Skip to Main Content

Information appearing in brackets has been added by the authors to clarify and facilitate the use of nursing diagnoses.

A “RISK FOR” diagnosis is not evidenced by signs and symptoms, as the problem has not occurred; rather, nursing interventions are directed at prevention. Therefore, risk factors that are present are noted instead.

New nursing diagnoses for 2015–2017 appear in Appendix N2.

ACTIVITY INTOLERANCE [SPECIFY LEVEL]

Diagnostic Division: Activity/Rest

Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities.

RELATED FACTORS

Generalized weakness; Sedentary lifestyle; Bed rest; Immobility; Imbalance between oxygen supply and demand; [Anemia]; [Cognitive deficits, extreme stress; depression]; [Pain, dysrhythmias, vertigo]

DEFINING CHARACTERISTICS

Subjective

Report of fatigue or weakness; Exertional discomfort or dyspnea; [Verbalizes no desire and/or lack of interest in activity]

Objective

Abnormal heart rate or blood pressure response to activity; Electrocardiographic changes reflecting arrhythmias or ischemia; [Pallor, cyanosis]

ACTIVITY INTOLERANCE, RISK FOR

Diagnostic Division: Activity/Rest

Definition: Vulnerable to experiencing insufficient physiological or psychological energy to endure or complete required or desired daily activities, which may compromise health.

RISK FACTORS

History of previous activity intolerance; Presence of circulatory/respiratory problems; [Dysrhythmias]; Deconditioned status; [Aging]; Inexperience with an activity; [Diagnosis of progressive disease state/debilitating condition, anemia, extensive surgical procedures]; [Verbalized reluctance/inability to perform expected activity]

ACTIVITY PLANNING, INEFFECTIVE

Diagnostic Division: Activity/Rest

Definition: Inability to prepare for a set of actions fixed in time and under certain conditions.

RELATED FACTORS

Unrealistic perception of events [or] personal competence; Lack of family/friend support; Compromised ability to process information; Defensive flight behavior when faced with proposed solution; Hedonism [motivated by pleasure and/or pain]

DEFINING CHARACTERISTICS

Subjective

Reports fear/worries toward a task to be undertaken; Excessive anxieties toward a task to be undertaken

Objective

Failure pattern of behavior; Lack of plan, resources, sequential organization; History of procrastination; Unmet goals for chosen activity

ACTIVITY PLANNING, RISK FOR INEFFECTIVE

Diagnostic Division: Activity/Rest

Definition: Vulnerable to an inability to prepare for a set of actions fixed in time and under certain conditions, which may compromise health.

RISK FACTORS

Compromised ability to process information; Defensive flight behavior when faced with proposed solution; Hedonism; History of procrastination; Ineffective/insufficient support systems; Unrealistic perception of events/personal competence

ADAPTIVE CAPACITY, DECREASED INTRACRANIAL

Diagnostic Division: Circulation

Definition: Intracranial fluid dynamic mechanisms that normally compensate for increases in intracranial volumes are compromised, resulting in repeated disproportionate increases in intracranial pressure (ICP) in response to a variety of noxious and non-noxious stimuli.

RELATED FACTORS

Brain injuries; Sustained increase in ICP of 10 to 15 mm Hg; Decreased cerebral perfusion pressure ≤50 to 60 mm Hg; Systemic hypotension with intracranial hypertension

DEFINING CHARACTERISTICS

Objective

Repeated increases in ICP of >10 mm Hg for more than 5 minutes following any of a variety of external stimuli; Disproportionate increase in ICP following stimulus; Elevated P2 ICP waveform; Volume-pressure response test variation (volume-pressure ratio 2, pressure-volume index <10); Baseline ICP greater than or equal to 10 mm Hg; Wide amplitude ICP waveform; [Altered level of consciousness—coma]; [Changes in vital signs, cardiac rhythm]

AIRWAY CLEARANCE, INEFFECTIVE

Diagnostic Division: Respiration

Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.

RELATED FACTORS

Environmental

Smoking; Second-hand smoke; Smoke inhalation

Obstructed Airway

Retained secretions; Secretions in the bronchi; Exudate in the alveoli; Excessive mucus; Airway spasm; Foreign body in airway; Presence of artificial airway

Physiological

Chronic obstructive pulmonary disease (COPD); Asthma; Allergic airways; Hyperplasia of the bronchial walls; Neuromuscular dysfunction; Infection

DEFINING CHARACTERISTICS

Subjective

Dyspnea

Objective

Diminished/adventitious breath sounds [rales, crackles, rhonchi, wheezes]; Ineffective/absent cough; Excessive sputum; Changes in respiratory rate and rhythm; Difficulty vocalizing; Wide-eyed; Restlessness; Orthopnea; Cyanosis

ALLERGY RESPONSE, RISK FOR

Diagnostic Division: Safety

Definition: Vulnerable to an exaggerated immune response or reaction to substances, which may compromise health.

RISK FACTORS

Chemical products, e.g., bleach, cosmetics; Dander; Environmental substances, e.g., mold, dust, pollen; Foods, e.g., peanuts, shellfish, mushrooms; Insect stings; Pharmaceutical agents, e.g., penicillins; Repeated exposure to environmental substances

ANXIETY [specify level]

Diagnostic Division: Ego Integrity

Definition: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting sign that warns of impending danger and enables the individual to take measures to deal with that threat.

RELATED FACTORS

Unconscious conflict about essential [beliefs]/goals/values of life; Situational/maturational crises; Stress; Familial association/heredity; Interpersonal transmission/contagion; Threat to self-concept [perceived or actual]; [Unconscious conflict]; Threat of death [perceived or actual]; Threat to or change in health status [progressive/debilitating disease, terminal illness], interaction patterns, role function/status, environment [safety], economic status; Unmet needs; Exposure to toxins; Substance abuse; [Positive or negative self-talk]; [Physiological factors, e.g., hyperthyroidism, pheochromocytoma, drug therapy including steroids]

DEFINING CHARACTERISTICS

Subjective

Behavioral

Reports concerns due to change in life events; Insomnia

Affective

Regretful; Rattled; Distressed; Apprehensive; Uncertainty; Fear; Feelings of inadequacy; Jittery; Worried; Painful/persistent increased helplessness; [Sense of impending doom]; [Hopelessness]

Cognitive

Fear of unspecified consequences; Awareness of physiologic symptoms

Physiological

Shakiness

Sympathetic: Dry mouth; Heart pounding; Weakness; Respiratory difficulties; Anorexia; Diarrhea

Parasympathetic: Tingling in extremities; Nausea; Abdominal pain; Diarrhea; Urinary hesitancy/frequency; Faintness; Fatigue; Sleep disturbance; [Chest, back, neck pain]

Objective

Behavioral

Poor eye contact; Glancing about; Scanning; Vigilance; Extraneous movement [e.g., foot shuffling, hand/arm movements, rocking motion]; Fidgeting; Restlessness; Diminished productivity; [Crying/tearfulness]; [Pacing/purposeless activity]; [Immobility]

Affective

IIncreased wariness; Focus on self; Irritability; Overexcited; Anguish

Physiological

Voice quivering; Trembling/hand tremors; Increased tension; Facial tension; Increased perspiration

Sympathetic: Cardiovascular excitation; Facial flushing; Superficial vasoconstriction; Increased pulse/respiration; Increased blood pressure; Twitching; Pupil dilation; Increased reflexes

Parasympathetic: Urinary urgency; Decreased blood pressure/pulse

Cognitive

Preoccupation; Impaired attention; Difficulty concentrating; Forgetfulness; Diminished ability to problem-solve; Diminished ability to learn; Rumination; Tendency to blame others; Blocking of thought; Confusion; Decreased perceptual field

ASPIRATION, RISK FOR

Diagnostic Division: Respiration

Definition: Vulnerable to entry of gastrointestinal secretions, oropharyngeal secretions, solids or fluids into the tracheobronchial passages, which may compromise health.

RISK FACTORS

Barrier to elevating upper body; facial surgery or trauma; neck surgery or trauma; oral surgery or trauma; wired jaw; Decrease in gastrointestinal motility; delayed gastric emptying; incompetent lower esophageal sphincter; increase in gastric residual; increase in intragastric pressure; Decrease in level of consciousness; depressed gag reflex; impaired ability to swallow; ineffective cough; Presence of oral/nasal tube, e.g., tracheal, feeding; enteral feedings; Treatment regimen.

ATTACHMENT, RISK FOR IMPAIRED

Diagnostic Division: Social Interaction

Definition: Vulnerable to disruption of the interactive process between parent/significant other and child that fosters the development of a protective and nurturing reciprocal relationship.

RISK FACTORS

Inability of parent(s) to meet personal needs; Anxiety; [parents who themselves experienced impaired attachment]; Prematurity; child's illness prevents effective initiation of parental contact; Disorganized infant behavior; parental conflict resulting from disorganized behavioral organization; Parent-child separation, physical barrier, e.g., infant in isolette, insufficient privacy; Substance abuse; Difficult pregnancy and/or birth; Uncertainty of paternity, conception as a result of rape/sexual abuse.

AUTONOMIC DYSREFLEXIA

Diagnostic Division: Circulation

Definition: Life-threatening, uninhibited sympathetic response of the nervous system to a noxious stimulus after a spinal cord injury (SCI) at T7 or above.

RELATED FACTORS

Bladder/bowel distention; [catheter insertion/obstruction; irrigation; constipation]; Skin irritation; Insufficient [client or] caregiver knowledge; [Sexual excitation, menstruation, pregnancy, labor and delivery]; [Environmental temperature extremes]

DEFINING CHARACTERISTICS

Subjective

Headache (a diffuse pain in different portions of the head and not confined to any nerve distribution area); Paresthesia; Chilling; Blurred vision; Chest pain; Metallic taste in mouth; Nasal congestion

Objective

Paroxysmal hypertension (sudden periodic elevated blood pressure in which systolic pressure >140 mm Hg and diastolic >90 mm Hg); Bradycardia or tachycardia (heart rate <60 or >100 beats per minute, respectively); Diaphoresis (above the injury); Red splotches on skin (above the injury); Pallor (below the injury); Horner's syndrome [contraction of the pupil, partial ptosis of the eyelid, enophthalmos and sometimes loss of sweating over the affected side of the face]; Conjunctival congestion; Pilomotor reflex

AUTONOMIC DYSREFLEXIA, RISK FOR

Diagnostic Division: Circulation

Definition: Vulnerable to a life-threatening, uninhibited response of the sympathetic nervous system post-spinal shock, in an individual with spinal cord injury [SCI] or lesion at the 6th thoracic vertebra (T6) or above (has been demonstrated in patients with injuries at the 7th thoracic vertebra [T7] and the 8th thoracic vertebra [T8]), which may compromise health.

RISK FACTORS

An injury at T6 or above AND at least one of the following noxious stimuli

Cardiopulmonary Stimuli

Deep vein thrombosis; Pulmonary emboli

Musculoskeletal-Integumentary Stimuli

Cutaneous stimulations, e.g., pressure ulcer, ingrown toenail, dressings, burns, rash; Sunburn; Wounds; Pressure over bony prominences/genitalia; Range-of-motion exercises; Spasm; Fracture; Heterotopic bone

Gastrointestinal Stimuli

Constipation; Difficult passage of feces; Fecal impaction; Bowel distension; Hemorrhoids; Digital stimulation; Suppositories; Enemas; Gastrointestinal system pathology; Esophageal reflux disease; Gastric ulcers; Gallstones

Urological Stimuli

Bladder distention or spasm; Detrusor sphincter dyssynergia; Instrumentation; Surgery; Urinary tract infection; Cystitis; Urethritis; Epididymitis; Renal calculi; Urinary Catheterization

Regulatory Stimuli

Temperature fluctuations; Extremes of environmental temperatures

Situational Stimuli

Positioning; Surgical [/diagnostic]procedure; Constrictive clothing, e.g., straps, stockings, shoes; Reactions to pharmaceutical agents, e.g., decongestants, sympathomimetics, vasoconstrictors; Narcotic/opiate withdrawal

Neurological Stimuli

Painful/irritating stimuli below the level of injury

Reproductive [and Sexuality] Stimuli

Sexual intercourse; Ejaculation; [Vibrator overstimulation; Scrotal compression]; Menstruation; Pregnancy; Labor and delivery; Ovarian cyst

BEHAVIOR, DISORGANIZED INFANT

Diagnostic Division: Neurosensory

Definition: Disintegrated physiological and neurobehavioral responses of infant to the environment.

RELATED FACTORS

Prenatal

Congenital or genetic disorders; exposure to teratogen

Postnatal

Feeding intolerance; malnutrition; Impaired motor functioning; oral impairment; Invasive procedure; pain

Individual

Low postconceptual age; Immature neurological functioning; Illness; [hypoxia, birth asphyxia]

Environmental

Inadequate physical environment; insufficient containment within environment; Insufficient sensory stimulation, overstimulation, or deprivation

Caregiver

Cue misreading; insufficient knowledge of behavioral cues; Environmental overstimulation

DEFINING CHARACTERISTICS

Objective

Regulatory Problems

Inability to inhibit startle; Irritability

State-Organization System

Active-awake (fussy, worried gaze); Quiet-awake (staring, gaze aversion); Diffuse sleep; State-oscillation; Irritable crying

Attention-Interaction System

Abnormal response to sensory stimuli, e.g., difficult to soothe, unable to sustain alert status

Motor System

Finger splaying; Fisting; Hands to face; Hyperextension of extremities; Tremors; Startles; Twitches; Jittery; Uncoordinated movement; Changes to motor tone; Altered primitive reflexes

Physiological

Bradycardia; Tachycardia; Arrhythmias; Skin color changes; “Time-out signals”, e.g., gaze, grasp, hiccough, cough, sneeze, sigh, slack jaw, open mouth, tongue thrust; Feeding intolerances; Desaturation

BEHAVIOR, READINESS FOR ENHANCED ORGANIZED INFANT

Diagnostic Division: Neurosensory

Definition: A pattern of modulation of the physiological and behavioral systems of functioning, i.e., autonomic, motor, state, organizational, self-regulatory, and attentional-interactional systems, in an infant, which can be strengthened.

DEFINING CHARACTERISTICS

Objective

The parent expresses a desire to enhance cue recognition. The parent expresses a desire to enhance recognition of the infant's self-regulatory behaviors.

BEHAVIOR, RISK FOR DISORGANIZED INFANT

Diagnostic Division: Neurosensory

Definition: Vulnerable to alteration in integration and modulation of the physiological and behavioral systems of functioning, i.e., autonomic, motor, state-organization, self-regulatory, and attentional-interactional systems, which may compromise health.

RISK FACTORS

Pain; Oral/motor problems; Environmental overstimulation; Lack of containment within environment; Invasive/painful procedures; Prematurity; [immaturity of the central nervous system; generic problems that alter neurologic and/or physiologic functioning conditions resulting in hypoxia and/or birth asphyxia]; [Malnutrition; infection; drug addiction]; [Environmental events or conditions such as separation from parent, exposure to loud noise, excessive handling, bright lights]

BLEEDING, RISK FOR

Diagnostic Division: Circulation

Definition: Vulnerable to a decrease in blood volume, which may compromise health.

RISK FACTORS

Aneurysm; disseminated intravascular coaguloapathy; inherent coagulopathy, e.g., thrombocytopenia; Gastrointestinal condition, e.g., ulcer, polyps, varices; impaired liver function, e.g., cirrhosis, hepatitis; History of falls; trauma; Insufficient knowledge of bleeding precautions; Pregnancy complication, e.g., premature rupture of membranes, placenta previa/abruption, multiple gestation; postpartum complications, e.g., uterine atony, retained placenta; Treatment regimen, e.g., surgery, medications, administration of platelet-deficient blood products, chemotherapy; circumcision

BLOOD GLUCOSE LEVEL, RISK FOR UNSTABLE

Diagnostic Division: Food/Fluid

Definition: Vulnerable to variation of blood glucose/sugar levels from the normal range, which may compromise health.

RISK FACTORS

Does not accept diagnosis; insufficient knowledge of diabetes management; Insufficient diabetes management or nonadherence to diabetes management plan; inadequate blood glucose monitoring; ineffective medication management; Insufficient dietary intake; excessive weight gain or loss; rapid growth period; pregnancy; Compromised physical health status; Average daily physical activity is less than recommended for gender and age; Excessive stress; alteration in mental status; Delay in cognitive development

BODY IMAGE, DISTURBED

Diagnostic Division: Ego Integrity

Definition: Confusion [and/or dissatisfaction] in mental picture of one's physical self.

RELATED FACTORS

Illness; trauma; injury; surgical procedure; treatment regimen; Alteration in body function (due to anomaly, disease, medication, pregnancy, radiation, surgery, trauma, etc.); Cultural or spiritual incongruences; Alteration in self-perception, cognitive functioning; Impaired psychosocial functioning; Developmental transition

DEFINING CHARACTERISTICS

Behaviors of acknowledgement/avoidance/monitoring of one's body; Nonverbal response to actual/perceived change in body, e.g., appearance, structure, function; Reports feelings that reflect an altered view of one's body, e.g., appearance, structure, function; Reports perceptions that reflect an altered view of one's body in appearance

Subjective

Alteration in view of one's body, e.g., appearance, structure, or function; Perceptions that reflect an altered view of one's body appearance; Fear of reaction by others; Focus on past strength, function, or appearance; Negative feeling about body; Preoccupation with change/loss; Refusal to verify actual change; Emphasis on remaining strengths; Personalization of body part/loss by name; Depersonalization of body part/loss by use of impersonal pronouns

Objective

Behaviors of: acknowledgment of one's body, monitoring one's body; Nonverbal response to actual or perceived change in body, e.g., appearance, structure, or function; Alteration in body structure or function; absence of body part; Avoids looking at or touching one's body; Trauma to nonfunctioning part; Change in ability to estimate spatial relationship of body to environment; Extension of body boundary, e.g., included external object; Hiding or overexposure of body part; Change in lifestyle, social involvement; Heightened achievement; Aggression; low frustration tolerance level

BODY TEMPERATURE, RISK FOR IMBALANCED

Diagnostic Division: Safety

Definition: Vulnerable to failure to maintain body temperature within normal parameters, which may compromise health.

RISK FACTORS

Acute brain injury; sepsis; Alteration in metabolic rate; condition affecting temperature regulation; increase in oxygen demand; inefficient nonshivering thermogenesis; Decreased sweat response; dehydration; Extremes of age or weight; increased body surface area to weight ratio; insufficient supply of subcutaneous fat; Exposure to extremes of environmental temperature; improper clothing for environmental temperature; Inactivity; vigorous activity; Pharmaceutical agents causing vasoconstriction/vasodilation; Sedation

BREAST MILK, INSUFFICIENT

Diagnostic Division: Food/Fluid

Definition: Low production of maternal breast milk.

