Care deficit, dressing, Section III)
Toileting Self-Care deficit (See Self-Care deficit, toileting, Section III)
Readiness for enhanced Self-Concept (See Self-Concept, readiness for enhanced, Section III)
Post-Trauma Syndrome r/t unresolved feelings from traumatic event
Risk for Self-Mutilation: Risk factors: feelings of depression, rejection, self-hatred, depersonalization; command hallucinations
Risk for Suicide: Risk factor: history of self-destructive behavior
Risk for self-directed Violence: Risk factors: panic state, history of child abuse, toxic reaction to medication
Chronic low Self-Esteem (See Self-Esteem, low, chronic, Section III)
Risk for disturbed personal Identity r/t chronic low self-esteem
Situational low Self-Esteem (See Self-Esteem, low, situational, Section III)
Risk for situational low Self-Esteem (See Self-Esteem, low, situational, risk for, 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)
Self-Mutilation (See Self-Mutilation, Section III)
Ineffective Impulse Control r/t ineffective management of anxiety
Risk for Self-Mutilation (See Self-Mutilation, risk for, Section III)
Sedentary lifestyle r/t lack of interest
Ineffective Relationship r/t cognitive changes in one partner
See Dementia
Ineffective Coping r/t maturational and situational crises, vulnerability related to developmental age, hospitalization, separation from family and familiar surroundings, multiple caregivers
Insomnia r/t separation for significant others
Imbalanced Nutrition: less than body requirements r/t anorexia, generalized weakness, poor sucking reflex
Ineffective peripheral Tissue Perfusion: r/t arterial or venous blood flow exchange problems, septic shock
Delayed Surgical Recovery r/t presence of infection
Ineffective Thermoregulation r/t infectious process, septic shock
Risk for impaired Skin Integrity: Risk factors: desquamation caused by disseminated intravascular coagulation
Imbalanced Nutrition: less than body requirements r/t anorexia, generalized weakness
Ineffective peripheral Tissue Perfusion r/t decreased systemic vascular resistance
Risk for imbalanced Fluid Volume r/t vasodilation of peripheral vessels, leaking of capillaries
Sexual Dysfunction (See Sexual Dysfunction, Section III)
Ineffective Relationship r/t reported sexual dissatisfaction between partners
Chronic Sorrow r/t loss of ideal sexual experience, altered relationships
Disturbed Body Image r/t anxiety caused by unachieved developmental milestone (puberty) or deficient knowledge regarding reproductive maturation as manifested by amenorrhea or expressed concerns regarding lack of growth of secondary sex characteristics
Decisional Conflict: sexual activity r/t undefined personal values or beliefs, multiple or divergent sources of information, lack of relevant information
Ineffective Impulse Control r/t denial of consequences of actions
Deficient Knowledge: potential for enhanced health maintenance r/t multiple or divergent sources of information or lack of relevant information regarding sexual transmission of disease, contraception, prevention of toxic shock syndrome
Ineffective Sexuality Pattern (See Sexuality Pattern, ineffective, Section III)
Decreased Intracranial Adaptive Capacity r/t brain injury
Impaired Parenting r/t stress, history of being abusive
Impaired individual Resilience r/t poor impulse control
Stress overload r/t intense repeated family stressors, family violence
Risk for other-directed Violence: Risk factors: history of violence against others, perinatal complications
See Child Abuse; Suspected Child Abuse and Neglect (SCAN), Child; Suspected Child Abuse and Neglect (SCAN), Parent
Situational low Self-Esteem r/t inability to deal with past traumatic events, blaming of self for events not under one’s control
Impaired Comfort r/t inflammation
Acute Pain r/t vesicular eruption along the nerves
Ineffective Protection r/t abnormal blood profiles
Social Isolation r/t altered state of wellness, contagiousness of disease
Risk for Infection: Risk factor: tissue destruction
Readiness for enhanced Immunization Status: expresses desire to enhance immunization status
See Itching
Impaired Comfort r/t altered health status
Fear r/t serious threat to health status
Hypothermia r/t exposure to cool environment
Risk for Injury: Risk factor: prolonged shock resulting in multiple organ failure or death
