Adult Failure to Thrive r/t (See Thrive, failure to, Section III)
Imbalanced Nutrition: less than body requirements r/t inability to ingest food because of physiological factors
Activity Intolerance r/t side effects of treatment, weakness from cancer
Death Anxiety r/t unresolved issues regarding dying
Disturbed Body Image r/t side effects of treatment, cachexia
Decisional Conflict r/t selection of treatment choices, continuation or discontinuation of treatment, “do not resuscitate” decision
Constipation r/t side effects of medication, altered nutrition, decreased activity
Compromised family Coping r/t prolonged disease or disability progression that exhausts supportive ability of significant others
Ineffective Coping r/t personal vulnerability in situational crisis, terminal illness
Ineffective Denial r/t complicated grieving process
Fear r/t serious threat to well-being
Grieving r/t potential loss of significant others, high risk for infertility
Ineffective Health Maintenance r/t deficient knowledge regarding prescribed treatment
Hopelessness r/t loss of control, terminal illness
Impaired physical Mobility r/t weakness, neuromusculoskeletal impairment, pain
Imbalanced Nutrition: less than body requirements r/t loss of appetite, difficulty swallowing, side effects of chemotherapy, obstruction by tumor
Impaired Oral Mucous Membrane r/t chemotherapy, effects of radiation, oral pH changes, decreased oral secretions
Chronic Pain r/t metastatic cancer
Powerlessness r/t treatment, progression of disease
Ineffective Protection r/t cancer suppressing immune system
Ineffective Role Performance r/t change in physical capacity, inability to resume prior role
Self-Care deficit: specify r/t pain, intolerance to activity, decreased strength
Impaired Skin Integrity r/t immunological deficit, immobility
Social Isolation r/t hospitalization, lifestyle changes
Chronic Sorrow r/t chronic illness of cancer
Spiritual Distress r/t test of spiritual beliefs
Risk for Bleeding: Risk factor: bone marrow depression from chemotherapy
Risk for Disuse Syndrome: Risk factors: immobility, fatigue
Risk for impaired Home Maintenance: Risk factor: lack of familiarity with community resources
Risk for Infection: Risk factor: inadequate immune system
Risk for compromised Resilience: Risk factors: multiple stressors, pain, chronic illness
Risk for Spiritual Distress: Risk factor: physical illness of cancer
Readiness for enhanced Knowledge: expresses an interest in learning
Readiness for enhanced Spiritual Well-Being: desire for harmony with self, others, higher power, God, when faced with serious illness
See Chemotherapy; Child with Chronic Condition; Hospitalized Child; Leukemia; Radiation Therapy; Terminally Ill Child, Adolescent; Terminally Ill Child, Infant/Toddler; Terminally Ill Child, Preschool Child; Terminally Ill Child, School-Age Child/Preadolescent; Terminally Ill Child/Death of Child, Parent
Readiness for enhanced Knowledge: expresses an interest in learning
Impaired Oral Mucous Membrane r/t overgrowth of infectious agent, depressed immune function
Impaired Gas Exchange r/t ventilation perfusion imbalance
Ineffective peripheral Tissue Perfusion r/t interruption of arterial flow
Fear r/t invasive procedure, uncertainty of outcome of procedure
Risk for Injury: hematoma: Risk factor: invasive procedure
Risk for decreased Cardiac tissue perfusion: Risk factors: ventricular ischemia, dysrhythmia
Risk for Peripheral Neurovascular Dysfunction: Risk factor: vascular obstruction
Readiness for enhanced Knowledge: expresses an interest in learning postprocedure care, treatment, and prevention of coronary artery disease.