RELATED FACTORS

INFANT: Ineffective latching on to breast, sucking reflex; Insufficient opportunity for suckling at the breast or suckling time at breast; Rejection of breast

MOTHER: Insufficient fluid volume [e.g., dehydration, hemorrhage]; Smoking; alcohol consumption; Malnutrition; Treatment regimen [e.g., medication side effects—contraceptives, diuretics]; Pregnancy

DEFINING CHARACTERISTICS

Subjective

INFANT: Does not seem satisfied after sucking time; Refuses to suck; Wants to suck very frequently

Objective

INFANT: Frequently seeks to suckle at breast; prolonged breastfeeding time; Suckling time at breast appears unsatisfactory; frequent crying; Refuses to suckle at breast; Voids small amounts of concentrated urine; constipation; Weight gain 500 g in a month

MOTHER: Expresses breast milk less than prescribed volume; Delay in milk production; Absence of milk production with nipple stimulation

BREASTFEEDING, INEFFECTIVE

Diagnostic Division: Food/Fluid

Definition: Dissatisfaction or difficulty that a mother, infant, or child experiences with the breastfeeding process.

RELATED FACTORS

Insufficient parental knowledge regarding importance of breastfeeding techniques; Insufficient opportunity for suckling at the breast; inadequate milk supply; delayed lactogenesis II; Prematurity [late preterm (35 to 37 weeks)]; poor infant sucking reflex; Oropharyngeal defect [e.g., cleft palate/lip, ankyloglossia (tongue tied)]; Supplemental feedings with artificial nipple; pacifier use; Maternal anxiety or ambivalence, fatigue, pain, obesity; Previous history of breastfeeding failure; Interrupted breastfeeding; short maternity leave; Maternal breast anomaly; previous breast surgery

DEFINING CHARACTERISTICS

Subjective

Sore nipples persisting beyond the first week of breastfeeding; Insufficient emptying of each breast per feeding; Perceived inadequate milk supply

Objective

Insufficient opportunity for suckling at the breast; Infant inability to latch on to maternal breast correctly; unsustained suckling at the breast; Infant arching or crying at the breast; resisting latching on to breast; Infant crying within the first hour after breastfeeding; fussing within 1 hour of breastfeeding; unresponsive to other comfort measures; Insufficient signs of oxytocin release; Inadequate infant stooling; Insufficient infant weight gain; sustained infant weight loss

BREASTFEEDING, INTERRUPTED

Diagnostic Division: Food/Fluid

Definition: Break in the continuity of providing milk to an infant or young child directly from the breasts, which may compromise breastfeeding success and/or nutritional status of the infant/child.

RELATED FACTORS

Maternal/infant illness; Prematurity; Maternal-infant separation; maternal employment; hospitalization of child; Contraindications to breastfeeding [e.g., certain pharmaceutical agents]; Need to abruptly wean infant

DEFINING CHARACTERISTICS

Subjective

Nonexclusive breastfeeding

BREASTFEEDING, READINESS FOR ENHANCED

Diagnostic Division: Food/Fluid

Definition: A pattern of providing milk to an infant or young child directly from the breasts, which may be strengthened.

DEFINING CHARACTERISTICS

Subjective

Mother expresses desire to enhance ability to exclusively breastfeed; Mother expresses desire to provide breast milk for child's nutritional needs

BREATHING PATTERN, INEFFECTIVE

Diagnostic Division: Activity/Rest

Definition: Inspiration and/or expiration that does not provide adequate ventilation.

RELATED FACTORS

Neuromuscular impairment; Spinal cord injury; Neurological impairment; Musculoskeletal impairment; Bony/chest wall deformity; Anxiety [panic attack]; Pain; Fatigue; [Deconditioning]; Respiratory muscle fatigue; Neurological damage; Body position; Obesity; Hyperventilation; Hypoventilation syndrome; [alteration of patient's normal O2 : CO2 ratio [e.g., lung diseases, pulmonary hypertension, airway obstruction, or O2 therapy in chronic obstructive pulmonary disease (COPD)]

DEFINING CHARACTERISTICS

Subjective

Dyspnea; [Feeling breathless]; Orthopnea

Objective

Bradypnea; Tachypnea; Alterations in depth of breathing; Prolonged expiration phases; Pursed-lip breathing; Decreased minute ventilation/vital capacity; Decreased inspiratory/expiratory pressure; Use of accessory muscles to breathe; Assumption of three-point position; Altered chest excursion, [paradoxical breathing patterns]; Nasal flaring; [Grunting]; Increased anterior-posterior diameter

CARDIAC OUTPUT, DECREASED

Diagnostic Division: Circulation

Definition: Inadequate blood pumped by the heart to meet the metabolic demands of the body.

NOTE: [In a hypermetabolic state, although cardiac output may be within normal range, it may still be inadequate to meet the needs of the body's tissues. Cardiac output and tissue perfusion are interrelated, although there are differences. When cardiac output is decreased, tissue perfusion problems will develop; however, tissue perfusion problems can exist without decreased cardiac output.]

RELATED FACTORS

Altered heart rate/rhythm [conduction]; Altered stroke volume: Altered preload [e.g., decreased venous return]; Altered afterload [e.g., altered systemic vascular resistance]; Altered contractility [e.g., ventricular-septal rupture, ventricular aneurysm, papillary muscle rupture, valvular disease]

DEFINING CHARACTERISTICS

Subjective

Altered Heart Rate/Rhythm:

Palpitations

Altered Preload:

Fatigue

Altered Afterload:

Dyspnea; [Feeling breathless]

Altered Contractility:

Orthopnea/paroxysmal nocturnal dyspnea [PND]

Behavioral/Emotional:

Anxiety

Objective

Altered Heart Rate/Rhythm:

[Dys]arrhythmias (tachycardia, bradycardia); EKG [ECG] changes

Altered Preload:

Jugular vein distention (JVD); Edema; Weight gain; Increased/decreased central venous pressure (CVP); Increased/decreased pulmonary artery wedge pressure (PAWP); Murmurs

Altered Afterload:

Dyspnea; Clammy skin; Skin [and mucous membrane] color changes [cyanosis, pallor]; Prolonged capillary refill; Decreased peripheral pulses; Variations in blood pressure readings; Increased/decreased systemic vascular resistance (SVR); Increased/decreased pulmonary vascular resistance (PVR); Oliguria; [Anuria]

Altered Contractility:

Crackles; Cough; Decreased cardiac output/cardiac index; Decreased ejection fraction; Decreased stroke volume index (SVI)/left ventricular stroke work index (LVSWI); S3 or S4 sounds [gallop rhythm]

Behavioral/Emotional:

Restlessness

CARDIAC OUTPUT, RISK FOR DECREASED

Diagnostic Division: Circulation

Definition: Vulnerable to inadequate blood pumped by the heart to meet the metabolic demands of the body, which may compromise health.

RISK FACTORS

Alteration in heart rate or rhythm; Altered afterload; Altered contractility; Altered pre-load; Altered stroke volume

CARDIOVASCULAR FUNCTION, RISK FOR IMPAIRED

Diagnostic Division: Circulation

Definition: Vulnerable to internal or external causes which damage one or more vital organs and the circulatory system itself.

RISK FACTORS

Age ≥65; Diabetes mellitus; Hypertension, dyslipidemia; Family history of cardiovascular disease; history of cardiovascular disease; Insufficient knowledge of modifiable risk factors; obesity; sedentary lifestyle; smoking; Pharmaceutical agent

CHILDBEARING PROCESS, INEFFECTIVE

Diagnostic Division: Sexuality

Definition: Pregnancy and childbirth process and care of the newborn that does not match the environmental context, norms, and expectations.

RELATED FACTORS

Deficient knowledge, e.g., of labor and delivery, newborn care; Domestic violence; Inconsistent prenatal health visits; Lack of: Appropriate role models for parenthood, Cognitive readiness for parenthood, Maternal Confidence, Prenatal health visits, A realistic birth plan, Sufficient support systems; Maternal powerlessness/psychological distress; Suboptimal maternal nutrition; Substance abuse; Unplanned/unwanted pregnancy; Unsafe environment

DEFINING CHARACTERISTICS

During Pregnancy

Subjective

Does not: Access support systems appropriately, Report appropriate physical preparations, Report appropriate prenatal lifestyle, e.g., nutrition, elimination, sleep, bodily movement, exercise, personal hygiene, Report availability of support systems, Report managing unpleasant symptoms of pregnancy, Report realistic birth plan, Seek necessary knowledge, e.g., of labor and delivery, newborn care; Failure to prepare necessary newborn care items

Objective

Inconsistent/lack of prenatal health visits; Lack of respect for unborn baby

During Labor and Delivery

Subjective

Does not: Access support systems appropriately, Demonstrate attachment behavior to the newborn baby, Report availability of support systems, Report lifestyle, e.g., diet, elimination, sleep, bodily movement, personal hygiene, that is appropriate for the stage of labor, Respond appropriately to onset of labor

Objective

Lacks proactivity during labor and delivery

After Birth

Subjective

Does not: Access support systems appropriately, Demonstrate appropriate: baby feeding techniques/breast care/attachment behavior to the baby/basic baby care techniques, Provide safe environment for the baby, Report appropriate postpartum lifestyle, e.g., diet, elimination, sleep, bodily movement, exercise, personal hygiene, Report availability of support systems

CHILDBEARING PROCESS, READINESS FOR ENHANCED

Diagnostic Division: Sexuality

Definition: A pattern for preparing for and maintaining a healthy pregnancy, childbirth process, and care of newborn that is sufficient for ensuring well-being, which can be strengthened.

DEFINING CHARACTERISTICS

During Pregnancy

Subjective

Expresses desire to enhance prenatal lifestyle, e.g., nutrition, elimination, sleep, exercise, and personal hygiene; Expresses desire to enhance knowledge of childbearing process; Expresses desire to enhance management of unpleasant pregnancy symptoms; Expresses desire to enhance preparation for newborn

Objective

Attends regular prenatal health visits; Demonstrates respect for unborn baby; Prepares necessary newborn care items

During Labor and Delivery

Subjective

Expresses desire to enhance lifestyle appropriate for stage of labor, e.g., nutrition, elimination, sleep, exercise, personal hygiene, that is appropriate for the stage of labor; Expresses desire to enhance proactivity during labor and delivery

Objective

Responds appropriately to onset of labor; Is proactive during labor and delivery, uses relaxation techniques appropriate for stage of labor, utilizes support systems appropriately; Demonstrates attachment behavior to the newborn baby

After Birth

Subjective

Expresses desire to enhance attachment behavior, baby care/feeding techniques, environmental safety for the baby; Expresses desire to enhance postpartum lifestyle, e.g., nutrition, elimination, sleep, exercise, personal hygiene, breast care; Expresses desire to enhance use of support system

Objective

Demonstrates attachment behavior to the baby, basic baby care techniques, appropriate baby feeding techniques; Provides safe environment for the baby; Utilizes support system appropriately; Demonstrates appropriate breast care

CHILDBEARING PROCESS, RISK FOR INEFFECTIVE

Diagnostic Division: Sexuality

Definition: Vulnerable to not matching the environmental context, norms, and expectations of pregnancy, childbirth process, and care of the newborn.

RISK FACTORS

Insufficient knowledge of childbearing process; unrealistic birth plan; Unplanned/unwanted pregnancy; Inconsistent prenatal health visits; insufficient prenatal care; Inadequate maternal nutrition; Substance abuse; Insufficient parental role model or cognitive readiness for parenting; Low maternal confidence; Maternal powerlessness, psychological distress; insufficient support systems; Unsafe environment; domestic violence

COMFORT, IMPAIRED

Diagnostic Division: Pain/Discomfort

Definition: Perceived lack of ease, relief, and transcendence in physical, psychospiritual, environmental, cultural, and social dimensions.

RELATED FACTORS

Illness-related symptoms; Insufficient resources, e.g., financial, social support; Insufficient environmental/situational control; Insufficient privacy; Noxious environmental stimuli; Treatment-related side effects, e.g., medication, radiation

DEFINING CHARACTERISTICS

Subjective

Reports: distressing symptoms, feeling of hunger, discomfort; feeling cold or hot; itching, Alteration in sleep pattern, inability to relax; Anxiety, fear; uneasy in situation

Objective

Restlessness, irritability, moaning, crying; Sighing

COMFORT, READINESS FOR ENHANCED

Diagnostic Division: Pain/Discomfort

Definition: A pattern of ease, relief and transcendence in physical, psychospiritual, environmental, and/or social dimensions, which can be strengthened.

DEFINING CHARACTERISTICS

Subjective

Expresses desire to enhance: comfort/feeling of contentment, relaxation, and resolution of complaints

COMMUNICATION, IMPAIRED VERBAL

Diagnostic Division: Social Interaction

Definition: Decreased, delayed, or absent ability to receive, process, transmit, and/or use a system of symbols.

RELATED FACTORS

Alteration in development; Physical barrier, e.g., tracheostomy, intubation; oropharyngeal defect; Physiological condition, e.g., decreased circulation to brain, weakened musculoskeletal system; central nervous system impairment; Vulnerability; emotional disturbance; psychotic disorder; Environmental barrier; Cultural incongruence; Insufficient information; Treatment regimen; Alteration in self-concept; low self-esteem; Alteration in perception; Absence of significant other

DEFINING CHARACTERISTICS

Objective

Inability to speak language of caregiver; Difficulty speaking/verbalizing; stuttering; slurred speech; Does not speak; refusal to speak; inability to speak; Difficulty forming sentences or words, e.g., aphonia, dyslalia, dysarthria; Difficulty expressing thoughts verbally, e.g., aphasia, dysphasia, apraxia, dyslexia; Inappropriate verbalization [e.g., incessant, loose association of ideas; flight of ideas]; Difficulty comprehending or maintaining communication; Absence of eye contact; difficulty in selective attending; partial/total visual deficit; Inability/difficulty in use of facial or body expressions; Dyspnea; Disoriented to person, space, time; [Inability to modulate speech; message inappropriate to content]; [Use of nonverbal cues, e.g., pleading eyes, gestures, or turning away]

COMMUNICATION, READINESS FOR ENHANCED

Diagnostic Division: Teaching/Learning

Definition: A pattern of exchanging information and ideas with others, which can be strengthened.

DEFINING CHARACTERISTICS

Subjective

Expresses desire to enhance communication

CONFUSION, ACUTE

Diagnostic Division: Neurosensory

Definition: Abrupt onset of reversible disturbances of consciousness, attention, cognition, and perception that develop over a short period of time

RELATED FACTORS

Substance abuse; Anesthesia/surgery; Metabolic imbalances]; Fluctuation in sleep-wake cycle; Over 60 years of age; Delirium [including febrile epilepticum— following or instead of an epileptic attack; toxic and traumatic; [Endocrine or metabolic crisis, liver or renal failure; hypoxemia, hypercarbia; shock]

DEFINING CHARACTERISTICS

Subjective

Hallucinations [Visual/auditory]; [Exaggerated emotional responses]

Objective

Agitation; restlessness; Alteration in cognitive functioning, or level of consciousness; Alteration in psychomotor functioning; Misperception; Inability to initiate goal-directed or purposeful behavior; Inability to follow-through with goal-directed or purposeful behavior

CONFUSION, CHRONIC

Diagnostic Division: Neurosensory

Definition: Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli and decreased capacity for intellectual thought processes and manifested by disturbances of memory, orientation, and behavior.

RELATED FACTORS

Alzheimer's disease; Korsakoff's psychosis; Multi-infarct dementia; Cerebral vascular attack; Brain injury, e.g., cerebrovascular impairment, neurological illness, trauma, tumor

DEFINING CHARACTERISTICS

Objective

Alteration in interpretation or response to stimuli; Progressive alteration in cognitive function; chronic cognitive impairment; organic brain disorder; Normal level of consciousness; Impaired social functioning; Alteration in short-term/long-term memory; Alteration in personality

CONFUSION, RISK FOR ACUTE

Diagnostic Division: Neurosensory

Definition: Vulnerable to reversible disturbances of consciousness, attention, cognition, and perception that develop over a short period of time, which may compromise health.

RISK FACTORS

Age ≥60 years; male gender; Alteration in cognitive functioning; dementia; Alteration in sleep-wake cycle; sensory deprivation; Dehydration; malnutrition; History of cerebral vascular accident; History of metabolic functioning, e.g., azotemia, decreased hemoglobin, electrolyte imbalance, increase in blood urea nitrogen/creatinine; Impaired mobility; inappropriate use of restraints; pain; Pharmaceutical agent; Substance abuse; Infection; urinary retention

CONSTIPATION

Diagnostic Division: Elimination

Definition: Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool.

RELATED FACTORS

Functional

Abdominal muscle weakness; Average daily physical activity is less than recommended for gender and age; Habitually ignores urge to defecate; irregular defecation habits; inadequate toileting habits; Recent environmental change

Psychological

Emotional disturbance; depression; confusion

Pharmacological

Pharmaceutical agent; laxative abuse; iron salts (risk for constipation)

Mechanical

Electrolyte imbalance; Hemorrhoids; pregnancy; obesity; Neurological impairment, e.g., positive EEG, head trauma, seizure disorders; Hirschsprung's disease; tumor; Prostate enlargement; postsurgical bowel obstruction; [colostomy]; Rectal abscess, ulcer; rectal prolapse; rectal anal fissure or stricture; rectocele

Physiological

Eating habit change, e.g., foods, eating times; insufficient dietary habits; insufficient fiber or fluid intake; dehydration; Inadequate dentition or oral hygiene; Decrease in gastrointestinal motility

DEFINING CHARACTERISTICS

Subjective

Abdominal pain; pain with defecation; Change in bowel pattern; decrease in frequency or volume of stool; hard, formed stool; inability to defecate; Increase in abdominal pressure; feeling of rectal fullness or pressure; straining with defecation; Indigestion; vomiting; headache; fatigue

Objective

Hard, formed stool; Straining with defecation; Hypoactive or hyperactive bowel sounds; borborygmi; Distended abdomen; abdominal tenderness with/without palpable muscle resistance; palpable abdominal or rectal mass; Percussed abdominal dullness; Presence of soft paste-like stool in rectum; liquid stool; bright red blood with stool; Severe flatus; anorexia; Atypical presentations in older adults, e.g., changes in mental status, urinary incontinence, unexplained falls, or elevated body temperature

CONSTIPATION, CHRONIC FUNCTIONAL

Diagnostic Division: Elimination

Definition: Infrequent or difficult evacuation of feces, which has been present for at least 3 of the prior 12 months.