Risk for decreased Cardiac tissue perfusion: Risk factor: hypotension, hypovolemia
Risk for ineffective Renal Perfusion: Risk factor: hypovolemia
Risk for Shock (See Shock, risk for, Section III)
Deficient Fluid Volume r/t abnormal loss of fluid through capillaries, pooling of blood in peripheral circulation
Ineffective Protection r/t inadequately functioning immune system
See Sepsis, Child; Septicemia
Self-Care deficit: bathing, dressing, feeding r/t immobilization of affected shoulder
Risk for Perioperative Positioning Injury: Risk factor: immobility
See Surgery, Preoperative; Surgery, Perioperative; Surgery, Postoperative; Total Joint Replacement (Total Hip/Total Knee/Shoulder)
Activity Intolerance r/t fatigue, effects of chronic anemia
Impaired Comfort r/t altered health status
Deficient Fluid Volume r/t decreased intake, increased fluid requirements during sickle cell crisis, decreased ability of kidneys to concentrate urine
Impaired physical Mobility r/t pain, fatigue
Acute Pain r/t viscous blood, tissue hypoxia
Ineffective peripheral Tissue Perfusion r/t effects of red cell sickling, infarction of tissues
Risk for disproportionate Growth: Risk factor: chronic illness
Risk for Infection: Risk factor: alterations in splenic function
Risk for decreased Cardiac tissue perfusion: Risk factors: effects of red cell sickling, infarction of tissues
Risk for ineffective cerebral, gastrointestinal, renal Tissue Perfusion: Risk factors: effects of red cell sickling, infarction of tissues
Risk for compromised Resilience: Risk factor: chronic illness
Readiness for enhanced Immunization Status: receives appropriate immunizations to prevent disease
Anxiety/Fear: parental r/t life-threatening event
Interrupted Family Processes r/t stress as a result of special care needs of infant with apnea
Grieving r/t potential loss of infant
Insomnia: parental/infant r/t home apnea monitoring
Deficient Knowledge: potential for enhanced health maintenance r/t knowledge or skill acquisition of cardiopulmonary resuscitation and home apnea monitoring
Impaired Resilience r/t sudden loss
Risk for Sudden Infant Death Syndrome (See Sudden Infant Death Syndrome, risk for, Section III)
Risk for Powerlessness: Risk factor: unanticipated life-threatening event
Ineffective Coping r/t situational crisis
Interrupted Family Processes r/t situational crisis
Risk for ineffective Activity Planning r/t inability to process information
Risk for disturbed personal Identity r/t situational crisis
Readiness for enhanced Communication: willingness to share feelings and thoughts
Readiness for enhanced Religiosity: requests religious material and/or experiences
Readiness for enhanced Resilience: desire to enhance resilience
Readiness for enhanced Spiritual Well-Being: desire for harmony following crisis
Ineffective Health Maintenance r/t deficient knowledge regarding self-care with skin cancer
Ineffective Protection r/t weakened immune system
Impaired Skin Integrity r/t abnormal cell growth in skin, treatment of skin cancer
Readiness for enhanced Knowledge: self-care to prevent and treat skin cancer
Readiness for enhanced Self-Health Management: follows preventive measures
Risk for impaired Skin Integrity (See Skin Integrity, impaired, risk for, Section III)
Insomnia: child r/t anxiety or fear
Insomnia: parent r/t parental responsibilities, stress
See Suspected Child Abuse and Neglect (SCAN), Child and Parent
Impaired verbal Communication r/t decrease in circulation to brain, brain tumor, anatomical defect, cleft palate
Risk for Injury: Risk factors: inability to detect gas fumes, smoke smells
See Anosmia
Ineffective Airway Clearance r/t smoke inhalation
Impaired Gas Exchange r/t ventilation-perfusion imbalance
Risk for acute Confusion: Risk factor: decreased oxygen supply
Risk for Poisoning: Risk factor: exposure to carbon monoxide
Readiness for enhanced Self-Health Management: functioning smoke detectors and carbon monoxide detectors in home and work, plan for escape route worked out and reviewed
See Atelectasis; Burns; Pneumonia
Insufficient Breast Milk r/t smoking
Risk-prone Health Behavior r/t smoking
Altered Health Maintenance r/t denial of effects of smoking, lack of effective support for smoking withdrawal
Readiness for enhanced Knowledge: expresses interest in smoking cessation
Risk for ineffective peripheral Tissue Perfusion r/t effect of nicotine