Decreased Cardiac Output r/t cardiac disorder
Risk for decreased Cardiac tissue perfusion: Risk factor: cardiac disorder
Activity Intolerance r/t cardiac pathophysiology, increased demand for cardiac output because of pregnancy, weakness, fatigue
Death Anxiety r/t potential danger of condition
Compromised family Coping r/t prolonged hospitalization or maternal incapacitation that exhausts supportive capacity of significant others
Ineffective Coping r/t personal vulnerability
Interrupted Family Processes r/t hospitalization, maternal incapacitation, changes in roles
Fatigue r/t physiological, psychological, and emotional demands
Fear r/t potential maternal effects, potential poor fetal or maternal outcome
Powerlessness r/t illness-related regimen
Ineffective Role Performance r/t changes in lifestyle, expectations from disease process with superimposed pregnancy
Situational low Self-Esteem r/t situational crisis, pregnancy
Social Isolation r/t limitations of activity, bed rest or hospitalization, separation from family and friends
Risk for delayed Development: Risk factor: poor maternal oxygenation
Risk for deficient Fluid Volume: Risk factor: sudden changes in circulation after delivery of placenta
Risk for excess Fluid Volume: Risk factors: compromised regulatory mechanism with increased afterload, preload, circulating blood volume
Risk for impaired Gas Exchange: Risk factor: pulmonary edema
Risk for disproportionate Growth: Risk factor: poor maternal oxygenation
Risk for disturbed Maternal/Fetal Dyad: Risk factor: compromised oxygen transport
Risk for decreased Cardiac tissue perfusion: Risk factor: strain on compromised heart from work of pregnancy, delivery
Risk for compromised Resilience: Risk factors: multiple stressors, fear
Risk for Spiritual Distress: Risk factor: fear of diagnosis for self and infant
Readiness for enhanced Knowledge: expresses an interest in learning
Caregiver Role Strain (See Caregiver Role Strain, Section III)
Risk for compromised Resilience: Risk factor: stress of prolonged caregiving
Fear r/t surgery in vital area
Risk for ineffective Airway Clearance: Risk factor: hematoma compressing trachea
Risk for Bleeding Risk factor: possible hematoma formation, trauma to region
Risk for ineffective Cerebral tissue perfusion: Risk factors: hemorrhage, clot formation
Readiness for enhanced Knowledge: expresses an interest in learning
Impaired physical Mobility r/t neuromuscular impairment
Deficient Diversional Activity r/t physical limitations from cast
Impaired physical Mobility r/t limb immobilization
Self-Care deficit: bathing, dressing, feeding r/t presence of cast(s) on upper extremities
Self-Care deficit: toileting r/t presence of cast(s) on lower extremities
Impaired Walking r/t cast(s) on lower extremities, fracture of bones
Risk for Peripheral Neurovascular Dysfunction: Risk factor: mechanical compression from cast, trauma from fracture
Risk for impaired Skin Integrity: Risk factor: unrelieved pressure on skin from cast
Readiness for enhanced Knowledge: expresses an interest in learning
Anxiety r/t threat of permanent vision loss, surgical procedure
Vision Loss r/t edema from surgery
Risk for Injury: Risk factors: increased intraocular pressure, accommodation to new visual field
Readiness for enhanced Knowledge: expresses an interest in learning
Impaired verbal Communication r/t cognitive impairment
Impaired Memory r/t cognitive impairment
Impaired physical Mobility r/t cognitive impairment, maintenance of rigid posture, inappropriate or bizarre postures
Imbalanced Nutrition: less than body requirements r/t decrease in outside stimulation, loss of perception of hunger, resistance to instructions to eat
Social Isolation r/t inability to communicate, immobility
See Schizophrenia
Risk for Infection: Risk factor: invasive procedure
Readiness for enhanced Knowledge: expresses an interest in learning
Impaired Dentition r/t ineffective oral hygiene, barriers to self-care, economic barriers to professional care, nutritional deficits, dietary habits
Imbalanced Nutrition: less than body requirements r/t malabsorption due to immune effects of gluten
Diarrhea r/t malabsorption of food, immune effects of gluten on gastrointestinal system
Readiness for enhanced Knowledge: Expresses an interest in learning
Acute Pain r/t inflammatory changes in tissues from infection
Ineffective peripheral Tissue Perfusion r/t edema of extremities
Impaired Tissue Integrity r/t inflammatory process damaging skin and underlying tissue
Risk for Vascular Trauma: Risk factor: infusion of antibiotics
Readiness for enhanced Knowledge: expresses an interest in learning
Acute Pain r/t edema and inflammation of skin/tissues
Vision Loss r/t decreased visual field secondary to edema of eyelids
Impaired Skin Integrity r/t inflammation or infection of skin, tissues
Readiness for enhanced Knowledge: expresses an interest in learning
