Appendix N3: Nursing Diagnoses Grouped by Diseases/Disorders

abdominal hysterectomy

Refer to Hysterectomy.

abdominal perineal resection

(also refer to surgery, general)

disturbed Body Image may be related to presence of surgical wounds possibly evidenced by verbalizations of feelings or perceptions, fear of reaction by others, preoccupation with change.

risk for Constipation risk factors may include decreased physical activity, slowed gastric motility, abdominal muscle weakness, insufficient fluid intake, change in usual foods and/or eating pattern.

risk for Sexual Dysfunction risk factors may include altered body structure or function (radical resection/treatment procedures), vulnerability, psychological concern about response of significant other(s), and disruption of sexual response pattern, e.g., erection difficulty.

abortion, elective termination

risk for decisional Conflict risk factors may include unclear personal values/beliefs, lack of experience or interference with decision making, information from divergent sources, deficient support system.

deficient Knowledge [Learning Need] regarding reproduction, contraception, self-care, Rh factor may be related to lack of exposure/recall or misinterpretation of information possibly evidenced by request for information, statement reflecting misconception, inaccurate follow-through of instructions, development of preventable complications.

risk for Moral Distress risk factors may include perception of moral/ethical implications of therapeutic procedure, time constraints for decision making.

Anxiety may be related to situational or maturational crises, unmet needs, unconscious conflict about essential values or beliefs, possibly evidenced by increased tension, apprehension, fear of unspecific consequences, sympathetic stimulation, focus on self.

acute Pain/impaired Comfort may be related to aftereffects of procedure, drug effect, possibly evidenced by verbal report, distraction behaviors, changes in muscle tone, changes in vital signs

risk for [maternal] injury risk factors may include surgical procedure, effects of anesthesia and medications.

abortion, spontaneous termination

risk for Bleeding risk factors may include pregnancy-related complications.

risk for Spiritual Distress is possibly evidenced by risk factors of challenged beliefs/values, blame for loss directed at self or higher power.

deficient Knowledge [Learning Need] regarding cause of abortion, self-care, contraception/future pregnancy may be related to lack of familiarity with new self or healthcare needs, sources for support, possibly evidenced by requests for information and statement of concern or misconceptions, development of preventable complications.

Grieving related to perinatal loss, possibly evidenced by crying, expressions of sorrow, or changes in eating habits or sleep patterns.

risk for Sexual dysfunction risk factors may include increasing fear of pregnancy and/or repeat loss, impaired relationship with significant other(s), self-doubt regarding own femininity.

abruptio placentae

risk for Shock is possibly evidenced by risk factors of hypotension, hypovolemia.

Fear related to threat of death (perceived or actual) to fetus and self, possibly evidenced by verbalization of apprehension, increased tension, sympathetic stimulation.

acute Pain may be related to collection of blood between uterine wall and placenta, uterine contractions, possibly evidenced by verbal reports, abdominal guarding, muscle tension, or alterations in vital signs.

risk for disturbed Maternal-Fetal Dyad is possibly evidenced by risk factors of complication of pregnancy, compromised oxygen transport.

abscess, brain (acute)

acute Pain may be related to inflammation, edema of tissues, and is possibly evidenced by reports of headache, restlessness, irritability, and moaning.

risk for Hyperthermia may be related to risk factors of illness [inflammatory process], hypermetabolic state, and dehydration.

acute Confusion may be related to delirium [cerebral edema, altered perfusion, fever], possibly evidenced by fluctuation in cognition or level of consciousness, increased agitation, restlessness, hallucinations.

risk for Suffocation/Trauma are possibly evidenced by risk factors of disease process [seizure activity], cognitive difficulties.

abscess, skin/tissue

impaired Skin/Tissue Integrity may be related to immunological deficit, infection, possibly evidenced by disruption of skin, destruction of skin layers or tissues, invasion of body structures.

risk for Infection [spread] possibly evidenced by risk factors of broken skin, traumatized tissues, chronic disease, malnutrition, insufficient knowledge.

abuse, physical

(also refer to battered child syndrome)

risk for Trauma is possibly evidenced by risk factors of vulnerable client, recipient of verbal threats, history of physical abuse.

Powerlessness may be related to interpersonal interactions, lifestyle of helplessness as evidenced by verbal expressions of having no control, reluctance to express true feelings, apathy, passivity.

chronic low Self-Esteem may be related to situational or maturational crisis, overwhelming threat to self, personal vulnerability, inadequate support systems, possibly evidenced by verbalized concern about ability to deal with current situation, chronic worry, anxiety, depression, poor self-esteem, inability to problem-solve, high illness rate, destructive behavior toward self or others.

Sexual dysfunction may be related to ineffectual or absent role model, vulnerability, physical abuse possibly evidenced by verbalizations, change in sexual behaviors or activities, inability to achieve desired satisfaction.

abuse, psychological

ineffective Coping may be related to situational or maturational crisis, overwhelming threat to self, personal vulnerability, inadequate support systems, possibly evidenced by verbalized concern about ability to deal with current situation, chronic worry, anxiety, depression, poor self-esteem, inability to problem-solve, high illness rate, destructive behavior toward self or others.

Powerlessness may be related to abusive relationship, lifestyle of helplessness as evidenced by verbal expressions of having no control, reluctance to express true feelings, apathy, passivity.

Sexual Dysfunction may be related to ineffectual or absent role model, vulnerability, psychological abuse (harmful relationship) possibly evidenced by reported difficulties, inability to achieve desired satisfaction, conflicts involving values, seeking confirmation of desirability.

achalasia (cardiospasm)

impaired Swallowing may be related to neuromuscular impairment, possibly evidenced by observed difficulty in swallowing or regurgitation.

imbalanced Nutrition: less than body requirements may be related to inability and/or reluctance to ingest adequate nutrients to meet metabolic demands and nutritional needs, possibly evidenced by reported or observed inadequate intake, weight loss, and pale conjunctiva and mucous membranes.

acute Pain may be related to spasm of the lower esophageal sphincter, possibly evidenced by reports of substernal pressure, recurrent heartburn, or gastric fullness (gas pains).

Anxiety [specify level]/Fear may be related to recurrent pain, choking sensation, altered health status, possibly evidenced by verbalizations of distress, apprehension, restlessness, or insomnia.

risk for Aspiration is possibly evidenced by risk factor of regurgitation or spillover of esophageal contents.

deficient Knowledge [Learning Need] regarding condition, prognosis, self-care, and treatment needs may be related to lack of familiarity with pathology and treatment of condition, possibly evidenced by requests for information, statement of concern, or development of preventable complications.

acidosis, metabolic

Refer to diabetic ketoacidosis.

acidosis, respiratory

(also refer to underlying cause or condition).

impaired Gas Exchange may be related to ventilation perfusion imbalance (decreased oxygen-carrying capacity of blood, altered oxygen supply, alveolar-capillary membrane changes) possibly evidenced by dyspnea with exertion, tachypnea, changes in mentation, irritability, tachycardia, hypoxia, hypercapnia.

acne

impaired Skin Integrity may be related to secretions, infectious process as evidenced by disruptions of skin surface.

disturbed Body Image may be related to change in visual appearance as evidenced by fear of rejection of others, focus on past appearance, negative feelings about body, change in social involvement.

situational low Self-Esteem may be related to adolescence, negative perception of appearance as evidenced by self-negating verbalizations, expressions of helplessness.

acoustic neuroma

(also refer to surgery, general)

[disturbed auditory Sensory Perception] may be related to altered sensory reception (compression of eighth cranial nerve), possibly evidenced by unilateral sensorineural hearing loss, tinnitus.

risk for Falls is possibly evidenced by risk factors of hearing difficulties, dizziness, sense of unsteadines

Acquired immune deficiency syndrome

Refer to AIDS.

acromegaly

chronic Pain may be related to soft tissue swelling, joint degeneration, peripheral nerve compression possibly evidenced by verbal reports, altered ability to continue previous activities, changes in sleep pattern, fatigue.

disturbed Body Image may be related to biophysical illness or changes, possibly evidenced by verbalization of feelings, concerns, fear of rejection or of reaction of others, negative comments about body, actual change in structure or appearance, change in social involvement.

risk for Sexual Dysfunction is possibly evidenced by altered body structure, changes in libido.

acute respiratory distress syndrome (ARDS)

Refer to Respiratory distress syndrome, acute.

Adams-Stokes syndrome

Refer to dysrhythmia, cardiac.

ADD

Refer to Attention Deficit Disorder.

addiction

Refer to specific substances; Substance dependence/abuse rehabilitation.

Addison's disease

deficient [hypotonic] Fluid Volume may be related to vomiting, diarrhea, increased renal losses, as possibly evidenced by delayed capillary refill, poor skin turgor, dry mucous membranes, report of thirst.

risk for Electrolyte Imbalance is possibly evidenced by risk factors of vomiting, diarrhea, endocrine dysfunction.

decreased Cardiac Output may be related to hypovolemia and altered electrical conduction (dysrhythmias) and/or diminished cardiac muscle mass, possibly evidenced by alterations in vital signs, changes in mentation, irregular pulse or pulse deficit.

Fatigue may be related to decreased metabolic energy production, altered body chemistry (fluid, electrolyte, and glucose imbalance), as possibly evidenced by unremitting, overwhelming lack of energy, inability to maintain usual routines, decreased performance, impaired ability to concentrate, lethargy, disinterest in surroundings.

disturbed Body Image may be related to changes in skin pigmentation, mucous membranes, loss of axillary or pubic hair, possibly evidenced by verbalization of negative feelings about body and decreased social involvement.

risk for impaired physical Mobility is possibly evidenced by risk factors of neuromuscular impairment (muscle wasting, weakness) and dizziness or syncope.

imbalanced Nutrition: less than body requirements may be related to glucocorticoid deficiency; abnormal fat, protein, and carbohydrate metabolism; nausea, vomiting, anorexia, possibly evidenced by weight loss, muscle wasting, abdominal cramps, diarrhea, and severe hypoglycemia.

risk for impaired Home Maintenance is possibly evidenced by risk factors of effects of disease process, impaired cognitive functioning, and inadequate support systems.

adenoidectomy

Refer to tonsillectomy.

adjustment disorder

Refer to Anxiety disorders—PED.

adoption/loss of child custody

risk for Complicated Grieving is possibly evidenced by risk factors of actual loss of child, expectations for future of child and self, thwarted grieving response to loss.

risk for Powerlessness is possibly evidenced by risk factors of perceived lack of options, no input into decision process, no control over outcome.

adrenal crisis, acute

(also refer to Addison's disease; shock)

deficient [hypotonic] Fluid Volume may be related to failure of regulatory mechanism (damage to or suppression of adrenal gland), inability to concentrate urine, possibly evidenced by decreased venous filling and pulse volume and pressure, hypotension, dry mucous membranes, changes in mentation, decreased serum sodium.

acute pain may be related to effects of disease process, metabolic imbalances, decreased tissue perfusion, possibly evidenced by reports of severe pain in abdomen, lower back, or legs.

impaired physical Mobility may be related to neuromuscular impairment, decreased muscle strength and control, possibly evidenced by generalized weakness, inability to perform desired activities or movements.

risk for Hyperthermia is possibly evidenced by risk factors of presence of illness, infectious process, dehydration.

ineffective Protection related to hormone deficiency, drug therapy, nutritional and metabolic deficiencies is possibly evidenced by weakness, anorexia, alteration in perspiration, disorientation.

adrenalectomy

ineffective Tissue Perfusion (specify) may be related to hypovolemia and vascular pooling (vasodilation), and is possibly evidenced by diminished pulse, pallor or cyanosis, hypotension, and changes in mentation.

risk for Infection is possibly evidenced by risk factors of inadequate primary defenses (incision, traumatized tissues), suppressed inflammatory response, invasive procedures.

deficient Knowledge [Learning Need] regarding condition, prognosis, self-care and treatment needs may be related to unfamiliarity with long-term therapy requirements, possibly evidenced by request for information and statement of concern or misconceptions.

adrenal insufficiency

Refer to Addison's disease.

affective disorder

Refer to bipolar disorder; depressive disorders, major.

affective disorder, seasonal

(also refer to depressive disorders, major)

[intermittent] ineffective Coping may be related to situational crisis (fall or winter season), disturbance in pattern of tension release, and inadequate resources available, possibly evidenced by verbalizations of inability to cope, changes in sleep pattern (too little or too much), reports of lack of energy, fatigue, lack of resolution of problem, behavioral changes (irritability, discouragement).

imbalanced Nutrition: less than body requirements/risk for Overweight is possibly evidenced by risk factors of eating in response to internal cues other than hunger, alteration in usual coping patterns, change in usual activity level, decreased appetite, lack of energy or interest to prepare food.

agoraphobia

(also refer to phobia)

Anxiety [panic] may be related to contact with feared situation (public place, crowds), possibly evidenced by tachycardia, chest pain, dyspnea, gastrointestinal distress, faintness, sense of impending doom.

agranulocytosis

risk for Infection is possibly evidenced by risk factor of suppressed inflammatory response.

risk for impaired Oral Mucous Membrane is possibly evidenced by risk factor of infection.

risk for imbalanced Nutrition: less than body requirements is possibly evidenced by risk factor of inability to ingest food or fluids.

AIDS (acquired immunodeficiency syndrome)

(also refer to HIV infection)

risk for Infection, [progression to sepsis/onset of new opportunistic infection] is possibly evidenced by risk factors of depressed immune system, use of antimicrobial agents, inadequate primary defenses, broken skin, traumatized tissue, malnutrition, environmental exposure, invasive techniques, and chronic disease processes.

risk for deficient Fluid Volume is possibly evidenced by risk factors of excessive losses— copious diarrhea, profuse sweating, vomiting, hypermetabolic state or fever, and restricted intake (nausea, anorexia, lethargy).

acute/chronic Pain may be related to tissue inflammation or destruction—infections; internal or external cutaneous lesions; rectal excoriation; malignancies; necrosis; peripheral neuropathies, myalgias, and arthralgias, possibly evidenced by verbal reports, self-focusing, or narrowed focus; alteration in muscle tone; paresthesias; paralysis; guarding behaviors; changes in vital signs (acute); restlessness.

ineffective Breathing Pattern/risk for impaired Gas Exchange is possibly evidenced by risk factors of muscular impairment—wasting of respiratory musculature, decreased energy, fatigue, respiratory muscle fatigue; retained secretions—tracheobronchial obstruction; pain.

imbalanced Nutrition: less than body requirements may be related to altered ability to ingest, digest, and/or absorb nutrients (nausea, vomiting, hyperactive gag reflex, gastrointestinal disturbances, fatigue); increased metabolic rate and nutritional needs (fever, infection); possibly evidenced by weight loss, decreased subcutaneous fat and muscle mass, lack of interest in food, aversion to eating, altered taste sensation, abdominal cramping, hyperactive bowel sounds, diarrhea, sore and inflamed buccal cavity, abnormal laboratory results—vitamin, mineral, and protein deficiencies; electrolyte imbalances.

Fatigue may be related to decreased metabolic energy production, increased energy requirements (hypermetabolic state), overwhelming psychological or emotional demands, altered body chemistry (side effects of medication, chemotherapy), sleep deprivation possibly evidenced by unremitting or overwhelming lack of energy, inability to maintain usual routines, decreased performance, impaired ability to concentrate, lethargy, listlessness, and disinterest in surroundings.

ineffective Protection may be related to chronic disease affecting immune and neurological systems, inadequate nutrition, drug therapies, possibly evidenced by deficient immunity, impaired healing, neurosensory alterations, maladaptive stress response, fatigue, anorexia, disorientation.

Social Isolation may be related to alteration in physical appearance or mental status, altered state of wellness, perceptions of unacceptable social behavior or values, [phobic fear of others (transmission of disease)], possibly evidenced by expressed feelings of aloneness or rejection, absence of supportive SO(s), and withdrawal from usual activities.

chronic Confusion may be related to physiological changes (hypoxemia, central nervous system [CNS] infection by HIV, brain malignancies, and/or disseminated systemic opportunistic infection), altered drug metabolism or excretion, accumulation of toxic elements (renal failure, severe electrolyte imbalance, hepatic insufficiency), possibly evidenced by clinical evidence of organic impairment, altered response to stimuli, memory deficit, and altered personality.

AIDS dementia

(also refer to Dementia, presenile/senile)

chronic Confusion/impaired Memory related to physiological changes (neuronal degeneration), possibly evidenced by inaccurate interpretation of or response to stimuli, progressive or long-standing cognitive impairment, short-term memory deficit, impaired socialization, altered personality, clinical evidence of organic impairment.

ineffective Protection may be related to immune disorder, inadequate nutrition, drug therapies, possibly evidenced by deficient immunity, impaired healing, neurosensory alterations, maladaptive stress response, fatigue, anorexia, disorientation.

alcohol abuse/withdrawal

Refer to Drug overdose, acute [depressants]; Delirium tremens; Substance dependency/abuse rehabilitation.

alcohol intoxication, acute

(also refer to Delirium tremens)

acute Confusion may be related to substance abuse, hypoxemia, and is possibly evidenced by hallucinations, exaggerated emotional response, fluctuation in cognition or level of consciousness, increased agitation.

risk for ineffective Breathing Pattern is possibly evidenced by risk factors of hypoventilation syndrome, neuromuscular dysfunction, fatigue.

risk for Aspiration is possibly evidenced by risk factors of reduced level of consciousness, depressed cough or gag reflexes, delayed gastric emptying.

alcoholism

Refer to Substance dependence/abuse rehabilitation.

aldosteronism, primary

deficient Fluid Volume, deficient may be related to increased urinary losses, possibly evidenced by dry mucous membranes, poor skin turgor, dilute urine, excessive thirst, weight loss.

impaired physical Mobility may be related to neuromuscular impairment, decreased muscle strength, and pain, possibly evidenced by limited range of motion, slowed movement, limited ability to perform gross/fine motor skills.

risk for decreased Cardiac Output is possibly evidenced by risk factors of altered preload and altered heart rhythm.

alkalosis, metabolic

Refer to underlying cause or condition, e.g., Renal dialysis.

alkalosis, respiratory

(also refer to underlying cause/condition)

impaired Gas Exchange may be related to ventilation perfusion imbalance (decreased oxygen-carrying capacity of blood, altered oxygen-supply, alveolar-capillary membrane changes) possibly evidenced by dyspnea, tachypnea, changes in mentation, tachycardia, hypoxia, hypocapnia.

allergies, seasonal

Refer to Hay fever.

alopecia

disturbed Body Image may be related to effects of illness or therapy, aging process, change in appearance, possibly evidenced by verbalization of feelings, concerns, fear of rejection or reaction of others, focus on past appearance, preoccupation with change, feelings of helplessness.

ALS

Refer to Amyotrophic lateral sclerosis.

Alzheimer's disease

(also refer to dementia, presenile/senile)

risk for Injury/Trauma is possibly evidenced by risk factors of inability to recognize or identify danger in environment, disorientation, confusion, impaired judgment, weakness, muscular incoordination, balancing difficulties, altered perception, seizure activity.

chronic Confusion related to physiological changes (neuronal degeneration), possibly evidenced by inaccurate interpretation of or response to stimuli, progressive or longstanding cognitive impairment, short-term memory deficit, impaired socialization, altered personality, and clinical evidence of organic impairment.

disturbed Sensory Perception (specify) may be related to altered sensory reception, transmission, and/or integration (neurological disease or deficit), socially restricted environment (homebound, institutionalized), sleep deprivation, possibly evidenced by changes in usual response to stimuli, change in problem-solving abilities, exaggerated emotional responses (anxiety, paranoia, hallucinations), inability to tell position of body parts, diminished or altered sense of taste.

Sleep Deprivation may be related to sensory impairment, changes in activity patterns, psychological stress (neurological impairment), possibly evidenced by wakefulness, disorientation (day/night reversal), increased aimless wandering, inability to identify need or time for sleeping, changes in behavior, lethargy; dark circles under eyes and frequent yawning.

ineffective Health Maintenance may be related to deterioration affecting ability in all areas, including coordination and communication, cognitive impairment, ineffective individual/family coping, possibly evidenced by reported or observed inability to take responsibility for meeting basic health practices, lack of equipment, financial, or other resources, and impairment of personal support system.

risk for Stress Overload is possibly evidenced by risk factors of inadequate resources, chronic illness, physical demands, threats of violence.