Impaired Social Interaction (See Social Interaction, impaired, Section III)
Anxiety r/t unresolved conflicts channeled into physical complaints or conditions
Ineffective Coping r/t lack of insight into underlying conflicts
Ineffective Denial r/t displaces psychological stress to physical symptoms
Chronic Pain r/t unexpressed anger, multiple physical disorders, depression
Impaired individual Resilience r/t possible psychological disorders
Ineffective Breastfeeding r/t deficient knowledge regarding correct feeding procedure
Impaired Comfort r/t sore throat
Deficient Knowledge r/t treatment, relief of discomfort
Impaired Oral Mucous Membrane r/t inflammation or infection of oral cavity
Grieving r/t loss of significant person, object, or role
Chronic Sorrow (See Sorrow, chronic, Section III)
Readiness for enhanced Communication: expresses thoughts and feelings
Readiness for enhanced Spiritual Well-Being: desire to find purpose and meaning of loss
Anxiety r/t difficulty with communication
Impaired verbal Communication r/t anatomical defect, cleft palate, psychological barriers, decrease in circulation to brain
Delayed Growth and Development r/t effects of physical or mental disability
Deficient Diversional Activity r/t long-term hospitalization, frequent lengthy treatments
Fear r/t powerlessness over loss of body function
Complicated Grieving r/t loss of usual body function
Sedentary Lifestyle r/t lack of resources or interest
Impaired wheelchair Mobility r/t neuromuscular impairment
Urinary Retention r/t inhibition of reflex arc
Risk for Latex Allergy Response: Risk factor: continuous or intermittent catheterization
Risk for Autonomic Dysreflexia: Risk factors: bladder or bowel distention, skin irritation, deficient knowledge of patient and caregiver
Risk for ineffective Breathing Pattern: Risk factor: neuromuscular impairment
Risk for Infection: Risk factors: chronic disease, stasis of body fluids
Risk for Loneliness: Risk factor: physical immobility
Risk for Powerlessness: Risk factor: loss of function
See Child with Chronic Condition; Hospitalized Child; Neural Tube Defects; Paralysis
Impaired bed Mobility r/t impaired ability to turn side to side while keeping spine in proper alignment
Impaired physical Mobility r/t musculoskeletal impairment associated with surgery, possible back brace
Readiness for enhanced Knowledge: expresses interest in information associated with surgery
See Acute Back; Back Pain; Scoliosis; Surgery, Preoperative Care; Surgery, Perioperative Care; Surgery, Postoperative Care
Spiritual Distress (See Spiritual Distress, Section III)
Risk for chronic low Self-Esteem r/t unresolved spiritual issues
Risk for Spiritual Distress (See Spiritual Distress, risk for, Section III)
Readiness for enhanced Spiritual Well-Being (See Spiritual Well-Being, readiness for enhanced, Section III)
Impaired Comfort r/t infection
Fear r/t altered body function, risk for social isolation, fear of incurable illness
Ineffective Health Maintenance r/t deficient knowledge regarding transmission, symptoms, treatment of STD
Ineffective Sexuality Pattern r/t illness, altered body function
Social Isolation r/t fear of contracting or spreading disease
Risk for Infection: spread of infection: Risk factor: lack of knowledge concerning transmission of disease
Readiness for enhanced Knowledge: seeks information regarding prevention and treatment of STDs
See Maturational Issues, Adolescent; PID (Pelvic Inflammatory Disease)
Risk for Injury: Risk factor: complications associated with stent placement
Risk for decreased Cardiac tissue perfusion: Risk factor: possible restenosis
Risk for Vascular Trauma: Risk factor: insertion site, catheter width
Readiness for enhanced Decision-Making: expresses desire to enhance risk-benefit analysis, understanding and meaning of choices, and decisions regarding treatment
Decisional Conflict r/t multiple or divergent sources of information, unclear personal values or beliefs
See Surgery, Preoperative Care; Surgery, Perioperative Care; Surgery, Postoperative Care; Tubal Ligation; Vasectomy
Impaired Oral Mucous Membrane r/t immunocompromised condition associated with allergic medication reaction
Acute Pain r/t painful skin lesions and painful oral mucosa lesions
Impaired Skin Integrity r/t allergic medication reaction
Risk for acute Confusion: Risk factors: dehydration, electrolyte disturbances