Risk for Infection: Risk factor: invasive procedure
Risk for Vascular Trauma (See Vascular Trauma, risk for, Section III)
Readiness for enhanced Knowledge: expresses an interest in learning
See Craniectomy/Craniotomy; Intracranial Pressure, Increased; Subarachnoid Hemorrhage
Impaired verbal Communication r/t impaired ability to articulate or speak words because of facial muscle involvement
Deficient Diversional Activity r/t physical impairments, limitations on ability to participate in recreational activities
Impaired physical Mobility r/t spasticity, neuromuscular impairment or weakness
Imbalanced Nutrition: less than body requirements r/t spasticity, feeding or swallowing difficulties
Self-Care deficit: specify r/t neuromuscular impairments, sensory deficits
Impaired Social Interaction r/t impaired communication skills, limited physical activity, perceived differences from peers
Chronic Sorrow r/t presence of chronic disability
Risk for Falls: Risk factor: impaired physical mobility
Risk for Injury: Risk factors: muscle weakness, inability to control spasticity
Risk for impaired Parenting: Risk factor: caring for child with overwhelming needs resulting from chronic change in health status
Risk for Spiritual Distress: Risk factors: psychological stress associated with chronic illness
Risk for ineffective Cerebral tissue perfusion (See Cerebral tissue perfusion, ineffective, risk for, Section III)
Ineffective Health Maintenance r/t deficient knowledge regarding care and prevention of condition
Ineffective Sexuality Pattern r/t abstinence during acute stage
Risk for Infection: Risk factors: spread of infection, recurrence of infection
Disturbed Body Image r/t surgery, unmet expectations for childbirth
Interrupted Family Processes r/t unmet expectations for childbirth
Fear r/t perceived threat to own well-being, outcome of birth
Impaired physical Mobility r/t pain
Acute Pain r/t surgical incision
Ineffective Role Performance r/t unmet expectations for childbirth
Situational low Self-Esteem r/t inability to deliver child vaginally
Risk for Bleeding: Risk factor: surgery
Risk for imbalanced Fluid Volume: Risk factors: loss of blood, fluid shifts
Risk for Infection: Risk factor: surgical incision
Risk for Urinary Retention: Risk factor: regional anesthesia
Readiness for enhanced Childbearing Process: a pattern of preparing for, maintaining, and strengthening care of newborn
Readiness for enhanced Knowledge: expresses an interest in learning
Death Anxiety r/t chemotherapy not accomplishing desired results
Disturbed Body Image r/t loss of weight, loss of hair
Fatigue r/t disease process, anemia, drug effects
Nausea r/t effects of chemotherapy
Imbalanced Nutrition: less than body requirements r/t side effects of chemotherapy
Impaired Oral Mucous Membrane r/t effects of chemotherapy
Ineffective Protection r/t suppressed immune system, decreased platelets
Risk for Bleeding: Risk factors: tumor eroding blood vessel, stress effects on GI system
Risk for Infection: Risk factor: immunosuppression
Risk for Vascular Trauma: Risk factor: infusion of irritating medications
Readiness for enhanced Knowledge: expresses an interest in learning
See Cancer
Fear r/t potential threat of death
Acute Pain r/t myocardial injury, ischemia
Risk for decreased Cardiac tissue perfusion: Risk factor: ventricular ischemia
Ineffective Breathing Pattern r/t asymmetrical lung expansion secondary to pain
Impaired Gas Exchange r/t decreased functional lung tissue
Acute Pain r/t presence of chest tubes, injury
Risk for Injury: Risk factor: presence of invasive chest tube
Ineffective Breathing Pattern r/t critical illness
See cause of Cheyne-Stokes Respiration
Activity Intolerance r/t weakness, fatigue
Decreased Cardiac Output r/t impaired cardiac function, increased preload, decreased contractility, increased afterload
Constipation r/t activity intolerance
Fatigue r/t disease process with decreased cardiac output
Fear r/t threat to one’s own well-being
Excess Fluid Volume r/t impaired excretion of sodium and water
Impaired Gas Exchange r/t excessive fluid in interstitial space of lungs
Powerlessness r/t illness-related regimen
Risk for Shock (Cardiogenic): Risk factors: decreased contractility of heart, increased afterload
Readiness for enhanced Self-Health Management (See Self-Health Management, readiness for enhanced, Section III)
See Child with Chronic Condition; Congenital Heart Disease/Cardiac Anomalies; Hospitalized Child
Interrupted Family Processes r/t inadequate coping skills
Fear r/t threat of punishment for perceived wrongdoing
Delayed Growth and Development r/t inadequate caretaking, stimulation deficiencies
Insomnia r/t hypervigilance, fear
Imbalanced Nutrition: less than body requirements r/t inadequate caretaking
Acute Pain r/t physical injuries
Impaired Parenting r/t psychological impairment, physical or emotional abuse of parent, substance abuse, unrealistic expectations of child