Compromised family Coping/Caregiver Role Strain may be related to disruptive behavior of client, family grief about their helplessness watching loved one deteriorate, prolonged disease or disability progression that exhausts the supportive capacity of SO or family, highly ambivalent family relationships.

risk for Relocation Stress Syndrome is possibly evidenced by risk factors of little or no preparation for transfer to a new setting, changes in daily routine, sensory impairment, physical deterioration, separation from support systems.

amphetamine abuse

Refer to stimulant abuse.

amputation

risk for ineffective peripheral Tissue Perfusion is possibly evidenced by risk factors of reduced arterial or venous blood flow, tissue edema, hematoma formation, hypovolemia.

acute Pain may be related to tissue and nerve trauma, psychological impact of loss of body part, possibly evidenced by reports of incisional or phantom pain, observed guarding or protective behavior, narrowed focus or self-focus, and changes in vital signs.

impaired physical Mobility may be related to loss of limb (primarily lower extremity), altered sense of balance, pain, or discomfort, possibly evidenced by reluctance to attempt movement; impaired coordination; decreased muscle strength, control, and mass.

situational low Self-Esteem may be related to loss of a body part, change in functional abilities, possibly evidenced by verbalization of feelings of powerlessness, grief, preoccupation with loss, negative feelings about body, focus on past strength, function, or appearance; change in usual patterns of responsibility or physical capacity to resume role, fear of rejection or reaction by others, and unwillingness to look at or touch residual limb.

amyotrophic lateral sclerosis (ALS)

impaired physical Mobility may be related to muscle wasting, weakness, possibly evidenced by impaired coordination, limited range of motion, and impaired purposeful movement.

ineffective Breathing Pattern/impaired spontaneous Ventilation may be related to neuromuscular impairment, decreased energy, fatigue, tracheobronchial obstruction, possibly evidenced by shortness of breath, fremitus, respiratory depth changes, and reduced vital capacity.

impaired Swallowing may be related to muscle wasting and fatigue, possibly evidenced by recurrent coughing or choking, and signs of aspiration.

Powerlessness [specify level] may be related to chronic and debilitating nature of illness, lack of control over outcome, possibly evidenced by expressions of frustration about inability to care for self and depression over physical deterioration.

Grieving may be related to perceived potential loss of self and physiopsychosocial well-being, possibly evidenced by sorrow, choked feelings, expression of distress, changes in eating habits, sleeping patterns, and altered communication patterns or libido.

impaired verbal Communication may be related to physical barrier (neuromuscular impairment), possibly evidenced by impaired articulation, inability to speak in sentences, and use of nonverbal cues (changes in facial expression).

risk for Caregiver Role Strain is possibly evidenced by risk factors of illness severity of care receiver, complexity and amount of home-care needs, duration of caregiving required, caregiver is spouse, family/caregiver isolation, lack of respite or recreation for caregiver.

anaphylaxis

(also refer to shock)

ineffective Airway Clearance may be related to airway spasm (bronchial), laryngeal edema, as possibly evidenced by diminished breath sounds, presence of adventitious sounds, cough ineffective or absent, difficulty vocalizing, wide-eyed.

decreased Cardiac Ouput may be related to decreased preload, increased capillary permeability (third spacing) and vasodilation, possibly evidenced by tachycardia, palpitations, changes in blood pressure (BP), anxiety, restlessness.

anemia

Activity Intolerance may be related to imbalance between oxygen supply (delivery) and demand, possibly evidenced by reports of fatigue and weakness, abnormal heart rate or blood pressure (BP) response, decreased exercise/activity level, and exertional discomfort or dyspnea.

imbalanced Nutrition: less than body requirements may be related to failure to ingest or inability to digest food or absorb nutrients necessary for formation of normal red blood cells (RBCs), possibly evidenced by weight loss or weight below normal for age, height, and body build; decreased triceps skinfold measurement; changes in gums or oral mucous membranes; decreased tolerance for activity; weakness; and loss of muscle tone.

deficient Knowledge [Learning Need] regarding condition, prognosis, self-care and treatment needs may be related to inadequate understanding or misinterpretation of dietary and physiological needs, possibly evidenced by inadequate dietary intake, request for information, and development of preventable complications.

anemia, iron-deficiency

(also refer to anemia)

fatigue may be related to anemia, malnutrition, possibly evidenced by feeling tired, inability to maintain usual routines or level of physical activity.

risk for deficient Fluid Volume is possibly evidenced by risk factors of active or chronic blood loss.

risk for impaired oral Mucous Membrane is possibly evidenced by risk factors of dehydration, malnutrition, vitamin deficiency.

anemia, sickle cell

impaired Gas Exchange may be related to decreased oxygen-carrying capacity of blood, reduced RBC life span, abnormal RBC structure, increased blood viscosity, predisposition to bacterial pneumonia/pulmonary infarcts, possibly evidenced by dyspnea, use of accessory muscles, cyanosis/signs of hypoxia, tachycardia, changes in mentation, and restlessness.

ineffective Tissue Perfusion: (specify) may be related to stasis, vaso-occlusive nature of sickling, inflammatory response, atrioventricular shunts in pulmonary and peripheral circulation, myocardial damage (small infarcts, iron deposits, fibrosis), possibly evidenced by signs and symptoms dependent on system involved, such as renal (decreased specific gravity and pale urine in face of dehydration), cerebral (paralysis and visual disturbances), peripheral (distal ischemia, tissue infarctions, ulcerations, bone pain), or cardiac (angina, palpitations).

acute/chronic Pain may be related to intravascular sickling with localized vascular stasis, occlusion, infarction/necrosis and deprivation of oxygen and nutrients, accumulation of noxious metabolites, possibly evidenced by reports of localized, generalized, or migratory joint and/or abdominal/back pain; guarding and distraction behaviors (moaning, crying, restlessness), facial grimacing, narrowed focus, and changes in vital signs.

deficient Knowledge [Learning Need] regarding disease process, genetic factors, prognosis, self-care, and treatment needs may be related to lack of exposure or recall, misinterpretation of information, unfamiliarity with resources, possibly evidenced by questions, statement of concern or misconceptions, exacerbation of condition, inadequate follow-through of therapy instructions, and development of preventable complications.

risk for Sedentary Lifestyle is possibly evidenced by risk factors of lack of interest or motivation, lack of resources, lack of training or knowledge of specific exercise needs, safety concerns or fear of injury.

risk for disproportionate Growth and/or delayed Development are/is possibly evidenced by risk factors of inadequate nutrition, chronic illness.

compromised family Coping may be related to chronic nature of disease and disability, family disorganization, presence of other crises or situations impacting significant person/parent, lifestyle restrictions, possibly evidenced by SO expressing preoccupation with own reaction and displaying protective behavior disproportionate to client's ability or need for autonomy.

aneurysm, abdominal aortic (AAA)

Refer to: Aortic aneurysm, abdominal.

aneurysm, cerebral

Refer to cerebrovascular accident.

aneurysm, ventricular

decreased cardiac output may be related to altered stroke volume, changes in heart rate or rhythm, possibly evidenced by dyspnea, adventitious breath sounds, S₃/S₄ heart sounds, changes in hemodynamic measurements, dysrhythmias.

ineffective Tissue Perfusion [specify] may be related to decreased arterial blood flow, possibly evidenced by BP changes, diminished pulses, edema, dyspnea, dysrhythmias, altered mental status, decreased renal function.

activity intolerance may be related to imbalance between oxygen supply and demand, possibly evidenced by weakness, fatigue, abnormal heart rate/BP response to activity, electrocardiogram changes (dysrhythmias, ischemia).

angina pectoris

acute Pain may be related to decreased myocardial blood flow, increased cardiac workload/oxygen consumption, possibly evidenced by verbal reports, narrowed focus, distraction behaviors (restlessness, moaning), and autonomic responses (diaphoresis, changes in vital signs).

risk for decreased Cardiac Output is possibly evidenced by risk factors of inotropic changes (transient or prolonged myocardial ischemia, effects of medications), alterations in rate, rhythm, and electrical conduction.

Anxiety [specify level] may be related to situational crises, change in health status and/or threat of death, negative self-talk, possibly evidenced by verbalized apprehension, expressed concerns, association of condition with loss of abilities, facial tension, extraneous movements, and focus on self.

Activity Intolerance may be related to imbalance between oxygen supply and demand, possibly evidenced by exertional dyspnea, abnormal pulse/BP response to activity, and electrocardiogram (ECG) changes.

deficient Knowledge [Learning Need] regarding condition, prognosis, self-care and treatment needs may be related to lack of exposure, inaccurate or misinterpretation of information, possibly evidenced by questions, request for information, statement of concern, and inaccurate follow-through of instructions.

risk for sedentary Lifestyle is possibly evidenced by risk factors of lack of training or knowledge of specific exercise needs, safety concerns, fear of myocardial injury.

risk for risk-prone Health Behavior is possibly evidenced by risk factors of condition requiring long-term therapy, changes in lifestyle, multiple stressors, assault to self-concept, altered locus of control.

anorexia nervosa

imbalanced Nutrition: less than body requirements may be related to psychological restrictions of food intake and/or excessive activity laxative abuse, possibly evidenced by weight loss, poor skin turgor, decreased muscle tone, denial of hunger, unusual hoarding or handling of food, amenorrhea, electrolyte imbalance, cardiac irregularities, hypotension.

risk for deficient Fluid Volume is possibly evidenced by risk factors of inadequate intake of food and liquids, chronic or excessive laxative or diuretic use.

disturbed Body Image may be related to perceptual developmental changes, possibly evidenced by verbalized perceptions reflecting altered view of body appearance, refusal to verify actual change.

chronic low Self-Esteem may be related to lack of approval, repeated negative reinforcement, perceived lack of respect from others possibly evidenced by reports of feelings of shame or guilt, overly conforming, dependent on others' opinions.

impaired Parenting may be related to issues of control in family, situational or maturational crises, history of inadequate coping methods, possibly evidenced by enmeshed family, dissonance among family members, focus on “identified patient,” family developmental tasks not being met, family members acting as enablers, ill-defined family rules, functions, or roles.

antisocial personality disorder

risk for other-directed Violence is possibly evidenced by risk factors of contempt for authority or rights of others, inability to tolerate frustration, need for immediate gratification, easy agitation, vulnerable self-concept, inability to verbalize feelings, use of maladjusted coping mechanisms, history of substance abuse.

ineffective Coping may be related to very low tolerance for external stress, lack of experience of internal anxiety, e.g., guilt, shame, personal vulnerability, unmet expectations, multiple life changes, possibly evidenced by choice of aggression and manipulation to handle problems or conflicts, inappropriate use of defense mechanisms, e.g., denial, projection, chronic worry, anxiety, destructive behaviors, high rate of accidents.

chronic low Self-Esteem may be related to lack of positive and/or repeated negative feedback, unmet dependency needs, retarded ego development, dysfunctional family system, possibly evidenced by acting-out behaviors, e.g., substance abuse, sexual promiscuity, feelings of inadequacy, nonparticipation in therapy.

compromised/disabled family Coping may be related to family disorganization or role changes, highly ambivalent family relationships, client providing little support in turn for the primary person(s), history of abuse or neglect in the home, possibly evidenced by expressions of concern or complaints, preoccupation of primary person with own reactions to situation, display of protective behaviors disproportionate to client's abilities, or need for autonomy.

impaired Social Interaction may be related to inadequate personal resources (shallow feelings), immature interests, underdeveloped conscience, unaccepted social values, possibly evidenced by difficulty meeting expectations of others; lack of belief that rules pertain to self; sense of emptiness or inadequacy covered by expressions of self-conceit, arrogance, or contempt; behavior unaccepted by dominant cultural group.

anxiety disorder, generalized

Anxiety [specify level]/Powerlessness may be related to real or perceived threat to physical integrity or self-concept (may or may not be able to identify the threat), unconscious conflict about essential values or beliefs and goals of life, unmet needs, negative self-talk, possibly evidenced by sympathetic stimulation, extraneous movements (foot shuffling, hand or arm fidgeting, rocking movements, restlessness), persistent feelings of apprehension and uneasiness, a general anxious feeling that client has difficulty alleviating, poor eye contact, focus on self, impaired functioning, free-floating anxiety, and nonparticipation in decision making.

ineffective Coping may be related to level of anxiety being experienced by the client, personal vulnerability, unmet expectations or unrealistic perceptions, inadequate coping methods and/or support systems, possibly evidenced by verbalization of inability to cope or problem-solve, excessive compulsive behaviors, e.g., smoking, drinking, and emotional or muscle tension, alteration in societal participation, high rate of accidents.

Insomnia may be related to stress, repetitive thoughts, possibly evidenced by reports of difficulty in falling/staying asleep, dissatisfaction with sleep, nonrestorative sleep, lack of energy.

compromised family Coping possibly evidenced by risk factors of inadequate or incorrect information or understanding by a primary person, temporary family disorganization and role changes, prolonged disability that exhausts the supportive capacity of SO(s).

impaired Social Interaction/Social Isolation may be related to low self-concept, inadequate personal resources, misinterpretation of internal or external stimuli, hyper-vigilance, possibly evidenced by discomfort in social situations, withdrawal from or reported change in pattern of interactions, dysfunctional interactions, expressed feelings of difference from others, sad, dull affect.

anxiety disorders

[severe/panic] Anxiety may be related to situational or maturational crisis, internal transmission and contagion, threat to physical integrity or self-concept, unmet needs, dysfunctional family system, independence conflicts possibly evidenced by somatic complaints, nightmares, excessive psychomotor activity, refusal to attend school, persistent worry or fear of catastrophic doom to family or self.

ineffective Coping may be related to situational or maturational crisis, multiple life changes or losses, personal vulnerability, lack of self-confidence possibly evidenced by inability to problem-solve, persistent or overwhelming fears, inability to meet role expectations, social inhibition, panic attacks.

impaired Social Interaction may be related to excessive self-consciousness, inability to interact with unfamiliar people, altered thought processes possibly evidenced by verbalized or observed discomfort in social situations, inability to receive or communicate a satisfying sense of belonging, caring, or interest; use of unsuccessful social interaction behaviors.

risk for Self-Mutilation/self-directed Violence are possibly evidenced by risk factors of panic states, dysfunctional family, history of self-destructive behaviors, emotional disturbance, increasing motor activity.

compromised/disabled family Coping may be related to situational or developmental crisis, e.g., divorce, addition to the family, unrealistic parental expectations, frequent disruptions in living arrangements, high-risk family situations (neglect or abuse, substance abuse), possibly evidenced by SO reports of frustration with clinging behaviors, emotional lability, harsh or punitive response to tyrannical behaviors, disproportionate protective behaviors.

anxiolytic abuse

Refer to depressant abuse.

Aortic aneurysm, abdominal (AAA)

risk for ineffective Renal Perfusion is possibly evidenced by risk factors of hypertension, hypovolemia, hypoxia.

acute Pain may be related to physical agent [vascular enlargement—dissection or rupture], possibly evidenced by verbal/coded reports, guarding behavior, facial mask, change in vital signs.

aortic aneurysm repair, abdominal

(also refer to surgery, general)

Anxiety related to change in health status, threat of death, surgical intervention, possibly evidenced by expressed concerns, apprehension, increased tension, changes in vital signs.

risk for Bleeding is possibly evidenced by risk factors of aneurysm, treatment-related side effects—surgery, failure of vascular repair.

risk for ineffective renal/peripheral Tissue Perfusion are possibly evidenced by risk factors of hypertension, treatment-related side effects—surgery, hypovolemia, hypoxia.

aortic stenosis

decreased Cardiac Output may be related to altered contractility, altered preload or afterload possibly evidenced by fatigue, dyspnea, changes in vital signs, jugular vein distension, increased central venous pressure (CVP)/PAWP, and syncope.

risk for impaired Gas Exchange is possibly evidenced by risk factors of alveolar-capillary membrane changes.

risk for acute Pain is possibly evidenced by risk factors of physical agent [episodic ischemia of myocardial tissues and stretching of left atrium].

Activity Intolerance may be related to imbalance between oxygen supply and demand (decreased/fixed cardiac output), possibly evidenced by exertional dyspnea, reported fatigue/weakness, and abnormal blood pressure or ECG changes/dysrhythmias in response to activity.

aplastic anemia

(also refer to anemia)

ineffective Protection may be related to abnormal blood profile (leukopenia, thrombocytopenia), drug therapies (antineoplastics, antibiotics, nonsteroidal anti-inflammatory drugs, anticonvulsants) as possibly evidenced by fatigue, dyspnea, alteration in clotting.

Fatigue may be related to anemia, disease states, malnutrition, possibly evidenced by verbalization of overwhelming lack of energy, inability to maintain usual routines or level of physical activity, tired, compromised libido, lethargy, increase in physical complaints.

appendicitis

acute Pain may be related to physical agent [distention of intestinal tissues/inflammation], possibly evidenced by verbal reports, guarding behavior, narrowed focus, diaphoresis, changes in vital signs.

risk for deficient Fluid Volume is possibly evidenced by risk factors of excessive losses through normal routes (vomiting), deviations affecting intake of fluids (nausea, anorexia), and factors influencing fluid needs (hypermetabolic state).

risk for Infection is possibly evidenced by risk factors of tissue destruction [release of pathogenic organisms into peritoneal cavity].

ARDS

Refer to Respiratory distress syndrome, acute.

arrhythmia, cardiac

Refer to dysrhythmia, cardiac.

Arterial occlusive disease, peripheral

ineffective peripheral Tissue Perfusion may be related to deficient knowledge of disease process, hypertension, smoking, sedentary lifestyle, possibly evidenced by altered skin characteristics, diminished pulses, claudication, delayed peripheral wound healing.

risk for impaired Walking is possibly evidenced by risk factors of limited endurance, pain.

risk for impaired Skin/Tissue integrity are possibly evidenced by risk factors of altered circulation or sensation.

arthritis, juvenile rheumatoid

(also refer to arthritis, rheumatoid)

risk for delayed Development is possibly evidenced by risk factors of chronic illness, effects of required therapy.

Social Isolation risk factors may include delay in accomplishing developmental task, altered state of wellness, and alterations in physical appearance.

arthritis, rheumatoid

acute/chronic Pain may be related to accumulation of fluid, inflammatory process, degeneration of joint, and deformity, possibly evidenced by verbal reports, narrowed focus, guarding or protective behaviors, and physical and social withdrawal.

impaired physical Mobility/Walking may be related to musculoskeletal deformity, pain or discomfort, decreased muscle strength, possibly evidenced by limited range of motion, impaired coordination, reluctance to attempt movement, and decreased muscle strength, control, and mass.

Self-Care Deficit [specify] may be related to musculoskeletal impairment, decreased strength and endurance, limited range of motion, pain on movement, possibly evidenced by inability to manage activities of daily living (ADLs).

disturbed Body Image/ineffective Role Performance may be related to change in body structure or function, impaired mobility or ability to perform usual tasks, focus on past strength, function, or appearance, possibly evidenced by negative self-talk, feelings of helplessness, change in lifestyle or physical abilities, dependence on others for assistance, decreased social involvement.

arthritis, septic

acute Pain may be related to joint inflammation, possibly evidenced by verbal or coded reports, guarding behaviors, restlessness, narrowed focus.

impaired physical Mobility may be related to joint stiffness, pain or discomfort, reluctance to initiate movement, possibly evidenced by limited range of motion, slowed movement.

Self-Care deficit [specify] may be related to musculoskeletal impairment, pain or discomfort, decreased strength, impaired coordination, possibly evidenced by inability to perform desired ADLs.

risk for Infection [spread] is possibly evidenced by risk factors of the presence of infectious process, chronic disease states, invasive procedures.

arthroplasty

risk for Infection is possibly evidenced by risk factors of breach of primary defenses (surgical incision), stasis of body fluids at operative site, and altered inflammatory response.

risk for Bleeding is possibly evidenced by risk factors of surgical procedure, trauma to vascular area.

impaired physical Mobility may be related to decreased strength, pain, musculoskeletal changes, possibly evidenced by impaired coordination and reluctance to attempt movement.

acute Pain may be related to tissue trauma, local edema, possibly evidenced by verbal reports, narrowed focus, guarded movement, diaphoresis, changes in vital signs.

arthroscopy, knee

deficient Knowledge [Learning Need] regarding procedure/outcomes and self-care needs may be related to unfamiliarity with information or resources, misinterpretations, possibly evidenced by questions and requests for information, misconceptions.

risk for impaired Walking is possibly evidenced by risk factors of joint stiffness, discomfort, prescribed movement restrictions, use of assistive devices (crutches) for ambulation.

Asperger's disorder (now Autism spectrum disorder)

impaired Social Interaction may be related to skill deficit about ways to enhance mutuality, communication barriers (poor pragmatic language skills), compulsions, repetitive motor mannerisms, possibly evidenced by observed discomfort in social situations, dysfunctional interactions with others, inability to receive or communicate satisfying sense of belonging.

risk for Delayed Development is possibly evidenced by the risk factor of behavior disorder.

impaired Parenting may be related to developmental delay of child, deficient knowledge of child development, lack of social supports.

risk for Injury is possibly evidenced by risk factors of rituals, repetitive motor mannerisms, poor coordination, vulnerability to manipulation of peers.

asthma

(also refer to emphysema)

ineffective Airway Clearance may be related to increased production and retained pulmonary secretions, bronchospasm, decreased energy, fatigue, possibly evidenced by wheezing, difficulty breathing, changes in depth and rate of respirations, use of accessory muscles, and persistent ineffective cough with or without sputum production.

impaired Gas Exchange may be related to altered delivery of inspired oxygen/air trapping, possibly evidenced by dyspnea, restlessness, reduced tolerance for activity, cyanosis, and changes in ABGs and vital signs.