Risk for imbalanced Fluid Volume: Risk factors: factors affecting fluid needs (hypermetabolic state, hyperthermia), excessive losses through normal routes (vomiting and diarrhea)
Constipation r/t inadequate fluid intake, inadequate fiber intake, decreased activity level, decreased gastric motility
Decreased Cardiac Output r/t vagal stimulation with dysrhythmia resulting from Valsalva maneuver
Constipation r/t less than adequate fluid intake, less than adequate dietary intake
Anxiety r/t feelings of helplessness, feelings of being threatened
Ineffective Coping r/t ineffective use of problem-solving process, feelings of apprehension or helplessness
Disturbed Energy Field r/t low energy level, feelings of hopelessness
Fear r/t powerlessness over feelings
Stress overload r/t intense or multiple stressors
Risk for Post-Trauma Syndrome: Risk factors: perception of event, survivor’s role in event
Readiness for enhanced Communication: shows willingness to share thoughts and feelings
Readiness for enhanced Spiritual Well-Being: expresses desire for harmony and peace in stressful situation
See Anxiety
Stress urinary Incontinence r/t degenerative change in pelvic muscles
Risk for urge urinary Incontinence: Risk factor: involuntary sphincter relaxation
Anxiety r/t impaired verbal communication
Impaired verbal Communication r/t anxiety, psychological problems
Acute Pain: headache r/t irritation of meninges from blood, increased intracranial pressure
Risk for ineffective Cerebral tissue perfusion: Risk factor: bleeding from cerebral vessel
Compromised/disabled family Coping r/t codependency issues
Defensive Coping r/t substance abuse
Ineffective Coping r/t use of substances to cope with life events
Ineffective Denial r/t refusal to acknowledge substance abuse problem
Dysfunctional Family Processes r/t substance abuse
Deficient community Health r/t prevention and control of illegal substances in community
Ineffective Impulse Control r/t addictive process
Ineffective Relationship r/t inability for well-balanced collaboration between partners
Insomnia r/t irritability, nightmares, tremors
Risk for impaired Attachment: Risk factor: substance abuse
Risk for disturbed personal Identity r/t ingestion/inhalation of toxic chemicals
Risk for chronic low Self Esteem
Risk for Vascular Trauma: Risk factor: chemical irritant
Risk for self- or other-directed Violence: Risk factors: reactions to substances used, impulsive behavior, disorientation, impaired judgment
Readiness for enhanced Coping: seeking social support and knowledge of new strategies
Readiness for enhanced Self-Concept: accepting strengths and limitations
See Alcohol Withdrawal; Maturational Issues, Adolescent; Substance Abuse
Ineffective Childbearing Process r/t use of substance abuse
Defensive Coping r/t denial of situation, differing value system
Ineffective Health Maintenance r/t addiction
Deficient Knowledge r/t lack of exposure to information regarding effects of substance abuse in pregnancy
Noncompliance r/t differing value system, cultural influences, addiction
Risk for impaired Attachment: Risk factors: substance abuse, inability of parent to meet infant’s or own personal needs
Risk for Infection: Risk factors: intravenous drug use, lifestyle
Risk for Injury: fetal: Risk factor: effects of drugs on fetal growth and development
Risk for Injury: maternal: Risk factor: drug use
Risk for impaired Parenting: Risk factor: lack of ability to meet infant’s needs
Risk-prone Health Behavior r/t low self-efficacy
Ineffective Coping r/t anger, complicated grieving
Hopelessness r/t perceived or actual loss, substance abuse, low self-concept, inadequate support systems
Ineffective Impulse Control r/t inability to modulate stress/anxiety
Post-Trauma Syndrome r/t history of traumatic events, abuse, rape, incest, war, torture
Impaired individual Resilience r/t poor impulse control
Situational low Self-Esteem r/t guilt, inability to trust, feelings of worthlessness or rejection
Social Isolation r/t inability to engage in satisfying personal relationships
Spiritual Distress r/t hopelessness, despair
Risk for Post-Trauma Syndrome: Risk factor: survivor’s role in suicide attempt
Risk for Suicide (See Suicide, risk for, Section III)
Readiness for enhanced Communication: willingness to share thoughts and feelings
Readiness for enhanced Spiritual Well-Being: desire for harmony and inner strength to help redefine purpose for life