RELATED FACTORS

Anal fissure/stricture; hemorrhoids; proctitis; Insufficient dietary/fluid intake; dehydration; low fiber diet; low calorie intake; diet disproportionately high in protein and fat; failure to thrive; Inflammatory bowel disease; chronic intestinal pseudo-obstruction; ischemic stenosis; postinflammatory stenosis; surgical stenosis; colorectal cancer; extra intestinal mass; Hirschprung's disease; Sedentary lifestyle; impaired mobility; Parkinson's disease; slow colon transit time; spinal cord injury; paraplegia; multiple sclerosis; autonomic neuropathy; myotonic dystrophy; cerebral vascular accident; Pharmaceutical agent; polypharmacy; Pregnancy; perineal damage; pelvic floor dysfunction; Hypercalcemia; hypothyroidism; panhypopituitarism; Diabetes mellitus; chronic renal insufficiency; scleroderma; dermatomyositis; depression; dementia; habitually ignores urge to defecate

DEFINING CHARACTERISTICS

Subjective

Pain with defecation; Prolonged straining; [Feeling as though stool is still in rectum after bowel movement]; [Feeling as though something is blocking stool from passing]; [Using fingers to help with stool passage]

Objective

ADULT: Presence of 2 of the following symptoms on Rome III classification system: Lumpy or hard stools; or straining; or sensation of incomplete evacuation; or sensation of anorectal obstructions; or manual maneuvers to facilitate defecations (digital manipulation, pelvic floor support) in 25% of defecations; 3 evacuations per week; CHILD 4 years: Presence of 2 criteria on Roman III Pediatric classification system for 1 month: 2 defecations per week; 1 episode of fecal incontinence per week; stool retentive posturing; painful or hard bowel movements; presence of large fecal mass in the rectum; large diameter stools that may obstruct the toilet; CHILD 4 years: Presence of 2 criteria on Roman III Pediatric classification system for 2 months: 2 defecations per week; 1 episode of fecal incontinence per week; stool retentive posturing; painful or hard bowel movements; presence of large fecal mass in the rectum; large diameter stools that may obstruct the toilet; Abdominal distention; Palpable abdominal mass; Type 1 or 2 Bristol Stool Chart; Fecal impaction; Fecal incontinence (in children); Leakage of stool with digital stimulation; Positive fecal occult blood; Prolonged straining Type 1 or 2 Bristol Stool Chart; Type 1 or 2 Bristol Stool Chart: after “Prolonged straining”

CONSTIPATION, PERCEIVED

Diagnostic Division: Elimination

Definition: Self-diagnosis of constipation combined with abuse of laxatives, enemas, and/or suppositories to ensure a daily bowel movement.

RELATED FACTORS

Cultural/family health beliefs; Impaired thought processes

DEFINING CHARACTERISTICS

Subjective

Expects daily bowel movement; Expects daily bowel movement at same time every day; Laxative, enema, or suppository abuse

CONSTIPATION, RISK FOR

Diagnostic Division: Elimination

Definition: Vulnerable to a decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool, which may compromise health.

RISK FACTORS

Functional

Irregular defecation habits; Inadequate toileting, e.g., timeliness, positioning for defecation, privacy; Insufficient physical activity; Abdominal muscle weakness; Recent environmental changes; Habitual denial/ignoring of urge to defecate

Psychological

Emotional disturbance; Depression; Confusion

Physiological

Change in usual foods/eating patterns; Insufficient fiber/fluid intake; Dehydration; Poor eating habits; Inadequate dentition or oral hygiene; Decreased motility of gastrointestinal tract

Pharmacological

Phenothiazines; Nonsteroidal anti-inflammatory agents; Sedatives; Aluminum-containing antacids; Laxative abuse; Bismuth salts; Iron salts; Anticholinergics; Antidepressants; Anticonvulsants; Antilipemic agents; Calcium channel blockers; Calcium carbonate; Diuretics; Sympathomimetics; Opiates

Mechanical

Hemorrhoids; Pregnancy; Obesity; Rectal abscess/ulcer; Rectal anal stricture/fissures; Rectal prolapse; Rectocele; Prostate enlargement; Postsurgical obstruction; Neurological impairment; Hirschsprung's disease; Tumors; Electrolyte imbalance

CONSTIPATION, RISK FOR CHRONIC FUNCTIONAL

Diagnostic Division: Elimination

Definition: Vulnerable to infrequent or difficult evacuation of feces, which has been present nearly 3 of the prior 12 months, which may compromise health.

RISK FACTORS

Aluminum-containing antacids; anti-epileptic drugs; antihypertensive agents; anti-Parkinsonian agents (anticholinergic or dopaminergic); calcium-channel antagonists; diuretics; iron preparations; non-steroidal anti-inflammatories (NSAIDs); opioids; tricyclic antidepressants; polypharmacy; Chronic intestinal pseudo-obstruction; slow colon transit time; Decreased food intake; diet proportionally high in protein and fat; low fiber diet, low caloric intake; Dehydration; insufficient fluid take; Impaired mobility; inactive lifestyle; Failure to thrive; Habitual ignoring of urge to defecate

CONTAMINATION

Diagnostic Division: Safety

Definition: Exposure to environmental contaminants in doses sufficient to cause adverse health effects.

RELATED FACTORS

External

Carpeted flooring; flaking, peeling surface in presence of young children, e.g., paint, plaster; playing where environmental contaminants are used; Chemical contamination of food or water; ingestion of contaminated material, e.g., radioactive, food, water; Economically disadvantaged; Exposure to areas with high contaminant level or atmospheric pollutants; inadequate breakdown of contaminant; Exposure to bioterrorism, or disaster (natural or man-made), or radiation; unprotected exposure to chemical, e.g., arsenic; Inadequate household or personal hygiene practices. Inadequate municipal services, e.g., trash removal, sewage treatment facilities; Use of environmental contaminants in the home; Use of noxious material (e,g., lacquer, paint) in an insufficiently ventilated area or without effective protection

Internal

Age (children less than 5 years, older adults); gestational age during exposure; Female gender; pregnancy; Inadequate nutrition; Preexisting disease states; smoking; Concomitant exposure or previous exposures to contaminants

DEFINING CHARACTERISTICS

(Defining characteristics are dependent on the causative agent. Agents cause a variety of individual organ responses as well as systemic responses.)

Subjective/Objective

Pesticides

[Major categories of pesticides: insecticides, herbicides, fungicides, antimicrobials, rodenticides; major pesticides: organophosphates, carbamates, organochlorines, pyrethrum, arsenic, glycophosphates, bipyridyis, chlorophenoxy compounds]; Dermatological, gastrointestinal, neurological, pulmonary, or renal effects of pesticide

Chemicals

[Major chemical agents: petroleum-based agents, anticholinesterases; type I agents act on proximal tracheobronchial portion of the respiratory tract, type II agents act on alveoli, type III agents produce systemic effects]; Dermatological, gastrointestinal, immunological, neurological, pulmonary, or renal effects of chemical exposure

Biologicals

[Toxins from living organisms (bacteria, viruses, fungi)] Dermatological/gastrointestinal/neurological/pulmonary/renal effects of exposure to biologicals

Pollution

[Major locations: air, water, soil; major agents: asbestos, radon, tobacco [smoke], heavy metal, lead, noise, exhaust fumes]; Neurological or pulmonary effects of pollution exposure

Waste

[Major categories of waste: trash, raw sewage, industrial waste]; Dermatological, gastrointestinal, hepatic, or pulmonary effects of waste exposure

Radiation

[External exposure through direct contact with radioactive material]; Immunological, genetic, neurological, or oncological effects of radiation exposure

CONTAMINATION, RISK FOR

Diagnostic Division: Safety

Definition: Vulnerable to exposure to environmental contaminants, which may compromise health.

RISK FACTORS

External

Chemical contamination of food/water; Presence of atmospheric pollutants; Inadequate municipal services (trash removal, sewage treatment facilities); Geographic area (living in area where high level of contaminants exist); Playing in outdoor areas where environmental contaminants are used; Personal/household hygiene practices; Economically disadvantaged (increases potential for multiple exposure, lack of access to healthcare, and poor diet); Use of environmental contaminants in the home, e.g., pesticides, chemicals, environmental tobacco smoke; Lack of breakdown of contaminants once indoors (breakdown is inhibited without sun and rain exposure); Flooring surface (carpeted surfaces hold contaminant residue more than hard floor surfaces); Flaking, peeling paint/plaster in presence of young children; Paint, lacquer, etc. in poorly ventilated areas/without effective protection; Inappropriate use/lack of protective clothing; Unprotected contact with heavy metals or chemicals, e.g., arsenic, chromium, lead; Exposure to radiation (occupation in radiography, employment in nuclear industries and electrical generating plants, living near nuclear industries and/or electrical generating plants); Exposure to disaster (natural or man-made); exposure to bioterrorism

Internal

Age (children less than 5 years, older adults); Gestational age during exposure; Developmental characteristics of children; Female gender; Pregnancy; Nutritional factors, e.g., obesity, vitamin and mineral deficiencies; Pre-existing disease states; Smoking; Concomitant exposure; Previous exposures

COPING, COMPROMISED FAMILY

Diagnostic Division: Social Interaction

Definition: A usually supportive primary person (family member, significant other, or close friend) provides insufficient, ineffective, or compromised support, comfort, assistance, or encouragement that may be needed by the client to manage or master adaptive tasks related to his or her health challenge.

RELATED FACTORS

Coexisting situations affecting the significant person; preoccupation by support person with concern outside of family; Developmental crisis; situational crisis faced by support person; Prolonged disease that exhausts the capacity of support person; Exhaustion of support person's capacity; Insufficient understanding/misunderstanding of information by support person; Insufficient information available to support person; misinformation obtained by support person; Insufficient reciprocal support; Insufficient support given by client to support person; Family disorganization, role change

DEFINING CHARACTERISTICS

Subjective

Client complaint/concern about support person's response to health problem; Support person reports inadequate knowledge or understanding that interferes with effective behaviors; Support person reports preoccupation with own personal reaction to client's need

Objective

Assistive behaviors by support person produce unsatisfactory results; Protective behavior by support person incongruent with client's abilities; Limitation in communication between support person and client; Support person withdraws from client

COPING, DEFENSIVE

Diagnostic Division: Ego Integrity

Definition: Repeated projection of falsely positive self-evaluation based on a self-protective pattern that defends against underlying perceived threats to positive self-regard.

RELATED FACTORS

Conflict between self-perception and value system; uncertainty; Fear of failure, humiliation, or repercussions; insufficient self-confidence; Unrealistic self-expectations; Insufficient resilience; Insufficient confidence in others; insufficient support

DEFINING CHARACTERISTICS

Subjective

Denial of obvious problems/weaknesses; Projection of blame/responsibility; Hypersensitive to a discourtesy/criticism; Grandiosity; Rationalization of failures

Objective

Superior attitude toward others; ridicule of others; hostile laughter; Difficulty establishing/maintaining relationships; Alteration in reality testing; reality distortion; Insufficient participation in or follow-through with treatment

COPING, DISABLED FAMILY

Diagnostic Division: Social Interaction

Definition: Behavior of a primary person (family member, significant other, or close friend) that disables his or her capacities and the client's capacities to effectively address tasks essential to either person's adaptation to the health challenge.

RELATED FACTORS

Chronically unexpressed feelings by support person; Differing coping styles between support person and client; Differing coping styles between support persons; Ambivalent family relationships

DEFINING CHARACTERISTICS

Subjective

Expresses despair regarding family reactions or lack of involvement

Objective

Psychosomatic symptoms; Intolerance; rejection; abandonment; desertion; agitation; aggression; hostility; depression; Performing routines without regard for client's needs; disregard for client's needs; Neglect of basic needs of client, or treatment regimen; Neglect of relationship with family member; Family behaviors detrimental to well-being; Distortion of reality about client's health problem; Impaired ability to structure a meaningful life; impaired individualization; prolonged hyperfocus on client; Adopts illness symptoms of client; Client's dependence

COPING, INEFFECTIVE

Diagnostic Division: Ego Integrity

Definition: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.

RELATED FACTORS

Situational or maturational crisis; inadequate opportunity to prepare for stressor; High degree of threat; inaccurate threat appraisal; Ineffective tension release strategies; Inadequate confidence in ability to deal with a situation; insufficient sense of control; uncertainty; Inadequate resources; insufficient social support; Ineffective tension release strategies; Inability to conserve adaptive energies; Gender differences in coping strategies; Severe/chronic pain

DEFINING CHARACTERISTICS

Subjective

Inability to deal with a situation, ask for help; Alteration in sleep pattern; fatigue; Substance abuse

Objective

Insufficient goal-directed behavior, problem-solving, or problem resolution; Ineffective coping strategies; Inability to meet role expectation/basic needs; Insufficient access of social support; Alteration in concentration; inability to attend to information; difficulty organizing information; Change in communication pattern; Frequent illness; Risk-taking behavior; Destructive behavior toward self/others

COPING, INEFFECTIVE COMMUNITY

Diagnostic Division: Social Interaction

Definition: A pattern of community activities for adaptation and problem-solving that is unsatisfactory for meeting the demands or needs of the community.

RELATED FACTORS

Insufficient community resources, e.g., respite, recreation, social support services; Inadequate resources for problem-solving; Nonexistent community systems; History of exposure to disaster, e.g., natural/man-made

DEFINING CHARACTERISTICS

Subjective

Community does not meet expectations of its members; Perceived community vulnerability/powerlessness; Excessive stressors

Objective

Deficient community participation; Excessive community conflict; Elevated community illness rate; High incidence of community problems, e.g., homicides, vandalism, robbery, terrorism, abuse, unemployment, poverty, militancy, mental illness

COPING, READINESS FOR ENHANCED

Diagnostic Division: Ego Integrity

Definition: A pattern of cognitive and behavioral efforts to manage demands that is sufficient for well-being, which can be strengthened.

DEFINING CHARACTERISTICS

Subjective

Expresses desire to enhance knowledge of stress management strategies, management of stressors; Expresses desire to enhance use of emotion-oriented/problem-oriented strategies; Expresses desire to enhance social support; Awareness of possible environmental change

COPING, READINESS FOR ENHANCED COMMUNITY

Diagnostic Division: Social Interaction

Definition: A pattern of community activities for adaptation and problem solving for meeting the demands or needs of the community, which can be improved.

DEFINING CHARACTERISTICS

Subjective

Expresses desire to enhance problem-solving for identified issue, planning for predictable stressors; Expresses desire to enhance community responsibility for stress management, resources for managing stressors; Expresses desire to enhance communication among community members, between aggregates and larger community; Expresses desire to enhance availability of community recreation/relaxation programs

COPING, READINESS FOR ENHANCED FAMILY

Diagnostic Division: Social Interaction

Definition: A pattern of management of adaptive tasks by primary person (family member, significant other, or close friend) involved with the client's health challenge, which can be strengthened.

DEFINING CHARACTERISTICS

Subjective

Expresses desire to acknowledge growth impact of crisis; Expresses desire to enhance connection with others who have experienced a similar situation; Expresses desire to choose experiences that optimize wellness; Expresses desire to enhance health promotion, enrichment of lifestyle

DEATH ANXIETY

Diagnostic Division: Ego Integrity

Definition: Vague uneasy feeling of discomfort or dread generated by perceptions of a real or imagined threat to one's existence.

RELATED FACTORS

Anticipation of pain, suffering, adverse consequences of anesthesia, impact of death on others; Confronting the reality of terminal disease; experiencing dying process; perceived imminence of death; Discussions on the topic of death; observations related to death; near-death experience; Uncertainty of prognosis; nonacceptance of own mortality; Uncertainty about the existence of a higher power, life after death, an encounter with a higher power

DEFINING CHARACTERISTICS

Subjective

Fear of developing a terminal illness, the dying process, pain/suffering related to dying, loss of mental/[physical] abilities when dying, premature death, or prolonged dying process; Negative thoughts related to death and dying; Deep sadness; powerlessness; Concerns about strain on the caregiver; worried about the impact of one's own death on significant other

DECISIONAL CONFLICT

Diagnostic Division: Ego Integrity

Definition: Uncertainty about course of action to be taken when choice among competing actions involves risk, loss, or challenge to values and beliefs.

RELATED FACTORS

Unclear personal values/beliefs; perceived threat to value system; Inexperience with or interference in decision-making; Insufficient information; conflicting information sources; Conflict with moral obligation; Moral principle, rule, value support mutually inconsistent actions; Insufficient support system deficit; Age; developmental stage/level of functioning

DEFINING CHARACTERISTICS

Subjective

Uncertainty about choices; recognizes undesired consequences of actions being considered; Distress while attempting a decision; Questioning of moral principle, rule, value, or personal beliefs/values while attempting a decision

Objective

Vacillating among choices; delay in decision making; Self-focused; Physical signs of tension or distress, e.g., increase in heart rate, restlessness

DECISION-MAKING, READINESS FOR ENHANCED

Diagnostic Division: Ego Integrity

Definition: A pattern of choosing a course of action for meeting short- and long-term health-related goals, which can be strengthened.

DEFINING CHARACTERISTICS

Subjective

Expresses desire to enhance decision-making, use of reliable evidence for decisions, risk-benefit analysis of decisions; Expresses desire to enhance understanding of choices for decision-making, meaning of choices; Expresses desire to enhance congruency of decisions with values/goal, or sociocultural values/goal

DENIAL, INEFFECTIVE

Diagnostic Division: Ego Integrity

Definition: Conscious or unconscious attempt to disavow the knowledge or meaning of an event to reduce anxiety and/or fear, leading to the detriment of health.

RELATED FACTORS

Anxiety; perceived inadequacy in dealing with strong emotions; Insufficient sense of control; fear of losing autonomy; Excessive stress; ineffective coping strategies; Threat of unpleasant reality; Fear of separation/death; Insufficient emotional support

DEFINING CHARACTERISTICS

Subjective

Minimizes symptoms; Displaces source of symptoms; Does not admit impact of disease on life; Displaces fear of impact of the condition; Denies fear of death/invalidism

Objective

Delay in seeking or refusal of healthcare; Does not perceive relevance of symptoms/danger; Use of dismissive gestures or comments when speaking of distressing event; Inappropriate affect; Use of treatment not advised by healthcare professional

DENTITION, IMPAIRED

Diagnostic Division: Food/Fluid

Definition: Disruption in tooth development/eruption patterns or structural integrity of individual teeth.

RELATED FACTORS

Insufficient dietary habits; malnutrition; Pharmaceutical agent; habitual use of staining substances, e.g., tobacco, coffee, tea, red wine; Insufficient oral hygiene; oral temperature sensitivity; Insufficient knowledge of dental health; excessive intake of fluoride or use of abrasive oral cleaning agents; Barrier to self-care; difficulty accessing dental care; Economically disadvantaged; Genetic predisposition; bruxism

DEFINING CHARACTERISTICS

Subjective

Toothache

Objective

Halitosis; Enamel discoloration; erosion of enamel; excessive oral plaque/calculus; Abraded teeth; dental or root caries; tooth fracture; loose tooth; absence of teeth; Premature loss of primary teeth; incomplete tooth eruption for age; Malocclusion; tooth misalignment; facial asymmetry

DEVELOPMENT, RISK FOR DELAYED

Diagnostic Division: Teaching/Learning

Definition: Vulnerable to delay of 25% or more in one or more of the areas of social or self-regulatory behavior or in cognitive, language, or gross or fine motor skills, which may compromise health.