Anxiety [specify level] may be related to perceived threat of death, possibly evidenced by apprehension, fearful expression, and extraneous movements.

Activity Intolerance may be related to imbalance between oxygen supply and demand, possibly evidenced by fatigue and exertional dyspnea.

risk for Contamination is possibly evidenced by risk factors of presence of atmospheric pollutants, environmental contaminants in the home, e.g., smoking or secondhand tobacco smoke.

athlete's foot

impaired Skin Integrity may be related to fungal invasion, humidity, secretions, possibly evidenced by disruption of skin surface, reports of painful itching.

risk for Infection [spread] is possibly evidenced by risk factors of multiple breaks in skin, exposure to moist and warm environment.

atrial fibrillation

(also refer to dysrhythmia, cardiac)

Activity Intolerance may be related to imbalance between oxygen supply and demand, possibly evidenced by dyspnea, dizziness, presyncope, or syncopal episodes.

risk for ineffective cerebral Tissue Perfusion is possibly evidenced by risk factors of arterial fibrillation, embolism, thrombolytic therapy (microemboli).

atrial flutter

Refer to dysrhythmia, cardiac.

atrial tachycardia

Refer to dysrhythmia, cardiac.

attention deficit disorder (ADD)

ineffective Coping may be related to situational or maturational crisis, retarded ego development, low self-concept, possibly evidenced by easy distraction by extraneous stimuli, shifting between uncompleted activities.

chronic low Self-Esteem may be related to retarded ego development, lack of positive or repeated negative feedback, negative role models, possibly evidenced by lack of eye contact, derogatory self-comments, hesitance to try new tasks, inadequate level of confidence.

deficient Knowledge regarding condition, prognosis, therapy may be related to misinformation or misinterpretations, unfamiliarity with resources, possibly evidenced by verbalization of problems or misconceptions, poor school performance, unrealistic expectations of medication regimen.

autism spectrum disorder

impaired Social Interaction may be related to abnormal response to sensory input or inadequate sensory stimulation, organic brain dysfunction, delayed development of secure attachment or trust, lack of intuitive skills to comprehend and accurately respond to social cues, disturbance in self-concept, possibly evidenced by lack of responsiveness to others, lack of eye contact or facial responsiveness, treating persons as objects, lack of awareness of feelings in others, indifference or aversion to comfort, affection, or physical contact, failure to develop cooperative social play and peer friendships in childhood.

impaired verbal Communication may be related to inability to trust others, withdrawal into self, organic brain dysfunction, abnormal interpretation or response to and/or inadequate sensory stimulation, possibly evidenced by lack of interactive communication mode, no use of gestures or spoken language, absent or abnormal nonverbal communication, lack of eye contact or facial expression, peculiar patterns of speech (form, content, or speech production), and impaired ability to initiate or sustain conversation despite adequate speech.

risk for Self-Mutilation is possibly evidenced by risk factors of organic brain dysfunction; inability to trust others; disturbance in self-concept; inadequate sensory stimulation or abnormal response to sensory input (sensory overload); history of physical, emotional, or sexual abuse and response to demands of therapy; realization of severity of condition.

disturbed Personal Identity may be related to organic brain dysfunction, lack of development of trust, maternal deprivation, fixation at presymbiotic phase of development, possibly evidenced by lack of awareness of the feelings or existence of others, increased anxiety resulting from physical contact with others, absent or impaired imitation of others, repeating what others say, persistent preoccupation with parts of objects, obsessive attachment to objects, marked distress over changes in environment, auto-erotic or ritualistic behaviors, self-touching, rocking, swaying.

compromised/disabled family Coping may be related to family members unable to express feelings; excessive guilt, anger, or blaming among family members regarding child's condition; ambivalent or dissonant family relationships; prolonged coping with problem exhausting supportive ability of family members, possibly evidenced by denial of existence or severity of disturbed behaviors, preoccupation with personal emotional reaction to situation, rationalization that problem will be outgrown, attempts to intervene with child are achieving increasingly ineffective results, family withdraws from or becomes overly protective of child.

barbiturate abuse

Refer to depressant abuse.

battered child syndrome

(also refer to abuse)

risk for Trauma is possibly evidenced by risk factors of dependent position in relationship(s), vulnerability, e.g., congenital problems, chronic illness, history of previous abuse or neglect, lack of or nonuse of support systems by caregiver(s).

interrupted Family Processes/impaired Parenting may be related to poor role model, unrealistic expectations, presence of stressors, and lack of support, possibly evidenced by verbalization of negative feelings, inappropriate caretaking behaviors, and evidence of physical or psychological trauma to child.

chronic low Self-Esteem may be related to deprivation and negative feedback of family members, personal vulnerability, feelings of abandonment, possibly evidenced by lack of eye contact, withdrawal from social contacts, discounting own needs, nonassertive or passive, indecisive or overly conforming behaviors.

Post-Trauma Syndrome may be related to sustained or recurrent physical or emotional abuse, possibly evidenced by acting-out behavior, development of phobias, poor impulse control, and emotional numbness.

ineffective Coping may be related to situational or maturational crisis, overwhelming threat to self, personal vulnerability, inadequate support systems, possibly evidenced by verbalized concern about ability to deal with current situation, chronic worry, anxiety, depression, poor self-esteem, inability to problem-solve, high illness rate, destructive behavior toward self or others.

benign prostatic hyperplasia

[acute/chronic] Urinary Retention/overflow Urinary Incontinence may be related to mechanical obstruction (enlarged prostate), decompensation of detrusor musculature, inability of bladder to contract adequately, possibly evidenced by frequency, hesitancy, inability to empty bladder completely, incontinence or dribbling, nocturia, bladder distention, residual urine.

acute Pain may be related to mucosal irritation, bladder distention, colic, urinary infection, and radiation therapy, possibly evidenced by verbal reports (bladder or rectal spasm), narrowed focus, altered muscle tone, grimacing, distraction behaviors, restlessness, and changes in vital signs.

risk for deficient Fluid Volume/Electrolyte Imbalance are possibly evidenced by risk factors of postobstructive diuresis, renal or endocrine dysfunction.

Fear/Anxiety [specify level] may be related to change in health status (possibility of surgical procedure, malignancy); embarrassment or loss of dignity associated with genital exposure before, during, and after treatment; and concern about sexual ability, possibly evidenced by increased tension, apprehension, worry, expressed concerns regarding perceived changes, and fear of unspecific consequences.

bipolar disorder

risk for other-directed Violence is possibly evidenced by risk factors of irritability, impulsive behavior, delusional thinking, angry response when ideas are refuted or wishes denied, manic excitement, with possible indicators of threatening body language or verbalizations, increased motor activity, overt and aggressive acts, hostility.

imbalanced Nutrition: less than body requirements may be related to inadequate intake in relation to metabolic expenditures, possibly evidenced by body weight 20% or more below ideal weight, observed inadequate intake, inattention to mealtimes, and distraction from task of eating, laboratory evidence of nutritional deficits or imbalances.

risk for Poisoning [lithium toxicity] is possibly evidenced by risk factors of narrow therapeutic range of drug, client's ability (or lack of) to follow through with medication regimen and monitoring, and denial of need for information or therapy.

Insomnia may be related to psychological stress, lack of recognition of fatigue or need to sleep, hyperactivity, possibly evidenced by denial of need to sleep, interrupted nighttime sleep, one or more nights without sleep, changes in behavior and performance, increasing irritability, restlessness, and dark circles under eyes.

disturbed Sensory Perception (specify)/Stress Overload may be related to decrease in sensory threshold, endogenous chemical alteration, psychological stress, sleep deprivation, possibly evidenced by increased distractibility and agitation, anxiety, disorientation, poor concentration, auditory or visual hallucination, bizarre thinking, and motor incoordination.

interrupted Family Processes may be related to situational crises (illness, economics, change in roles), euphoric mood and grandiose ideas or actions of client, manipulative behavior and limit testing, client's refusal to accept responsibility for own actions, possibly evidenced by statements of difficulty coping with situation, lack of adaptation to change, or not dealing constructively with illness, ineffective family decision-making process, failure to send and receive clear messages, and inappropriate boundary maintenance.

bone cancer

(also refer to myeloma, multiple; amputation)

acute Pain may be related to bone destruction, pressure on nerves, possibly evidenced by verbal or coded report, protective behavior, changes in vital signs.

risk for Trauma is possibly evidenced by risk factors of increased bone fragility, general weakness, balancing difficulties.

bone marrow transplantation

(also refer to transplantation, recipient)

risk for Injury is possibly evidenced by risk factors of immune dysfunction or suppression, abnormal blood profile, action of donor T cells.

deficient Diversional Activity may be related to hospitalization or length of treatment, restriction of visitors, limitation of activities, possibly evidenced by expressions of boredom, restlessness, withdrawal, and requests for something to do.

risk for imbalanced Nutrition: less than body requirements is possibly evidenced by risk factors of increased metabolic needs for healing, altered ability to ingest nutrients— nausea, vomiting, anorexia, taste changes, oral lesions.

borderline personality disorder

risk for self/other-directed Violence/Self-Mutilation are possibly evidenced by risk factors of use of projection as a major defense mechanism, pervasive problems with negative transference, feelings of guilt or need to “punish” self, distorted sense of self, inability to cope with increased psychological or physiological tension in a healthy manner.

Anxiety [severe to panic] may be related to unconscious conflicts (experience of extreme stress), perceived threat to self-concept, unmet needs, possibly evidenced by easy frustration and feelings of hurt, abuse of alcohol or other drugs, transient psychotic symptoms, and performance of self-mutilating acts.

chronic low Self-Esteem/disturbed personal Identity may be related to lack of positive feedback, unmet dependency needs, retarded ego development or fixation at an earlier level of development, possibly evidenced by difficulty identifying self or defining self-boundaries, feelings of depersonalization, extreme mood changes, lack of tolerance of rejection or of being alone, unhappiness with self, striking out at others, performance of ritualistic self-damaging acts, and belief that punishing self is necessary.

Social Isolation may be related to immature interests, unaccepted social behavior, inadequate personal resources, and inability to engage in satisfying personal relationships, possibly evidenced by alternating clinging and distancing behaviors, difficulty meeting expectations of others, experiencing feelings of difference from others, expressing interests inappropriate to developmental age, and exhibiting behavior unaccepted by dominant cultural group.

botulism (food-borne)

deficient Fluid Volume may be related to active losses—vomiting, diarrhea, decreased intake—nausea, dysphagia, possibly evidenced by reports of thirst, dry skin and mucous membranes, decreased BP and urine output, change in mental state, increased hematocrit (Hct).

impaired physical Mobility may be related to neuromuscular impairment, possibly evidenced by limited ability to perform gross or fine motor skills.

Anxiety [specify level]/Fear may be related to threat of death, interpersonal transmission, possibly evidenced by expressed concerns, apprehension, awareness of physiological symptoms, focus on self.

risk for impaired spontaneous Ventilation is possibly evidenced by risk factors of neuromuscular impairment, presence of infectious process.

Contamination may be related to lack of proper precautions in food storage or preparation as evidenced by gastrointestinal and neurological effects of exposure to biological agent.

bowel obstruction

Refer to ileus.

brain tumor

acute Pain may be related to pressure on brain tissues, possibly evidenced by reports of headache, facial mask of pain, narrowed focus, and changes in vital signs.

impaired Memory may be related to altered circulation to and/or destruction of brain tissue, possibly evidenced by memory loss, personality changes, impaired ability to make decisions or conceptualize, and inaccurate interpretation of environment.

disturbed Sensory/Perception (specify) may be related to altered sensory reception/integration, possibly evidenced by changes in sensory acuity, change in behavior pattern, poor concentration/problem-solving abilities, disorientation.

risk for deficient Fluid Volume is possibly evidenced by risk factors of recurrent vomiting from irritation of vagal center in medulla and decreased intake.

Self-Care Deficit [specify] may be related to sensory or neuromuscular impairment interfering with ability to perform tasks, possibly evidenced by unkempt and disheveled appearance, body odor, and verbalization or observation of inability to perform ADLs.

breast cancer

(also refer to cancer)

Anxiety [specify level] may be related to change in health status, threat of death, stress, interpersonal transmission, possibly evidenced by expressed concerns, apprehension, uncertainty, focus on self, diminished productivity.

deficient Knowledge [Learning Need] regarding diagnosis, prognosis, and treatment options may be related to lack of exposure or unfamiliarity with information resources, information misinterpretation, cognitive limitation, anxiety, possibly evidenced by verbalizations, statements of misconceptions, inappropriate behaviors.

disturbed Body Image may be related to surgical procedure, alteration in self-perception and is possibly evidenced by absence of body part, focus on past appearance, fear of rejection by others.

risk for Sexual Dysfunction is possibly evidenced by risk factors of health-related changes, medical treatments, concern about relationship with significant other.

bronchitis

ineffective Airway Clearance may be related to excessive, thickened mucus secretions, possibly evidenced by presence of rhonchi, tachypnea, and ineffective cough.

Activity Intolerance [specific level] may be related to imbalance between oxygen supply and demand, possibly evidenced by reports of fatigue, dyspnea, and abnormal vital sign response to activity.

acute Pain may be related to inflammation of lung parenchyma, persistent cough, cellular reactions to circulating toxins, aching associated with fever, possibly evidenced by reports of pleuritic chest pain, guarding affected area, distraction behaviors, and restlessness.

bronchopneumonia

(also refer to bronchitis)

ineffective Airway Clearance may be related to tracheal bronchial inflammation, edema formation, increased sputum production, pleuritic pain, decreased energy, fatigue, possibly evidenced by changes in rate and depth of respirations, abnormal breath sounds, use of accessory muscles, dyspnea, cyanosis, effective or ineffective cough— with or without sputum production.

impaired Gas Exchange may be related to inflammatory process, collection of secretions affecting oxygen exchange across alveolar membrane, and hypoventilation, possibly evidenced by restlessness/changes in mentation, dyspnea, tachycardia, pallor, cyanosis, and ABGs or oximetry evidence of hypoxia.

risk for Infection [spread] is possibly evidenced by risk factors of decreased ciliary action, stasis of secretions, presence of existing infection, immunosuppression, chronic disease, malnutrition.

bulimia nervosa

(also refer to anorexia nervosa)

impaired Dentition may be related to dietary habits, poor oral hygiene, chronic vomiting, possibly evidenced by erosion of tooth enamel, multiple caries, abraded teeth.

impaired oral Mucous Membrane may be related to malnutrition or vitamin deficiency, poor oral hygiene, chronic vomiting, possibly evidenced by sore, inflamed buccal mucosa, swollen salivary glands, ulcerations of mucosa, reports of constant sore mouth or throat.

risk for deficient Fluid Volume/Bleeding are possibly evidenced by risk factors of consistent self-induced vomiting, chronic or excessive laxative or diuretic use, esophageal erosion or tear (Mallory-Weiss syndrome).

deficient Knowledge [Learning Need] regarding condition, prognosis, complication, treatment may be related to lack of exposure or recall, unfamiliarity with information about condition, learned maladaptive coping skills, possibly evidenced by verbalization of misconception of relationship of current situation and binging and purging behaviors, distortion of body image, verbalized need for information, desire to change behaviors.

burns (dependent on type, degree, and severity of the injury)

risk for deficient Fluid Volume/Bleeding are possibly evidenced by risk factors of loss of fluids through wounds, capillary damage and evaporation, hypermetabolic state, insufficient intake, hemorrhagic losses.

risk for ineffective Airway Clearance is possibly evidenced by risk factors of tracheo-bronchial obstruction—mucosal edema and loss of ciliary action with smoke inhalation; circumferential full-thickness burns of the neck, thorax, and chest, with compression of the airway or limited chest excursion, trauma—direct upper airway injury by flame, steam, chemicals, or gases; fluid shifts, pulmonary edema, decreased lung compliance.

risk for Infection is possibly evidenced by risk factors of loss of protective dermal barrier, traumatized tissue, necrosis, decreased hemoglobin (Hb), suppressed inflammatory response, environmental exposure, invasive procedures.

acute/chronic Pain may be related to destruction of skin, tissues, and nerves; edema formation, and manipulation of injured tissues, possibly evidenced by verbal reports, narrowed focus, distraction and guarding behaviors, facial mask of pain, and changes in vital signs.

risk for imbalanced Nutrition: less than body requirements is possibly evidenced by risk factors of hypermetabolic state as much as 50% to 60% higher than normal proportional to the severity of injury, protein catabolism, anorexia, restricted oral intake.

Post-Trauma Syndrome may be related to life-threatening event, possibly evidenced by reexperiencing the event, repetitive dreams or nightmares, psychic or emotional numbness, and sleep disturbance.

ineffective Protection may be related to extremes of age, inadequate nutrition, anemia, impaired immune system, possibly evidenced by impaired healing, deficient immunity, fatigue, anorexia.

deficient Diversional Activity may be related to long-term hospitalization, frequent lengthy treatments, and physical limitations, possibly evidenced by expressions of boredom, restlessness, withdrawal, and requests for something to do.

risk for delayed Development is possibly evidenced by risk factors of effects of physical disability, separation from SO(s), and environmental deficiencies.

bursitis

acute/chronic Pain may be related to inflammation of affected joint, possibly evidenced by verbal reports, guarding behavior, and narrowed focus.

impaired physical Mobility may be related to inflammation and swelling of joint and pain, possibly evidenced by diminished range of motion, reluctance to attempt movement, and imposed restriction of movement by medical treatment.

calculi, urinary

acute Pain may be related to increased frequency or force of ureteral contractions, tissue trauma, edema formation, cellular ischemia, possibly evidenced by reports of sudden, severe, colicky pain, guarding and distraction behaviors, self-focus, and changes in vital signs.

impaired Urinary Elimination may be related to stimulation of the bladder by calculi, renal or ureteral irritation, mechanical obstruction of urinary flow, inflammation, possibly evidenced by urgency and frequency, oliguria, hematuria.

risk for deficient Fluid Volume is possibly evidenced by risk factors of stimulation of renal-intestinal reflexes—nausea, vomiting, and diarrhea, changes in urinary output, postobstructive diuresis.

risk for Infection is possibly evidenced by risk factors of stasis of urine, insufficient fluid intake.

deficient Knowledge [Learning Need] regarding condition, prognosis, self-care and treatment needs may be related to lack of exposure or recall and information misinterpretation, possibly evidenced by requests for information, statements of concern, and recurrence or development of preventable complications.

cancer

(also refer to chemotherapy)

Fear/death Anxiety may be related to situational crises, threat to or change in health or socioeconomic status, role functioning, interaction patterns, threat of death, separation from family, interpersonal transmission of feelings, possibly evidenced by expressed concerns, feelings of inadequacy or helplessness, insomnia, increased tension, restlessness, focus on self, sympathetic stimulation.

Grieving may be related to potential loss of physiological well-being (body part or function), change in lifestyle, perceived potential death, possibly evidenced by anger, sadness, withdrawal, choked feelings, changes in eating or sleep patterns, activity level, libido, and communication patterns.

acute/chronic Pain may be related to the disease process (compression of nerve tissue, infiltration of nerves or their vascular supply, obstruction of a nerve pathway, inflammation), or side effects of therapeutic agents, possibly evidenced by verbal reports, self-focusing or narrowed focus, alteration in muscle tone, facial mask of pain, distraction or guarding behaviors, autonomic responses, and restlessness.