See Violent Behavior
Readiness for enhanced family Coping: ability to adapt to tasks associated with care, support of significant other during health crisis
Readiness for enhanced Family Processes: activities support the growth of family members
Readiness for enhanced Parenting: children or other dependent person(s) expressing satisfaction with home environment
Risk for imbalanced Fluid Volume: Risk factor: surgery
Risk for Perioperative Positioning Injury: Risk factors: predisposing condition, prolonged surgery
Activity Intolerance r/t pain, surgical procedure
Anxiety r/t change in health status, hospital environment
Deficient Knowledge r/t postoperative expectations, lifestyle changes
Nausea r/t manipulation of gastrointestinal tract, postsurgical anesthesia
Imbalanced Nutrition: less than body requirements r/t anorexia, nausea, vomiting, decreased peristalsis
Ineffective peripheral Tissue Perfusion r/t hypovolemia, circulatory stasis, obesity, prolonged immobility, decreased coughing, decreased deep breathing
Acute Pain r/t inflammation or injury in surgical area
Delayed Surgical Recovery r/t extensive surgical procedure, postoperative surgical infection
Urinary Retention r/t anesthesia, pain, fear, unfamiliar surroundings, client’s position
Risk for Bleeding: Risk factor: surgical procedure
Risk for ineffective Breathing Pattern: Risk factors: pain, location of incision, effects of anesthesia or opioids
Risk for Constipation: Risk factors: decreased activity, decreased food or fluid intake, anesthesia, pain medication
Risk for imbalanced Fluid Volume: Risk factors: hypermetabolic state, fluid loss during surgery, presence of indwelling tubes
Risk for Infection: Risk factors: invasive procedure, pain, anesthesia, location of incision, weakened cough as a result of aging
Anxiety r/t threat to or change in health status, situational crisis, fear of the unknown
Insomnia r/t anxiety about upcoming surgery
Deficient Knowledge r/t preoperative procedures, postoperative expectations
Readiness for enhanced Knowledge: shows understanding of preoperative and postoperative expectations for self-care
Ineffective Activity Planning r/t lack of family support
Anxiety/Fear: child r/t threat of punishment for perceived wrongdoing
Deficient community Health r/t inadequate reporting and follow-up of SCAN
Disturbed personal Identity r/t dysfunctional family processes
Rape-Trauma Syndrome r/t altered lifestyle because of abuse, changes in residence
Risk for compromised Resilience: Risk factor: adverse situation
Readiness for enhanced community Coping: obtaining resources to prevent child abuse, neglect
See Child Abuse; Hospitalized Child; Maturational Issues, Adolescent
Disabled family Coping r/t dysfunctional family, underdeveloped nurturing parental role, lack of parental support systems or role models
Dysfunctional Family Processes r/t inadequate coping skills
Ineffective Health Maintenance r/t deficient knowledge of parenting skills as a result of unachieved developmental tasks
Impaired Home Maintenance r/t disorganization, parental dysfunction, neglect of safe and nurturing environment
Ineffective Impulse Control r/t projection of anger/frustration onto the child
Impaired Parenting r/t unrealistic expectations of child; lack of effective role model; unmet social, emotional, or maturational needs of parents; interruption in bonding process
Powerlessness r/t inability to perform parental role responsibilities
Impaired individual Resilience r/t poor impulse control
Chronic low Self-Esteem r/t lack of successful parenting experiences
Risk for other-directed Violence: parent to child: Risk factors: inadequate coping mechanisms, unresolved stressors, unachieved maturational level by parent
Disturbed personal Identity r/t psychiatric disorder
Powerlessness r/t repetitive paranoid thinking
Impaired Social Interaction r/t disturbed thought processes, paranoid delusions, hallucinations
Risk for self- or other-directed Violence: Risk factor: inability to trust
Decreased Cardiac Output r/t dysrhythmia
Impaired physical Mobility r/t fear of falling
Social Isolation r/t fear of falling
Risk for Falls: Risk factor: syncope
Risk for Injury: Risk factors: altered sensory perception, transient loss of consciousness, risk for falls
Risk for ineffective Cerebral tissue perfusion: Risk factor: interruption of blood flow