RISK FACTORS

Prenatal

Maternal age ≤ 15 or ≥ 35 years; Unplanned or unwanted pregnancy; insufficient or late-term prenatal care; Inadequate nutrition; economically disadvantaged; Functional illiteracy; Genetic or endocrine disorder; infection; substance abuse

Individual

Prematurity; congenital or genetic disorder; Visual or hearing impairment; recurrent otitis media; Inadequate nutrition; failure to thrive; Chronic illness; treatment regimen; Brain injury, e.g., hemorrhage, shaken baby syndrome, abuse, or accident; seizures; Positive drug screening; substance abuse; lead poisoning; Involvement with the foster care system; history of adoption; Behavior disorder, e.g., attention deficit, oppositional defiant; Technology dependence, e.g., ventilator, augmentative communication; Natural disaster

Environmental

Economically disadvantaged; Exposure to violence

Caregiver

Learning disability; Presence of abuse, e.g., physical, psychological, or sexual; Mental health issue, e.g., depression, psychosis, personality disorder, or substance abuse

DIARRHEA

Diagnostic Division: Elimination

Definition: Passage of loose, unformed stools.

RELATED FACTORS

Psychological

Increase in stress level; anxiety

Situational

Laxative or substance abuse; exposure to toxin, contaminant; Treatment regimen; Enteral feedings; Travel

Physiological

Gastrointestinal inflammation, irritation; Infection; parasite; Malabsorption

DEFINING CHARACTERISTICS

Subjective

Abdominal pain; Bowel urgency; cramping

Objective

Hyperactive bowel sounds; Loose liquid stools >3 in 24 hours

DISUSE SYNDROME, RISK FOR

Diagnostic Division: Activity/Rest

Definition: Vulnerable to deterioration of body systems as the result of prescribed or unavoidable musculoskeletal inactivity, which may compromise health.

NOTE: Complications from immobility can include pressure ulcer, constipation, stasis of pulmonary secretions, thrombosis, urinary tract infection/retention, decreased strength/endurance, orthostatic hypotension, decreased range of joint motion, disorientation, body image disturbance, and powerlessness.

RISK FACTORS

Alteration in level of consciousness; Mechanical or prescribed immobility; paralysis; Pain

DIVERSIONAL ACTIVITY, DEFICIENT

Diagnostic Division: Activity/Rest

Definition: Decreased stimulation from (or interest or engagement in) recreational or leisure activities.

NOTE: Internal/external factors that may or may not be beyond the individual's control.

RELATED FACTORS

Insufficient diversional activity [e.g., lack of resources]; Prolonged hospitalization/institutionalization; [frequent, lengthy treatments; homebound/bedridden]; Extremes of age; [Physical limitations; fatigue; chronic pain]

DEFINING CHARACTERISTICS

Subjective

Boredom [e.g., wishes there were something to do, to read]

Objective

Current setting does not allow engagement in activities

DRY EYE, RISK FOR

Diagnostic Division: Safety

Definition: Vulnerable to eye discomfort or damage to the cornea and conjunctiva due to reduced quantity or quality of tears to moisten the eye, which may compromise health.

RISK FACTORS

Aging; female gender; hormonal change; vitamin A deficiency; Autoimmune disease, e.g., rheumatoid arthritis, diabetes mellitus; history of allergy; Contact lens wearer; ocular surface damage; Environmental factor, e.g., air conditioning, excessive wind, sunlight exposure, air pollution, low humidity; Lifestyle choice, e.g., smoking, caffeine use, prolonged reading/(computer use); Neurological lesion with sensory or motor reflex loss, e.g., lagophthalmos, lack of spontaneous blink reflex; Treatment regimen; mechanical ventilation

DYSFUNCTION, RISK FOR PERIPHERAL NEUROVASCULAR

Diagnostic Division: Neurosensory

Definition: Vulnerable to disruption in the circulation, sensation, and motion of an extremity, which may compromise health.

RISK FACTORS

Burns; trauma; vascular obstruction; Fracture; immobilization; orthopedic surgery; Mechanical compression, e.g., tourniquet, cane, cast, brace, dressing, restraint

ELECTROLYTE IMBALANCE, RISK FOR

Diagnostic Division: Food/Fluid

Definition: Vulnerable to changes in serum electrolyte levels that may compromise health.

RISK FACTORS

Insufficient fluid volume; diarrhea; vomiting; Excessive fluid volume; Endocrine regulatory dysfunction, e.g., glucose intolerance, increase in IGF-1, androgen, DHEA, and cortisol; renal dysfunction; Compromised regulatory mechanisms [e.g., diabetes insipidus, syndrome of inappropriate secretion of antidiuretic hormone]; Treatment regimen

ELIMINATION, IMPAIRED URINARY

Diagnostic Division: Elimination

Definition: Dysfunction in urine elimination.

RELATED FACTORS

Multiple causality; sensory motor impairment; anatomic obstruction; urinary tract infection; [fluid/volume states; psychogenetic factors; surgical diversion]

DEFINING CHARACTERISTICS

Subjective

Frequent voiding; urinary urgency; Hesitancy; Dysuria; Nocturia; [enuresis]

Objective

Urinary Incontinence; Urinary Retention

ELIMINATION, READINESS FOR ENHANCED URINARY

Diagnostic Division: Elimination

Definition: A pattern of urinary functions for meeting eliminatory needs, which can be strengthened.

DEFINING CHARACTERISTICS

Subjective

Expresses desire to enhance urinary elimination

EMANCIPATED DECISION-MAKING, IMPAIRED

Diagnostic Division: Ego Integrity

Definition: A process of choosing a healthcare decision that does not include personal knowledge and/or consideration of social norms or does not occur in a flexible environment, resulting in decisional dissatisfaction.

RELATED FACTORS

Traditional hierarchical family or healthcare systems; Limited decision-making experience; Decrease in understanding of all available healthcare options; Inability to adequately verbalize perceptions about healthcare options; Inadequate time to discuss healthcare options; insufficient privacy to openly discuss healthcare options

DEFINING CHARACTERISTICS

Subjective

Feeling constrained in describing own option; Inability to choose a healthcare option that best fits current lifestyle; Inability to describe how option will fit into current lifestyle; Excessive concern about what others think is the best decision; Excessive fear of what others think about decision

Objective

Delay in enacting chosen healthcare option; Distress when listening to other's opinion; Limited verbalization about healthcare option in other's presence

EMANCIPATED DECISION-MAKING, READINESS FOR ENHANCED

Diagnostic Division: Ego Integrity

Definition: A process of choosing a healthcare decision that includes personal knowledge and/or consideration of social norms, which can be strengthened.

DEFINING CHARACTERISTICS

Subjective

Expresses desire to enhance: Decision making; confidence in decision making; Ability to understand all available healthcare options; Privacy to discuss healthcare options; confidence to discuss healthcare options openly; Ability to verbalize own options without constraint; comfort to verbalize healthcare options in the presence of others; Ability to choose healthcare options that best fit current lifestyle; ability to enact chosen healthcare options

EMANCIPATED DECISION-MAKING, RISK FOR IMPAIRED

Diagnostic Division: Ego Integrity

Definition: Vulnerable to a process of choosing a healthcare decision that does not include personal knowledge and/or consideration of social norms or does not occur in a flexible environment, resulting in decisional dissatisfaction.

RISK FACTORS

Traditional hierarchical family or healthcare systems; Limited decision-making experience; insufficient self-confidence in decision making; Insufficient information regarding healthcare options; Inadequate time to discuss healthcare options; Insufficient confidence or privacy to openly discuss healthcare options

NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred; rather, nursing interventions are directed at prevention.

EMOTIONAL CONTROL, LABILE

Diagnostic Division: Ego Integrity

Definition: Uncontrollable outbursts of exaggerated and involuntary emotional expression.

RELATED FACTORS

Fatigue; insufficient muscle strength; musculoskeletal impairment; Functional impairment; physical disability; Stressors; social distress; alteration in self-esteem; Brain injury; Emotional disturbance; mood disorder; psychiatric disorder; Insufficient knowledge of disease or about symptom control; Pharmaceutical agent; substance abuse

DEFINING CHARACTERISTICS

Subjective

Embarrassment regarding emotional expression; Excessive laughing/crying without feeling happiness; Expression of emotion incongruent with triggering factor

Objective

Uncontrollable/involuntary crying, laughing; Tearfulness; Absence of eye contact; Difficulty in use of facial expressions; Withdrawal from social or occupational situations

FALLS, RISK FOR

Diagnostic Division: Safety

Definition: Vulnerable to increased susceptibility to falling, which may cause physical harm and compromise health.

RISK FACTORS

Adults:

Age 65 or over; living alone; History of falls; Use of assistive device, e.g., walker, cane, wheelchair; Lower-limb prosthesis

Physiological:

Acute illness; postoperative recovery period; Alteration in blood glucose level; anemia; Arthritis; condition affecting the foot; decrease in lower extremity strength; difficulty with gait; Diarrhea; incontinence; urinary urgency; Faintness when extending or turning neck; orthostatic hypotension; Hearing or visual impairment; Impaired balance or mobility; proprioceptive deficit; neuropathy; Sleeplessness

Cognitive:

Alteration in cognitive functioning

Pharmaceutical Agents:

Alcohol consumption; Pharmaceutical agent

Environment:

Use of restraints; Exposure to unsafe weather-related condition, e.g., wet floors, ice; Cluttered environment; use of throw rugs; insufficient antislip material in bathroom; Unfamiliar setting; insufficient lighting

Children

Age ≤2; male gender when >1 year of age [Note: Centers for Disease Control and Prevention (CDC) statistics suggest male gender is a factor for children age 1 to 19 but gender not significant during first year of life]; Absence of stairway gate or window guard: insufficient automobile restraints; Inadequate supervision

FAMILY PROCESSES, DYSFUNCTIONAL

Diagnostic Division: Social Interaction

Definition: Psychosocial, spiritual, and physiological functions of the family unit are chronically disorganized, which leads to conflict, denial of problems, resistance to change, ineffective problem-solving, and a series of self-perpetuating crises.

RELATED FACTORS

Substance abuse; Family history of substance abuse; resistance to treatment; Ineffective coping strategies; Addictive personality; Insufficient problem-solving skills; Biochemical influences; Genetic predisposition to substance abuse

DEFINING CHARACTERISTICS

Subjective

Feelings

Anxiety, tension, distress; low self-esteem; worthlessness; lingering resentment; Anger; frustration; shame; embarrassment; hurt; unhappiness; guilt; Emotional isolation; loneliness; powerlessness; insecurity; hopelessness; rejection; Taking responsibility for substance abuser's behavior; vulnerability; mistrust; Depression; hostility; fear; confusion; dissatisfaction; loss; Feeling different from others; feeling unloved, misunderstood; Emotionally controlled by others; loss of identity; Abandonment; confuses love and pity; moodiness; failure

Roles and Relationships

Family denial; deterioration in family relationships; disturbance in family dynamics; ineffective communication with partner; intimacy dysfunction; Change in role function; disrupted family roles; inconsistent parenting; perceived insufficient parental support; chronic family problems; Insufficient relationship skills; insufficient cohesiveness; disrupted family rituals; Pattern of rejection; economically disadvantaged; neglect of obligation to family member

Objective

Feelings

Repressed emotions; Surgical procedure

Roles and Relationships

Closed communication system; Conflict between partners; diminished ability of family members to relate to each other for mutual growth and maturation; Insufficient family respect for individuality or autonomy of its members

Behaviors

Substance abuse; Nicotine addiction; Enabling substance use pattern; insufficient knowledge about substance abuse; Special occasions centered on substance use; Rationalization; denial of problems; refusal to get help; inability to accept or receive help appropriately; Inappropriate anger expression; blaming; criticizing; verbal abuse of children, partner, or parent; Lying; broken promises; unreliable behavior; manipulation; dependency; Inability to express or accept a wide range of feelings; difficulty with intimate relationship; decrease in physical contact; Harsh self-judgment; difficulty having fun; self-blaming; social isolation; complicated grieving; seeking of approval or affirmation; Ineffective communication skills; controlling, contradictory, or paradoxical communication pattern; power struggles; Insufficient problem-solving skills; conflict avoidance; orientation favors tension relief rather than goal attainment; agitation; escalating conflict; chaos; Alteration in concentration; disturbance in academic performance in children; failure to accomplish developmental tasks; difficulty with life-cycle transition; Inability to meet the emotional, security, or spiritual needs of its members; Inability to adapt to change; immaturity; stress-related physical illnesses; inability to deal constructively with traumatic experiences

FAMILY PROCESSES, INTERRUPTED

Diagnostic Division: Social Interaction

Definition: Change in family relationships and/or functioning.

RELATED FACTORS

Situational transition or crisis; Developmental transition or crisis; Shift in health status of a family member; Shift in family roles; power shift among family members; Alteration in family finances; Change in family social status, or interaction with community

DEFINING CHARACTERISTICS

Subjective

Changes in relationship pattern; alteration in family satisfaction; Alteration in availability for affective responsiveness; decrease in mutual support; decrease in available emotional support; alteration in intimacy; Changes in expression of conflict with, or isolation from, community resources

Objective

Assigned tasks change; ineffective task completion; alteration in participation for problem-solving; change in participation for decision-making; Change in communication pattern; alteration in family conflict resolution; power alliance changes; Change in stress-reduction behavior; change in somatization

FAMILY PROCESSES, READINESS FOR ENHANCED

Diagnostic Division: Social Interaction

Definition: A pattern of family functioning that is sufficient to support the well-being of family members and can be strengthened.

DEFINING CHARACTERISTICS

Subjective

Expresses desire to enhance: Family dynamics; Communication pattern; Interdependence with community; Energy level of family to support activities of daily living; Family adaptation to change; Growth/safety of family members; Family resilience; Respect for family members; Maintenance of boundaries between family members; Balance between autonomy and cohesiveness

FATIGUE

Diagnostic Division: Activity/Rest

Definition: An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at the usual level.

RELATED FACTORS

Stressors; anxiety; depression; Nonstimulating lifestyle; negative life event; occupational demands, e.g., shift work, high level of activity, stress; Environmental barrier, e.g., ambient noise, daylight/darkness exposure, ambient temperature/humidity, unfamiliar setting; Increase in physical exertion; sleep deprivation; Physiological condition, e.g., pregnancy, disease, anemia; malnutrition; Physical deconditioning; Altered body chemistry, e.g., medications, drug withdrawal, chemotherapy

DEFINING CHARACTERISTICS

Subjective

Insufficient energy; impaired ability to maintain usual routines or usual physical activity; Tiredness; nonrestorative sleep pattern, i.e., due to caregiver responsibilities, parenting practices, sleep partner; Guilt about difficulty maintaining responsibilities; Alteration in libido; Increase in physical symptoms, rest requirements

Objective

Lethargy; listlessness; drowsiness; Alteration in concentration; Disinterest in surroundings; introspection; Ineffective role performance

FEAR

Diagnostic Division: Ego Integrity

Definition: Response to perceived threat that is consciously recognized as a danger.

RELATED FACTORS

Innate response to stimuli, e.g., sudden noise, height; innate releasing mechanism to external stimuli, e.g., neurotransmitters; phobic stimulus; Learned response [e.g., conditioning, modeling from others]; Unfamiliar setting; Separation from support system; Language barrier; sensory deficit, e.g., visual, hearing

DEFINING CHARACTERISTICS

Subjective

Apprehensiveness; excitedness; decrease in self-assurance; increase in tension; jitteriness; nausea; Feeling alarm, dread, fear, terror, panic

Cognitive

Identifies object of fear; Stimulus believed to be a threat

Physiological

Anorexia; Fatigue; Dry mouth; dyspnea; [Palpitations]

Objective

Vomiting; muscle tension; pallor; increase in blood pressure; pupil dilation

Cognitive

Decrease in productivity, learning ability, or problem-solving ability

Behaviors

Increase in alertness; avoidance behaviors; attack behaviors; impulsiveness; focus narrowed to the source of fear

Physiological

Increased pulse; diarrhea; increase in respiratory rate; change in physiological response, e.g., blood pressure, heart rate, respiratory rate, oxygen saturation and end-tidal CO2; increase in perspiration

FEEDING PATTERN, INEFFECTIVE INFANT

Diagnostic Division: Food/Fluid

Definition: Impaired ability of an infant to suck or coordinate the suck/swallow response resulting in inadequate oral nutrition for metabolic needs.

RELATED FACTORS

Prematurity; Neurological delay or impairment, e.g., positive EEG, head trauma, seizure disorder; Oral hypersensitivity; Prolonged nil by mouth (NPO); Otopharyngeal defect

DEFINING CHARACTERISTICS

Subjective

[Caregiver reports infant's inability to achieve effective suck]

Objective

Inability to initiate or sustain effective suck; Inability to coordinate sucking, swallowing, and breathing

FLUID BALANCE, READINESS FOR ENHANCED

Diagnostic Division: Food/Fluid

Definition: A pattern of equilibrium between the fluid volume and chemical composition of body fluids which can be strengthened.

DEFINING CHARACTERISTICS

Subjective

Expresses desire to enhance fluid balance

[FLUID VOLUME, DEFICIENT HYPER/HYPOTONIC]

Diagnostic Division: Food/Fluid

Definition: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration with changes in sodium.

NOTE: NANDA-I has restricted Fluid Volume deficit to address only isotonic dehydration. For patient needs related to dehydration associated with alterations in sodium, the authors have provided this second diagnostic label.

RELATED FACTORS

[Hypertonic dehydration: uncontrolled diabetes mellitus/insipidus, hyperosmolar hyperglycemic state (HHS), increased intake of hypertonic fluids/IV therapy, inability to respond to thirst reflex, inadequate free water supplementation (high-osmolarity enteral feeding formulas), renal insufficiency or failure]; [Hypotonic dehydration: chronic illness, malnutrition, excessive use of hypotonic IV solutions, e.g., D5W, renal insufficiency]

DEFINING CHARACTERISTICS

Subjective

[Reports of fatigue, nervousness, exhaustion]; [Thirst]

Objective

[Increased urine output, dilute urine (initially)]; [Decreased output/oliguria]; [Weight loss]; [Decreased venous filling]; [Hypotension (postural)]; [Increased pulse rate]; [Decreased pulse volume/pressure]; [Decreased skin turgor]; [Dry skin/mucous membranes]; [Increased body temperature]; [Change in mental status, e.g., confusion]; [Hemoconcentration]; [Altered serum sodium]

FLUID VOLUME, DEFICIENT [ISOTONIC]

Diagnostic Division: Food/Fluid

Definition: Decreased intravascular, interstitial and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium.

NOTE: This diagnosis has been structured to address isotonic dehydration (hypovolemia) when fluids and electrolytes are lost in even amounts and excluding states in which changes in sodium occur. For client needs related to dehydration associated with alterations in sodium, refer to [deficient hyper/hypotonic Fluid Volume]

RELATED FACTORS

Active fluid volume loss [e.g., hemorrhage, gastric intubation, acute or prolonged diarrhea, wounds, abdominal cancer; burns, fistulas, ascites (third spacing); use of hyperosmotic radiopaque contrast agents]; Compromised regulatory mechanisms [e.g., fever, thermoregulatory response, renal tubule damage]

DEFINING CHARACTERISTICS

Subjective

Thirst; Weakness

Objective

Alteration in mental status; Alteration in skin or tongue turgor; dry skin and mucous membranes; Decrease in blood pressure; decrease in pulse pressure and volume; decrease in venous filling; Decrease in urine output; Increase in body temperature and heart rate; Increase in hematacrit and urine concentration; Sudden weight loss

FLUID VOLUME EXCESS

Diagnostic Division: Food/Fluid

Definition: Increased isotonic fluid retention.