Fatigue may be related to decreased metabolic energy production, increased energy requirements (hypermetabolic state), overwhelming psychological or emotional demands, and altered body chemistry—side effects of medications, chemotherapy, radiation therapy, biotherapy—possibly evidenced by unremitting or overwhelming lack of energy, inability to maintain usual routines, decreased performance, impaired ability to concentrate, lethargy, listlessness, and disinterest in surroundings.

impaired Home Maintenance may be related to debilitation, lack of resources, and/or inadequate support systems, possibly evidenced by verbalization of problem, request for assistance, and lack of necessary equipment or aids.

risk for interrupted Family Processes possibly evidenced by risk factors of situational or transitional crises—long-term illness, change in roles or economic status; developmental—anticipated loss of a family member.

readiness for enhanced family Coping possibly evidenced by verbalizations of impact of crisis on own values, priorities, goals, or relationships.

candidiasis

(also refer to thrush)

impaired Skin/Tissue Integrity may be related to infectious lesions, possibly evidenced by disruption of skin surfaces and mucous membranes.

acute Pain/impaired Comfort may be related to exposure of irritated skin and mucous membranes to excretions (urine, feces), possibly evidenced by verbal or coded reports, restlessness, or guarding behaviors.

risk for Sexual Dysfunction is possibly evidenced by risk factors of the presence of infectious process and vaginal discomfort.

cannabis abuse

Refer to stimulant abuse.

cardiac catheterization

Anxiety [specify level] may be related to threat to or change in health status, stress, family heredity possibly evidenced by expressed concerns, apprehension, uncertainty, focus on self.

risk for decreased Cardiac Output is possibly evidenced by risk factors of altered heart rate and rhythm (vasovagal response, ventricular dysrhythmias), decreased myocardial contractility (ischemia).

risk for decreased cardiac Tissue Perfusion is possibly evidenced by risk factors of coronary artery spasm, hypovolemia, hypoxia, [thrombosis, emboli].

risk for adverse Reaction to Iodinated Contrast Media is possibly evidenced by risk factors of underlying disease—heart disease, concurrent use of medications, e.g., beta blockers, metformin, history of allergies.

cardiac surgery

risk for decreased Cardiac Output is possibly evidenced by risk factors of altered myocardial contractility secondary to temporary factors (ventricular wall surgery, recent myocardial infarction, response to certain medications or drug interactions), altered preload (hypovolemia), and afterload (systemic vascular resistance), altered heart rate or rhythm (dysrhythmias).

risk for Bleeding/deficient Fluid Volume [isotonic] are possibly evidenced by risk factors of intraoperative bleeding with inadequate blood replacement; bleeding related to insufficient heparin reversal, fibrinolysis, or platelet destruction; or volume depletion effects of intraoperative or postoperative diuretic therapy.

risk for impaired Gas Exchange is possibly evidenced by risk factors of alveolar-capillary membrane changes (atelectasis), intestinal edema, inadequate function or premature discontinuation of chest tubes, and diminished O₂-carrying capacity of the blood.

acute Pain/impaired Comfort may be related to tissue inflammation or trauma, edema formation, intraoperative nerve trauma, and myocardial ischemia, possibly evidenced by reports of incisional discomfort, pain in chest and donor site; paresthesia or pain in hand, arm, shoulder; anxiety, restlessness, irritability; distraction behaviors; and changes in heart rate and BP.

impaired Skin/Tissue Integrity related to mechanical trauma (surgical incisions, puncture wounds) and edema evidenced by disruption of skin surface and tissues.

cardiogenic shock

Refer to shock, cardiogenic.

cardiomyopathy

decreased Cardiac Output may be related to altered contractility, possibly evidenced by dyspnea, fatigue, chest pain, dizziness, syncope.

Activity Intolerance may be related to imbalance between oxygen supply and demand, possibly evidenced by weakness, fatigue, dyspnea, abnormal heart rate and BP response to activity, ECG changes.

ineffective Role Performance may be related to changes in physical health, stress, demands of job/life, possibly evidenced by change in usual patterns of responsibility, role strain, change in capacity to resume role.

carotid endarterectomy

(also refer to surgery, general)

risk for ineffective cerebral Tissue Perfusion is possibly evidenced by risk factors of carotid stenosis, embolism, thrombolytic therapy.

carpal tunnel syndrome

acute/chronic Pain may be related to pressure on median nerve, possibly evidenced by verbal reports, reluctance to use affected extremity, guarding behaviors, expressed fear of re-injury, altered ability to continue previous activities.

impaired physical Mobility may be related to neuromuscular impairment and pain, possibly evidenced by decreased hand strength, weakness, limited range of motion, and reluctance to attempt movement.

risk for peripheral neurovascular Dysfunction is possibly evidenced by risk factors of mechanical compression, e.g., brace, repetitive tasks or motions, immobilization.

deficient Knowledge [Learning Need] regarding condition, prognosis and treatment/safety needs may be related to lack of exposure or recall, information misinterpretation, possibly evidenced by questions, statements of concern, request for information, inaccurate follow-through of instructions, development of preventable complications.

casts

(also refer to fractures)

risk for peripheral neurovascular Dysfunction is possibly evidenced by risk factors of presence of fracture(s), mechanical compression (cast), tissue trauma, immobilization, vascular obstruction.

risk for impaired Skin Integrity is possibly evidenced by risk factors of pressure of cast, moisture or debris under cast, objects inserted under cast to relieve itching, and altered sensation or circulation.

Self-Care Deficit [specify] may be related to impaired ability to perform self-care tasks, possibly evidenced by statements of need for assistance and observed difficulty in performing ADLs.

cataract

[disturbed visual Sensory Perception] may be related to altered sensory reception or status of sense organs, and therapeutically restricted environment (surgical procedure, patching), possibly evidenced by diminished acuity, visual distortions, and change in usual response to stimuli.

risk for Trauma is possibly evidenced by risk factors of poor vision, reduced hand-eye coordination.

Anxiety [specify level]/Fear may be related to alteration in visual acuity, threat of permanent loss of vision/independence, possibly evidenced by expressed concerns, apprehension, and feelings of uncertainty.

deficient Knowledge [Learning Need] regarding ways of coping with altered abilities, therapy choices, lifestyle changes may be related to lack of exposure or recall, misinterpretation, or cognitive limitations, possibly evidenced by requests for information, statement of concern, inaccurate follow-through of instructions, development of preventable complications.

cat scratch disease

acute Pain may be related to effects of circulating toxins (fever, headache, and lymphadenitis), possibly evidenced by verbal reports, guarding behavior, and changes in vital signs.

Hyperthermia may be related to inflammatory process, possibly evidenced by increased body temperature, flushed warm skin, tachypnea, tachycardia.

celiac disease

imbalanced Nutrition: less than body requirements may be related to inability to absorb nutrients (mucosal damage, loss of villi, proliferation of crypt cells, shortened transit time through gastrointestinal tract), possibly evidenced by weight loss, abdominal distention, steatorrhea, evidence of anemia, vitamin deficiencies.

Diarrhea may be related to irritation, malabsorption, possibly evidenced by abdominal pain, hyperactive bowel sounds, at least three loose stools per day.

risk for deficient Fluid Volume is possibly evidenced by risk factors of mild to massive steatorrhea, diarrhea.

cellulitis

risk for Infection [abscess, bacteremia] is possibly evidenced by risk factors of broken skin, chronic disease, presence of pathogens, insufficient knowledge to avoid exposure to pathogens.

acute Pain/impaired Comfort may be related to inflammatory process, circulating toxins possibly evidenced by reports of localized pain or headache, guarding behaviors, restlessness, changes in vital signs.

impaired Tissue Integrity may be related to trauma, inflammation and/or invasion of tissues by infectious bacterial agent, or altered circulation, possibly evidenced by redness, warmth, edema, tenderness or pain under the surface of skin, or deep in tissues.

cerebrovascular accident (CVA)

ineffective cerebral Tissue Perfusion may be related to interruption of blood flow (occlusive disorder, hemorrhage, cerebral vasospasm, or edema), possibly evidenced by altered level of consciousness, changes in vital signs, changes in motor or sensory responses, restlessness, memory loss, as well as sensory, language, intellectual, and emotional deficits.

impaired physical Mobility may be related to neuromuscular involvement (weakness, paresthesia, flaccid or hypotonic paralysis, spastic paralysis), perceptual or cognitive impairment, possibly evidenced by inability to purposefully move involved body parts, limited range of motion, impaired coordination, and/or decreased muscle strength or control.

impaired verbal [and/or written] Communication may be related to impaired cerebral circulation, neuromuscular impairment, loss of facial/oral muscle tone and control, generalized weakness, fatigue, possibly evidenced by impaired articulation; inability to speak (dysarthria); inability to modulate speech, find and/or name words, identify objects; and/or inability to comprehend written or spoken language, inability to produce written communication.

Self-Care Deficit [specify] may be related to neuromuscular impairment, decreased strength or endurance, loss of muscle control or coordination, perceptual or cognitive impairment, pain, discomfort, and depression, possibly evidenced by stated or observed inability to perform ADLs, requests for assistance, disheveled appearance, and incontinence.

risk for impaired Swallowing is possibly evidenced by risk factors of muscle paralysis or perceptual impairment.

risk for Unilateral Neglect is possibly evidenced by risk factors of sensory loss of part of visual field with perceptual loss of corresponding body segment.

impaired Home Maintenance may be related to condition of individual family member, insufficient finances, family organization or planning, unfamiliarity with resources, and inadequate support systems, possibly evidenced by members expressing difficulty in managing home in a comfortable manner, requesting assistance with home maintenance, disorderly surroundings, and overtaxed family members.

situational low Self-Esteem/disturbed Body Image/ineffective Role Performance may be related to functional impairment, loss, focus on past function/strength, and cognitive or perceptual changes, possibly evidenced by actual change in function, self-negating verbalizations, reports perceptions reflecting altered view of body function.

Grieving may be related to loss of processes of body [neuromuscular impairments], loss of job/role function, status/independence, possibly evidenced by psychological distress, despair, anger, disorganization.

cervix, dysfunctional

Refer to dilation of cervix, premature.

cesarean birth

(also refer to cesarean birth, unplanned; cesarean birth, postpartal)

deficient Knowledge [Learning Need] regarding surgical procedure and expectation, postoperative routines and therapy, and self-care needs may be related to lack of information/misinterpretation, possibly evidenced by statements of concern, questions, and misconceptions.

risk for deficient Fluid Volume/Bleeding: are possibly evidenced by risk factors of restrictions of oral intake, blood loss; pregnancy-related complications.

risk for impaired Attachment is possibly evidenced by risk factors of separation, existing health conditions of mother or infant, lack of privacy.

cesarean birth, postpartal

(also refer to postpartal period)

risk for impaired Attachment is possibly evidenced by risk factors of developmental transition or gain of a family member, situational crisis, e.g., surgical intervention, physical complications interfering with initial acquaintance and interaction, negative self-appraisal.

acute Pain/impaired Comfort may be related to surgical trauma, effects of anesthesia, hormonal effects, bladder or abdominal distention, possibly evidenced by verbal reports, e.g., incisional pain, cramping, afterpains, spinal headache, guarding or distraction behaviors, irritability, facial mask of pain.

risk for situational low Self-Esteem is possibly evidenced by risk factors of perceived “failure” at life event, maturational transition, perceived loss of control in unplanned delivery.

risk for Injury is possibly evidenced by risk factors of biochemical or regulatory functions, e.g., orthostatic hypotension, development of pregnancy-induced hypertension or eclampsia, effects of anesthesia, thromboembolism, abnormal blood profile (anemia or excessive blood loss, rubella sensitivity, Rh incompatibility), tissue trauma.

risk for Infection is possibly evidenced by risk factors of tissue trauma, broken skin, decreased Hb, invasive procedures and/or increased environmental exposure, prolonged rupture of amniotic membranes, malnutrition.

Self-Care Deficit [specify] may be related to effects of anesthesia, decreased strength and endurance, physical discomfort, possibly evidenced by verbalization of inability to perform desired ADL(s).

cesarean birth, unplanned

(also refer to cesarean birth, postpartal)

deficient Knowledge [Learning Need] regarding underlying procedure, pathophysiology, and self-care needs may be related to incomplete or inadequate information, possibly evidenced by request for information, verbalization of concerns or misconceptions, and inappropriate or exaggerated behavior.

Anxiety [specify level] may be related to actual or perceived threat to mother/fetus, emotional threat to self-esteem, unmet needs or expectations, interpersonal transmission, possibly evidenced by increased tension, apprehension, feelings of inadequacy, sympathetic stimulation, narrowed focus, restlessness.

Powerlessness may be related to interpersonal interaction, perception of illness-related regimen, lifestyle of helplessness, possibly evidenced by verbalization of lack of control, lack of participation in care or decision making, passivity.

risk for disturbed Maternal-Fetal Dyad is possibly evidenced by risk factors of compromised oxygen transport, complication of pregnancy.

risk for labor Pain is possibly evidenced by risk factors of increased or prolonged contractions, psychological reaction.

risk for Infection is possibly evidenced by risk factors of invasive procedures, rupture of amniotic membranes, break in skin, decreased Hb, exposure to pathogens.

chemotherapy

(also refer to cancer)

risk for deficient Fluid volume is possibly evidenced by risk factors of gastrointestinal losses (vomiting, diarrhea), interference with adequate intake (stomatitis, anorexia), losses through abnormal routes (indwelling tubes, wounds, fistulas), hypermetabolic state.

imbalanced Nutrition: less than body requirements may be related to inability to ingest adequate nutrients—nausea, stomatitis, gastric irritation, taste distortions, and fatigue; hypermetabolic state, poorly controlled pain, possibly evidenced by weight loss (wasting), aversion to eating, reported altered taste sensation, sore and inflamed buccal cavity, diarrhea and/or constipation.

impaired oral Mucous Membrane may be related to side effects of therapeutic agents or radiation, dehydration, and malnutrition, possibly evidenced by ulcerations, leukoplakia, decreased salivation, and reports of pain.

disturbed Body Image may be related to anatomical or structural changes, loss of hair and weight, possibly evidenced by negative feelings about body, preoccupation with change, feelings of helplessness or hopelessness, and change in social environment.

ineffective Protection may be related to inadequate nutrition, drug or radiation therapy, abnormal blood profile, disease state (cancer), possibly evidenced by impaired healing, deficient immunity, anorexia, fatigue.

readiness for enhanced Hope is possibly evidenced by expressed desire to enhance belief in possibilities and sense of meaning to life.

cholecystectomy

acute Pain may be related to interruption in skin and tissue layers with mechanical closure (sutures or staples) and invasive procedures (including T-tube, nasogastric [NG] tube), possibly evidenced by verbal reports, guarding or distraction behaviors, and changes in vital signs.

ineffective Breathing Pattern may be related to pain, muscular impairment, decreased energy, fatigue, possibly evidenced by fremitus, tachypnea, and decreased respiratory depth and vital capacity, holding breath, reluctance to cough.

risk for deficient Fluid Volume/Bleeding is possibly evidenced by risk factors of losses from vomiting or NG aspiration, medically restricted intake, altered coagulation.

cholelithiasis

acute Pain may be related to obstruction or ductal spasm, inflammatory process, tissue ischemia, necrosis, possibly evidenced by verbal reports, guarding or distraction behaviors, self- or narrowed focus, and changes in vital signs.

risk for imbalanced Nutrition: less than body requirements is possibly evidenced by risk factors of self-imposed or prescribed dietary restrictions, nausea and vomiting, dyspepsia, pain; loss of nutrients; impaired fat digestion—obstruction of bile flow.

deficient Knowledge [Learning Need] regarding pathophysiology, therapy choices, and self-care needs may be related to lack of information or recall, misinterpretation, possibly evidenced by verbalization of concerns, questions, and recurrence of condition.

chronic obstructive lung disease

ineffective Airway Clearance may be related to bronchospasm, increased production of tenacious secretions, retained secretions, and decreased energy, fatigue, possibly evidenced by presence of wheezes, crackles, tachypnea, dyspnea, changes in depth of respirations, use of accessory muscles, persistent cough, and chest x-ray findings.

impaired Gas Exchange may be related to altered oxygen delivery (obstruction of airways by secretions/bronchospasm, air-trapping) and alveoli destruction, possibly evidenced by dyspnea, restlessness, confusion, abnormal ABG values, and reduced tolerance for activity.

Activity Intolerance may be related to imbalance between oxygen supply and demand, and generalized weakness, possibly evidenced by verbal reports of fatigue, exertional dyspnea, and abnormal vital sign response.

imbalanced Nutrition: less than body requirements may be related to inability to ingest adequate nutrients (dyspnea, fatigue, medication side effects, sputum production, anorexia), possibly evidenced by weight loss, reported altered taste sensation, decreased muscle mass or subcutaneous fat, poor muscle tone, and aversion to eating/lack of interest in food.

risk for Infection is possibly evidenced by risk factors of decreased ciliary action, stasis of secretions, and debilitated state or malnutrition.

circumcision

deficient Knowledge [Learning Need] regarding surgical procedure, prognosis, and treatment may be related to lack of exposure, misinterpretation, unfamiliarity with information resources, possibly evidenced by request for information, verbalization of concern/misconceptions, inaccurate follow-through of instructions.

acute Pain may be related to trauma to/edema of tender tissues, possibly evidenced by crying, changes in sleep pattern, refusal to eat.

impaired Urinary Elimination may be related to tissue injury or inflammation or development of urethral fistula, possibly evidenced by edema, difficulty voiding.

risk for Bleeding is possibly evidenced by risk factors of decreased clotting factors immediately after birth, previously undiagnosed problems with bleeding or clotting.

risk for Infection is possibly evidenced by risk factors of immature immune system, invasive procedure, tissue trauma, environmental exposure.

cirrhosis

(also refer to Substance dependence/abuse rehabilitation; hepatitis, acute viral)

risk for impaired Liver Function are possibly evidenced by risk factors of viral infection, alcohol abuse.

imbalanced Nutrition: less than body requirements may be related to inability to ingest or absorb nutrients (anorexia, nausea, indigestion, early satiety), abnormal bowel function, impaired storage of vitamins, possibly evidenced by aversion to eating, observed lack of intake, poor muscle tone, muscle wasting, weight loss, and imbalances in nutritional studies.

excess Fluid Volume may be related to compromised regulatory mechanism, e.g., syndrome of inappropriate antidiuretic hormone, decreased plasma proteins, malnutrition, and excess sodium and/or fluid intake, possibly evidenced by generalized or abdominal edema, weight gain, dyspnea, BP changes, positive hepatojugular reflex, change in mentation, altered electrolytes, changes in urine specific gravity, and pleural effusion.

risk for impaired Skin Integrity is possibly evidenced by risk factors of altered circulation and metabolic state, poor skin turgor, skeletal prominence, presence of edema or ascites, and accumulation of bile salts in skin.

risk for Bleeding is possibly evidenced by risk factors of abnormal blood profile, altered clotting factors—decreased production of prothrombin, fibrinogen, and factors VIII, IX, and X; impaired vitamin K absorption; release of thromboplastin, portal hypertension, development of esophageal varices.

risk for acute Confusion is possibly evidenced by risk factors of alcohol abuse, increased serum ammonia level, and inability of liver to detoxify certain enzymes or drugs.

Self-Esteem (specify)]/disturbed Body Image may be related to biophysical changes, altered physical appearance, uncertainty of prognosis, changes in role function, personal vulnerability, self-destructive behavior (alcohol-induced disease), possibly evidenced by verbalization of changes in lifestyle, fear of rejection/reaction of others, negative feelings about body or abilities, and feelings of helplessness, hopelessness, powerlessness.

ineffective Protection may be related to abnormal blood profile (altered clotting factors), portal hypertension, development of esophageal varices as evidenced by fatigue, anorexia, itching, disorientation.

cocaine hydrochloride poisoning, acute

(also refer to stimulant abuse; substance dependence/abuse rehabilitation)

ineffective Breathing Pattern may be related to pharmacological effects on respiratory center of the brain, possibly evidenced by tachypnea, altered depth of respiration, shortness of breath, and abnormal ABGs.

risk for decreased Cardiac Output is possibly evidenced by risk factors of drug effect on myocardium (degree dependent on drug purity and quality used), alterations in electrical rate, rhythm, or conduction, preexisting myocardiopathy.

risk for impaired Liver Function is possibly evidenced by risk factors of cocaine abuse and direct effects of cocaine on the myocardium.

imbalanced Nutrition: less than body requirements may be related to anorexia, insufficient or inappropriate use of financial resources, and is possibly evidenced by reported inadequate intake, weight loss or less than normal weight gain, lack of interest in food, poor muscle tone, signs or laboratory evidence of vitamin deficiencies.

risk for Infection is possibly evidenced by risk factors of injection techniques, impurities of drugs, localized trauma/nasal septum damage, malnutrition, altered immune state.

ineffective Coping may be related to personal vulnerability, negative role modeling, inadequate support systems, ineffective or inadequate coping skills with substitution of drug, possibly evidenced by use of harmful substance despite evidence of undesirable consequences.

[disturbed Sensory/Perception (specify)] may be related to exogenous chemical, altered sensory reception, transmission, or integration (hallucination), altered status of sense organs, possibly evidenced by responding to internal stimuli from hallucinatory experiences, bizarre thinking, anxiety, panic, changes in sensory acuity (sense of smell or taste).

coccidioidomycosis (San Joaquin/Valley Fever)

acute Pain may be related to inflammation, possibly evidenced by verbal reports, distraction behaviors, narrowed focus.