Post-Trauma Syndrome r/t physical abuse, incest, rape, molestation
Chronic low Self-Esteem r/t lack of positive feedback, excessive negative feedback
Impaired Skin Integrity r/t altered nutritional state, physical abuse
Social Isolation: family imposed r/t fear of disclosure of family dysfunction and abuse
Risk for delayed Development: Risk factors: shaken baby syndrome, abuse
Risk for disproportionate Growth: Risk factor: abuse
Risk for Poisoning: Risk factors: inadequate safeguards, lack of proper safety precautions, accessibility of illicit substances because of impaired home maintenance
Risk for Suffocation: Risk factors: unattended child, unsafe environment
Risk for Trauma: Risk factors: inadequate precautions, cognitive or emotional difficulties
Ineffective Childbearing Process (See Childbearing Process, ineffective, Section III)
Risk for ineffective Childbearing Process: Risk factors: (See Childbearing Process, risk for ineffective, Section III)
Activity Intolerance r/t fatigue associated with chronic illness
Decisional Conflict r/t treatment options, conflicting values
Parental Role Conflict r/t separation from child as a result of chronic illness, home care of child with special needs, interruptions of family life resulting from home care regimen
Compromised family Coping r/t prolonged overconcern for child; distortion of reality regarding child’s health problem, including extreme denial about its existence or severity
Disabled family Coping r/t prolonged disease or disability progression that exhausts supportive capacity of significant others
Ineffective Coping: child r/t situational or maturational crises
Deficient Diversional Activity r/t immobility, monotonous environment, frequent or lengthy treatments, reluctance to participate, self-imposed social isolation
Interrupted Family Processes r/t intermittent situational crisis of illness, disease, hospitalization
Delayed Growth and Development r/t effects of physical disability, prescribed dependence, separation from significant others
Ineffective Health Maintenance r/t exhausting family resources (finances, physical energy, support systems)
Impaired Home Maintenance r/t overtaxed family members (e.g., exhausted, anxious)
Hopelessness: child r/t prolonged activity restriction, long-term stress, lack of involvement in or passively allowing care as a result of parental overprotection
Insomnia: child or parent r/t time-intensive treatments, exacerbation of condition, 24-hour care needs
Deficient Knowledge r/t knowledge or skill acquisition regarding health practices, acceptance of limitations, promotion of maximal potential of child, self-actualization of rest of family
Imbalanced Nutrition: less than body requirements r/t anorexia, fatigue from physical exertion
Imbalanced Nutrition: more than body requirements r/t effects of steroid medications on appetite
Chronic Pain r/t physical, biological, chemical, or psychological factors
Powerlessness: child r/t health care environment, illness-related regimen, lifestyle of learned helplessness
Chronic low Self-Esteem r/t actual or perceived differences; peer acceptance; decreased ability to participate in physical, school, and social activities
Ineffective Sexuality Pattern: parental r/t disrupted relationship with sexual partner
Impaired Social Interaction r/t developmental lag or delay, perceived differences
Social Isolation: family r/t actual or perceived social stigmatization, complex care requirements
Chronic Sorrow r/t developmental stages and missed opportunities or milestones that bring comparisons with social or personal norms, unending caregiving as reminder of loss
Risk for delayed Development: Risk factor: chronic illness
Risk for disproportionate Growth: Risk factor: chronic illness
Risk for Infection: Risk factor: debilitating physical condition
Risk for impaired Parenting: Risk factors: impaired or disrupted bonding, caring for child with perceived overwhelming care needs
Readiness for enhanced family Coping: impact of crisis on family values, priorities, goals, or relationships; changes in family choices to optimize wellness
Readiness for enhanced Childbearing Process (See Childbearing Process, readiness for enhanced, Section III)
Impaired Swallowing r/t neuromuscular impairment
Risk for Aspiration: Risk factors: depressed cough and gag reflexes
Imbalanced Nutrition: less than body requirements r/t high metabolic needs, decreased ability to digest fatty foods
Acute Pain r/t trauma from surgery
Risk for deficient Fluid Volume: Risk factors: restricted intake, nausea, vomiting
Readiness for enhanced Knowledge: expresses an interest in learning
Imbalanced Nutrition: less than body requirements r/t anorexia, nausea, vomiting
Acute Pain r/t obstruction of bile flow, inflammation in gallbladder
Readiness for enhanced Knowledge: expresses an interest in learning
Anxiety r/t threat to self and infant
