Ineffective Airway Clearance r/t hesitation or reluctance to cough because of pain
Deficient Knowledge: potential for enhanced health maintenance r/t insufficient knowledge regarding postoperative nutritional and rest requirements, signs and symptoms of complications, positioning
Nausea r/t gastric irritation, pharmaceuticals, anesthesia
Acute Pain r/t surgical incision
Risk for Aspiration/Suffocation: Risk factors: postoperative drainage and impaired swallowing
Risk for deficient Fluid Volume: Risk factors: decreased intake because of painful swallowing, effects of anesthesia (nausea, vomiting), hemorrhage
Risk for imbalanced Nutrition: less than body requirements: Risk factors: hesitation or reluctance to swallow
Ineffective Self-Health Management r/t complexity of therapeutic regimen or medication
Deficient Knowledge r/t cognitive limitation in assimilating information relating to side effects associated with neuroleptic medications
Risk for Injury: Risk factor: drug-induced abnormal body movements
Adult Failure to Thrive r/t imbalanced nutrition: less than body requirements associated with taste abnormality
Ineffective Airway Clearance r/t increased secretions, excessive mucus
Ineffective Breathing Pattern r/t decreased energy, fatigue
Impaired Gas Exchange r/t disease process
Ineffective Self-Health Management r/t deficient knowledge of prevention and treatment regimen
Impaired Home Maintenance management r/t client or family member with disease
Risk for Infection: Risk factors: insufficient knowledge regarding avoidance of exposure to pathogens
Readiness for enhanced Self-Health Management: takes medications according to prescribed protocol for prevention and treatment
Interrupted Family Processes r/t traumatic injury to family member
Chronic Sorrow r/t change in health status and functional ability
Risk for Post-Trauma Syndrome: Risk factor: perception of event causing TBI
Risk for impaired Religiosity: Risk factor: impaired physical mobility
Risk for compromised Resilience: Risk factor: crisis of injury
Risk for deficient Fluid Volume: Risk factors: excessive loss of fluids, diarrhea
Risk for Infection: Risk factors: insufficient knowledge regarding avoidance of exposure to pathogens (water supply, iced drinks, local cheeses, ice cream, undercooked meat, fish and shellfish, uncooked vegetables, unclean eating utensils, improper handwashing)
Anxiety r/t threat to or change in health status, situational crisis
Disturbed Energy Field r/t change in health status, discouragement, pain
Readiness for enhanced Communication: expresses willingness to share feelings and thoughts
See Stress
Death Anxiety r/t unresolved issues relating to death and dying
Disturbed Energy Field r/t impending disharmony of mind, body, spirit
Risk for Spiritual Distress: Risk factor: impending death
Readiness for enhanced Religiosity: requests religious material and/or experiences
Readiness for enhanced Spiritual Well-Being: desire to achieve harmony of mind, body, spirit
Disturbed Body Image r/t effects of terminal disease, already critical feelings of group identity and self-image
Ineffective Coping r/t inability to establish personal and peer identity because of the threat of being different or not being healthy, inability to achieve maturational tasks
Impaired Social Interaction/Social Isolation r/t forced separation from peers
See Child with Chronic Condition; Hospitalized Child, Terminally Ill Child/Death of Child, Parent
Ineffective Coping r/t separation from parents and familiar environment attributable to inability to understand dying process
See Child with Chronic Condition, Terminally Ill Child/Death of Child, Parent
Fear r/t perceived punishment, bodily harm, feelings of guilt caused by magical thinking (i.e., believing that thoughts cause events)
See Child with Chronic Condition, Terminally Ill Child/Death of Child, Parent
Fear r/t perceived punishment, body mutilation, feelings of guilt
See Child with Chronic Condition, Terminally Ill Child/Death of Child, Parent
Compromised family Coping r/t inability or unwillingness to discuss impending death and feelings with child or support child through terminal stages of illness
Decisional Conflict r/t continuation or discontinuation of treatment, do-not-resuscitate decision, ethical issues regarding organ donation