Fatigue may be related to decreased energy production, states of discomfort, possibly evidenced by reports of overwhelming lack of energy, inability to maintain usual routine, emotional lability or irritability, impaired ability to concentrate, decreased endurance or libido.

deficient Knowledge [Learning Need] regarding nature/course of disease, therapy and self-care needs may be related to lack of information, possibly evidenced by statements of concern and questions.

colitis, ulcerative

Diarrhea may be related to inflammation or malabsorption of the bowel, presence of toxins, segmental narrowing of the lumen, possibly evidenced by increased bowel sounds and peristalsis, frequent watery stools (acute phase), changes in stool color, abdominal pain, urgency, cramping.

acute/chronic Pain may be related to inflammation of the intestines, hyperperistalsis, prolonged diarrhea, and anal/rectal irritation, fissures, fistulas, possibly evidenced by verbal reports, guarding or distraction behaviors—restlessness, or self-focusing.

risk for deficient Fluid Volume is possibly evidenced by risk factors of excessive losses through normal routes—severe frequent diarrhea, vomiting; capillary plasma loss; hypermetabolic state—inflammation, fever; restricted intake—nausea, anorexia.

imbalanced Nutrition: less than body requirements may be related to altered intake or absorption of nutrients—medically restricted intake, fear that eating may cause diarrhea; and hypermetabolic state, possibly evidenced by weight loss, decreased subcutaneous fat and muscle mass, poor muscle tone, hyperactive bowel sounds, steatorrhea, pale conjunctiva and mucous membranes, aversion to eating.

ineffective Coping may be related to chronic nature and indefinite outcome of disease, multiple stressors repeated over time, situational crisis, personal vulnerability, severe pain, inadequate sleep, lack of or ineffective support systems, possibly evidenced by verbalization of inability to cope, discouragement, anxiety, preoccupation with physical self, chronic worry, emotional tension, depression, recurrent exacerbation of symptoms.

risk for Powerlessness is possibly evidenced by risk factors of unresolved dependency conflicts, feelings of insecurity or resentment, repression of anger and aggressive feelings, lacking a sense of control in stressful situations, sacrificing own wishes for others, retreat from aggression or frustration.

colostomy

risk for impaired Skin Integrity is possibly evidenced by risk factors of absence of sphincter at stoma, character and flow of effluent and flatus from stoma, reaction to product or removal of adhesive, improperly fitting or care of appliance.

risk for Diarrhea/Constipation are possibly evidenced by risk factors of interruption or alteration of normal bowel function/placement of ostomy, changes in dietary or fluid intake, and effects of medication.

deficient Knowledge [Learning Need] regarding changes in physiologic function and self-care/treatment needs may be related to lack of exposure or recall, information misinterpretation, possibly evidenced by questions, statement of concern, and inaccurate follow-through of instruction or performance of ostomy care, development of preventable complications.

disturbed Body Image may be related to biophysical changes (presence of stoma, loss of control of bowel elimination) and psychosocial factors (altered body structure, disease process—cancer, colitis, and associated treatment regimen, possibly evidenced by verbalization of change in perception of self, negative feelings about body, fear of rejection/reaction of others, not touching or looking at stoma, and refusal to participate in care.

impaired Social Interaction may be related to fear of embarrassing situation secondary to altered bowel control with loss of contents, odor, possibly evidenced by reduced participation and verbalized or observed discomfort in social situations.

risk for Sexual Dysfunction is possibly evidenced by risk factors of altered body structure and function, radical resection and treatment procedures, vulnerability, psychological concern about response of SO(s), and disruption of sexual response pattern—erection difficulty.

coma

risk for Suffocation is possibly evidenced by risk factors of cognitive impairment/loss of protective reflexes and purposeful movement.

risk for deficient Fluid Volume/imbalanced Nutrition: less than body requirements are possibly evidenced by risk factors of inability to ingest food or fluids, increased needs—hypermetabolic state.

[total] Self-Care Deficit may be related to cognitive impairment and absence of purposeful activity, evidenced by inability to perform ADLs.

risk for ineffective cerebral Tissue Perfusion is possibly evidenced by risk factors of head trauma, substance abuse, embolism, cerebral aneurysm, brain tumor/neoplasm.

risk for Infection is possibly evidenced by risk factors of stasis of body fluids (oral, pulmonary, urinary), invasive procedures, and nutritional deficits.

coma, diabetic

Refer to diabetic ketoacidosis; coma.

complex regional pain syndrome

acute/chronic Pain may be related to continued nerve stimulation, possibly evidenced by verbal reports, distraction or guarding behaviors, narrowed focus, changes in sleep patterns, and altered ability to continue previous activities.

ineffective peripheral Tissue Perfusion may be related to reduction of arterial blood flow (arteriole vasoconstriction), possibly evidenced by extremity pain, altered skin characteristics, diminished pulses, and edema.

[disturbed tactile Sensory Perception] may be related to altered sensory reception (neurological deficit, pain), possibly evidenced by change in usual response to stimuli, abnormal sensitivity of touch, physiological anxiety, and irritability.

risk for ineffective Role Performance is possibly evidenced by risk factors of situational crisis, chronic disability, debilitating pain.

risk for compromised family Coping is possibly evidenced by risk factors of temporary family disorganization and role changes and prolonged disability that exhausts the supportive capacity of SO(s).

concussion, brain

acute Pain may be related to trauma to or edema of cerebral tissue, possibly evidenced by reports of headache, guarding or distraction behaviors, and narrowed focus.

risk for deficient Fluid Volume is possibly evidenced by risk factors of vomiting, decreased intake, and hypermetabolic state (fever).

risk for impaired Memory is possibly evidenced by risk factor of neurological disturbances.

deficient Knowledge [Learning Need] regarding condition, treatment/safety needs, and potential complications may be related to lack of recall, misinterpretation, cognitive limitation, possibly evidenced by questions or statement of concerns, development of preventable complications.

conduct disorder (childhood, adolescence)

risk for self/other-directed Violence are possibly evidenced by risk factors of retarded ego development, antisocial character, poor impulse control, dysfunctional family system, loss of significant relationships, history of suicidal or acting-out behaviors.

defensive Coping may be related to inadequate coping strategies, maturational crisis, multiple life changes or losses, lack of control of impulsive actions, and personal vulnerability, possibly evidenced by inappropriate use of defense mechanisms, inability to meet role expectations, poor self-esteem, failure to assume responsibility for own actions, hypersensitivity to slight or criticism, and excessive smoking, drinking, or drug use.

ineffective Impulse Control may be related to chronic low self-esteem, anger, disorder of development, mood, personality possibly evidenced by acting without thinking, irritability, temper outbursts.

chronic low Self-Esteem may be related to life choices perpetuating failure, personal vulnerability, possibly evidenced by self-negating verbalizations, anger, rejection of positive feedback, frequent lack of success in life events.

compromised/disabled family Coping may be related to excessive guilt, anger, or blaming among family members regarding child's behavior; parental inconsistencies; disagreements regarding discipline, limit setting, and approaches; and exhaustion of parental resources (prolonged coping with disruptive child), possibly evidenced by unrealistic parental expectations, rejection or overprotection of child; and exaggerated expressions of anger, disappointment, or despair regarding child's behavior or ability to improve or change.

impaired Social Interaction may be related to retarded ego development, developmental state (adolescence), lack of social skills, low self-concept, dysfunctional family system, and neurological impairment, possibly evidenced by dysfunctional interaction with others (difficulty waiting turn in games or group situations, not seeming to listen to what is being said), difficulty playing quietly and maintaining attention to task or play activity, often shifting from one activity to another and interrupting or intruding on others.

congestive heart failure

Refer to heart failure, chronic.

Conn's syndrome

Refer to aldosteronism, primary.

constipation

Constipation may be related to weak abdominal musculature, gastrointestinal obstructive lesions, pain on defecation, diagnostic procedures, pregnancy, possibly evidenced by change in character and frequency of stools, feeling of abdominal or rectal fullness or pressure, changes in bowel sounds, abdominal distention.

impaired Comfort may be related to abdominal fullness or pressure, straining to defecate, and trauma to delicate tissues, possibly evidenced by verbal reports, reluctance to defecate, and distraction behaviors.

deficient Knowledge [Learning Need] regarding dietary needs, bowel function, and medication effect may be related to lack of information, misconceptions, possibly evidenced by development of problem and verbalization of concerns or questions.

coronary artery bypass surgery

risk for decreased Cardiac Output is possibly evidenced by risk factors of decreased myocardial contractility, diminished circulating volume (preload), alterations in electrical conduction, and increased systemic vascular resistance (SVR) (afterload).

acute Pain may be related to direct chest tissue and bone trauma, invasive tubes and lines, donor site incision, tissue inflammation and edema formation, intraoperative nerve trauma, possibly evidenced by verbal reports, changes in vital signs, and distraction behaviors (restlessness), irritability.

[disturbed Sensory Perception (specify)] may be related to restricted environment (postoperative or acute), sleep deprivation, effects of medications, continuous environmental sounds and activities, and psychological stress of procedure, possibly evidenced by disorientation, alterations in behavior, exaggerated emotional responses, and visual or auditory distortions.

ineffective Role Performance may be related to situational crises (dependent role), recuperative process, uncertainty about the future, possibly evidenced by delay or alteration in physical capacity to resume role, change in usual role or responsibility, change in self or others' perception of role.

Crohn's disease

(also refer to colitis, ulcerative)

imbalanced Nutrition: less than body requirements may be related to intestinal pain after eating, decreased transit time through bowel, fear that eating may cause diarrhea, possibly evidenced by weight loss, decreased subcutaneous fat and muscle mass, poor muscle tone, aversion to eating, and observed lack of intake.

Diarrhea may be related to inflammation, irritation—particular dietary intake, malabsorption of the bowel, presence of toxins, segmental narrowing of the lumen, possibly evidenced by hyperactive bowel sounds, increased peristalsis, cramping, and frequent loose liquid stools.

deficient Knowledge [Learning Need] regarding condition, nutritional needs, and prevention of recurrence may be related to misinterpretation of information, lack of recall, unfamiliarity with resources, possibly evidenced by statements of concern, questions, inaccurate follow-through of instructions, and development of preventable complications or exacerbation of condition.

croup

ineffective Airway Clearance may be related to presence of thick, tenacious mucus and swelling or spasms of the epiglottis, possibly evidenced by harsh, brassy cough; tachypnea, use of accessory breathing muscles, and presence of wheezes.

deficient Fluid Volume may be related to decreased ability or aversion to swallowing, presence of fever, and increased respiratory losses, possibly evidenced by dry mucous membranes, poor skin turgor, and scanty, concentrated urine.

croup, membranous

(also refer to croup)

risk for Suffocation is possibly evidenced by risk factors of inflammation of larynx with formation of false membrane.

Anxiety [specify level]/Fear may be related to change in environment, perceived threat to self (difficulty breathing), and transmission of anxiety of adults, possibly evidenced by restlessness, facial tension, glancing about, and sympathetic stimulation.

c-section

Refer to cesarean birth; cesarean birth, unplanned.

Cushing's syndrome

risk for excess Fluid Volume is possibly evidenced by risk factor of compromised regulatory mechanism (fluid and sodium retention).

risk for Infection is possibly evidenced by risk factors of immunosuppressed inflammatory response, skin and capillary fragility, and negative nitrogen balance.

imbalanced Nutrition: less than body requirements may be related to inability to utilize nutrients (disturbance of carbohydrate metabolism), possibly evidenced by decreased muscle mass and increased resistance to insulin.

Self-Care Deficit [specify] may be related to muscle wasting, generalized weakness, fatigue, and demineralization of bones, possibly evidenced by statements of or observed inability to complete or perform ADLs.

disturbed Body Image may be related to change in structure or appearance (effects of disease process, drug therapy), possibly evidenced by negative feelings about body, feelings of helplessness, and changes in social involvement.

Sexual Dysfunction may be related to loss of libido, impotence, and cessation of menses, possibly evidenced by verbalization of concerns and/or dissatisfaction with and alteration in relationship with significant other.

risk for Trauma [fractures] is possibly evidenced by risk factors of increased protein breakdown, negative protein balance, demineralization of bones.

CVA

Refer to cerebrovascular accident.

cystic fibrosis

ineffective Airway Clearance may be related to excessive production of thick mucus and decreased ciliary action, possibly evidenced by abnormal breath sounds, ineffective cough, cyanosis, and altered respiratory rate and depth.

risk for Infection is possibly evidenced by risk factors of stasis of respiratory secretions and development of atelectasis.

imbalanced Nutrition: less than body requirements may be related to impaired digestive process and absorption of nutrients, possibly evidenced by failure to gain weight, muscle wasting, and retarded physical growth.

deficient Knowledge [Learning Need] regarding pathophysiology of condition, medical management, and available community resources may be related to insufficient information, misconceptions, possibly evidenced by statements of concern and questions, inaccurate follow-through of instructions, development of preventable complications.

compromised family Coping may be related to chronic nature of disease and disability, inadequate or incorrect information or understanding by a primary person, possibly evidenced by significant person attempting assistive or supportive behaviors with less than satisfactory results, protective behavior disproportionate to client's abilities, or need for autonomy.

cystitis

acute Pain may be related to inflammation and bladder spasms, possibly evidenced by verbal reports, distraction behaviors, and narrowed focus.

impaired urinary Elimination may be related to inflammation or irritation of bladder, possibly evidenced by frequency, nocturia, and dysuria.

deficient Knowledge [Learning Need] regarding condition, treatment, and prevention of recurrence may be related to inadequate information, misconceptions, possibly evidenced by statements of concern and questions, recurrent infections.

cytomegalic inclusion disease

Refer to cytomegalovirus infection.

cytomegalovirus (CMV) infection

[risk for disturbed visual Sensory Perception] is possibly evidenced by risk factor of inflammation of the retina.

risk for fetal Infection is possibly evidenced by risk factors of transplacental exposure, contact with blood or body fluids.

deep vein thrombosis (DVT)

Refer to thrombophlebitis.

degenerative joint disease

Refer to arthritis, rheumatoid.

dehiscence (abdominal)

impaired Skin Integrity may be related to altered circulation, altered nutritional state (obesity, malnutrition), and physical stress on incision, possibly evidenced by poor or delayed wound healing and disruption of skin surface or wound closure.

risk for Infection is possibly evidenced by risk factors of inadequate primary defenses (separation of incision, traumatized intestines, environmental exposure).

impaired Tissue Integrity is possibly evidenced by risk factor of exposure of abdominal contents to external environment.

Fear/[severe] Anxiety may be related to crises, perceived threat of death, possibly evidenced by fearfulness, restless behaviors, and sympathetic stimulation.

deficient Knowledge [Learning Need] regarding condition/prognosis and treatment needs may be related to lack of information or recall, misinterpretation of information, possibly evidenced by development of preventable complication, requests for information, and statement of concern.

dehydration

deficient Fluid Volume [specify] may be related to etiology as defined by the specific situation, possibly evidenced by dry mucous membranes, poor skin turgor, decreased pulse volume and pressure, and thirst.

risk for impaired oral Mucous Membrane is possibly evidenced by risk factors of dehydration and decreased salivation.

deficient Knowledge [Learning Need] regarding fluid needs may be related to lack of information, misinterpretation, possibly evidenced by questions, statement of concern, and inadequate follow-through of instructions, development of preventable complications.

delirium tremens (acute alcohol withdrawal)

Anxiety [severe/panic]/Fear may be related to cessation of alcohol intake, physiological withdrawal, threat to self-concept, perceived threat of death, possibly evidenced by increased tension, apprehension, feelings of inadequacy, shame, self-disgust, or remorse; fear of unspecified consequences, identifies object of fear.

[disturbed Sensory Perception (specify)] may be related to exogenous factors—alcohol consumption and sudden cessation; endogenous—electrolyte imbalance, elevated ammonia and blood urea nitrogen (BUN); sleep deprivation, and psychological stress, possibly evidenced by disorientation, restlessness, irritability, exaggerated emotional responses, bizarre thinking, and visual or auditory distortions or hallucinations.

risk for decreased Cardiac Output is possibly evidenced by risk factors of direct effect of alcohol on heart muscle, altered SVR, presence of dysrhythmias.

risk for Trauma is possibly evidenced by risk factors of alterations in balance, reduced muscle coordination, cognitive impairment, and involuntary clonic/tonic muscle activity.

imbalanced Nutrition: less than body requirements may be related to poor dietary intake, effects of alcohol on organs involved in digestion, interference with absorption or metabolism of nutrients and amino acids, possibly evidenced by reports of inadequate food intake, altered taste sensation, lack of interest in food, debilitated state, decreased subcutaneous fat and muscle mass, signs or laboratory findings of mineral and electrolyte deficiency.

delivery, precipitous/out of hospital

(also refer to labor, precipitous; labor stages I–II)

risk for deficient Fluid Volume is possibly evidenced by risk factors of presence of nausea, vomiting, lack of intake, excessive vascular loss.

risk for Infection is possibly evidenced by risk factors of broken or traumatized tissue, increased environmental exposure, rupture of amniotic membranes.

risk for fetal Injury is possibly evidenced by risk factors of rapid descent and pressure changes, compromised circulation, environmental exposure.

delusional disorder

risk for self/other-directed Violence are possibly evidenced by risk factors of perceived threats of danger, increased feelings of anxiety, acting out in an irrational manner.

[severe] Anxiety may be related to inability to trust, possibly evidenced by rigid delusional system, frightened of other people and own hostility.

Powerlessness may be related to lifestyle of helplessness, feelings of inadequacy, interpersonal interaction, possibly evidenced by verbal expressions of no control or influence over situation(s), use of paranoid delusions, aggressive behavior to compensate for lack of control.

impaired Social Interaction may be related to mistrust of others, delusional thinking, lack of knowledge or skills to enhance mutuality, possibly evidenced by discomfort in social situations, difficulty in establishing relationships with others, expression of feelings of rejection, no sense of belonging.

dementia, presenile/senile

(also refer to Alzheimer's disease)

impaired Memory may be related to neurological disturbances, possibly evidenced by observed experiences of forgetting, inability to determine if a behavior was performed, inability to perform previously learned skills, inability to recall factual information or recent or past events.

Fear may be related to decreases in functional abilities, public disclosure of disabilities, further mental or physical deterioration, possibly evidenced by social isolation, apprehension, irritability, defensiveness, suspiciousness, aggressive behavior.

Self-Care Deficit [specify] may be related to cognitive decline, physical limitations, frustration over loss of independence, depression, possibly evidenced by impaired ability to perform ADLs.

risk for Trauma is possibly evidenced by risk factors of changes in muscle coordination or balance, impaired judgment, seizure activity.

risk for sedentary Lifestyle is possibly evidenced by risk factors of lack of interest or motivation, lack of resources, lack of training or knowledge of specific exercise needs, safety concerns or fear of injury.

risk for caregiver Role Strain is possibly evidenced by risk factors of illness severity of care receiver, duration of caregiving required, complexity or amount of caregiving tasks, care receiver exhibiting deviant or bizarre behavior; family/caregiver isolation, lack of respite or recreation, spouse is caregiver.

Grieving may be related to awareness of something “being wrong,” predisposition for anxiety and feelings of inadequacy, family perception of potential loss of loved one, possibly evidenced by expressions of distress, anger at potential loss, choked feelings, crying, alteration in activity level, communication patterns, eating habits, and sleep patterns.

depressant abuse

(also refer to Drug Overdose, acute [depressants])

ineffective Denial may be related to weak, underdeveloped ego, unmet self-needs, possibly evidenced by inability to admit impact of condition on life, minimizes symptoms or problem, refuses healthcare attention.

ineffective Coping may be related to weak ego, possibly evidenced by abuse of chemical agents, lack of goal-directed behavior, inadequate problem-solving, destructive behavior toward self.

imbalanced Nutrition: less than body requirements may be related to use of substance in place of nutritional food, possibly evidenced by loss of weight, pale conjunctiva and mucous membranes, electrolyte imbalances, anemias.

risk for Injury is possibly evidenced by risk factors of changes in sleep, decreased concentration, loss of inhibitions.

depression, postpartum

(also refer to depressive disorders)

risk for impaired Attachment is possibly evidenced by risk factors of anxiety associated with the parent role, inability to meet personal needs, perceived guilt regarding relationship with infant.

Fatigue may be related to stress, sleep deprivation, depression as evidenced by reports of overwhelming lack of energy, inability to maintain usual routines, increase in physical complaints.

situational low Self-Esteem may be related to developmental changes, disturbed body image, possibly evidenced by evaluation of self as unable to deal with situation, self-negating verbalizations, reports helplessness.

depressive disorders, major depression, dysthymia

risk for self-directed Violence is possibly evidenced by risk factors of depressed mood and feeling of worthlessness and hopelessness.

[moderate to severe] Anxiety may be related to stress, unconscious conflict about essential values or goals of life, unmet needs, threat to self-concept, interpersonal transmission or contagion, possibly evidenced by feelings of inadequacy, sleep disturbances, fatigue, difficulty concentrating, diminished productivity/ability to problem-solve, rumination.

Insomnia may be related to biochemical alterations (decreased serotonin), unresolved fears and anxieties, and inactivity, possibly evidenced by difficulty in falling or remaining asleep, early morning awakening or awakening later than desired, reports of not feeling rested, physical signs, e.g., dark circles under eyes, excessive yawning).