Grieving r/t guilt about potential loss of ideal pregnancy and birth
Hyperthermia r/t infectious process
Situational low Self-Esteem r/t guilt about threat to infant’s health
Risk for delayed Growth and Development: Risk factor: risk of preterm birth
Risk for Infection: Risk factor: infection transmission from mother to fetus; infection in fetal environment
Acute Pain r/t surgical intervention
Risk for Bleeding: Risk factor: surgical trauma
Risk for Infection: Risk factor: surgical wound
Readiness for enhanced Knowledge: parent: expresses an interest in learning
Chronic Confusion r/t chronic organic disorder with increased ammonia levels, substance abuse
Defensive Coping r/t inability to accept responsibility to stop drinking
Ineffective Health Maintenance r/t deficient knowledge regarding correlation between lifestyle habits and disease process
Nausea r/t irritation to gastrointestinal system
Imbalanced Nutrition: less than body requirements r/t loss of appetite, nausea, vomiting
Chronic Pain r/t liver enlargement
Chronic low Self-Esteem r/t chronic illness
Chronic Sorrow r/t presence of chronic illness
Risk for Bleeding: Risk factors: impaired blood coagulation, bleeding from portal hypertension
Risk for Injury: Risk factors: substance intoxication, potential delirium tremens
Risk for impaired Oral Mucous Membrane: Risk factors: altered nutrition, inadequate oral care
Risk for impaired Skin Integrity: Risk factors: altered nutritional state, altered metabolic state
Ineffective Airway Clearance r/t common feeding and breathing passage, postoperative laryngeal, incisional edema
Ineffective Breastfeeding r/t infant anomaly
Impaired verbal Communication r/t inadequate palate function, possible hearing loss from infected eustachian tubes
Fear: parental r/t special care needs, surgery
Grieving r/t loss of perfect child
Ineffective infant Feeding Pattern r/t cleft lip, cleft palate
Impaired physical Mobility r/t imposed restricted activity, use of elbow restraints
Impaired Oral Mucous Membrane r/t surgical correction
Acute Pain r/t surgical correction, elbow restraints
Impaired Skin Integrity r/t incomplete joining of lip, palate ridges
Chronic Sorrow r/t birth of child with congenital defect
Risk for Aspiration: Risk factor: common feeding and breathing passage
Risk for disturbed Body Image: Risk factors: disfigurement, speech impediment
Risk for delayed Development: Risk factor: inadequate nutrition resulting from difficulty feeding
Risk for deficient Fluid Volume: Risk factor: inability to take liquids in usual manner
Risk for disproportionate Growth: Risk factor: inability to feed with normal techniques
Risk for Infection: Risk factors: invasive procedure, disruption of eustachian tube development, aspiration
Readiness for enhanced Knowledge: Parent: expresses an interest in learning
Risk for Bleeding: Risk factor: impaired clotting
Readiness for enhanced Knowledge: expresses an interest in learning
See Anticoagulant Therapy; DIC (Disseminated Intravascular Coagulation); Hemophilia
Ineffective Breathing Pattern r/t drug effect on respiratory center
Chronic Confusion r/t excessive stimulation of nervous system by cocaine
Ineffective Coping r/t inability to deal with life stresses
Risk for decreased Cardiac tissue perfusion r/t increase in sympathetic response in the body damaging the heart
Caregiver Role Strain r/t codependency
Impaired verbal Communication r/t psychological barriers
Decisional Conflict r/t support system deficit
Ineffective Coping r/t inadequate support systems
Readiness for enhanced Comfort (See Comfort, readiness for enhanced, Section III)
Readiness for enhanced Knowledge: expresses an interest in learning
Constipation r/t decreased activity, decreased fluid intake
Imbalanced Nutrition: less than body requirements r/t high metabolic needs, decreased ability to ingest or digest food
Risk for Infection: Risk factor: invasive procedure
Readiness for enhanced Knowledge: expresses an interest in learning
Diarrhea r/t inflammation in colon
Deficient Fluid Volume r/t frequent stools
Acute Pain r/t inflammation in colon
Readiness for enhanced Knowledge: expresses an interest in learning
See Crohn’s Disease; Inflammatory Bowel Disease (Child and Adult)
See specific disease (e.g., Lupus Erythematosus; JRA [Juvenile Rheumatoid Arthritis]); Congenital Heart Disease/Cardiac Anomalies
Disturbed Body Image r/t presence of stoma, daily care of fecal material
Ineffective Sexuality Pattern r/t altered body image, self-concept
Social Isolation r/t anxiety about appearance of stoma and possible leakage of stool
Risk for Constipation: Risk factor: inappropriate diet
Risk for Diarrhea: Risk factor: inappropriate diet
Risk for impaired Skin Integrity: Risk factor: irritation from bowel contents
Readiness for enhanced Knowledge: expresses an interest in learning
Death Anxiety: significant others r/t unknown outcome of coma state