RELATED FACTORS

Compromised regulatory mechanism [e.g., syndrome of inappropriate antidiuretic hormone (SIADH), or decreased plasma proteins]; Excessive fluid intake; Excessive sodium intake

DEFINING CHARACTERISTICS

Subjective

Anxiety; Orthopnea; paroxysmal nocturnal dyspnea

Objective

Edema; Anasarca; Weight gain over short period of time; Intake exceeds output; Oliguria; Adventitious breath sounds [rales or crackles]; Changes in respiratory pattern; Dyspnea; Pulmonary congestion; Pleural effusion; Pulmonary artery pressure changes (PAP); Alteration in blood pressure; Increased central venous pressure (CVP); Jugular vein distension; Positive hepatojugular reflex; Hepatomegaly; Presence of S3 heart sound; Change in mental status; Restlessness; Decrease in hemoglobin or hematocrit; Azotemia; Electrolyte imbalance; Alteration in urine-specific gravity

FLUID VOLUME, RISK FOR DEFICIENT

Diagnostic Division: Food/Fluid

Definition: Vulnerable to experiencing decreased intravascular, interstitial, and/or intracellular fluid volumes, which may compromise health.

RISK FACTORS

Active fluid volume loss; excessive fluid loss through normal routes [e.g., diarrhea]; Barrier to accessing fluid; deviations affecting intake or absorption; Extremes of age or weight; Factors influencing fluid needs [e.g., hypermetabolic state]; Fluid loss through abnormal routes [e.g., indwelling tubes]; compromised regulatory mechanism; Insufficient knowledge about fluid needs; Pharmaceutical agent [e.g., diuretics]

FLUID VOLUME, RISK FOR IMBALANCED

Diagnostic Division: Food/Fluid

Definition: Vulnerable to a decrease, increase, or rapid shift from one to the other of intravascular, interstitial, and/or intracellular fluid, which may compromise health. This refers to body fluid loss, gain, or both.

RISK FACTORS

Intestinal obstruction; Pancreatitis; ascites; Burns; sepsis; Trauma; Treatment regimen; apheresis

FRAIL ELDERLY SYNDROME

Diagnostic Division: Safety

Definition: Dynamic state of unstable equilibrium that affects the older individual experiencing deterioration in one or more domain of health (physical, functional, psychological, or social) and leads to increased susceptibility to adverse health effects, in particular disability.

RELATED FACTORS

Alteration in cognitive functioning; psychiatric disorder; chronic illness; prolonged hospitalization; malnutrition; sarcopenia; sarcopenic obesity; history of falls; living alone; sedentary lifestyle

DEFINING CHARACTERISTICS

Subjective

Activity intolerance; Fatigue; Hopelessness

Objective

Bathing, dressing, feeding, or toileting self-care deficit; decreased cardiac output; imbalanced nutrition: less than body requirements; impaired memory; impaired physical mobility; impaired walking; social isolation

FRAIL ELDERLY SYNDROME, RISK FOR

Diagnostic Division: Safety

Definition: Vulnerable to a dynamic state of unstable equilibrium that affects the older individual experiencing deterioration in one or more domain of health (physical, functional, psychological, or social) and leads to increased susceptibility to adverse health effects, in particular, disability.

RISK FACTORS

Activity intolerance; average daily physical activity is less than recommended for gender and age; decrease in energy; exhaustion; sedentary lifestyle; Age >70 years; female gender; ethnicity other than Caucasian; Alteration in cognitive functioning; Anorexia; malnutrition; decrease in serum 25–hydroxyvitamin D concentration; Anxiety; depression; sadness; Chronic illness; prolonged hospitalization; Decrease in muscle strength; muscle weakness; walking 15 feet requires >6 seconds (4 meters >5 seconds); Fear of falling; history of falls; Impaired balance or mobility; immobility; Sensory deficit, e.g., visual, hearing; Sarcopenia; unintentional weight loss of 25% body weight over one year; unintentional weight loss >10 pounds (>4.5 Kg) in one year; Obesity; sarcopenic obesity; Endocrine regulatory dysfunction, e.g., glucose intolerance, increase in IGF-1, androgen, DHEA, and cortisol; Suppressed inflammatory response, e.g., IL-6, CRP; altered clotting process, e.g., factor VII, D-dimers; Constricted life space; economically disadvantaged; low educational level; Insufficient social support; living alone; social isolation; Social vulnerability, e.g., disempowerment, decreased life control

GAS EXCHANGE, IMPAIRED

Diagnostic Division: Respiration

Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane [This may be an entity of its own but also may be an end result of other pathology with an interrelatedness between airway clearance and/or breathing pattern problems.]

RELATED FACTORS

Ventilation-perfusion imbalance [as in altered blood flow, e.g., pulmonary embolus, increased vascular resistance, vasospasm, heart failure, hypovolemic shock]; Alveolar-capillary membrane changes [e.g., acute adult respiratory distress syndrome); chronic conditions such as restrictive/obstructive lung disease, pneumoconiosis, respiratory depressant drugs, brain injury, asbestosis/silicosis]; [Altered oxygen supply, e.g., altitude sickness]; [Altered oxygen-carrying capacity of blood, e.g., sickle cell/other anemia, carbon monoxide poisoning]

DEFINING CHARACTERISTICS

Subjective

Dyspnea; Visual disturbances; Headache upon awakening; [sense of impending doom]

Objective

Confusion; [Decreased mental acuity]; Restlessness; Irritability; [Agitation]; Somnolence; [Lethargy]; Abnormal ABGs/arterial pH; Hypoxia; Hypoxemia; Hypercapnia; Decreased carbon dioxide; Cyanosis (in neonates only); Abnormal skin color, e.g., pale, dusky; Abnormal breathing, e.g., rate, rhythm, depth; Nasal flaring; Tachycardia; [Dysrhythmias]; Diaphoresis; [Polycythemia]

GASTROINTESTINAL MOTILITY, DYSFUNCTIONAL

Diagnostic Division: Elimination

Definition: Increased, decreased, ineffective, or lack of peristaltic activity within the gastrointestinal system.

RISK FACTORS

Aging; prematurity; Anxiety; stressors; Change in water source; unsanitary food preparation; Decrease in gastrointestinal circulation; gastroesophageal reflux disease; diabetes mellitus; Eating habit change, e.g., foods, eating times; food intolerance; Immobility; sedentary lifestyle; Pharmaceutical agent; Infection

RELATED FACTORS

Aging, prematurity; Anxiety; Enteral feedings; treatment regimen; Food intolerance [e.g., gluten, lactose]; malnutrition; Immobility; sedentary lifestyle; Ingestion of contaminated material, e.g., radioactive, food, water

DEFINING CHARACTERISTICS

Subjective

Absence of flatus; Abdominal cramping, pain; Diarrhea, Difficulty passing stool; Nausea, regurgitation

Objective

Change in bowel sounds, e.g., absent, hypoactive, hyperactive; Abdominal distension; Accelerated gastric emptying, diarrhea; Increased gastric residual, bile-colored gastric residual; Dry stool, hard stool; Vomiting

GASTROINTESTINAL MOTILITY, RISK FOR DYSFUNCTIONAL

Diagnostic Division: Elimination

Definition: Vulnerable to a decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool, which may compromise health.

RISK FACTORS

Aging; prematurity; Anxiety; stressors; Change in water source; unsanitary food preparation; Decrease in gastrointestinal circulation; gastroesophageal reflux disease; diabetes mellitus; Eating habit change, e.g., foods, eating times; food intolerance; Immobility; sedentary lifestyle; Pharmaceutical agent; Infection

RELATED FACTORS

Aging, prematurity; Anxiety; Enteral feedings; treatment regimen; Food intolerance [e.g., gluten, lactose]; malnutrition; Immobility; sedentary lifestyle; Ingestion of contaminated material, e.g., radioactive, food, water

GASTROINTESTINAL PERFUSION, RISK FOR INEFFECTIVE

Diagnostic Division: Circulation

Definition: Vulnerable to decrease in gastrointestinal circulation, which may compromise health.

RISK FACTORS

Abdominal aortic aneurysm; abdominal compartment syndrome; Abnormal prothrombin time (PT); abnormal partial thromboplastin time (PTT); coagulopathy, e.g., sickle sell anemia; anemia; disseminated intravascular coagulopathy; hemodynamic instability; Age >60 years; female gender; Cerebral vascular accident; vascular disease; diabetes mellitus; Gastrointestinal condition, e.g., ulcer, ischemic colitis or pancreatitis; acute gastrointestinal hemorrhage; gastroesophageal varicies; Impaired liver function, e.g., cirrhosis, hepatitis; Myocardial infarction; decrease in left ventricular performance; Renal disease, e.g., polycystic kidney, renal artery stenosis, failure; Smoking; Trauma; treatment regimen

GRIEVING

Diagnostic Division: Ego Integrity

Definition: A normal complex process that includes emotional, physical, spiritual, social, and intellectual responses and behaviors by which individuals, families, and communities incorporate an actual, anticipated, or perceived loss into their daily lives.

RELATED FACTORS

Anticipatory loss of a significant object, e.g., possession, job, status, home, body part; Anticipatory loss or death of a significant other

DEFINING CHARACTERISTICS

Subjective

Anger; pain; suffering; despair; blaming; Alteration in activity level, sleep pattern, dream patterns; Finding meaning in a loss; personal growth; Guilt about feeling relief

Objective

Detachment; Disorganization; Psychological distress; Panic behavior; Maintaining the connection to the deceased; Alterations in immune or neuroendocrine functioning

GRIEVING, COMPLICATED

Diagnostic Division: Ego Integrity

Definition: A disorder that occurs after the death of a significant other, in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment.

RELATED FACTORS

Death of a significant other; Emotional instability; [loss of significant object, e.g., possessions, job, status, home, parts and processes of body]; Insufficient social support

DEFINING CHARACTERISTICS

Subjective

Anxiety; nonacceptance of a death; persistent painful memories; distress about the deceased person; self-blame; Anger, disbelief, mistrust; Feeling dazed, detachment from others, stunned, of emptiness, shock; Insufficient sense of well-being; fatigue; low levels of intimacy; depression; Yearning for deceased person

Objective

Decrease in functioning in life roles; Excessive stress; separation or traumatic distress; Preoccupation with thoughts about a deceased person; longing/searching for a deceased person; Experiencing symptoms the deceased experienced; Rumination; Avoidance of grieving

GRIEVING, RISK FOR COMPLICATED

Diagnostic Division: Ego Integrity

Definition: Vulnerable to a disorder that occurs after death of a significant other, in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment, which may compromise health.

RISK FACTORS

Death of a significant other; Emotional instability; Insufficient of social support

GROWTH, RISK FOR DISPROPORTIONATE

Diagnostic Division: Teaching/Learning

Definition: Vulnerable to growth above the 97th percentile or below the 3rd percentile for age, crossing two percentile channels, which may compromise health.

RISK FACTORS

Prenatal

Decrease in functioning in life roles; Excessive stress; separation or traumatic distress; Preoccupation with thoughts about a deceased person; longing/searching for a deceased person; Experiencing symptoms the deceased experienced; Rumination; Avoidance of grieving

Individual

Prematurity; Malnutrition; maladaptive feeding behaviors, or self-feeding; insatiable appetite; anorexia; Infection; chronic illness; Substance abuse [including anabolic steroids]

Environmental

Deprivation; Economically disadvantaged; Exposure to violence; natural disasters; Exposure to teratogen; lead poisoning

Caregiver

Presence of abuse, e.g., physical, psychological, sexual; Mental health issue, e.g., depression, psychosis, personality disorder, substance abuse; Learning disability; alteration in cognitive functioning

HEALTH, DEFICIENT COMMUNITY

Diagnostic Division: Teaching/Learning

Definition: Presence of one or more health problems or factors that deter wellness or increase the risk of health problems experienced by an aggregate.

RELATED FACTORS

Insufficient access to healthcare providers; insufficient resources, e.g., financial, social, knowledge; Insufficient community experts; Inadequate program budget, outcome data, or evaluation plan; Inadequate social support or consumer satisfaction with program

DEFINING CHARACTERISTICS

Subjective

[Community members or agencies verbalize overburdening of resources or inability to meet therapeutic needs of all members.]

Objective

Risk of hospitalization experienced by aggregates or populations; Risk of physiological or psychological states experienced by aggregates or populations; Health problem experienced by aggregates or populations; Program unavailable to enhance wellness of an aggregate or population; Program unavailable to prevent, reduce, or eliminate health problem(s) of an aggregate or population

HEALTH BEHAVIOR, RISK-PRONE

Diagnostic Division: Teaching/Learning

Definition: Inability to modify lifestyle/behaviors in a manner that improves health status.

RELATED FACTORS

Inadequate comprehension; Low self-efficacy; stressors; Smoking, substance abuse; Insufficient social support; economically disadvantaged; Negative attitude toward healthcare

DEFINING CHARACTERISTICS

Subjective

Minimization of health status change; Failure to achieve optimal sense of control

Objective

Failure to take action that prevents health problems; Nonacceptance of health status change

HEALTH MAINTENANCE, INEFFECTIVE

Diagnostic Division: Safety

Definition: Inability to identify, manage, and/or seek out help to maintain health.

NOTE: This diagnosis contains components of other NDs. We suggest subsuming health maintenance interventions under the “basic” nursing diagnosis when a single causative factor is identified, e.g., deficient Knowledge [specify]; ineffective Health Management; chronic Confusion; impaired verbal Communication; ineffective Coping; compromised family Coping; risk for delayed Development).

RELATED FACTORS

Ineffective communication skills; Unachieved developmental tasks; Alteration in cognitive functioning; impaired decision-making; Perceptual impairment; Decrease in gross or fine motor skills; Ineffective coping strategies; complicated grieving; spiritual distress; Insufficient resources, e.g., financial, social, knowledge

DEFINING CHARACTERISTICS

Objective

Insufficient knowledge about basic health practices; Absence of interest in improving health behaviors; pattern of lack of health-seeking behavior; Absence of adaptive behaviors to environmental changes; Insufficient social support

HEALTH MANAGEMENT, INEFFECTIVE

Diagnostic Division: Teaching/Learning

Definition: Pattern of regulating and integrating into daily living a therapeutic regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals.

RELATED FACTORS

Complexity of healthcare system or therapeutic regimen; Decisional conflicts; Economically disadvantaged; Excessive demands; family conflict; Family pattern of health-care; Inadequate number of cues to action; Insufficient knowledge of therapeutic regimen; Perceived seriousness of condition, susceptibility, benefit, or barrier; Powerlessness; Insufficient social support

DEFINING CHARACTERISTICS

Subjective

Difficulty with prescribed regimens

Objective

Reports desire to manage the illness; Reports difficulty with prescribed regimens

HEALTH MANAGEMENT, INEFFECTIVE FAMILY

Diagnostic Division: Health Promotion

Definition: A pattern of regulating and integrating into family processes a program for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals.

RELATED FACTORS

Complexity of healthcare system/therapeutic regimen; Decisional conflicts; Economic difficulties; Excessive demands; Family conflict

DEFINING CHARACTERISTICS

Subjective

Reports difficulty with prescribed regimen; Reports desire to manage the illness

Objective

Failure to include treatment regimen in daily living, or to take action to reduce risk factors; Ineffective choices in daily living for meeting health goal; Unexpected acceleration of illness symptoms

HEALTH MANAGEMENT, READINESS FOR ENHANCED

Diagnostic Division: Teaching/Learning

Definition: A pattern of regulating and integrating into daily living a therapeutic regimen for the treatment of illness and its sequelae, which can be strengthened.

DEFINING CHARACTERISTICS

Subjective

Expresses desire to enhance management of illness, symptoms, or risk factors; Expresses desire to enhance management of prescribed regimens; Expresses desire to enhance immunization/vaccination status; Expresses desire to enhance choices of daily living for meeting goals

HOME MAINTENANCE, IMPAIRED

Diagnostic Division: Safety

Definition: Inability to independently maintain a safe growth-promoting immediate environment.

RELATED FACTORS

Condition impacting ability to maintain home, e.g., disease; illness; injury; Illness/injury impacting ability to maintain home; Alteration in cognitive functioning; Insufficient role model, support system; Insufficient knowledge of home maintenance, neighborhood resources

DEFINING CHARACTERISTICS

Subjective

Difficulty maintaining a comfortable [safe] environment; Request for assistance with home maintenance; Excessive family responsibilities; Financial crisis, e.g., debt, insufficient finances

Objective

Unsanitary environment; Pattern of disease or infection caused by unhygienic conditions; Insufficient equipment for maintaining home; insufficient cooking equipment, clothing, or linen

HOPE, READINESS FOR ENHANCED

Diagnostic Division: Ego Integrity

Definition: A pattern of expectations and desires for mobilizing energy on one's own behalf, which can be strengthened.

DEFINING CHARACTERISTICS

Subjective

Expresses desire to enhance hope; belief in possibilities; congruency of expectation with goal; ability to set achievable goals; problem-solving to meet goals; Expresses desire to enhance sense of meaning in life; connectedness with others; spirituality

HOPELESSNESS

Diagnostic Division: Ego Integrity

Definition: Subjective state in which an individual sees limited or no alternatives or personal choices available and is unable to mobilize energy on own behalf.

RELATED FACTORS

Prolonged activity restriction, social isolation; Deteriorating physiological condition; Chronic stress; history of abandonment; Lost belief in spiritual power or transcendent values

DEFINING CHARACTERISTICS

Subjective

Despondent verbal cues (despondent content, “I can't,” sighing); [Believes things will not change/problems will always be there]

Objective

Passivity; Decrease in verbalization; Decrease in affect, appetite, or response to stimuli; Decrease in initiative; inadequate /involvement in care; Alteration in sleep pattern; Turning away from speaker; Shrugging in response to speaker; poor eye contact

HUMAN DIGNITY, RISK FOR COMPROMISED

Diagnostic Division: Ego Integrity

Definition: Vulnerable for perceived loss of respect and honor, which may compromise health.

RISK FACTORS

Loss of control over body function; exposure of the body; Humiliation; invasion of privacy; Disclosure of confidential information; stigmatization; Dehumanizing treatment; intrusion by clinician; Insufficient comprehension of health information; Little decision-making experience; Cultural incongruence

HYPERTHERMIA

Diagnostic Division: Safety

Definition: Core body temperature above the normal diurnal range due to failure of thermoregulation.

RELATED FACTORS

Decreased sweat response; dehydration; vigorous activity; High environmental temperature; inappropriate clothing; Illness; increase in metabolic rate; ischemia; sepsis; Pharmaceutical agent; Trauma

DEFINING CHARACTERISTICS

Objective

Abnormal posturing; convulsion, seizure; Flushed skin; skin warm to touch; vasodilation; Hypotension; tachycardia; tachypnea; apnea; Irritability; lethargy; stupor; coma; Infant does not maintain suck

HYPOTHERMIA

Diagnostic Division: Safety

Definition: Core body temperature below the normal diurnal range due to failure of thermoregulation.