Social Isolation/impaired Social Interaction may be related to alterations in mental status or thought processes (depressed mood), inadequate personal resources, decreased energy, inertia, difficulty engaging in satisfying personal relationships, feelings of worthlessness, low self-concept, inadequacy or absence of significant purpose in life, and knowledge or skill deficit about social interactions, possibly evidenced by decreased involvement with others, expressed feelings of difference from others, remaining in home/room/bed, refusing invitations or suggestions for social involvement, and dysfunctional interaction with peers, family, and/or others.

interrupted Family Processes may be related to situational crises of illness of family member with change in roles or responsibilities, developmental crises, e.g., loss of family member or relationship), possibly evidenced by statements of difficulty coping with situation, family system not meeting needs of its members, difficulty accepting or receiving help appropriately, ineffective family decision-making process, and failure to send and to receive clear messages.

risk for impaired Religiosity is possibly evidenced by risk factors of ineffective support or coping, lack of social interaction, depression.

dermatitis seborrheic

impaired Skin Integrity may be related to chronic inflammatory condition of the skin, possibly evidenced by disruption of skin surface with dry or moist scales, yellowish crusts, erythema, and fissures.

diabetes, gestational

(also refer to diabetes mellitus)

risk for unstable Blood Glucose Level is possibly evidenced by risk factors of pregnancy, dietary intake, lack of diabetes management, inadequate blood glucose monitoring.

risk for disturbed Maternal-Fetal Dyad is possibly evidenced by risk factors of impaired glucose metabolism, compromised oxygen transport—changes in circulation; treatment-related side effects.

deficient Knowledge [Learning Need] regarding diabetic condition, prognosis, and treatment needs may be related to lack of resources or exposure to information, misinformation, possibly evidenced by questions, statements of misconceptions, inaccurate follow-through of instructions, development of preventable complications.

diabetes mellitus

deficient Knowledge [Learning Need] regarding disease process/treatment and individual care needs may be related to unfamiliarity with information, lack of recall, misinterpretation, possibly evidenced by requests for information, statements of concern, misconceptions, inadequate follow-through of instructions, or development of preventable complications.

risk for unstable Blood Glucose Level is possibly evidenced by risk factors of lack of adherence to diabetes management, medication management, inadequate blood glucose monitoring, physical activity level, health status, stress, rapid growth periods.

risk-prone Health Behavior may be related to inadequate comprehension, multiple stressors, as evidenced by minimization of health status change, failure to achieve optimal sense of control.

risk for Infection is possibly evidenced by risk factors of decreased leukocyte function, circulatory changes, and delayed healing.

[risk for disturbed Sensory Perception (specify)] is possibly evidenced by risk factors of endogenous chemical alteration (glucose, insulin, and/or electrolyte imbalance).

compromised family Coping may be related to inadequate or incorrect information or understanding by primary person(s), other situational or developmental crises or situations the significant person(s) may be facing, lifelong condition requiring behavioral changes impacting family, possibly evidenced by family expressions of confusion about what to do, verbalizations that they are having difficulty coping with situation, family does not meet physical or emotional needs of its members; SO(s) preoccupied with personal reaction, e.g., guilt, fear, display protective behavior disproportionate (too little or too much) to client's abilities or need for autonomy.

diabetic ketoacidosis

deficient Fluid Volume [specify] may be related to hyperosmolar urinary losses, gastric losses and inadequate intake, possibly evidenced by increased urinary output, dilute urine; reports of weakness, thirst, sudden weight loss, hypotension, tachycardia, delayed capillary refill, dry mucous membranes, poor skin turgor.

unstable Blood Glucose Level may be related to medication management, lack of diabetes management, inadequate blood glucose monitoring, presence of infection, possibly evidenced by elevated serum glucose level, presence of ketones in urine, nausea, weight loss, blurred vision, irritability.

Fatigue may be related to decreased metabolic energy production, altered body chemistry (insufficient insulin), increased energy demands (hypermetabolic state—infection), possibly evidenced by overwhelming lack of energy, inability to maintain usual routines, decreased performance, impaired ability to concentrate, listlessness.

risk for Infection possibly evidenced by risk factors of high glucose levels, decreased leukocyte function, stasis of body fluids, invasive procedures, alterations in circulation.

dialysis, general

(also refer to dialysis, peritoneal; hemodialysis)

imbalanced Nutrition: less than body requirements may be related to inadequate ingestion of nutrients—dietary restrictions, anorexia, nausea, vomiting, stomatitis, sensation of feeling full with continuous ambulatory peritoneal dialysis; loss of peptides and amino acids (building blocks for proteins) during dialysis, possibly evidenced by reported inadequate intake, aversion to eating, altered taste sensation, poor muscle tone, weakness, sore and inflamed buccal cavity, pale conjunctiva and mucous membranes.

Grieving may be related to actual or perceived loss, chronic and/or fatal illness, and thwarted grieving response to a loss, possibly evidenced by verbal expression of distress or unresolved issues, denial of loss, altered eating habits, sleep and dream patterns, activity levels, libido, crying, labile affect; feelings of sorrow, guilt, and anger.

disturbed Body Image/situational low Self-Esteem may be related to situational crisis and chronic illness with changes in usual roles and body image, possibly evidenced by verbalization of changes in lifestyle, focus on past function, negative feelings about body, feelings of helplessness and powerlessness, extension of body boundary to incorporate environmental objects, e.g., dialysis setup, change in social involvement, overdependence on others for care, not taking responsibility for self-care, lack of follow-through, and self-destructive behavior.

Self-Care Deficit [specify] may be related to perceptual or cognitive impairment (accumulated toxins), intolerance to activity, decreased strength and endurance, pain, discomfort, possibly evidenced by reported inability to perform ADLs, disheveled or unkempt appearance, strong body odor.

Powerlessness may be related to illness-related regimen and healthcare environment, possibly evidenced by verbal expression of having no control, depression over physical deterioration, nonparticipation in care, anger, and passivity.

compromised/disabled family Coping may be related to inadequate or incorrect information or understanding by a primary person, temporary family disorganization and role changes, client providing little support in turn for the primary person, and prolonged disease and disability progression that exhausts the supportive capacity of significant persons, possibly evidenced by expressions of concern or reports about response of SO(s)/family to client's health problem, preoccupation of SO(s) with own personal reactions, display of intolerance or rejection, and protective behavior disproportionate (too little or too much) to client's abilities or need for autonomy.

dialysis, peritoneal

(also refer to dialysis, general)

risk for excess Fluid Volume is possibly evidenced by risk factors of inadequate osmotic gradient of dialysate, fluid retention—malpositioned, kinked, or clotted catheter; bowel distention, peritonitis, scarring of peritoneum; excessive oral or IV intake.

risk for Trauma is possibly evidenced by risk factors of improper placement during insertion or manipulation of catheter.

acute Pain/impaired Comfort may be related to catheter irritation, improper catheter placement, presence of edema, abdominal distention, inflammation or infection, rapid infusion or infusion of cold or acidic dialysate, possibly evidenced by verbal reports, guarding or distraction behaviors, and self-focus.

risk for Infection [peritoneal] is possibly evidenced by risk factors of contamination of catheter or infusion system, skin contaminants, sterile peritonitis (response to composition of dialysate).

risk for ineffective Breathing Pattern is possibly evidenced by risk factors of increased abdominal pressure restricting diaphragmatic excursion, rapid infusion of dialysate, pain or discomfort, inflammatory process—atelectasis/pneumonia.

diaper rash

Refer to candidiasis.

diarrhea

deficient Knowledge [Learning Need] regarding causative/contributing factors and therapeutic needs may be related to lack of information, misconceptions, possibly evidenced by statements of concern, questions, and development of preventable complications.

risk for deficient Fluid Volume is possibly evidenced by risk factors of excessive losses through gastrointestinal tract, altered intake.

acute Pain may be related to abdominal cramping and irritation or excoriation of skin, possibly evidenced by verbal reports, facial grimacing, and changes in vital signs.

impaired Skin Integrity may be related to effects of excretions on delicate tissues, possibly evidenced by reports of discomfort and disruption of skin surface or destruction of skin layers.

digitalis toxicity

decreased Cardiac Output may be related to altered myocardial contractility or electrical conduction, properties of digitalis (long half-life and narrow therapeutic range), concurrent medications, age and general health status, and electrolyte and acid-base balance, possibly evidenced by changes in rate, rhythm, or conduction (development or worsening of dysrhythmias); changes in mentation, worsening of heart failure, elevated serum drug levels.

risk for imbalanced Fluid Volume is possibly evidenced by risk factors of excessive losses from vomiting or diarrhea, decreased intake, nausea, decreased plasma proteins, malnutrition, continued use of diuretics; excess sodium and fluid retention.

deficient Knowledge [Learning Need] regarding condition/therapy and self-care needs may be related to information misinterpretation and lack of recall, possibly evidenced by inaccurate follow-through of instructions and development of preventable complications.

dilation and curettage (D and C)

(also refer to abortion, spontaneous; abortion, elective termination)

deficient Knowledge [Learning Need] regarding surgical procedure, possible postprocedural complications, and therapeutic needs may be related to lack of exposure or unfamiliarity with information, possibly evidenced by requests for information and statements of concern, misconceptions.

dilation of cervix, premature

(also refer to labor, preterm)

Anxiety [specify level] may be related to situational crisis, threat of death or fetal loss, possibly evidenced by increased tension, apprehension, feelings of inadequacy, sympathetic stimulation, and repetitive questioning.

risk for disturbed Maternal-Fetal Dyad is possibly evidenced by risk factors of surgical intervention, use of tocolytic drugs.

risk for fetal Injury is possibly evidenced by risk factors of premature delivery, surgical procedure.

Grieving may be related to perceived potential fetal loss, possibly evidenced by expression of distress, guilt, anger, choked feelings.

dislocation/subluxation of joint

acute Pain may be related to lack of continuity of bone/joint, muscle spasms, edema, possibly evidenced by verbal or coded reports, guarded or protective behaviors, narrowed focus, changes in vital signs.

risk for Injury is possibly evidenced by risk factors of nerve impingement, improper fitting of splint device.

impaired physical Mobility may be related to immobilization device, activity restrictions, pain, edema, decreased muscle strength, possibly evidenced by limited range of motion, limited ability to perform motor skills, gait changes.

disseminated intravascular coagulation (DIC)

risk for deficient Fluid Volume is possibly evidenced by risk factors of failure of regulatory mechanism (coagulation process) and active loss—hemorrhage.

ineffective Tissue Perfusion (specify) may be related to alteration of arterial or venous flow (microemboli throughout circulatory system, and hypovolemia), possibly evidenced by changes in respiratory rate and depth, changes in mentation, decreased urinary output, and development of acral cyanosis or focal gangrene.

Anxiety [specify level]/Fear may be related to sudden change in health status/threat of death, interpersonal transmission or contagion, possibly evidenced by sympathetic stimulation, restlessness, focus on self, and apprehension.

risk for impaired Gas Exchange risk factors may include reduced oxygen-carrying capacity, development of acidosis, fibrin deposition in microcirculation, and ischemic damage of lung parenchyma.

acute Pain may be related to bleeding into joints/muscles, with hematoma formation, and ischemic tissues with areas of acral cyanosis or focal gangrene, possibly evidenced by verbal reports, narrowed focus, alteration in muscle tone, guarding or distraction behaviors, restlessness, changes in vital signs.

dissociative disorders

Anxiety [severe/panic]/Fear may be related to a maladaptation or ineffective coping continuing from early life, unconscious conflict(s), threat to self-concept, unmet needs, or phobic stimulus, possibly evidenced by maladaptive response to stress, e.g., dissociating self or fragmentation of the personality, increased tension, feelings of inadequacy, and focus on self, projection of personal perceptions onto the environment.

risk for self/other-directed Violence is possibly evidenced by risk factors of dissociative state/conflicting personalities, depressed mood, panic states, and suicidal or homicidal behaviors.

disturbed Personal Identity may be related to psychological conflicts (dissociative state), childhood trauma or abuse, threat to physical integrity or self-concept, and underdeveloped ego, possibly evidenced by alteration in perception or experience of the self, loss of one's own sense of reality or the external world, poorly differentiated ego boundaries, confusion about sense of self, confusion regarding purpose or direction in life, memory loss, presence of more than one personality within the individual.

compromised family Coping may be related to multiple stressors repeated over time, prolonged progression of disorder that exhausts the supportive capacity of significant person(s), family disorganization and role changes, high-risk family situation, possibly evidenced by family/SO(s) describing inadequate understanding or knowledge that interferes with assistive or supportive behaviors, relationship and marital conflict.

diverticulitis

acute Pain may be related to inflammation of intestinal mucosa, abdominal cramping, and presence of fever or chills, possibly evidenced by verbal reports, guarding or distraction behaviors, changes in vital signs, and narrowed focus.

Diarrhea/Constipation may be related to altered structure or function and presence of inflammation, possibly evidenced by signs and symptoms dependent on specific problem, e.g., increase or decrease in frequency of stools and change in consistency.

deficient Knowledge [Learning Need] regarding disease process, potential complications, therapeutic and self-care needs may be related to lack of information/misconceptions, possibly evidenced by statements of concern, request for information, and development of preventable complications.

risk for Powerlessness is possibly evidenced by risk factors of chronic nature of disease process and recurrent episodes despite cooperation with medical regimen.

Down syndrome

(also refer to mental retardation)

risk for disproportionate Growth and/or delayed Development possibly evidenced by risk factor of genetic disorder.

risk for Trauma is possibly evidenced by risk factors of cognitive difficulties and poor muscle tone or coordination, weakness.

imbalanced Nutrition: less than body requirements may be related to poor muscle tone and protruding tongue, possibly evidenced by weak and ineffective sucking or swallowing and observed lack of adequate intake with weight loss or failure to gain.

interrupted Family Processes may be related to situational or maturational crises requiring incorporation of new skills into family dynamics, possibly evidenced by confusion about what to do, verbalized difficulty coping with situation, unexamined family myths.

risk for complicated Grieving is possibly evidenced by risk factors of loss of “the perfect child,” chronic condition requiring long-term care, and unresolved feelings.

risk for impaired Attachment is possibly evidenced by risk factors of ill infant/child who is unable to effectively initiate parental contact due to altered behavioral organization, inability of parents to meet personal needs.

Social Isolation is possibly evidenced by risk factors of withdrawal from usual social interactions and activities, assumption of total child care, and becoming overindulgent or overprotective.

drug overdose, acute (depressants)

(also refer to substance dependence/abuse rehabilitation)

ineffective Breathing Pattern/impaired Gas Exchange may be related to neuromuscular impairment or CNS depression, decreased lung expansion, possibly evidenced by changes in respirations, cyanosis, and abnormal ABGs.

risk for Trauma/Suffocation/Poisoning are possibly evidenced by risk factors of CNS depression or agitation, hypersensitivity to the drug(s), psychological stress.

risk for self/other-directed Violence are possibly evidenced by risk factors of suicidal behaviors, toxic reactions to drug(s).

risk for Infection is possibly evidenced by risk factors of drug injection techniques, impurities in injected drugs, localized trauma; malnutrition, altered immune state.

drug withdrawal

[disturbed Sensory Perception (specify)] may be related to biochemical imbalance, altered sensory integration possibly evidenced by sensory distortions, poor concentration, irritability, hallucinations.

risk for Injury is possibly evidenced by risk factors of CNS agitation (depressants).

risk for Suicide is possibly evidenced by risk factors of alcohol or other substance abuse, legal or disciplinary problems, depressed mood (stimulants).

acute Pain/impaired Comfort may be related to biochemical changes associated with cessation of drug use, possibly evidenced by reports of muscle aches, fever, diaphoresis, rhinorrhea, lacrimation, malaise.

Self-Care Deficit (specify) may be related to perceptual or cognitive impairment, therapeutic management (restraints), possibly evidenced by inability to meet own physical needs.

Insomnia may be related to cessation of substance use, fatigue possibly evidenced by reports of insomnia/hypersomnia, decreased ability to function, increased irritability.

Fatigue may be related to altered body chemistry (drug withdrawal), sleep deprivation, malnutrition, poor physical condition possibly evidenced by verbal reports of overwhelming lack of energy, inability to maintain usual level of physical activity, inability to restore energy after sleep, compromised concentration.

Duchenne's muscular dystrophy

Refer to muscular dystrophy (Duchenne's).

DVT

Refer to thrombophlebitis.

dysmenorrhea

acute Pain may be related to exaggerated uterine contractibility, possibly evidenced by verbal reports, guarding or distraction behaviors, narrowed focus, and changes in vital signs.

ineffective Coping may be related to chronic, recurrent nature of problem, anticipatory anxiety, and inadequate coping methods, possibly evidenced by muscular tension, headaches, general irritability, chronic depression, and verbalization of inability to cope, report of poor self-concept.

dysrhythmia, cardiac

risk for decreased Cardiac Output is possibly evidenced by risk factors of altered electrical conduction and reduced myocardial contractility.

deficient Knowledge [Learning Need] regarding medical condition/therapy needs may be related to lack of information or recall, misinterpretation, and unfamiliarity with information resources, possibly evidenced by questions, statement of misconception, failure to improve on previous regimen, and development of preventable complications.

risk for Poisoning, [digitalis toxicity] is possibly evidenced by risk factors of limited range of therapeutic effectiveness, lack of education or proper precautions, reduced vision, cognitive limitations.

eating disorders

Refer to anorexia nervosa; bulimia nervosa; obesity.

eclampsia

(also refer to pregnancy-induced hypertension)

Anxiety [specify level]/Fear may be related to situational crisis, threat of change in health status or death (self/fetus), separation from support system, interpersonal contagion possibly evidenced by expressed concerns, apprehension, increased tension, decreased self-assurance, difficulty concentrating.

risk for maternal Injury is possibly evidenced by risk factors of tissue edema, hypoxia, tonic/clonic convulsions, abnormal blood profile and/or clotting factors.

impaired physical Mobility may be related to prescribed bedrest, discomfort, anxiety possibly evidenced by difficulty turning, postural instability.

risk for Self-Care Deficit (specify) is possibly evidenced by risk factors of weakness, discomfort, physical restrictions.

ectopic pregnancy (tubal)

(also refer to abortion, spontaneous termination)

acute Pain may be related to distention or rupture of fallopian tube, possibly evidenced by verbal reports, guarding or distraction behaviors, facial mask of pain, diaphoresis, changes in vital signs.

risk for Bleeding/deficient Fluid Volume are possibly evidenced by risk factors of pregnancy-related complications, hemorrhagic losses and decreased or restricted intake.

Anxiety [specify level]/Fear may be related to threat of death and possible loss of ability to conceive, possibly evidenced by increased tension, apprehension, sympathetic stimulation, restlessness, and focus on self.

eczema (dermatitis)

acute Pain/impaired Comfort may be related to cutaneous inflammation and irritation, possibly evidenced by verbal reports, irritability, and scratching.

risk for Infection is possibly evidenced by risk factors of broken skin and tissue trauma.

Social Isolation may be related to alterations in physical appearance, possibly evidenced by expressed feelings of rejection and decreased interaction with peers.

edema, pulmonary

excess Fluid Volume may be related to decreased cardiac functioning, excessive fluid/sodium intake, possibly evidenced by dyspnea, presence of crackles (rales), pulmonary congestion on x-ray, restlessness, anxiety, and increased CVP and pulmonary pressures.

impaired Gas Exchange may be related to altered blood flow and decreased alveolar/capillary exchange (fluid collection or shifts into interstitial space or alveoli), possibly evidenced by hypoxia, restlessness, and confusion.

Anxiety [specify level]/Fear may be related to perceived threat of death (inability to breathe), possibly evidenced by responses ranging from apprehension to panic state, restlessness, and focus on self.

electroconvulsive therapy

Decisional Conflict may be related to lack of relevant or multiple and divergent sources of information, mistrust of regimen or healthcare personnel, sense of powerlessness, support system deficit.

acute Confusion may be related to CNS effects of electric shock, medications, and anesthesia, possibly evidenced by fluctuation in cognition, agitation.

impaired Memory may be related to neurological disturbance, possibly evidenced by reported or observed experiences of forgetting, difficulty recalling recent events or factual information.

emphysema

impaired Gas Exchange may be related to alveolar-capillary membrane changes and destruction, possibly evidenced by dyspnea, restlessness, changes in mentation, abnormal ABG values.

ineffective Airway Clearance may be related to increased production or retained tenacious secretions, decreased energy level, and muscle wasting, possibly evidenced by abnormal breath sounds (rhonchi), ineffective cough, changes in rate and depth of respirations, and dyspnea.