Interrupted Family Processes r/t illness or disability of family member
Functional urinary Incontinence r/t presence of comatose state
Self-Care deficit: specify r/t neuromuscular impairment
Ineffective family Therapeutic Regimen Management r/t complexity of therapeutic regimen
Risk for Aspiration: Risk factors: impaired swallowing, loss of cough or gag reflex
Risk for Disuse Syndrome: Risk factor: altered level of consciousness impairing mobility
Risk for Injury: Risk factor: potential seizure activity
Risk for impaired Oral Mucous Membrane: Risk factor: dry mouth, inability to do own mouth care
Risk for impaired Skin Integrity: Risk factor: immobility
Risk for Spiritual Distress: significant others: Risk factors: loss of ability to relate to loved one, unknown outcome of coma
See cause of Coma
Impaired Comfort (See Comfort, impaired, Section III)
Readiness for enhanced Comfort (See Comfort, readiness for enhanced, Section III)
Impaired Comfort r/t pruritus, inflammation or infection of skin, subdermal organisms
Deficient Diversional Activity r/t imposed isolation from peers, disruption in usual play activities, fatigue, activity intolerance
Ineffective Health Maintenance r/t nonadherence to appropriate immunization schedules, lack of prevention of transmission of infection
Acute Pain r/t impaired skin integrity, edema
Risk for Infection: transmission to others: Risk factor: contagious organisms
Readiness for enhanced Immunization Status (See Immunization Status, readiness for enhanced, Section III)
See Meningitis/Encephalitis; Respiratory Infections, Acute Childhood; Reye’s Syndrome
Readiness for enhanced Communication (See Communication, readiness for enhanced, Section III)
Impaired verbal Communication (See Communication, verbal, impaired, Section III)
Ineffective community Coping (See Coping, community, ineffective, Section III)
Readiness for enhanced community Coping: community sense of power to manage stressors, social supports available, resources available for problem solving
Deficient community Health r/t (See Health, deficient, community, Section III)
Fear r/t possible loss of limb, damage to limb
Acute Pain r/t pressure in compromised body part
Ineffective peripheral Tissue Perfusion r/t increased pressure within compartment
Acute Confusion r/t older than 70 years of age with hospitalization, alcohol abuse, delirium, dementia, drug abuse
Chronic Confusion r/t dementia, Korsakoff’s psychosis, multi-infarct dementia, cerebrovascular accident, head injury
Adult Failure to Thrive r/t confusion
Impaired Memory r/t fluid and electrolyte imbalance, neurological disturbances, excessive environmental disturbances, anemia, acute or chronic hypoxia, decreased cardiac output
Risk for acute Confusion: Risk factor (See Confusion, acute, risk for, Section III)
Activity Intolerance r/t fatigue, generalized weakness, lack of adequate oxygenation
Ineffective Breathing Pattern r/t pulmonary vascular disease
Decreased Cardiac Output r/t cardiac dysfunction
Excess Fluid Volume r/t cardiac dysfunction, side effects of medication
Impaired Gas Exchange r/t cardiac dysfunction, pulmonary congestion
Delayed Growth and Development r/t inadequate oxygen and nutrients to tissues
Imbalanced Nutrition: less than body requirements r/t fatigue, generalized weakness, inability of infant to suck and feed, increased caloric requirements
Risk for delayed Development: Risk factor: inadequate oxygen and nutrients to tissues
Risk for deficient Fluid Volume: Risk factor: side effects of diuretics
Risk for disproportionate Growth: Risk factor: inadequate oxygen and nutrients to tissues
Risk for disorganized Infant behavior: Risk factor: invasive procedures
Risk for Poisoning: Risk factor: potential toxicity of cardiac medications
Risk for ineffective Thermoregulation: Risk factor: neonatal age
Acute Pain r/t inflammatory process
Vision Loss r/t change in visual acuity resulting from inflammation
Acute Confusion r/t alcohol abuse, delirium, dementia, drug abuse, head injury
Chronic Confusion r/t multi-infarct dementia, Korsakoff’s psychosis, head injury, cerebrovascular accident, neurological deficit
Adult Failure to Thrive r/t altered level of consciousness
Functional urinary Incontinence r/t neurological dysfunction
Decreased Intracranial Adaptive Capacity r/t brain injury
Impaired Memory r/t neurological disturbances
Self-Care deficit: specify r/t neuromuscular impairment
Risk for Aspiration: Risk factors: impaired swallowing, loss of cough or gag reflex
Risk for Disuse Syndrome: Risk factors: impaired mobility resulting from altered level of consciousness
Risk for impaired Oral Mucous Membrane: Risk factor: dry mouth, interrupted oral care
Risk for ineffective Cerebral tissue perfusion: Risk factor: increased intracranial pressure, altered cerebral perfusion
Risk for impaired Skin Integrity: Risk factor: immobility
See cause of Altered Level of Consciousness