RELATED FACTORS

Alcohol consumption; Economically disadvantaged; Extremes of age or weight; Insufficient clothing; Heat transfer, e.g., conduction, convection, evaporation, radiation; Insufficient knowledge of hypothermia prevention; Malnutrition; decrease in metabolic rate; insufficient supply of subcutaneous fat; inactivity; Pharmaceutical agent, [drug overdose]; Trauma; damage to hypothalamus; radiation

Neonates

High risk or unplanned out-of-hospital birth; early bathing of newborn; delay in breastfeeding; Immature stratum corneum; Increased body surface area to weight ratio; Increase in oxygen demand; increase in pulmonary vascular resistance (PVR); ineffective vascular control; Insufficient nonshivering thermogenesis

DEFINING CHARACTERISTICS

Objective

Acrocyanosis, cyanotic nail beds; peripheral vasoconstriction; hypoxia; Bradycardia; tachycardia; Decrease in blood glucose level; hypoglycemia; Increase in metabolic rate; increase in oxygen consumption; Shivering; piloerection; Skin cool to touch; slow capillary refill

Accidental Low Body Temperature in Children and Adults

Mild hypothermia, core temperature 32°–35°C (89.6°–95°F); Moderate hypothermia, core temperature 30°–32°C (86°–89.6°F); Severe hypothermia, core temperature <30°C (86°F)

Injured Adults and Children

Hypothermia, core temperature <35°C (95°F); Severe hypothermia, core temperature <32°C (89.6°F)

Neonates

Grade 1 hypothermia, core temperature 36°–36.5°C (96.8°–97.7°F); Grade 2 hypothermia, core temperature 35°–35.9°C (95°–96.6°F); Grade 3 hypothermia, core temperature 34°–34.9°C (93.2°–94.8°F); Grade 4 hypothermia, core temperature <34°C (93.2°F); Infant with insufficient energy to maintain sucking; or with insufficient weight gain (<30 g/d); Irritability; Jaundice, pallor; Respiratory distress; metabolic acidosis

HYPOTHERMIA, RISK FOR

Diagnostic Division: Safety

Definition: Vulnerable to a failure of thermoregulation that may result in a core body temperature below the normal diurnal range, which may compromise health.

RISK FACTORS

Alcohol consumption; Economically disadvantaged; Extremes of age or weight; Heat transfer, e.g., conduction, convection, evaporation, radiation; Insufficient caregiver knowledge of hypothermia prevention; Low environmental temperature; inactivity; insufficient clothing; Malnutrition; insufficient supply of subcutaneous fat; Pharmaceutical agent; Trauma; damage to hypothalamus; radiation

Children and Adults: Accidental

Mild hypothermia, core temperature approaching 35°C (95°F); Moderate hypothermia, core temperature approaching 32°C (89.6°F); Severe hypothermia, core temperature approaching 30°C (86°F)

Children and Adults: Injured Patients

Hypothermia, core temperature approaching 35°C (95°F); Severe hypothermia, core temperature approaching 32°C (89.6°F)

Neonates

Grade 1 hypothermia, core temperature approaching 97.7°F (36.5°C); Grade 2 hypothermia, core temperature approaching 96.8°F (36°C); Grade 3 hypothermia, core temperature approaching 95°F (35°C); Grade 4 hypothermia, core temperature approaching 93.2°F (34°C); Decrease in metabolic rate; increase in oxygen demand; increase in pulmonary vascular resistance (PVR); ineffective vascular control; Delay in breastfeeding; Early bathing of newborn; High-risk or unplanned-out-of-hospital birth; Immature stratum corneum; Increased body surface area to weight ratio; Ineffective nonshivering thermogenesis

NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred; rather, nursing interventions are directed at prevention.

HYPOTHERMIA, RISK FOR PERIOPERATIVE

Diagnostic Division: Safety

Definition: Vulnerable to an inadvertent drop in core body temperature below 36°C (96.8°F) occurring 1 hour before to 24 hours after surgery, which may compromise health.

RISK FACTORS

American Society of Anesthesiologists (ASA) Physical Status classification score >1; Cardiovascular complications; Combined regional and general anesthesia; Diabetic neuropathy; Heat transfer, e.g., high volume of unwarmed infusion, unwarmed irrigation >20 liters; Low body weight; Low environmental temperature; Low preoperative temperature (<36°C [96.8°F]); Surgical procedure

NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred; rather, nursing interventions are directed at prevention.

IMPULSE CONTROL, INEFFECTIVE

Diagnostic Division: Ego Integrity

Definition: A pattern of performing rapid, unplanned reactions to internal or external stimuli without regard for the negative consequences of these reactions to the impulsive individual or to others.

RELATED FACTORS

Anger; denial; delusion; Insomnia; fatigue; Chronic low self-esteem; disturbed body image; hopelessness; Stress vulnerability; environment that might cause irritation, frustration; Ineffective coping; codependency; Smoker; substance abuse; Economically disadvantage; Social isolation; suicidal feelings; Compunction, i.e., feeling of uneasiness about rightness of action; unpleasant physical symptoms; Organic brain disorders; disorder of cognition, development, mood, personality

DEFINING CHARACTERISTICS

Subjective

Inability to save money or regulate finances; Asking personal questions of others despite their discomfort

Objective

Acting without thinking; Sensation seeking; sexual promiscuity; Sharing personal details inappropriately; too familiar with strangers; Irritability; temper outbursts; violence; Pathological gambling

INCONTINENCE, BOWEL

Diagnostic Division: Elimination

Definition: Change in normal bowel habits characterized by involuntary passage of stool.

RELATED FACTORS

Abnormal increase in abdominal or intestinal pressure; Alteration in cognitive functioning; stressors; Chronic diarrhea; impaction; incomplete emptying of the bowel; Colorectal lesion; dysfunctional or abnormal rectal sphincter; impaired reservoir capacity; upper or lower motor nerve damage; Deficient dietary habits; Difficulty in toileting self-care; Environmental factor, e.g., inaccessible bathroom; Generalized decline in muscle tone; immobility; Pharmaceutical agent; laxative abuse

DEFINING CHARACTERISTICS

Subjective

Inability to expel formed stool despite recognition of rectal fullness; Bowel urgency; inability to delay defecation; Inability to recognize rectal fullness

Objective

Constant passage of soft stool; Fecal staining of clothing, bedding; Fecal odor; Reddened perianal skin; Does not recognize or inattention to urge to defecate

INCONTINENCE, FUNCTIONAL URINARY

Diagnostic Division: Elimination

Definition: Inability of a usually continent person to reach the toilet in time to avoid unintentional loss of urine.

RELATED FACTORS

Alteration in environmental factors; Impaired vision; Neuromuscular impairment; Psychological factors; Weakened supporting pelvic structures; Psychological disorder; alteration in cognitive functioning; [reluctance to call for assistance or use bedpan]

DEFINING CHARACTERISTICS

Subjective

Sensation of need to void

Objective

Voiding prior to reaching toilet; time between sensation of urge and ability to reach toilet is too short; Completely empties bladder; Early morning urinary incontinence

INCONTINENCE, OVERFLOW URINARY

Diagnostic Division: Elimination

Definition: Involuntary loss of urine associated with overdistention of the bladder.

RELATED FACTORS

Bladder outlet obstruction; Detrusor external sphincter dyssynergia; Detrusor hypocontractility; Fecal impaction; Severe pelvic prolapse; Side effects of anticholinergic medications; Side effects of calcium channel blockers; Side effects of decongestant medications; Urethral obstruction; Treatment regimen [e.g., side effects of medications]

DEFINING CHARACTERISTICS

Subjective

Involuntary leakage of small volume of urine; Nocturia

Objective

Bladder distention; High post-void residual volume

INCONTINENCE, REFLEX URINARY

Diagnostic Division: Elimination

Definition: Involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached.

RELATED FACTORS

Neurological impairment above level of pontine or sacral micturition center; Tissue damage, e.g., due to radiation cystitis, inflammatory bladder conditions, radical pelvic surgery

DEFINING CHARACTERISTICS

Subjective

Absence of sensation of bladder fullness, urge to void, or of voiding sensation; Sensation of urgency to void without voluntary inhibition of bladder contraction; Sensation of bladder fullness

Objective

Predictable pattern of voiding; Inability to voluntarily inhibit or initiate voiding; Incomplete emptying of bladder with [brain] lesion above pontine micturition center

INCONTINENCE, RISK FOR URGE URINARY

Diagnostic Division: Elimination

Definition: Vulnerable to involuntary passage of urine occurring soon after a strong sensation of urgency to void, which may compromise health.

RISK FACTORS

Decrease in bladder capacity; Bladder infection; atrophic urethritis or vaginitis; Alcohol consumption; caffeine intake; [increased fluid intake]; Treatment regimen [e.g., diuretic use]; Fecal impaction; Detrusor hyperactivity with impaired bladder contractility

INCONTINENCE, STRESS URINARY

Diagnostic Division: Elimination

Definition: Sudden leakage of urine with activities that increase intra-abdominal pressure.

RELATED FACTORS

Degenerative changes in pelvic muscles; Increase in intra-abdominal pressure [e.g., obesity, gravid uterus]; Intrinsic urethral sphincter deficiency; Weak pelvic muscles

DEFINING CHARACTERISTICS

Subjective

Involuntary leakage of small volume of urine, e.g., with sneezing, laughing, coughing, on exertion; in the absence of detrusor contraction or an overdistended bladder

Objective

Involuntary leakage of small volume of urine in the absence of detrusor contraction or an overdistended bladder

INCONTINENCE, URGE URINARY

Diagnostic Division: Elimination

Definition: Involuntary passage of urine occurring soon after a strong sense of urgency to void.

RELATED FACTORS

Decrease in bladder capacity; Bladder infection; atrophic urethritis or vaginitis; Alcohol consumption; caffeine intake; [increased fluid intake]; Treatment regimen [e.g., diuretic use]; Fecal impaction; Detrusor hyperactivity with impaired bladder contractility

DEFINING CHARACTERISTICS

Subjective

Urinary urgency; involuntary loss of urine with bladder contractions or spasms; Inability to reach toilet in time to avoid urine loss

INFECTION, RISK FOR

Diagnostic Division: Safety

Definition: Vulnerable to invasion and multiplication of pathogenic organisms, which may compromise health.

RISK FACTORS

Chronic illness (e.g., diabetes mellitus); Inadequate vaccination; Insufficient knowledge to avoid exposure to pathogens

Inadequate Primary Defenses: Alteration in peristalsis; Alteration in pH of secretions; status of body fluids; Alteration in skin integrity; Decrease in ciliary action; Premature or prolonged rupture of amniotic membrane; Smoking

Inadequate Secondary Defenses: Decrease in hemoglobin; leukopenia, suppressed inflammatory response, e.g., interleukin-6 [IL-6], C-reactive protein [CRP]; immunosuppression; Inadequate vaccination

Increased Environmental Exposure to Pathogens: Exposure to disease outbreak; [Exposure to multiple healthcare workers, multiple care settings]

INJURY, RISK FOR

Diagnostic Division: Safety

Definition: Vulnerable to physical damage due to environmental conditions interacting with the individual's adaptive and defensive resources, which may compromise health.

RISK FACTORS

Internal

Abnormal blood profile [e.g., leukocytosis/leukopenia, altered clotting factors, thrombocytopenia, sickle cell, thalassemia, decreased hemoglobin]; immune/autoimmune dysfunction; biochemical dysfunction; Alteration in affective orientation; effector dysfunction; Alteration in sensation (resulting from spinal cord injury, diabetes mellitus, etc.); Extremes of age; Impaired primary defense mechanisms, e.g., broken skin; tissue hypoxia; malnutrition

External

Alteration in cognitive or psychomotor functioning; Compromised nutritional source, e.g., vitamins, food types; Exposure to pathogen or toxic chemical [pollutants, poisons, drugs, pharmaceutical agents, alcohol, nicotine]; Immunization level within community; nosocomial agent; Physical barrier, e.g., design, structure, and arrangement of community, building, equipment; unsafe mode of transport

INJURY, RISK FOR CORNEAL

Diagnostic Division: Safety

Definition: Vulnerable to infection or inflammatory lesion in the corneal tissue that can affect superficial or deep layers, which may compromise health.

RISK FACTORS

Blinking <5 times per minute; Exposure of the eyeball; periorbital edema; Glasgow Coma Scale score <7; Pharmaceutical agent; Prolonged hospitalization; Use of supplemental oxygen; intubation; mechanical ventilation; tracheostomy

INJURY, RISK FOR URINARY TRACT

Diagnostic Division: Safety

Definition: Vulnerable to damage of the urinary tract structures from use of catheters, which may compromise health.

RISK FACTORS

Condition preventing ability to secure catheter, e.g., burn, trauma, amputation; Long-term use of urinary catheters; multiple catheterizations; Retention balloon inflated to ≥30 ml; Use of large caliber urinary catheter

INSOMNIA

Diagnostic Division: Activity/Rest

Definition: A disruption in amount and quality of sleep that impairs functioning.

RELATED FACTORS

Alcohol consumption; pharmaceutical agent; hormonal change; Stressors; depression; fear; anxiety; grieving; Inadequate sleep hygiene; frequent naps; Average daily physical activity is less than recommended for gender and age; Physical discomfort; Environmental barrier, e.g., ambient noise, daylight/darkness exposure, ambient temperature/humidity, unfamiliar setting

DEFINING CHARACTERISTICS

Subjective

Difficulty initiating or maintaining sleep; early awaking; alteration in sleep pattern; Dissatisfaction with sleep; nonrestorative sleep pattern, e.g., due to caregiver responsibilities, parenting practices, sleep partner; Sleep disturbance producing next-day consequences; insufficient energy; Decrease in quality of life; compromised health status; Increase in accidents

Objective

Alteration in concentration; Alteration in mood/affect; Increase in absenteeism

JAUNDICE, NEONATAL

Diagnostic Division: Safety

Definition: The yellow-orange tint of the neonate's skin and mucous membranes that occurs after 24 hours of life as a result of unconjugated bilirubin in the circulation.

RELATED FACTORS

Age < 7 days; Deficient feeding pattern; Unintentional weight loss [more than 7% to 8% in breastfeeding newborn; 15% in term infant]; Delay in meconium passage; Infant experiences difficulty making the transition to extrauterine life

DEFINING CHARACTERISTICS

Objective

Yellow-orange skin color; yellow sclera, mucous membranes; Bruised skin; Abnormal blood profile [e.g., hemolysis; total serum bilirubin more than 2 mg/dL; total serum bilirubin in the high-risk range on age in hour-specific nomogram]

JAUNDICE, RISK FOR NEONATAL

Diagnostic Division: Safety

Definition: Vulnerable to the yellow-orange tint of the neonate's skin and mucous membranes that occurs after 24 hours of life as a result of unconjugated bilirubin in the circulation, which may compromise health.

RISK FACTORS

Age <7 days; prematurity; Feeding pattern not well established; Abnormal weight loss (more than 7% to 8% in breastfeeding newborn; 15% in nonbreastfeeding newborn); Delay in meconium passage; Infant experiences difficulty making the transition to extrauterine life

KNOWLEDGE, DEFICIENT

Diagnostic Division: Teaching/Learning

Definition: Absence or deficiency of cognitive information related to a specific topic.

RELATED FACTORS

Insufficient information; insufficient knowledge of resources; Insufficient interest in learning; Misinformation presented by others; Alteration in cognitive functioning or memory; Insufficient interest in learning

DEFINING CHARACTERISTICS

Subjective

Insufficient knowledge

Objective

Inaccurate follow-through of instruction or performance on a test or procedure; Inappropriate behavior, e.g., hysterical, hostile, agitated, apathetic; Development of preventable complication

KNOWLEDGE, READINESS FOR ENHANCED

Diagnostic Division: Teaching/Learning

Definition: A pattern of cognitive information related to a specific topic, or its acquisition, which can be strengthened.

RELATED FACTORS

To be developed

DEFINING CHARACTERISTICS

Subjective

Expresses desire to enhance learning

LATEX ALLERGY RESPONSE

Diagnostic Division: Safety

Definition: A hypersensitive reaction to natural latex rubber products.

RELATED FACTORS

Hypersensitivity to natural latex rubber protein

DEFINING CHARACTERISTICS

Life-threatening reactions within one hour of exposure

Chest tightness; Contact urticaria progressing to generalized symptoms; Edema, e.g., lips, throat, tongue, uvula; Dyspnea; wheezing; bronchospasm; respiratory arrest; Hypotension; syncope; myocardial infarction

Orofacial Characteristics

Itching, e.g., eyes; facial, nasal, oral; nasal congestion; Erythema, e.g., eyes, facial, nasal; periorbital edema; rhinorrhea, tearing of the eyes

Gastrointestinal Characteristics

Abdominal pain; Nausea

Generalized Characteristics

Generalized discomfort; reports total body warmth; Skin flushing; generalized edema; restlessness

Type IV Reactions Occurring ≥1 hour after Exposure

Discomfort reaction to additives, e.g., thiurams and carbamates; Eczema; skin irritation and/or redness

LATEX ALLERGY RESPONSE, RISK FOR

Diagnostic Division: Safety

Definition: Risk of hypersensitivity to natural latex rubber products that may compromise health.

RISK FACTORS

History of allergy or latex reaction; Frequent exposure to latex product; Food allergy, e.g., avocado, banana, chestnut, kiwi, peanut, shellfish, mushroom, tropical fruit; allergy to poinsettia plant; Asthma; Multiple surgical procedures; history of surgery during infancy

LIFESTYLE, SEDENTARY

Diagnostic Division: Activity/Rest

Definition: Reports a habit of life that is characterized by a low physical activity level

RELATED FACTORS

Insufficient interest in, motivation, or resources [e.g., time, money, companionship, facilities] for physical activity; Insufficient training for physical exercise; Insufficient knowledge of health benefits associated with physical exercise

DEFINING CHARACTERISTICS

Subjective

Preference for activity low in physical activity

Objective

Average daily physical activity is less than recommended for gender and age; Demonstrates physical deconditioning

LIVER FUNCTION, RISK FOR IMPAIRED

Diagnostic Division: Food/Fluid

Definition: Vulnerable to a decrease in liver function, which may compromise health.

RISK FACTORS

Viral infection [e.g., hepatitis A/B/C, Epstein-Barr]; HIV coinfection; Pharmaceutical agent [e.g., acetaminophen, statins]; Substance abuse

LONELINESS, RISK FOR

Diagnostic Division: Social Interaction

Definition: Vulnerable to experiencing discomfort associated with a desire or need for more contact with others, which may compromise health.

RISK FACTORS

Affectional deprivation; Physical or Social isolation; Emotional deprivation

MATERNAL-FETAL DYAD, RISK FOR DISTURBED

Diagnostic Division: Safety

Definition: Vulnerable to disruption of the symbiotic maternal-fetal dyad as a result of comorbid or pregnancy-related conditions, which may compromise health.