Activity Intolerance may be related to imbalance between oxygen supply and demand, possibly evidenced by reports of fatigue/weakness, exertional dyspnea, and abnormal vital sign response to activity.

imbalanced Nutrition: less than body requirements may be related to inability to ingest food (shortness of breath, anorexia, generalized weakness, medication side effects), possibly evidenced by lack of interest in food, reported altered taste, loss of muscle mass and tone, fatigue, and weight loss.

risk for Infection is possibly evidenced by risk factors of inadequate primary defenses (stasis of body fluids, decreased ciliary action), chronic disease process, and malnutrition.

Powerlessness may be related to illness-related regimen and healthcare environment, possibly evidenced by verbal expression of having no control, depression over physical deterioration, nonparticipation in therapeutic regimen, anger, and passivity.

encephalitis

risk for ineffective cerebral Tissue Perfusion is possibly evidenced by risk factors of cerebral edema altering or interrupting cerebral arterial or venous blood flow, hypovolemia, exchange problems at cellular level (acidosis).

Hyperthermia may be related to increased metabolic rate, illness, and dehydration, possibly evidenced by increased body temperature; flushed, warm skin; and increased pulse and respiratory rates.

acute Pain may be related to inflammation or irritation of the brain and cerebral edema, possibly evidenced by verbal reports of headache, photophobia, distraction behaviors, restlessness, and changes in vital signs.

risk for Trauma/Suffocation risk factors may include clonic/tonic activity, altered sensorium, cognitive impairment, generalized weakness.

endocarditis

risk for decreased Cardiac Output is possibly evidenced by risk factors of inflammation of lining of heart and structural change in valve leaflets.

Anxiety [specify level] may be related to change in health status and threat of death, possibly evidenced by apprehension, expressed concerns, and focus on self.

acute Pain may be related to generalized inflammatory process and effects of embolic phenomena, possibly evidenced by verbal reports, narrowed focus, distraction behaviors, and changes in vital signs.

risk for Activity Intolerance risk factors may include imbalance between oxygen supply and demand, debilitating condition.

risk for ineffective Tissue Perfusion (specify) is possibly evidenced by risk factors of embolic interruption of arterial flow (embolization of thrombi or valvular vegetations).

endometriosis

acute/chronic Pain may be related to pressure of concealed bleeding, formation of adhesions, possibly evidenced by verbal reports (pain between or with menstruation), guarding or distraction behaviors, and narrowed focus.

Sexual Dysfunction may be related to pain secondary to presence of adhesions, possibly evidenced by verbalization of problem, and altered relationship with partner.

deficient Knowledge [Learning Need] regarding pathophysiology of condition and therapy needs may be related to lack of information/misinterpretations, possibly evidenced by statements of concern and misconceptions.

enteral feeding

imbalanced Nutrition: less than body requirements may be related to conditions that interfere with nutrient intake or increase nutrient need or metabolic demand—cancer and associated treatments, anorexia, surgical procedures, dysphagia, or decreased level of consciousness, possibly evidenced by body weight 10% or more under ideal, decreased subcutaneous fat or muscle mass, poor muscle tone, changes in gastric motility and stool characteristics.

risk for Infection is possibly evidenced by risk factors of invasive procedure with surgical placement of feeding tube, malnutrition, chronic disease, improper preparation, handling, or contamination of the feeding solution.

risk for Aspiration is possibly evidenced by risk factors of presence of feeding tube, bolus tube feedings, increased intragastric pressure, delayed gastric emptying, medication administration.

risk for imbalanced Fluid Volume is possibly evidenced by risk factors of active loss or failure of regulatory mechanisms specific to underlying disease process or trauma, inability to obtain or ingest fluids.

Fatigue may be related to decreased metabolic energy production; increased energy requirements—hypermetabolic state, healing process; altered body chemistry—medications, chemotherapy; and is possibly evidenced by overwhelming lack of energy, inability to maintain usual routines/accomplish routine tasks, lethargy, impaired ability to concentrate.

enteritis

Refer to colitis, ulcerative; Crohn's disease.

epididymitis

acute Pain may be related to inflammation, edema formation, and tension on the spermatic cord, possibly evidenced by verbal reports, guarding or distraction behaviors (restlessness), and changes in vital signs.

risk for Infection, [spread] is possibly evidenced by risk factors of presence of inflammation, infectious process, insufficient knowledge to avoid spread of infection.

deficient Knowledge [Learning Need] regarding pathophysiology, outcome, and self-care needs may be related to lack of information, misinterpretations, possibly evidenced by statements of concern, misconceptions, and questions.

epilepsy

Refer to seizure disorder.

erectile dysfunction

Sexual Dysfunction may be related to altered body function possibly evidenced by reports of disruption of sexual response pattern, inability to achieve desired satisfaction.

situational low Self-Esteem may be related to functional impairment; rejection of other(s) possibly evidenced by self-negating verbalizations.

failure to thrive, infant/child

imbalanced Nutrition: less than body requirements, may be related to inability to ingest, digest, or absorb nutrients (defects in organ function or metabolism, genetic factors), physical deprivation, psychosocial factors, possibly evidenced by lack of appropriate weight gain or weight loss, poor muscle tone, pale conjunctiva, and laboratory tests reflecting nutritional deficiency.

risk for disproportionate Growth and/or delayed Development is possibly evidenced by risk factors of maladaptive feeding behavior, economically disadvantaged, caregiver mental health issue, or presence of abuse (physical, psychological, sexual).

risk for impaired Parenting is possibly evidenced by risk factors of lack of knowledge, inadequate bonding, unrealistic expectations for self or infant, and lack of appropriate response of child to relationship.

deficient Knowledge [Learning Need] regarding pathophysiology of condition, nutritional needs, growth/development expectations, and parenting skills may be related to lack of information, misinformation or misinterpretation, possibly evidenced by verbalization of concerns, questions, and misconceptions, or development of preventable complications.

fatigue syndrome, chronic

Fatigue may be related to disease state, inadequate sleep, possibly evidenced by verbalization of unremitting and overwhelming lack of energy, inability to maintain usual routines, listlessness, compromised concentration.

chronic Pain may be related to chronic physical disability, possibly evidenced by verbal reports of headache, sore throat, arthralgias, abdominal pain, muscle aches, altered ability to continue previous activities, changes in sleep pattern.

Self-Care Deficit [specify] may be related to tiredness, pain/discomfort, possibly evidenced by reports of inability to perform desired ADLs.

risk for ineffective Role Performance is possibly evidenced by risk factors of health alterations, stress.

femoral popliteal bypass

(also refer to surgery, general)

risk for ineffective peripheral Tissue Perfusion is possibly evidenced by risk factors of interruption of arterial blood flow, hypovolemia.

risk for peripheral neurovascular Dysfunction is possibly evidenced by risk factors of vascular obstruction, immobilization, mechanical compression, dressings.

impaired Walking may be related to surgical incisions, dressings, possibly evidenced by inability to walk desired distance, climb stairs, negotiate inclines.

fetal alcohol syndrome

risk for Injury [CNS damage] is possibly evidenced by risk factors of external chemical factors (alcohol intake by mother), placental insufficiency, fetal drug withdrawal in utero or postpartum, and prematurity.

disorganized infant Behavior may be related to prematurity, environmental overstimulation, lack of containment or boundaries, possibly evidenced by change from baseline physiological measures, tremors, startles, twitches, hyperextension of arms and legs, deficient self-regulatory behaviors, deficient response to visual or auditory stimuli.

risk for impaired Parenting is possibly evidenced by risk factors of mental and/or physical illness, inability of mother to assume the overwhelming task of unselfish giving and nurturing, presence of stressors (financial or legal problems), lack of available or ineffective role model, interruption of bonding process, lack of appropriate response of child to relationship.

ineffective [maternal] Coping may be related to personal vulnerability, low self-esteem, inadequate coping skills, and multiple stressors (repeated over period of time), possibly evidenced by inability to meet basic needs, fulfill role expectations, or problem-solve, and excessive use of drug(s).

dysfunctional Family Processes may be related to lack of or insufficient support from others, mother's drug problem and treatment status, together with poor coping skills, lack of family stability, overinvolvement of parents with children and multigenerational addictive behaviors, possibly evidenced by abandonment, rejection, neglectful relationships with family members, and decisions and actions by family that are detrimental.

fetal demise

Grieving may be related to death of fetus/infant (wanted or unwanted), possibly evidenced by verbal expressions of distress, anger, loss, crying, alteration in eating habits or sleep pattern.

situational low Self-Esteem may be related to perceived “failure” at a life event, possibly evidenced by negative self-appraisal in response to life event in a person with a previous positive self-evaluation, verbalization of negative feelings about the self (helplessness, uselessness), difficulty making decisions.

risk for Spiritual Distress is possibly evidenced by risk factors of loss of loved one, low self-esteem, poor relationships, challenged belief and value system (birth is supposed to be the beginning of life, not of death), and intense suffering.

fibromyalgia syndrome, primary

acute/chronic Pain may be related to idiopathic diffuse condition possibly evidenced by reports of achy pain in fibrous tissues (muscles, tendons, ligaments), muscle stiffness or spasm, disturbed sleep, guarding behaviors, fear of re-injury or exacerbation, restlessness, irritability, self-focusing, reduced interaction with others.

Fatigue may be related to disease state, stress, anxiety, depression, sleep deprivation, possibly evidenced by verbalization of overwhelming lack of energy, inability to maintain usual routines or desired level of physical activity, feeling tired, having feelings of guilt for not keeping up with responsibilities, having an increase in physical complaints, being listless.

risk for Hopelessness is possibly evidenced by risk factors of chronic debilitating physical condition, prolonged activity restriction (possibly self-induced) creating isolation, lack of specific therapeutic cure, prolonged stress.

fractures

(also refer to casts; traction)

risk for Trauma [additional injury] is possibly evidenced by risk factors of loss of skeletal integrity, movement of skeletal fragments, use of traction apparatus, etc.

acute Pain may be related to muscle spasms, movement of bone fragments, soft tissue trauma, edema, traction or immobility device, stress, and anxiety, possibly evidenced by verbal reports, distraction behaviors, self-focusing or narrowed focus, facial mask of pain, guarding or protective behavior, alteration in muscle tone, and changes in vital signs.

risk for peripheral neurovascular Dysfunction is possibly evidenced by risk factors of reduction or interruption of blood flow (direct vascular injury, tissue trauma, excessive edema, thrombus formation, hypovolemia).

impaired physical Mobility may be related to musculoskeletal impairment, pain, discomfort, restrictive therapies (extremity immobilization, bedrest), and psychological immobility, possibly evidenced by inability to purposefully move within the physical environment, imposed restrictions, reluctance to attempt movement, limited range of motion, and decreased muscle strength or control.

risk for impaired Gas Exchange is possibly evidenced by risk factors of altered blood flow, blood or fat emboli, alveolar-capillary membrane changes (interstitial pulmonary edema, congestion).

deficient Knowledge [Learning Need] regarding healing process, therapy requirements, potential complications, and self-care needs may be related to lack of exposure or recall, misinterpretation of information, possibly evidenced by statements of concern, questions, and misconceptions.

frostbite

impaired Tissue Integrity may be related to altered circulation and thermal injury, possibly evidenced by damaged or destroyed tissue.

acute Pain may be related to diminished circulation with tissue ischemia or necrosis, and edema formation, possibly evidenced by verbal reports, guarding or distraction behaviors, narrowed focus, and changes in vital signs.

risk for Infection is possibly evidenced by risk factors of traumatized tissue or tissue destruction, altered circulation, and compromised immune response in affected area.

gallstones

Refer to cholelithiasis.

gangrene, dry

ineffective peripheral Tissue Perfusion may be related to interruption in arterial flow, possibly evidenced by cool skin temperature, change in color (black), atrophy of affected part, and presence of pain.

acute Pain may be related to tissue hypoxia and necrotic process, possibly evidenced by verbal reports, guarding or distraction behaviors, narrowed focus, and changes in vital signs.

gas, lung irritant

ineffective Airway Clearance may be related to irritation and inflammation of airway, possibly evidenced by marked cough, abnormal breath sounds (wheezes), dyspnea, and tachypnea.

risk for impaired Gas Exchange is possibly evidenced by risk factors of irritation and inflammation of alveolar membrane (dependent on type of agent and length of exposure).

Anxiety [specify level] may be related to change in health status and threat of death, possibly evidenced by verbalizations, increased tension, apprehension, and sympathetic stimulation.

gastritis, acute

acute Pain may be related to irritation or inflammation of gastric mucosa, possibly evidenced by verbal reports, guarding or distraction behaviors, and changes in vital signs.

risk for deficient Fluid Volume/Bleeding are possibly evidenced by risk factors of excessive losses through vomiting and diarrhea, reluctance to ingest or restrictions of oral intake, gastrointestinal disorder, continued bleeding.

gastritis, chronic

risk for imbalanced Nutrition: less than body requirements is possibly evidenced by risk factors of inability to ingest adequate nutrients (prolonged nausea, vomiting, anorexia, epigastric pain).

deficient Knowledge [Learning Need] regarding pathophysiology, psychological factors, therapy needs, and potential complications may be related to lack of information or recall, unfamiliarity with information resources, information misinterpretation, possibly evidenced by verbalization of concerns, questions, and continuation of problem or development of preventable complications.

gastroenteritis

Diarrhea may be related to toxins, contaminants, travel, infectious process, parasites possibly evidenced by at least three loose, liquid stools/day, hyperactive bowel sounds, abdominal pain.

risk for deficient Fluid Volume is possibly evidenced by risk factors of excessive losses (diarrhea, vomiting), hypermetabolic state (infection), decreased intake (nausea, anorexia), extremes of age or weight.

risk for Infection [transmission] is possibly evidenced by risk factors of insufficient knowledge to prevent contamination (inappropriate hand hygiene and food handling).

gastroesophageal reflux disease (GERD)

acute/chronic Pain may be related to acidic irritation of mucosa, muscle spasm, recurrent vomiting, possibly evidenced by reports of heartburn, distraction behaviors.

impaired Swallowing may be related to GERD, esophageal defects, achalasia possibly evidenced by reports of heartburn or epigastric pain, “something stuck” when swallowing, food refusal or volume limiting, nighttime coughing or awakening.

risk for imbalanced Nutrition: less than body requirements is possibly evidenced by risk factors of limiting intake, recurrent vomiting.

risk for Insomnia is possibly evidenced by risk factors of nighttime heartburn, regurgitation of stomach contents.

risk for Aspiration is possibly evidenced by risk factors of incompetent lower esophageal sphincter, regurgitation of gastric acid.

gender identity disorder (For individuals experiencing persistent and marked distress regarding uncertainty about issues relating to personal identity, e.g., sexual orientation and behavior.)

Anxiety [specify level] may be related to unconscious or conscious conflicts about essential values and beliefs (ego-dystonic gender identification), threat to self-concept, unmet needs, possibly evidenced by increased tension, helplessness, hopelessness, feelings of inadequacy, uncertainty, insomnia and focus on self, and impaired daily functioning.

ineffective Role Performance/disturbed Personal Identity may be related to crisis in development in which person has difficulty knowing or accepting to which sex he or she belongs or is attracted, or has a sense of discomfort and inappropriateness about anatomical sex characteristics, possibly evidenced by confusion about sense of self, purpose or direction in life, sexual identification or preference, verbalization of desire to be or insistence that person is the opposite sex, change in self-perception of role, and conflict in roles.

ineffective Sexuality Pattern may be related to ineffective or absent role models and conflict with sexual orientation and/or preferences, lack of or impaired relationship with an SO, possibly evidenced by verbalizations of discomfort with sexual orientation or role, and lack of information about human sexuality.

compromised/disabled family Coping may be related to inadequate or incorrect information or understanding, SO unable to perceive or to act effectively in regard to client's needs, temporary family disorganization and role changes, and client providing little support in turn for primary person.

readiness for enhanced family Coping is possibly evidenced by expression of the desire to acknowledge growth impact of crisis/situation, to enhance connection with others who have experienced a similar situation.

genetic disorder

Anxiety may be related to presence of specific risk factors, e.g., exposure to teratogens, situational crisis, threat to self-concept, conscious or unconscious conflict about essential values and life goals, possibly evidenced by increased tension, apprehension, uncertainty, feelings of inadequacy, expressed concerns.

deficient Knowledge [Learning Need] regarding purpose/process of genetic counseling may be related to lack of awareness of ramifications of diagnosis, process necessary for analyzing available options, and information misinterpretation, possibly evidenced by verbalization of concerns, statement of misconceptions, request for information.

risk for interrupted Family Processes is possibly evidenced by risk factors of situational crisis, individual/family vulnerability, difficulty reaching agreement regarding options.

Spiritual Distress may be related to intense inner conflict about the outcome, normal grieving for the loss of the “perfect” child, anger that is often directed at God or greater power, religious beliefs and moral convictions, possibly evidenced by verbalization of inner conflict about beliefs, questioning of the moral and ethical implications of therapeutic choices, viewing situation as punishment, anger, hostility, and crying.

risk for complicated Grieving is possibly evidenced by risk factors of preloss psychological symptoms, predisposition for anxiety and feelings of inadequacy, frequency of major life events.

gigantism

Refer to acromegaly.

glaucoma

[disturbed visual Sensory Perception] may be related to altered sensory reception— increased intraocular pressure, atrophy of optic nerve head, possibly evidenced by progressive loss of visual field.

Anxiety [specify level] may be related to change in health status, presence of pain, possibility or reality of loss of vision, unmet needs, and negative self-talk, possibly evidenced by apprehension, uncertainty, and expressed concern regarding changes in life event.

glomerulonephritis

excess Fluid Volume may be related to failure of regulatory mechanism (inflammation of glomerular membrane inhibiting filtration), possibly evidenced by weight gain, edema or anasarca, intake greater than output, and BP changes.

acute Pain may be related to effects of circulating toxins and edema or distention of renal capsule, possibly evidenced by verbal reports, guarding or distraction behaviors, and changes in vital signs.

imbalanced Nutrition: less than body requirements may be related to anorexia and dietary restrictions, possibly evidenced by aversion to eating, reported altered taste, weight loss, and decreased intake.

deficient Diversional Activity may be related to treatment modality or restrictions, fatigue, and malaise, possibly evidenced by statements of boredom, restlessness, and irritability.

risk for disproportionate Growth is possibly evidenced by risk factors of infection, malnutrition, chronic illness.

goiter

disturbed Body Image may be related to visible swelling in neck, possibly evidenced by verbalization of feelings, fear of reaction of others, actual change in structure, change in social involvement.

Anxiety may be related to change in health status and progressive growth of mass perceived threat of death.

risk for imbalanced Nutrition: less than body requirements is possibly evidenced by risk factors of decreased ability to ingest or difficulty swallowing.

risk for ineffective Airway Clearance is possibly evidenced by risk factors of tracheal compression or obstruction.

gonorrhea

(also refer to sexually transmitted infection [STI])

risk for Infection [dissemination/bacteremia] is possibly evidenced by risk factors of presence of infectious process in highly vascular area and lack of recognition of disease process.

acute Pain may be related to irritation or inflammation of mucosa and effects of circulating toxins, possibly evidenced by verbal reports of genital or pharyngeal irritation, perineal or pelvic pain, guarding or distraction behaviors.

deficient Knowledge [Learning Need] regarding disease cause/transmission, therapy, and self-care needs may be related to lack of information, misinterpretation, denial of exposure, possibly evidenced by statements of concern, questions, misconceptions, and inaccurate follow-through of instructions, development of preventable complications.

gout

acute Pain may be related to inflammation of joint(s), possibly evidenced by verbal reports, guarding or distraction behaviors, and changes in vital signs.

impaired physical Mobility may be related to joint pain and inflammation, possibly evidenced by reluctance to attempt movement, limited range of motion, and therapeutic restriction of movement.

deficient Knowledge [Learning Need] regarding cause, treatment, and prevention of condition may be related to lack of information or misinterpretation, possibly evidenced by statements of concern, questions, misconceptions, and inaccurate follow-through of instructions.

Guillain-Barré syndrome (acute polyneuritis)

risk for ineffective Breathing Pattern/Airway Clearance are possibly evidenced by risk factors of weakness or paralysis of respiratory muscles, impaired gag or swallow reflexes, decreased energy, fatigue.

[disturbed Sensory Perception: (specify)] may be related to altered sensory reception, transmission, or integration (altered status of sense organs, sleep deprivation), therapeutically restricted environment, endogenous chemical alterations (electrolyte imbalance, hypoxia), and psychological stress, possibly evidenced by reported or observed change in usual response to stimuli, altered communication patterns, and measured change in sensory acuity and motor coordination.

impaired physical Mobility may be related to neuromuscular impairment, pain or discomfort, possibly evidenced by impaired coordination, partial or complete paralysis, decreased muscle strength and control.