Ineffective Denial r/t complicated grieving
Interrupted Family Processes r/t situational crisis
Hopelessness r/t overwhelming stresses caused by terminal illness
Impaired Parenting r/t risk for overprotection of surviving siblings
Powerlessness r/t inability to alter course of events
Impaired Social Interaction r/t complicated grieving
Social Isolation: imposed by others r/t feelings of inadequacy in providing support to grieving parents
Social Isolation: self-imposed r/t unresolved grief, perceived inadequate parenting skills
Spiritual Distress r/t sudden and unexpected death, prolonged suffering before death, questioning the death of youth, questioning the meaning of one’s own existence
Risk for complicated Grieving: Risk factors: prolonged, unresolved, obstructed progression through stages of grief and mourning
Risk for compromised Resilience: Risk factor: impending death
Readiness for enhanced family Coping: impact of crisis on family values, priorities, goals, or relationships; expressed interest or desire to attach meaning to child’s life and death
Autonomic Dysreflexia r/t spinal cord injury
Grieving r/t loss of previous functioning
Risk for imbalance in body Temperature, hyperthermia/hypothermia
Powerlessness r/t inability to perform previous activities
Risk for Impaired Skin Integrity r/t physical immobilization
Ineffective family Therapeutic Regimen Management (See Therapeutic Regimen Management, family, ineffective, Section III)
Disturbed Energy Field r/t low energy levels, disturbance in energy fields, pain, depression, fatigue
Ineffective Thermoregulation (See Thermoregulation, ineffective, Section III)
Activity Intolerance r/t pain, imbalance between oxygen supply and demand, presence of chest tubes
Ineffective Airway Clearance r/t drowsiness, pain with breathing and coughing
Ineffective Breathing pattern r/t decreased energy, fatigue, pain
Deficient Knowledge r/t self-care, effective breathing exercises, pain relief
Acute Pain r/t surgical procedure, coughing, deep breathing
Risk for Bleeding: Risk factor: surgery
Risk for Infection: Risk factor: invasive procedure
Risk for Injury: Risk factor: disruption of closed-chest drainage system
Risk for Perioperative Positioning Injury: Risk factor: lateral positioning, immobility
Risk for Vascular Trauma: Risk factor: chemical irritant; antibiotics
Constipation r/t inactivity, bed rest
Deficient Diversional Activity r/t bed rest
Deficient Knowledge r/t pathophysiology of condition, self-care needs, treatment regimen and outcome
Sedentary Lifestyle r/t deficient knowledge of benefits of physical exercise
Impaired physical Mobility r/t pain in extremity, forced bed rest
Acute Pain r/t vascular inflammation, edema
Ineffective peripheral Tissue Perfusion r/t interruption of venous blood flow
Delayed Surgical Recovery r/t complication associated with inactivity
Risk for Bleeding: Risk factors: treatment; anticoagulants
Risk for Injury: Risk factor: possible embolus
Risk for Vascular Trauma: Risk factor: anticoagulant therapy
Risk for ineffective Airway Clearance r/t edema or hematoma formation, airway obstruction
Risk for impaired verbal Communication: Risk factors: edema, pain, vocal cord or laryngeal nerve damage
Risk for Injury: Risk factor: possible parathyroid damage or removal
See Surgery, Preoperative Care; Surgery, Perioperative Care; Surgery, Postoperative Care
Readiness for enhanced Self-Health Management: obtains knowledge regarding treatment prevention of inadequate oxygenation
See Syncope
Impaired Tissue Integrity (See Tissue Integrity, impaired, Section III)
Ineffective peripheral Tissue Perfusion (See Tissue Perfusion, peripheral, ineffective, Section III)
Toileting Self-Care deficit r/t impaired transfer ability, impaired mobility status, intolerance of activity, neuromuscular impairment, cognitive impairment
Deficient Knowledge: parent r/t signs of child’s readiness for training
Impaired Dentition r/t ineffective oral hygiene, barriers to self-care, economic barriers to professional care, nutritional deficits, lack of knowledge regarding dental health
Disturbed Body Image r/t large scar, presence of prosthesis
Impaired physical Mobility r/t musculoskeletal impairment, surgery, prosthesis