Risk for Constipation: Risk factors (See Constipation, risk for, Section III)
Contamination (See Contamination, Section III)
Risk for Contamination: Risk factors (See Contamination, risk for, Section III)
Ineffective Coping r/t stress of disease, exacerbations caused by stress
Imbalanced Nutrition: less than body requirements r/t malabsorption from disease process
Risk for Injury: Risk factors: failure of valve, stomal cyanosis, intestinal obstruction
Readiness for enhanced Knowledge: expresses an interest in learning
Decisional Conflict: method of contraception r/t unclear personal values or beliefs, lack of experience or interference with decision-making, lack of relevant information, support system deficit
Ineffective Sexuality Pattern r/t fear of pregnancy
Readiness for enhanced Self-Health Management: requesting information about available and appropriate birth control methods
Anxiety r/t concern over controlling convulsions
Impaired Memory r/t neurological disturbance
Risk for Aspiration: Risk factor: impaired swallowing
Risk for delayed Development: Risk factor: seizures
Risk for Injury: Risk factor: seizure activity
Readiness for enhanced Knowledge: expresses an interest in learning
Activity Intolerance r/t imbalance between oxygen supply and demand
Ineffective Airway Clearance r/t bronchoconstriction, increased mucus, ineffective cough, infection
Anxiety r/t breathlessness, change in health status
Death Anxiety r/t seriousness of medical condition, difficulty being able to “catch breath,” feeling of suffocation
Interrupted Family Processes r/t role changes
Impaired Gas Exchange r/t ventilation-perfusion inequality
Ineffective Self-Health Management (See Self-Health Management, ineffective, Section III)
Imbalanced Nutrition: less than body requirements r/t decreased intake because of dyspnea, unpleasant taste in mouth left by medications, increased need for calories from work of breathing
Powerlessness r/t progressive nature of disease
Self-Care deficit: specify: r/t fatigue from the increased work of breathing
Chronic low Self-Esteem r/t chronic illness
Sleep deprivation r/t breathing difficulties when lying down
Impaired Social Interaction r/t social isolation because of oxygen use, activity intolerance
Chronic Sorrow r/t presence of chronic illness
Risk for Infection: Risk factor: stasis of respiratory secretions
Readiness for enhanced Self-Health Management (See Self-Health Management, readiness for enhanced, Section III)
Defensive Coping (See Coping, defensive, Section III)
Ineffective Coping (See Coping, ineffective, Section III) See Community Coping; Family Problems
Risk for Infection: Risk factors: invasive procedure, surgery
Readiness for enhanced Self-Health Management: describes need to rest and avoid strenuous activities during healing phase
Decreased Cardiac Output r/t dysrhythmia, depressed cardiac function, change in preload, contractility or afterload
Fear r/t outcome of surgical procedure
Deficient Fluid Volume r/t intraoperative blood loss, use of diuretics in surgery
Acute Pain r/t traumatic surgery
Risk for Perioperative Positioning Injury: Risk factors: hypothermia, extended supine position
Readiness for enhanced Knowledge: expresses an interest in learning
Ineffective Airway Clearance r/t decreased energy, fatigue, normal aging changes
See Bronchitis; COPD (Chronic Obstructive Pulmonary Disease); Pulmonary Edema
Disorganized Infant behavior r/t prematurity, drug withdrawal, lack of attachment
Risk for impaired Attachment: Risk factors: parent’s inability to meet infant’s needs, substance abuse
Risk for disturbed Maternal/Fetal Dyad: Risk factor: substance abuse
Ineffective Airway Clearance r/t excessive secretions in airways, ineffective cough
See cause of Coarse Crackles in Lungs
Ineffective Breathing Pattern r/t fatigue, surgery, decreased energy
See Bronchitis or Pneumonia (if from pulmonary infection); CHF (Congestive Heart Failure) (if cardiac in origin); Infection
Adult Failure to Thrive r/t altered cerebral tissue perfusion, decreased cognition
Decreased Intracranial Adaptive Capacity r/t brain injury, intracranial hypertension
Impaired Memory r/t neurological surgery
Acute Pain r/t recent brain surgery, increased intracranial pressure
Risk for Injury: Risk factor: potential confusion
Risk for ineffective Cerebral tissue perfusion: Risk factors: cerebral edema, increased intracranial pressure
See Coma (if relevant)
Anxiety r/t threat to or change in environment, health status, interaction patterns, situation, self-concept, or role functioning; threat of death of self or significant other
Death Anxiety r/t feelings of hopelessness associated with crisis
Compromised family Coping r/t situational or developmental crisis
Ineffective Coping r/t situational or maturational crisis
Disturbed Energy Field r/t disharmony caused by crisis
Grieving r/t potential significant loss