Anxiety [specify level]/Fear may be related to situational crisis, change in health status, or threat of death, possibly evidenced by increased tension, restlessness, helplessness, apprehension, uncertainty, fearfulness, focus on self, and sympathetic stimulation.

risk for Disuse Syndrome risk factors include paralysis and pain.

hallucinogen abuse

(also refer to Substance dependence/abuse rehabilitation)

Anxiety [specify level]/Fear may be related to situational crisis, threat to or change in health status, perceived threat of death, inexperience or unfamiliarity with effects of drug, possibly evidenced by assumptions of “losing my mind or control,” apprehension, preoccupation with feelings of impending doom, sympathetic stimulation.

Self-Neglect may be related to substance use, executive processing ability, possibly evidenced by inadequate personal/environmental hygiene, nonadherence to health activities.

Self-Care Deficit (specify) may be related to perceptual or cognitive impairment, therapeutic management (restraints), possibly evidenced by inability to meet own physical needs.

hay fever

impaired Comfort may be related to irritation or inflammation of upper airway mucous membranes and conjunctiva, possibly evidenced by verbal reports, irritability, and restlessness.

deficient Knowledge [Learning Need] regarding underlying cause, appropriate therapy, and required lifestyle changes may be related to lack of information, possibly evidenced by statements of concern, questions, and misconceptions.

heart failure, chronic

decreased Cardiac Output may be related to altered myocardial contractility, inotropic changes; alterations in rate, rhythm, and electrical conduction; and structural changes (valvular defects, ventricular aneurysm), possibly evidenced by tachycardia, dysrhythmias, changes in BP, extra heart sounds, decreased urine output, diminished peripheral pulses, cool, ashen skin; orthopnea, crackles; dependent or generalized edema and chest pain.

excess Fluid Volume may be related to reduced glomerular filtration rate/increased ADH production, and sodium/water retention, possibly evidenced by orthopnea and abnormal breath sounds, S₃ heart sound, jugular vein distention, positive hepatojugular reflex, weight gain, hypertension, oliguria, generalized edema.

risk for impaired Gas Exchange is possibly evidenced by risk factors of alveolar-capillary membrane changes (fluid collection or shifts into interstitial space or alveoli).

Activity Intolerance may be related to imbalance between oxygen supply/demand, generalized weakness, and prolonged bedrest/sedentary lifestyle, possibly evidenced by reported/observed weakness, fatigue; changes in vital signs, presence of dysrhythmias; dyspnea, pallor, and diaphoresis.

risk for impaired Skin Integrity is possibly evidenced by risk factors of prolonged chair or bedrest, edema, vascular pooling, decreased tissue perfusion.

deficient Knowledge [Learning Need] regarding cardiac function/disease process, therapy and self-care needs may be related to lack of information or misinterpretation, possibly evidenced by questions, statements of concern, misconceptions, development of preventable complications or exacerbations of condition.

heatstroke

Hyperthermia may be related to prolonged exposure to hot environment, vigorous activity with failure of regulating mechanism of the body, possibly evidenced by high body temperature; flushed, hot skin; tachycardia; and seizure activity.

decreased Cardiac Output may be related to functional stress of hypermetabolic state, altered circulating volume and venous return, and direct myocardial damage secondary to hyperthermia, possibly evidenced by decreased peripheral pulses, dysrhythmias, tachycardia, and changes in mentation.

hemodialysis

(also refer to dialysis, general)

risk for Injury, [loss of vascular access] is possibly evidenced by risk factors of clotting or thrombosis, infection, disconnection, and hemorrhage.

risk for deficient Fluid Volume/Bleeding are possibly evidenced by risk factors of excessive fluid losses or shifts via ultrafiltration, fluid restrictions, altered coagulation, disconnection of shunt.

risk for excess Fluid volume is possibly evidenced by risk factors of rapid or excessive fluid intake—IV, blood, plasma expanders, saline given to support BP during procedure.

ineffective Protection may be related to chronic disease state, drug therapy, abnormal blood profile, inadequate nutrition, possibly evidenced by altered clotting, impaired healing, deficient immunity, fatigue, anorexia.

hemophilia

risk for deficient Fluid Volume [isotonic]/Bleeding are possibly evidenced by risk factors of impaired coagulation/hemorrhagic losses.

acute/chronic Pain risk factors may include nerve compression from hematomas, nerve damage, or hemorrhage into joint space.

risk for impaired physical Mobility is possibly evidenced by risk factors of joint hemorrhage, swelling, degenerative changes, and muscle atrophy.

ineffective Protection may be related to abnormal blood profile, possibly evidenced by altered clotting.

compromised family Coping may be related to prolonged nature of condition that exhausts the supportive capacity of significant person(s), possibly evidenced by protective behaviors disproportionate to client's abilities or need for autonomy.

hemorrhoidectomy

acute Pain may be related to edema or swelling, and tissue trauma, possibly evidenced by verbal reports, guarding or distraction behaviors, focus on self, and changes in vital signs.

risk for Urinary Retention is possibly evidenced by risk factors of perineal trauma, edema or swelling, and pain.

deficient Knowledge [Learning Need] regarding therapeutic treatment and potential complications may be related to lack of information or misconceptions, possibly evidenced by statements of concern and questions.

hemorrhoids

acute Pain may be related to inflammation and edema of prolapsed varices, possibly evidenced by verbal reports, and guarding or distraction behaviors.

Constipation may be related to pain on defecation and reluctance to defecate, possibly evidenced by frequency less than usual pattern, and hard, formed stools.

hemothorax

(also refer to pneumothorax)

risk for Trauma/Suffocation are possibly evidenced by risk factors of concurrent disease or injury process, dependence on external device (chest drainage system), and lack of safety education or precautions.

Anxiety [specify level] may be related to change in health status and threat of death, possibly evidenced by increased tension, restlessness, expressed concern, sympathetic stimulation, and focus on self.

hepatitis, acute viral

impaired Liver Function related to viral infection as evidenced by jaundice, hepatic enlargement, abdominal pain, marked elevations in serum liver function tests.

Fatigue may be related to decreased metabolic energy production, discomfort, altered body chemistry—changes in liver function, effect on target organs, possibly evidenced by reports of lack of energy, inability to maintain usual routines, decreased performance, and increased physical complaints.

imbalanced Nutrition: less than body requirements may be related to inability to ingest adequate nutrients—nausea, vomiting, anorexia, hypermetabolic state, altered absorption and metabolism, possibly evidenced by aversion to eating or lack of interest in food, altered taste sensation, observed lack of intake, and weight loss.

acute Pain/impaired Comfort may be related to inflammation and swelling of the liver, arthralgias, urticarial eruptions, and pruritus, possibly evidenced by verbal reports, guarding or distraction behaviors, focus on self, and changes in vital signs.

risk for Infection is possibly evidenced by risk factors of inadequate secondary defenses and immunosuppression, malnutrition, insufficient knowledge to avoid exposure to pathogens.

risk for impaired Tissue Integrity is possibly evidenced by risk factors of bile salt accumulation in the tissues.

risk for impaired Home Management is possibly evidenced by risk factors of debilitating effects of disease process and inadequate support systems (family, financial, role model).

deficient Knowledge [Learning Need] regarding disease process/transmission, treatment needs, and future expectations may be related to lack of information or recall, misinterpretation, unfamiliarity with resources, possibly evidenced by questions, statement of concerns, misconceptions, inaccurate follow-through of instructions, or development of preventable complications.

hernia, hiatal

chronic Pain may be related to regurgitation of acidic gastric contents, possibly evidenced by verbal reports, facial grimacing, and focus on self.

deficient Knowledge [Learning Need] regarding pathophysiology, prevention of complications and self-care needs may be related to lack of information, misconceptions, possibly evidenced by statements of concern, questions, and recurrence of condition.

herniated nucleus pulposus (ruptured intervertebral disk)

acute/chronic Pain may be related to nerve compression or irritation and muscle spasms, possibly evidenced by verbal reports, guarding or distraction behaviors, preoccupation with pain, self-focus or narrowed focus, changes in vital signs when pain is acute, altered muscle tone or function, changes in eating or sleeping patterns and libido, physical or social withdrawal.

impaired physical Mobility may be related to pain (muscle spasms), discomfort, therapeutic restrictions—bedrest, traction, or braces; muscular impairment, and depressive mood state, possibly evidenced by reports of pain on movement, reluctance to attempt or difficulty with purposeful movement, decreased muscle strength, impaired coordination, and limited range of motion.

deficient Diversional Activity may be related to length of recuperation period and therapy restrictions, physical limitations, pain, and depression, possibly evidenced by statements of boredom, disinterest, “nothing to do,” restlessness, irritability, withdrawal.

heroin withdrawal

acute Pain/Impaired Comfort may be related to cessation of drug, muscle tremors/twitching, possibly evidenced by reports of muscle aches, hot or cold flashes, diaphoresis, lacrimation, rhinorrhea, drug cravings.

[severe] Anxiety may be related to CNS hyperactivity possibly evidenced by apprehension, pervasive anxious feelings, jittery, restlessness, weakness, insomnia, anorexia.

risk for ineffective Health Management possibly evidenced by risk factors of protracted withdrawal, economic difficulties, family or social support deficits, perceived barriers or benefits.

herpes, herpes simplex

acute Pain may be related to presence of localized inflammation and open lesions, possibly evidenced by verbal reports, distraction behaviors, and restlessness.

risk for [secondary] Infection is possibly evidenced by risk factors of broken or traumatized tissue, altered immune response, and untreated infection or treatment failure.

risk for Sexual Dysfunction is possibly evidenced by risk factors of lack of knowledge, values conflict, and/or fear of transmitting the disease.

herpes zoster (shingles)

acute Pain may be related to inflammation and local lesions along sensory nerve(s), possibly evidenced by verbal reports, guarding or distraction behaviors, narrowed focus, restlessness, and changes in vital signs.

deficient Knowledge [Learning Need] regarding pathophysiology, therapeutic needs, and potential complications may be related to lack of information, misinterpretation, possibly evidenced by statements of concern, questions, and misconceptions.

high-altitude pulmonary edema (HAPE)

(also refer to mountain sickness, acute)

impaired Gas Exchange may be related to ventilation perfusion imbalance, alveolar-capillary membrane changes, altered oxygen supply possibly evidenced by dyspnea, confusion, cyanosis, tachycardia, abnormal ABGs.

excess Fluid Volume may be related to compromised regulatory mechanism, possibly evidenced by shortness of breath, anxiety, edema, abnormal breath sounds, pulmonary congestion.

high-altitude sickness

Refer to mountain sickness, acute; high-altitude pulmonary edema.

HIV infection

(also refer to AIDS)

risk-prone Health Behavior may be related to life-threatening, stigmatizing condition or disease, assault to self-esteem, altered locus of control, inadequate support systems, possibly evidenced by verbalization of nonacceptance or denial of diagnosis, failure to take action that prevents health problems.

deficient Knowledge [Learning Need] regarding disease, prognosis, and treatment needs may be related to lack of exposure or recall, information misinterpretation, unfamiliarity with information resources, or cognitive limitation, possibly evidenced by statement of misconception, request for information, inappropriate or exaggerated behaviors (hostile, agitated, hysterical, apathetic), inaccurate follow-through of instructions, or development of preventable complications.

risk for ineffective Health Management is possibly evidenced by risk factors of complexity of healthcare system and access to care, economic difficulties; complexity of therapeutic regimen—confusing or difficult dosing schedule, duration of regimen; mistrust of regimen and/or healthcare personnel, client and provider interactions; health beliefs or cultural influences, perceived seriousness, susceptibility, or benefits of therapy; decisional conflicts, powerlessness.

risk for complicated Grieving is possibly evidenced by risk factors of preloss psychological symptoms, predisposition for anxiety and feelings of inadequacy, frequency of major life events.

Hodgkin's disease

(also refer to cancer; chemotherapy)

Anxiety [specify level]/Fear may be related to threat of self-concept and threat of death, possibly evidenced by apprehension, insomnia, focus on self, and increased tension.

deficient Knowledge [Learning Need] regarding diagnosis, pathophysiology, treatment, and prognosis may be related to lack of information/misinterpretation, possibly evidenced by statements of concern, questions, and misconceptions.

acute Pain/impaired Comfort may be related to manifestations of inflammatory response (fever, chills, night sweats) and pruritus, possibly evidenced by verbal reports, distraction behaviors, and focus on self.

risk for ineffective Breathing Pattern/Airway Clearance are possibly evidenced by risk factors of tracheobronchial obstruction (enlarged mediastinal nodes and/or airway edema).

hospice/end of life care

acute/chronic Pain may be related to biological, physical, psychological agent, chronic physical disability, possibly evidenced by verbal or coded report, preoccupation with pain, changes in appetite/eating, sleep pattern, altered ability to continue desired activities, guarded or protective behaviors, restlessness, irritability, narrowed focus— altered time perception, impaired thought processes.

Activity Intolerance/Fatigue may be related to generalized weakness, bedrest/immobility, pain, imbalance between oxygen supply and demand possibly evidenced by inability to maintain usual routine, verbalized lack of desire/interest in activity, decreased performance, lethargy.

Grieving/death Anxiety may be related to anticipated loss of physiological well-being, change in body function, perceived threat of death or dying process, possibly evidenced by changes in communication pattern, denial of potential loss; choked feelings, anger, fear of loss of physical or mental abilities; negative death images or unpleasant thoughts about any event related to death or dying; anticipated pain related to dying; powerlessness over issues related to dying, worrying about impact of one's own death on SO(s), being the cause of other's grief and suffering, concerns of overworking the caregiver as terminal illness incapacitates.

compromised/disabled family Coping/caregiver Role Strain may be related to prolonged disease/disability progression, temporary family disorganization and role changes, unrealistic expectations, inadequate or incorrect information or understanding by primary person, possibly evidenced by client expressing despair about family reactions or lack of involvement, history of poor relationship between caregiver and care receiver; altered caregiver health status; SO attempting assistive or supportive behaviors with less than satisfactory results, apprehension about future regarding caregiver's ability to provide care; SO describing preoccupation about personal reactions; displaying intolerance, abandonment, rejection; family behaviors that are detrimental to well-being.

risk for Spiritual Distress is possibly evidenced by risk factors of physical or psychological stress, energy-consuming anxiety; situational losses; blocks to self-love, low self-esteem, inability to forgive.

risk for moral Distress is possibly evidenced by risk factors of conflict among decision makers, cultural conflicts, end-of-life decisions, loss of autonomy, physical distance of decision makers.

hydrocephalus

ineffective cerebral Tissue Perfusion may be related to decreased arterial or venous blood flow (compression of brain tissue), possibly evidenced by changes in mentation, restlessness, irritability, reports of headache, pupillary changes, and changes in vital signs.

[disturbed visual Sensory Perception] may be related to pressure on sensory or motor nerves, possibly evidenced by reports of double vision, development of strabismus, nystagmus, pupillary changes, and optic atrophy.

risk for impaired physical Mobility is possibly evidenced by risk factors of neuromuscular impairment, decreased muscle strength, and impaired coordination.

risk for decreased intracranial Adaptive Capacity is possibly evidenced by risk factors of brain injury, changes in perfusion pressure or intracranial pressure.

risk for Infection is possibly evidenced by risk factors of invasive procedure, presence of shunt.

deficient Knowledge [Learning Need] regarding condition, prognosis, and long-term therapy needs/medical follow-up may be related to lack of information, misperceptions, possibly evidenced by questions, statement of concern, request for information, and inaccurate follow-through of instruction, or development of preventable complications.

hyperactivity disorder

ineffective Impulse Control may be related to compunction, possibly evidenced by acting without thinking, temper outbursts.

defensive Coping may be related to mild neurological deficits, dysfunctional family system, abuse or neglect, possibly evidenced by denial of obvious problems, projection of blame or responsibility, grandiosity, difficulty in reality testing perceptions.

impaired Social Interaction may be related to retarded ego development, negative role models, neurological impairment, possibly evidenced by having discomfort in social situations, interrupting or intruding on others, having difficulty waiting turn in games or group activities, having difficulty maintaining attention to task.

disabled family Coping may be related to excessive guilt, anger, or blaming among family members, parental inconsistencies, disagreements regarding discipline, limit-setting approaches, exhaustion of parental expectations, possibly evidenced by unrealistic parental expectations, rejection or overprotection of child, exaggerated expression of feelings, despair regarding child's behavior.

hyperbilirubinemia

neonatal Jaundice may be related to difficulty transitioning to extrauterine life, feeding pattern not well established, abnormal weight loss, possibly evidenced by abnormal blood profile—elevated BUN, yellow-orange skin/sclera.

risk for Injury [effects of treatment] is possibly evidenced by risk factors of physical properties of phototherapy and effects on body regulatory mechanisms, invasive procedure (exchange transfusion), abnormal blood profile, chemical imbalances.

deficient Knowledge [Learning Need] regarding condition, prognosis, treatment/safety needs may be related to lack of exposure or recall and information misinterpretation, possibly evidenced by questions, statement of concern, and inaccurate follow-through of instructions, or development of preventable complications.

hyperemesis gravidarum

deficient Fluid Volume may be related to excessive gastric losses and reduced intake, possibly evidenced by dry mucous membranes; decreased, concentrated urine; decreased pulse volume and pressure, thirst, and hemoconcentration.

risk for Electrolyte Imbalance is possibly evidenced by risk factors of vomiting, dehydration.

imbalanced Nutrition: less than body requirements may be related to inability to ingest, digest, or absorb nutrients (prolonged vomiting), possibly evidenced by reported inadequate food intake, lack of interest in food or aversion to eating, and weight loss.

risk for ineffective Coping is possibly evidenced by risk factors of situational or maturational crisis (pregnancy, change in health status, projected role changes, concern about outcome).

hypertension

deficient Knowledge [Learning Need] regarding condition, therapeutic regimen, and potential complications may be related to lack of information or recall, misinterpretation, cognitive limitations, and/or denial of diagnosis, possibly evidenced by statements of concern, questions, and misconceptions, inaccurate follow-through of instructions, and lack of BP control.

risk-prone health Behavior may be related to condition requiring change in lifestyle, altered locus of control, and absence of feelings, denial of illness, possibly evidenced by verbalization of nonacceptance of health status change and lack of movement toward independence.

risk for Activity Intolerance is possibly evidenced by risk factors of generalized weakness, imbalance between oxygen supply and demand.

risk for Sexual Dysfunction is possibly evidenced by risk factors of side effects of medication.

risk for decreased Cardiac Output is possibly evidenced by risk factors of increased afterload (vasoconstriction), fluid shifts, hypovolemia, myocardial ischemia, ventricular hypertrophy or rigidity.

acute Pain may be related to increased cerebrovascular pressure, possibly evidenced by verbal reports (throbbing pain located in suboccipital region, present on awakening and disappearing spontaneously after being up and about), reluctance to move head, avoidance of bright lights and noise, increased muscle tension.

hypertension, pulmonary

Refer to pulmonary hypertension.

hyperthyroidism

(also refer to thyrotoxicosis)

Fatigue may be related to hypermetabolic imbalance with increased energy requirements, irritability of CNS, and altered body chemistry, possibly evidenced by verbalization of overwhelming lack of energy to maintain usual routine, decreased performance, emotional lability or irritability, and impaired ability to concentrate.

Anxiety [specify level] may be related to increased stimulation of the CNS (hypermetabolic state, pseudocatecholamine effect of thyroid hormones), possibly evidenced by increased feelings of apprehension, overexcitement or distress, irritability or emotional lability, shakiness, restless movements, tremors.

risk for imbalanced Nutrition: less than body requirements is possibly evidenced by risk factors of inability to ingest adequate nutrients for hypermetabolic rate and constant activity level, impaired absorption of nutrients—vomiting, diarrhea, hyperglycemia, relative insulin insufficiency.

risk for Dry Eye is possibly evidenced by risk factors of periorbital edema, altered protective mechanisms of eye—reduced ability to blink, eye dryness.

hypoglycemia

acute Confusion may be related to inadequate glucose for cellular brain function and effects of endogenous hormone activity, possibly evidenced by increased restlessness, misperceptions, or fluctuation in cognition/level of consciousness.

risk for unstable Blood Glucose Level is possibly evidenced by risk factors of dietary intake, lack of adherence to diabetes management, inadequate blood glucose monitoring, medication management.

deficient Knowledge [Learning Need] regarding pathophysiology of condition and therapy/self-care needs may be related to lack of information or recall, misinterpretations, possibly evidenced by development of hypoglycemia and statements of questions, misconceptions.

hypoparathyroidism (acute)

risk for Injury is possibly evidenced by risk factors of neuromuscular excitability or tetany and formation of renal stones.

acute Pain may be related to recurrent muscle spasms and alteration in reflexes, possibly evidenced by verbal reports, distraction behaviors, and narrowed focus.

risk for ineffective Airway Clearance is possibly evidenced by risk factor of spasm of the laryngeal muscles.

Anxiety [specify level] may be related to threat to, or change in, health status, physiological responses.

hypothermia (systemic)

(also refer to frostbite)