RISK FACTORS

Pregnancy complication, e.g., premature rupture of membranes, placenta previa or abruption, multiple gestation; Compromised fetal oxygen transport, e.g., anemia, (sickle cell anemia), cardiac disease, asthma, hypertension, seizures, premature labor, hemorrhage, etc.; Alteration in glucose metabolism, e.g., diabetes, steroid use; Presence of abuse, e.g., physical, psychological, sexual; Substance abuse; Treatment regimen [e.g., pharmaceutical agents, surgery]

MEMORY, IMPAIRED

Diagnostic Division: Neurosensory

Definition: Inability to remember or recall bits of information or behavioral skills.

RELATED FACTORS

Hypoxia; anemia; Electrolyte imbalance; decrease in cardiac output; Neurological impairment, e.g., positive electroencephalogram (EEG), head trauma, seizure disorders; Distractions in the environment; [Substance abuse; effects of medications; Age]

DEFINING CHARACTERISTICS

Subjective

Inability to recall events or factual information

Objective

Inability to recall if a behavior was performed; Inability to learn/retain new skills/information; Inability to perform a previously learned skill; Forgets to perform a behavior at a scheduled time; Forgetfulness

MOBILITY, IMPAIRED BED

Diagnostic Division: Safety

Definition: Limitation of independent movement from one bed position to another.

RELATED FACTORS

Neuromuscular or musculoskeletal impairment; Insufficient muscle strength; physical deconditioning; obesity; Environmental barrier, e.g., bed size or type, equipment, restraints; Pain; pharmaceutical agent; Insufficient knowledge of mobility strategies; Alteration in cognitive functioning

DEFINING CHARACTERISTICS

Objective

Impaired ability to: reposition self in bed, turn from side to side; Impaired ability to move between prone and supine positions, sitting/long sitting and supine positions

MOBILITY, IMPAIRED PHYSICAL

Diagnostic Division: Safety

Definition: Limitation in independent, purposeful physical movement of the body or of one or more extremities.

RELATED FACTORS

Activity intolerance; decrease in endurance; physical deconditioning; sedentary lifestyle; Alteration in bone structure integrity; neuromuscular, musculoskeletal, or sensoriperceptual impairment; disuse; Alteration in cognitive functioning; developmental delay; Alteration in metabolism; body mass index above 75th age-appropriate percentile; malnutrition; Anxiety; depression; Cultural belief regarding appropriate activity; Decrease in muscle mass, control or strength; joint stiffness; contractures; Insufficient environmental support, e.g., physical, social; Insufficient knowledge of value of physical activity; Pain; Pharmaceutical agent; Prescribed movement restrictions; reluctance to initiate movement

DEFINING CHARACTERISTICS

Subjective

Discomfort; [reluctance/unwillingness to move]

Objective

Alteration in gait; postural instability; Decrease in fine or gross motor skills; movement-induced tremor; Decrease in range of motion; difficulty turning; Decrease in reaction time; slowed or spastic movement; uncoordinated movement; Engages in substitutions for movement, e.g., attention to other's activities, controlling behavior, focus on pre-illness activity; Exertional dyspnea

MOBILITY, IMPAIRED WHEELCHAIR

Diagnostic Division: Safety

Definition: Limitation of independent operation of wheelchair within environment.

RELATED FACTORS

Neuromuscular or musculoskeletal impairments; Insufficient muscle strength; decrease in endurance; physical deconditioning; obesity; Impaired vision; Pain; Alteration in mood; alteration in cognitive functioning; Insufficient knowledge of wheelchair use; Environmental barrier, e.g., stairs, inclines, uneven surfaces, obstacles, distance

DEFINING CHARACTERISTICS

Impaired ability to operate manual or power wheelchair on even/uneven surface, an incline/decline, or on curbs

MOOD REGULATION, IMPAIRED

Diagnostic Division: Ego Integrity

Definition: A mental state characterized by shifts in mood or affect and which is comprised of a constellation of affective, cognitive, somatic and/or physiological manifestations varying from mild to severe.

RELATED FACTORS

Appetite or weight change; alteration in sleep pattern; Chronic illness; pain; functional impairment; Loneliness; impaired social functioning; social isolation; Recurrent thoughts of death or suicide; Anxiety; hypervigilance; psychosis; Substance misuse

DEFINING CHARACTERISTICS

Subjective

Excessive self-awareness, guilt, self-blame; Hopelessness

Objective

Sad affect, withdrawal; Irritability; impaired concentration; Psychomotor agitation, retardation; Changes in verbal behavior; flight of thoughts; dysphoria; disinhibition; Influenced self-esteem

MORAL DISTRESS

Diagnostic Division: Ego Integrity

Definition: Response to the inability to carry out one's chosen ethical/moral decision/action.

RELATED FACTORS

Conflict among decision-makers, e.g., family, healthcare providers, insurance payers; Conflicting information available for moral or ethical decision-making; cultural incongruences; Treatment decision; end-of-life decisions; loss of autonomy; Time constraint for decision-making; physical distance of decision-maker

DEFINING CHARACTERISTICS

Subjective

Anguish about acting on one's moral choice, e.g., powerlessness, anxiety, fear

MUCOUS MEMBRANE, IMPAIRED ORAL

Diagnostic Division: Food/Fluid

Definition: Injury to the lips, soft tissue, buccal cavity, and/or oropharynx.

RELATED FACTORS

Alcohol consumption; smoking; Allergy; stressors; Alteration in cognitive functioning; Autoimmune disease; immunodeficiency; immunosuppression; infection; Autosomal disorder; Syndrome, e.g., Sjorgren's; Barrier to dental care or oral self-care; Insufficient oral hygiene; insufficient knowledge of oral hygiene; Behavior disorder, e.g., attention deficit, oppositional defiant; depression; Chemical injury agent, e.g., burn, capsaicin, methylene chloride, mustard agent; Chemotherapy; radiation therapy (risk); Cleft lip or palate; loss of oral support structure; Decrease in hormone level in women; Decrease in platelets; treatment regimen; Decrease in salivation; dehydration; malnutrition; inadequate nutrition (risk); Economically disadvantaged (risk); Mechanical factor, e.g., ill-fitting dentures, orthodontic appliance (risk), braces; endotrachael/nasogastric tube, oral surgery, oral trauma; Mouth breathing; nil per os (NPO) >24 hours; Surgical procedure; trauma (risk)

DEFINING CHARACTERISTICS

Subjective

Xerostomia (dry mouth); Oral pain, discomfort; Bad taste in mouth; decrease in taste sensation; difficulty eating or swallowing; Exposure to pathogen

Objective

Coated tongue; Smooth atrophic tongue; Geographic tongue; Gingival or mucosal pallor; Stomatitis; hyperemia; macroplasia; vesicles; nodules; papules; White patches or plaques; spongy patches; white, curd-like exudate; Oral lesions or ulcers; fissures; bleeding; cheilitis; desquamation; mucosal denudation; Purulent drainage or exudates; enlarged tonsils; Oral edema; Halitosis; Gingival hyperplasia or recession, pocketing deeper than 4 mm; [carious teeth]; Presence of mass, e.g., hemangiomas; Difficulty speaking

MUCOUS MEMBRANE, RISK FOR IMPAIRED ORAL

Diagnostic Division: Food/Fluid

Definition: Vulnerable to injury to the lips, soft tissue, buccal cavity, and/or oropharynx, which may compromise health.

RISK FACTORS

Alcohol consumption; smoking; Allergy; stressors; Alteration in cognitive functioning; Autoimmune disease; immunodeficiency; immunosuppression; infection; Autosomal disorder; Syndrome, e.g., Sjorgren's; Barrier to dental care or oral self-care; Insufficient oral hygiene; insufficient knowledge of oral hygiene; Behavior disorder, e.g., attention deficit, oppositional defiant; depression; Chemical injury agent, e.g., burn, capsaicin, methylene chloride, mustard agent; Chemotherapy; radiation therapy (risk); Cleft lip or palate; loss of oral support structure; Decrease in hormone level in women; Decrease in platelets; treatment regimen; Decrease in salivation; dehydration; malnutrition; inadequate nutrition (risk); Economically disadvantaged (risk); Mechanical factor, e.g., ill-fitting dentures, orthodontic appliance (risk), braces; endotrachael/nasogastric tube, oral surgery; oral trauma; Mouth breathing; nil per os (NPO) >24 hours; Surgical procedure; trauma (risk)

NAUSEA

Diagnostic Division: Food/Fluid

Definition: A subjective phenomenon of an unpleasant feeling in the back of the throat and stomach, which may or may not result in vomiting.

RELATED FACTORS

Treatment

Gastric irritation; Gastric distension; Pharmaceutical agents [e.g., analgesics—aspirin/nonsterodial anti-inflammatory drugs/opioids, anesthesia, antivirals for HIV, steroids, antibiotics, chemotherapeutic agents]; [Radiation therapy/exposure]

Biophysical

Biochemical dysfunction, e.g., uremia, diabetic ketoacidosis; pregnancy; Localized tumors, e.g., acoustic neuroma, brain tumor, bone metastasis; intra-abdominal tumors; Exposure to toxins; Esophageal or pancreatic disease; liver or splenetic capsule stretch; Gastric distention; gastrointestinal irritation; Motion sickness; Ménière's disease; labyrinthitis; Increase in intracranial pressure; meningitis; Treatment regimen

Situational

Noxious taste; Unpleasant visual stimuli; noxious environmental stimuli; Anxiety; fear; psychological disorder

DEFINING CHARACTERISTICS

Subjective

Nausea; sour taste

Objective

Aversion toward food; Increased in salivation; Increased in swallowing; Gagging sensation

NONCOMPLIANCE

Diagnostic Division: Teaching/Learning

Definition: Behavior of person and/or caregiver that fails to coincide with a health-promoting or therapeutic plan agreed on by the person (and/or family and/or community) and healthcare professional. In the presence of an agreed-upon health-promoting, or therapeutic plan, the person's or caregiver's behavior is fully or partially nonadherent and may lead to clinically ineffective or partially effective outcomes.

RELATED FACTORS

Health Care Plan

Lengthy duration or intensity of regimen; complex treatment regimen; Financial barriers; high-cost regimen

Individual factors

Insufficient knowledge about the regimen; insufficient skills to perform regimen; expectations incongruent with developmental phase; Health beliefs, values, or spiritual values incongruent with plan; cultural incongruence; Insufficient motivation; insufficient social support; Denial; issues of secondary gain

Health System

Insufficient health insurance coverage; insufficient provider reimbursement; Perceived low credibility of provider; difficulty in client-provider relationship; provider discontinuity; insufficient follow-up with provider; ineffective communication or insufficient teaching skills of the provider; Inadequate access or inconvenience of care; low satisfaction with care

Network

Insufficient involvement of members in plan; low social value attributed to plan; Perception that beliefs of significant other differ from plan

DEFINING CHARACTERISTICS

Subjective

[Does not believe in efficacy of therapy, unwilling to follow treatment regimen]

Objective

Nonadherence behavior; Failure to progress; exacerbation of symptoms; development-related complication; Failure to meet outcomes; missing of appointments

NUTRITION: LESS THAN BODY REQUIREMENTS, IMBALANCED

Diagnostic Division: Food/Fluid

Definition: Intake of nutrients insufficient to meet metabolic needs.

RELATED FACTORS

Inability to ingest or digest food; inability to absorb nutrients; Biological factors; psychological disorder; Economically disadvantaged

DEFINING CHARACTERISTICS

Subjective

Insufficient interest in food; food aversion; alteration in taste sensation; perceived inability to ingest food; Satiety immediately upon ingesting food; Abdominal pain or cramping; sore buccal cavity; Insufficient information; misinformation; misconception

Objective

Body weight 20% or more below ideal weight range; [decreased subcutaneous fat or muscle mass]; Weight loss with adequate food intake; Food intake less than recommended daily allowances; Hyperactive bowel sounds; diarrhea; steatorrhea; Weakness of muscles required for mastication or swallowing; insufficient muscle tone; Pale mucous membranes; capillary fragility; Excessive hair loss [or increased growth of hair on body (lanugo)]; [cessation of menses]; [Abnormal laboratory studies, e.g., decreased albumin, total proteins; iron deficiency; electrolyte imbalances]

NUTRITION: READINESS FOR ENHANCED

Diagnostic Division: Food/Fluid

Definition: A pattern of nutrient intake that is sufficient for meeting metabolic needs and can be strengthened.

DEFINING CHARACTERISTICS

Subjective

Expresses desire to enhance nutrition

OBESITY

Diagnostic Division: Food/Fluid

Definition: A condition in which an individual accumulates abnormal or excessive fat for age and gender that exceeds overweight.

RELATED FACTORS

Average daily physical activity is less than recommended for gender and age; energy expenditure below energy intake based on standard assessment, e.g., WAVE [weight, activity, variety in diet, excess] assessment; Consumption of sugar-sweetened beverages; frequent snacking; high frequency of restaurant or fried food; portion sizes larger than recommended; Disordered eating behaviors or perceptions; fear regarding lack of food supply; high disinhibition and restraint eating behavior score; Economically disadvantaged; Formula- or mixed-fed infants; overweight in infancy; low dietary calcium intake in children; Genetic disorder; heritability of interrelated factors, e.g., adipose tissue distribution, energy expenditure, lipid synthesis, lipolysis; Maternal diabetes mellitus, smoking; parental obesity

DEFINING CHARACTERISTICS

Objective

ADULT: BMI of >30 kg/m2; CHILD <2 years: Term not used with children this age; CHILD 2–18 years: BMI of >30 kg/m2 or >95th percentile for age and gender

OVERWEIGHT

Diagnostic Division: Food/Fluid

Definition: A condition in which an individual accumulates abnormal or excessive fat for age and gender.

RELATED FACTORS

Average daily physical activity is less than recommended for gender and age; sedentary behavior occurring for >2 hours/day; energy expenditure below energy intake based on standard assessment, e.g., WAVE [weight, activity, variety in diet, excess] assessment; Consumption of sugar-sweetened beverages; frequent snacking; high frequency of restaurant or fried food; portion sizes larger than recommended; Disordered eating behaviors or perceptions; fear regarding lack of food supply; high disinhibition and restraint eating behavior score; Economically disadvantaged; Genetic disorder; heritability of interrelated factors, e.g., adipose tissue distribution, energy expenditure, lipid synthesis, lipolysis; Maternal diabetes mellitus; maternal smoking; parental obesity; Rapid weight gain during infancy, including first week, first 4 months, and first year; solid foods as major food source at <5 months of age; Rapid weight gain during childhood, obesity in childhood; low dietary calcium intake in children; premature pubarche; Shortened sleep time; sleep disorder

DEFINING CHARACTERISTICS

Objective

ADULT: BMI of >25 kg/m2; CHILD <2 years: Weight-for-length >95th percentile; CHILD 2–18 years: BMI >25 kg/m2 or >85th but <95th percentile (whichever is smaller)

OVERWEIGHT, RISK FOR

Diagnostic Division: Food/Fluid

Definition: Vulnerable to abnormal or excessive fat accumulation for age and gender, which may compromise health.

RISK FACTORS

ADULT: BMI approaching 25 kg/m2; CHILD <2 years: Watch for weight-for-length approaching 95th percentile; CHILD 2–18 years: BMI approaching 25 kg/m2, or 85th percentile (whichever is smaller); Children with high BMI percentiles, or who are crossing BMI percentiles upward; Consumption of sugar-sweetened beverages; high frequency of restaurant or fried food; portion sizes larger than recommended; Disordered eating behaviors, e.g., binge eating, extreme weight control; disordered eating perceptions; fear regarding lack of food supply; high disinhibition and restraint eating behavior score; Eating in response to external cues, e.g., time of day, social situations; eating in response to internal cues other than hunger, e.g., anxiety; frequent snacking; Economically disadvantaged; Energy expenditure below energy intake based on standard assessment, e.g., WAVE [weight, activity, variety in diet, excess] assessment; sedentary behavior occurring for >2 hours/day; Excessive alcohol consumption; Formula- or mixed-fed infants; Genetic disorder; heritability of interrelated factors, e.g., adipose tissue distribution, energy expenditure, lipid synthesis, lipolysis; Higher baseline weight at beginning of each pregnancy; maternal diabetes, maternal smoking; Low dietary calcium intake in children; Rapid weight gain during infancy, including first week, first 4 months, and first year; solid foods as major food source at <5 months of age; Rapid weight gain in childhood; obesity in childhood; premature pubarche; parental obesity; Shortened sleep time; sleep disorder

PAIN, ACUTE

Diagnostic Division: Pain/Discomfort

Definition: An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity, from mild to severe, with an anticipated or predictable end.

RELATED FACTORS

Biological injury agent, e.g., infection, ischemia, neoplasm; Chemical injury agent, e.g., burn, capsaicin, methylene chloride, mustard agent; Physical injury agent, e.g., abscess, amputation, burn, cut, heavy lifting, operative procedure, trauma, overtraining

DEFINING CHARACTERISTICS

Subjective

Self-report of intensity using standardized pain scale, e.g., Wong-Baker FACES scale, visual analogue scale, numeric rating scale; Self-report of pain characteristics using standardized pain instrument, e.g., McGill Pain Questionnaire, Brief Pain Inventory; Appetite change; hopelessness; Proxy report of pain behavior activity changes, e.g., family member, caregiver

Objective

Guarding behavior; protective behavior; positioning to ease pain; Facial expression of pain, e.g., eyes lack luster, beaten look, fixed or scattered movement, grimace; Expressive behavior, e.g., restlessness, crying; Distraction behavior; Diaphoresis; changes in physiological parameter, e.g., blood pressure, heart rate, respiratory rate, oxygen saturation, and end-tidal volume; pupil dilation; Self-focused; narrowed focus, e.g., time perception, thought process, interaction with people and environment; Evidence of pain using standard pain behavior checklist for those unable to communicate verbally, e.g., Neonatal Infant Pain Scale, Pain Assessment Checklist for Seniors with Limited Ability to Communicate

PAIN, CHRONIC

Diagnostic Division: Pain/Discomfort

Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity, from mild to severe, constant or recurring without an anticipated or predictable end and a duration of greater than three (>3) months.

NOTE: Pain is a signal that something is wrong. Chronic pain may be recurrent and periodically disabling, e.g., migraine headaches, kidney stones, prostatitis, or may be unremitting. It is a complex entity, combining elements from many other NDs, such as risk for Disuse Syndrome; deficient Diversional Activity; disturbed Body Image; compromised family Coping; interrupted Family Processes; Powerlessness; Self-Care Deficit (specify); sexual Dysfunction; Social Isolation]. The nurse is encouraged to refer to other NDs as indicated.