Risk for Injury: neurovascular: Risk factors: altered peripheral tissue perfusion, altered mobility, prosthesis
Risk for Peripheral Neurovascular Dysfunction r/t immobilization
Ineffective peripheral Tissue Perfusion r/t surgery
See Surgery, Preoperative Care; Surgery, Perioperative Care; Surgery, Postoperative Care
Hopelessness r/t inability to control behavior
Impaired individual Resilience r/t uncontrollable behavior
Risk for situational low Self-Esteem: Risk factors: uncontrollable behavior, motor and phonic tics
Imbalanced Nutrition: less than body requirements r/t inability to ingest or digest food or absorb nutrients as a result of biological or psychological factors
Risk for unstable blood Glucose level
Risk for Electrolyte Imbalance
Risk for excess Fluid Volume: Risk factor: rapid administration of TPN
Risk for Infection: Risk factors: concentrated glucose solution, invasive administration of fluids
Risk for Vascular Trauma: Risk factors: insertion site, length of treatment time
Ineffective Airway Clearance r/t aspiration of feeding because of inability to swallow
Imbalanced Nutrition: less than body requirements r/t difficulties in swallowing
Risk for Aspiration: Risk factors: common passage of air and food
Risk for Vascular Trauma: Risk factors: venous medications and site
See Respiratory Conditions of the Neonate; Hospitalized Child
Ineffective Airway Clearance r/t increased secretions, mucous plugs
Anxiety r/t impaired verbal communication, ineffective airway clearance
Disturbed Body Image r/t abnormal opening in neck
Impaired verbal Communication r/t presence of mechanical airway
Deficient Knowledge r/t self-care, home maintenance management
Acute Pain r/t edema, surgical procedure
Risk for Aspiration: Risk factor: presence of tracheostomy
Risk for Bleeding: Risk factor: surgical incision
Risk for Infection: Risk factors: invasive procedure, pooling of secretions
Deficient Diversional Activity r/t immobility
Impaired physical Mobility r/t imposed restrictions on activity because of bone or joint disease injury
Acute Pain r/t immobility, injury, or disease
Self-Care deficit: feeding, dressing, bathing, toileting r/t degree of impaired physical mobility, body area affected by traction or cast
Impaired Transfer Ability r/t presence of traction, casts
Risk for Disuse Syndrome: Risk factor: mechanical immobilization
See Casts
Anxiety r/t threat to self or fetus, unknown outcome
Deficient Knowledge r/t lack of exposure to situation
Impaired Skin Integrity r/t trauma
Risk for Bleeding: Risk factor: trauma
Risk for imbalanced Fluid Volume: Risk factor: fluid loss
Risk for Infection: Risk factor: traumatized tissue
Risk for Injury: fetal: Risk factor: premature separation of placenta
Risk for disturbed Maternal/Fetal Dyad: Risk factor: complication of pregnancy
Anxiety/Fear r/t threat to or change in health status, threat of death, situational crisis
Ineffective Self-Health Management r/t deficient knowledge regarding prevention of stimuli that trigger pain
Imbalanced Nutrition: less than body requirements r/t pain when chewing
Acute Pain r/t irritation of trigeminal nerve
Risk for Injury (eye): Risk factor: possible decreased corneal sensation
Readiness for enhanced Self-Health Management: seeks information regarding self-examination
Risk for Aspiration: Risk factors: improperly administered feeding, improper placement of tube, improper positioning of client during and after feeding, excessive residual feeding or lack of digestion, altered gag reflex
Risk for imbalanced Fluid Volume: Risk factor: inadequate water administration with concentrated feeding
Risk for imbalanced Nutrition: less than body requirements: Risk factors: intolerance to tube feeding, inadequate calorie replacement to meet metabolic needs
Deficient Knowledge r/t postoperative self-care, home maintenance management
Acute Pain r/t incision, irritation from catheter, bladder spasms, kidney infection
Urinary Retention r/t obstruction of urethra or catheter with clots
Risk for Bleeding: Risk factor: surgery
Risk for deficient Fluid Volume: Risk factors: fluid loss, possible bleeding
Risk for urge urinary Incontinence: Risk factor: edema from surgical procedure
Risk for Infection: Risk factors: invasive procedure, route for bacteria entry
Risk for ineffective Renal Perfusion: Risk factor: hypovolemia