Impaired individual Resilience r/t onset of crisis
Situational low Self-Esteem r/t perception of inability to handle crisis
Stress overload (See Stress overload, Section III)
Risk for Spiritual Distress: Risk factors: physical or psychological stress, natural disasters, situational losses, maturational losses
Anxiety r/t change in health status
Ineffective Coping r/t repeated episodes of diarrhea
Diarrhea r/t inflammatory process
Ineffective Health Maintenance r/t deficient knowledge regarding management of disease
Imbalanced Nutrition: less than body requirements r/t diarrhea, altered ability to digest and absorb food
Acute Pain r/t increased peristalsis
Powerlessness r/t chronic disease
Risk for deficient Fluid Volume: Risk factor: abnormal fluid loss with diarrhea
Activity Intolerance r/t fatigue, weakness
Disturbed Body Image r/t change in appearance from disease process
Excess Fluid Volume r/t failure of regulatory mechanisms
Sexual Dysfunction r/t loss of libido
Impaired Skin Integrity r/t thin vulnerable skin from effects of increased cortisol
Risk for Infection: Risk factor: suppression of immune system caused by increased cortisol levels
Risk for Injury: Risk factors: decreased muscle strength, brittle bones
Readiness for enhanced Knowledge: expresses an interest in learning
Anxiety r/t situational crisis, change in physical or emotional condition
Disturbed Body Image r/t chronic illness, paralysis
Caregiver Role Strain r/t cognitive problems of care receiver, need for significant home care
Impaired verbal Communication r/t pressure damage, decreased circulation to brain in speech center informational sources
Chronic Confusion r/t neurological changes
Constipation r/t decreased activity
Ineffective Coping r/t disability
Adult Failure to Thrive r/t neurophysiological changes
Interrupted Family Processes r/t illness, disability of family member
Impaired Home Maintenance r/t neurological disease affecting ability to perform activities of daily living
Functional urinary Incontinence r/t neurological dysfunction
Reflex urinary Incontinence r/t loss of feeling to void
Impaired Memory r/t neurological disturbances
Impaired physical Mobility r/t loss of balance and coordination
Unilateral Neglect r/t disturbed perception from neurological damage
Self-Care deficit: specify r/t decreased strength and endurance, paralysis
Impaired Social Interaction r/t limited physical mobility, limited ability to communicate
Impaired Swallowing r/t neuromuscular dysfunction
Impaired Transfer Ability r/t limited physical mobility
Vision Loss r/t pressure damage to visual centers in the brain
Impaired Walking r/t loss of balance and coordination
Risk for Aspiration: Risk factors: impaired swallowing, loss of gag reflex
Risk for Disuse Syndrome: Risk factor: paralysis
Risk for Falls: Risk factor: paralysis, decreased balance
Risk for Injury: Risk factor: vision loss, decreased tissue perfusion with loss of sensation
Risk for ineffective Cerebral tissue perfusion: Risk factor: clot, emboli, or hemorrhage from cerebral vessel
Risk for impaired Skin Integrity: Risk factor: immobility
Readiness for enhanced Knowledge: Expresses an interest in learning
Impaired Gas Exchange r/t alveolar-capillary membrane changes
Ineffective peripheral Tissue Perfusion r/t interruption of arterial flow, severe vasoconstriction, cold temperatures
Activity Intolerance r/t imbalance between oxygen supply and demand
Ineffective Airway clearance r/t increased production of thick mucus
Anxiety r/t dyspnea, oxygen deprivation
Disturbed Body Image r/t changes in physical appearance, treatment of chronic lung disease (clubbing, barrel chest, home oxygen therapy)
Impaired Gas Exchange r/t ventilation-perfusion imbalance
Impaired Home Maintenance r/t extensive daily treatment, medications necessary for health
Imbalanced Nutrition: less than body requirements r/t anorexia; decreased absorption of nutrients, fat; increased work of breathing
Chronic Sorrow r/t presence of chronic disease
Risk for Caregiver Role Strain: Risk factors: illness severity of care receiver, unpredictable course of illness
Risk for deficient Fluid Volume: Risk factors: decreased fluid intake, increased work of breathing
Risk for Infection: Risk factors: thick, tenacious mucus; harboring of bacterial organisms; immunocompromised state
Risk for Spiritual Distress: Risk factor: presence of chronic disease
See Child with Chronic Condition; Hospitalized Child; Terminally Ill Child, Adolescent; Terminally Ill Child, Infant/Toddler; Terminally Ill Child, Preschool Child; Terminally Ill Child, School-Age Child/Preadolescent; Terminally Ill Child/Death of Child, Parent
Acute Pain: dysuria r/t inflammatory process in bladder and urethra
Impaired Urinary Elimination: frequency r/t urinary tract infection
Urge urinary Incontinence: Risk factor: infection in bladder
Readiness for enhanced Knowledge: expresses an interest in learning