RELATED FACTORS

Age >50 years; female gender; genetic disorder; Alteration in sleep pattern; Anorexia; emotional distress; fatigue; prolonged increase in cortisol level; whole body vibration; chronic musculoskeletal condition; muscle injury; damage to the nervous system; imbalance of neurotransmitters, neuromodulators, and receptors; nerve compression; ischemic condition; spinal cord injury; tumor infiltration; Contusion; crush injury; fracture; injury agent; post-trauma related condition, e.g., infection, inflammation; History of abuse, e.g., physical, psychological, sexual; history of genital mutilation; history of substance abuse; History of overindebtedness; History of static work postures; prolonged computer use (>20 hours/week); repeated handling of heavy loads; Immune disorder, e.g., HIV-associated neuropathy, varicella-zoster virus; impaired metabolic functioning; Increase in body mass index; malnutrition; Ineffective sexuality pattern; social isolation

DEFINING CHARACTERISTICS

Subjective

Self-report of intensity using standardized pain scale, e.g., Wong-Baker FACES scale, visual analogue scale, numeric rating scale; Self-report of pain characteristics using standardized pain instrument, e.g., McGill Pain Questionnaire, Brief Pain Inventory; Alteration in ability to continue previous activities; Alteration in sleep pattern; anorexia; [Preoccupation with pain]; [Desperately seeks alternative solutions or therapies for relief or control of pain]

PAIN, LABOR

Diagnostic Division: Pain/Discomfort

Definition: Sensory and emotional experience that varies from pleasant to unpleasant, associated with labor and childbirth.

RELATED FACTORS

Cervical dilation; Fetal expulsion

DEFINING CHARACTERISTICS

Subjective

Pain; perineal pressure; increase or decrease in appetite; nausea; vomiting; alteration in urinary functioning, sleep pattern

Objective

Uterine contraction; Alteration in blood pressure/heart rate/respiratory rate; Distraction/expressive behavior; protective behavior; positioning to ease pain; Alteration in muscle tension; diaphoresis; Alteration in neuroendocrine functioning; Narrowed focus; self-focused; pupil dilation; Facial expression of pain, e.g., eyes lack luster, beaten look, fixed or scattered movement, grimace

PAIN SYNDROME, CHRONIC

Diagnostic Division: Pain/Discomfort

Definition: Recurrent or persistent pain that has lasted at least three months, and that significantly affects daily functioning or well-being.

NOTE: Author Note: Pain is a signal that something is wrong. Chronic pain may be recurrent and periodically disabling, e.g., migraine headaches, kidney stones, prostatitis, or may be unremitting. It is a complex entity, combining elements from many other NDs, such as risk for Disuse Syndrome; deficient Diversional Activity; disturbed Body Image; compromised family Coping; interrupted Family Processes; Powerlessness; Self-Care Deficit (specify); sexual Dysfunction; Social Isolation]. The nurse is encouraged to refer to other NDs as indicated.

DEFINING CHARACTERISTICS

Subjective

Anxiety, fear; stress overload; Constipation; Disturbed sleep pattern, fatigue; insomnia

Objective

Deficient knowledge; Impaired mood regulation; social isolation; Impaired physical mobility; Obesity

PARENTING, IMPAIRED

Diagnostic Division: Social Interaction

Definition: Inability of the primary caretaker to create, maintain, or regain an environment that promotes the optimum growth and development of the child.

RELATED FACTORS

Infant or Child

Prematurity; multiple births; gender other than desired; Chronic illness; parent-child separation/prolonged separation from parent; Difficult temperament; temperament conflicts with parental expectations; Disabling condition; developmental delay; alteration in perceptual abilities; behavior disorder, e.g., attention deficit, oppositional defiant

Knowledge

Insufficient knowledge about child development/health maintenance or parenting skills; insufficient response to infant cues; Unrealistic expectations; Low educational level; alteration in cognitive functioning; insufficient cognitive readiness for parenting; Ineffective communication skills; Preference for physical punishment

Physiological

Physical illness

Psychological

Young parental age; Insufficient prenatal care; difficult birthing process; high number of/closely spaced pregnancies; Sleep deprivation/nonrestorative sleep pattern, i.e., due to caregiver responsibilities, parenting practices, sleep partner; Depression; history of mental illness or substance abuse; Disabling condition

Social

Stressors work difficulty; unemployment; relocation; compromised home environment; Low self-esteem; Insufficient family cohesiveness; conflict between partners; change in family unit; inadequate child-care arrangements; Single parent; father or mother of child not involved/parent-child separation; Insufficient parental role model; insufficient valuing of parenthood/inability to put child's needs before own; Unplanned or unwanted pregnancy/insufficient or late-term prenatal care; Economically disadvantaged; insufficient resources, e.g., financial, social, knowledge; insufficient transportation; Insufficient problem-solving skills; ineffective coping strategies; Insufficient social support; social isolation; History of abuse, e.g., physical. psychological, sexual, or being abusive; legal difficulty

DEFINING CHARACTERISTICS

Subjective

Parental

Perceived inability to meet child's needs; Speaks negatively about child; Frustration with child; perceived role inadequacy

Objective

Infant or Child

Frequent accidents or illness; failure to thrive; Low academic performance; delay in cognitive development; Impaired social functioning; behavior disorder, e.g., attention deficit, oppositional defiant; History of trauma/abuse, e.g., physical, psychological, sexual; Insufficient attachment behavior; diminished separation anxiety; runaway

Parental

Deficient parental-child interaction; decrease in cuddling; Inadequate child health maintenance; unsafe home environment; inappropriate child care arrangements; inappropriate stimulation, e.g., visual, tactile, auditory; Inappropriate care-taking skills; inconsistent care/behavior management; Inflexibility in meeting needs of child; Punitive; rejection of child; hostility; history of child abuse, e.g., physical, psychological, sexual; neglects needs of child; abandonment

PARENTING, READINESS FOR ENHANCED

Diagnostic Division: Social Interaction

Definition: A pattern of providing an environment for children or other dependent person(s) to nurture growth and development, which can be strengthened.

DEFINING CHARACTERISTICS

Subjective

Expresses desire to enhance parenting; Parent expresses desire to enhance emotional support of children/other dependent person; Children express desire to enhance home environment

PARENTING, RISK FOR IMPAIRED

Diagnostic Division: Social Interaction

Definition: Vulnerable to inability of the primary caretaker to create, maintain, or regain an environment that promotes the optimum growth and development of the child, which may compromise the well-being of the child.

RISK FACTORS

Infant or Child

Prematurity; multiple births; gender other than desired; Chronic illness; parent-child separation/prolonged separation from parent; Difficult temperament; temperament conflicts with parental expectations; Disabling condition; developmental delay; alteration in perceptual abilities; behavior disorder, e.g., attention deficit, oppositional defiant

Knowledge

Insufficient knowledge about child development/health maintenance or parenting skills; insufficient response to infant cues; Unrealistic expectations; Low educational level; alteration in cognitive functioning; insufficient cognitive readiness for parenting; Ineffective communication skills; Preference for physical punishment

Physiological

Physical illness

Psychological

Young parental age; Insufficient prenatal care; difficult birthing process; high number of/closely spaced pregnancies; Sleep deprivation/nonrestorative sleep pattern, i.e., due to caregiver responsibilities, parenting practices, sleep partner; Depression; history of mental illness or substance abuse; Disabling condition

Social

Stressors work difficulty; unemployment; relocation; compromised home environment; Low self-esteem; Insufficient family cohesiveness; conflict between partners; change in family unit; inadequate child-care arrangements; Single parent; father or mother of child not involved/parent-child separation; Insufficient parental role model; insufficient valuing of parenthood/inability to put child's needs before own; Unplanned or unwanted pregnancy/insufficient or late-term prenatal care; Economically disadvantaged; insufficient resources, e.g., financial, social, knowledge; insufficient transportation; Insufficient problem-solving skills; ineffective coping strategies; Insufficient social support; social isolation; History of abuse, e.g., physical. psychological, sexual, or being abusive; legal difficulty

PERSONAL IDENTITY, DISTURBED

Diagnostic Division: Ego Integrity

Definition: Inability to maintain an integrated and complete perception of self.

RELATED FACTORS

Low self-esteem; dysfunctional family processes; Situational crisis; stages of growth; developmental transition; alteration in social role; Exposure to toxic chemical; pharmaceutical agent; Cultural incongruence; discrimination; perceived prejudice; Manic states; psychiatric disorder; dissociative identity disorder; organic brain disorder; Cult indoctrination

DEFINING CHARACTERISTICS

Subjective

Alteration in body image; delusional description of self; Fluctuating feelings about self; feeling of strangeness, emptiness; Confusion about goals, cultural values, or ideological values; Gender confusion; Inability to distinguish between internal and external stimuli

Objective

Inconsistent behavior; Ineffective relationships; Ineffective coping or role performance

PERSONAL IDENTITY, RISK FOR DISTURBED

Diagnostic Division: Ego Integrity

Definition: Vulnerable to the inability to maintain an integrated and complete perception of self, which may compromise health.

RISK FACTORS

Low self-esteem; dysfunctional family processes; Situational crisis; stages of growth; developmental transition; alteration in social role; Exposure to toxic chemical; pharmaceutical agent; Cultural incongruence; discrimination; perceived prejudice; Manic states; psychiatric disorder; dissociative identity disorder; organic brain disorder; Cult indoctrination

POISONING, RISK FOR

Diagnostic Division: Safety

Definition: Vulnerable to accidental exposure to, or ingestion of, drugs or dangerous products in sufficient doses that may compromise health.

RISK FACTORS

Internal

Alteration in cognitive functioning; Emotional disturbance; Inadequate precautions against poisoning; inadequate knowledge of poisoning prevention; Inadequate knowledge of pharmacological agents; [narrow therapeutic margin of safety of specific pharmaceutical agents, e.g., therapeutic versus toxic level, half-life, method of uptake and degradation in body, adequacy of organ function]; Occupational setting without adequate safeguards; Reduced vision; [Cultural or religious beliefs or practices]

External

Access to dangerous product; Access to pharmaceutical agent; access to large supply of pharmaceutical agents in house; Access to illicit drugs potentially contaminated by poisonous additives; [Use of multiple herbal supplements or megadosing]

POSITIONING INJURY, RISK FOR PERIOPERATIVE

Diagnostic Division: Safety

Definition: Vulnerable to inadvertent anatomical and physical changes as a result of posture or equipment used during an invasive/surgical procedure, which may compromise health.

RISK FACTORS

Disorientation; Edema; Emaciation; Immobilization; Muscle weakness; Obesity; Sensory/perceptual disturbances due to anesthesia

POST-TRAUMA SYNDROME [SPECIFY STAGE]

Diagnostic Division: Ego Integrity

Definition: Sustained maladaptive response to a traumatic, overwhelming event.

RELATED FACTORS

Exposure to disaster (natural or man-made); destruction of one's home; Event outside the range of usual human experience; exposure to event involving multiple deaths; Exposure to war; history of being a prisoner of war; History of abuse, e.g., physical, psychological, sexual; history of criminal victimization; history of torture; witnessing mutilation or violent death; Self-injurious behavior; Serious accident, e.g., industrial, motor vehicle; serious injury to loved one; Serious threat to self or loved one

DEFINING CHARACTERISTICS

Subjective

Intrusive thoughts or dreams; nightmares; flashbacks; [excessive verbalization of the traumatic event]; Heart palpitations; headache; [loss of interest in usual activities, loss of feeling of intimacy or sexuality]; Hopelessness; shame; guilt; [verbalization of survival guilt or guilt about behavior required for survival]; Anxiety; fear; grieving; depression; horror; Reports feeling numb; Gastrointestinal irritation; [change in appetite]; Alteration in concentration; [Change in sleep; fatigue]

Objective

Alteration in mood; [poor impulse control or explosiveness]; panic attacks; Hypervigilance; exaggerated startle response; irritability; neurosensory irritability; Anger; rage; aggression; Avoidance behaviors; denial; repression; alienation; History of detachment; dissociative amnesia; Substance abuse; compulsive behavior; Enuresis; [Difficulty with interpersonal relationships; dependence on others; work or school failure]

[Stages: Acute: Begins within 6 months and does not last longer than 6 months; Chronic subtype: Lasts longer than 6 months; Delayed onset subtype: Period of latency of 6 months or longer before onset of symptoms]

POST-TRAUMA SYNDROME, RISK FOR

Diagnostic Division: Ego Integrity

Definition: Vulnerable to sustained maladaptive response to a traumatic, overwhelming event, which may compromise health.

RISK FACTORS

Diminished ego strength; environment not conducive to needs; insufficient social support; Displacement from home; Duration of traumatic event; perceives event as traumatic; survival role; Exaggerated sense of responsibility; Human service occupations, e.g., police, fire, rescue, corrections, emergency room, mental health

POWER, READINESS FOR ENHANCED

Diagnostic Division: Ego Integrity

Definition: A pattern of participating knowingly in change for well-being, which can be strengthened.

DEFINING CHARACTERISTICS

Subjective

Expresses desire to enhance: power; knowledge for participation in change; awareness of possible changes; identification of choices that can be made for change; Expresses desire to enhance: independence with actions for change; involvement in change; participation in choices for daily living and health

NOTE: Even though power (a response) and empowerment (an intervention approach) are different concepts, the literature related to both concepts supports the defining characteristics of this diagnosis.

POWERLESSNESS

Diagnostic Division: Ego Integrity

Definition: The lived experience of lack of control over a situation, including a perception that one's own actions do not significantly affect an outcome.

RELATED FACTORS

Dysfunctional institutional environment; Insufficient interpersonal interactions; Complex treatment regimen

DEFINING CHARACTERISTICS

Subjective

Alienation; shame; Depression; Doubt about inability to perform previous activities; insufficient sense of control

Objective

Dependency; Inadequate participation in care

POWERLESSNESS, RISK FOR

Diagnostic Division: Ego Integrity

Definition: Vulnerable to the lived experience of lack of control over a situation, including a perception that one's actions do not significantly affect an outcome, which may compromise health.

RISK FACTORS

Anxiety; ineffective coping strategies; low self-esteem; Caregiver role; Economically disadvantaged; Illness; progressive illness; unpredictability of illness trajectory; pain; Insufficient knowledge to manage a situation; Insufficient social support; social marginalization; stigmatization

PRESSURE ULCER, RISK FOR

Diagnostic Division: Safety

Definition: Vulnerable to localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear (National Pressure Ulcer Advisory Panel [NPUAP, 2007]).

RISK FACTORS

ADULT: Braden scale score of <18; CHILD: Braden scale score of ≤16; American Society of Anesthesiologists (ASA) Physical Status classification sore ≥2; Low score on Risk Assessment Pressure Sore (RAPS) scale; Alteration in cognitive functioning; Alteration in sensation; decrease in mobility; extended period of immobility on hard surface, e.g., surgical procedure ≥2 hours; Anemia; decrease in tissue oxygenation or perfusion; impaired circulation; lymphopenia; Cardiovascular disease; history of cerebral vascular accident; Dehydration; dry or scaly skin; skin moisture; edema; Elevated skin temperature by 1–2°C; hyperthermia; Extremes of age or weight; Female gender; Hip fracture; history of trauma; physical immobilization; History of pressure ulcer; Inadequate nutrition; reduced triceps skin fold thickness; decrease in serum albumin; Incontinence; Insufficient caregiver knowledge of pressure ulcer prevention; Nonblanchable erythema; pressure over bony prominence; Pharmaceutical agents, e.g., vasopressors, antidepressnt, norepinephrine; Self-care deficit; Shearing forces; friction; Use of linen with insufficient moisture wicking property; Smoking

PROTECTION, INEFFECTIVE

Diagnostic Division: Safety

Definition: Decrease in the ability to guard self from internal or external threats such as illness or injury.

RELATED FACTORS

Extremes of age; Inadequate nutrition; Substance abuse; Abnormal blood profile, e.g., leukopenia, thrombocytopenia, anemia; Pharmaceutical agent, e.g., antineoplastic, corticosteroid, immune, thrombolytic; Treatment regimen; Cancer; Immune disorder, e.g., HIV-associated neuropathy, varicella-zoster virus

DEFINING CHARACTERISTICS

Subjective

Neurosensory impairment; Chilling; Itching; Insomnia; Fatigue; Weakness; Anorexia

Objective

Deficient immunity; Impaired healing; Alteration in clotting; Maladaptive stress response; Alteration in perspiration; Dyspnea; Coughing; Restlessness; Immobility; Disorientation; Pressure ulcer

RAPE-TRAUMA SYNDROME

Diagnostic Division: Ego Integrity

Definition: Sustained maladaptive response to a forced, violent sexual penetration against the victim's will and consent. [Rape is not a sexual crime, but a crime of violence and identified as sexual assault. Although attacks are most often directed toward women, men also may be victims.]

RELATED FACTORS

Rape [actual or attempted forced sexual penetration]

DEFINING CHARACTERISTICS

Subjective

Embarrassment; Humiliation; Shame; Guilt; Self-blame; Chronic self-esteem; Helplessness; Powerlessness; Shock; Fear; Anxiety; Anger; Revenge; Nightmares; Disturbed sleep pattern; Change in relationship(s); Sexual dysfunction

Objective

Physical trauma; muscle tension or spasm; Confusion; disorganization; impaired decision-making; Agitation; hyperalertness; aggression; Mood swings; perceived vulnerability; dependency; low self-esteem; depression; Substance abuse; history of suicide attempts; Denial; phobias; paranoia; dissociative identity disorder

REACTION TO IODINATED CONTRAST MEDIA, RISK FOR ADVERSE

Diagnostic Division: Safety

Definition: Vulnerable to noxious or unintended reaction associated with the use of iodinated contrast media that can occur within seven days after contrast agent injection, which may compromise health.

RISK FACTORS

Anxiety; Chronic illness; Concurrent use of pharmaceutical agents, e.g., beta-blockers, interleukin-2, metformin, nephrotoxins; Contrast media precipitates adverse event, e.g., iodine concentration, viscosity, high osmolality, iron toxicity; Dehydration; Extremes of age, generalized debilitation; Fragile veins, e.g., chemotherapy or radiation in limb to be injected; indwelling line in place for more than 24 hours; axillary lymph node dissection in limb to be injected; distal intravenous access site; History of allergies, or previous adverse effect from iodinated contrast media [ICM]; Unconsciousness

RELATIONSHIP, INEFFECTIVE

Diagnostic Division: Ego Integrity

Definition: A pattern of mutual partnership that is insufficient to provide for each other's needs.

RELATED FACTORS

Stressors; developmental crisis; Substance abuse; Unrealistic expectations; Ineffective communication skills; History of domestic violence; Alteration in cognitive functioning in one partner; Incarceration of one partner

DEFINING CHARACTERISTICS

Subjective

Dissatisfaction with complementary relation between partners; Dissatisfaction with physical or emotional need fulfillment between partners; Dissatisfaction with information or idea sharing between partners

Objective

Unsatisfactory communication with partner; Insufficient balance in autonomy or collaboration between partners; Insufficient mutual respect between partners; Insufficient mutual support in daily activities between partners; Inadequate understanding of partner's compromised functioning, e.g., physical, social, psychological; Delay in meeting of developmental goals appropriate for family life-cycle stage; Partner not identified as support person

RELATIONSHIP, READINESS FOR ENHANCED

Diagnostic Division: Ego Integrity

Definition: A pattern of mutual partnership that is sufficient to provide for each other's needs, which can be strengthened.

DEFINING CHARACTERISTICS

Subjective

Communication between partners; Satisfaction with information/idea sharing between partners; Emotional need fulfillment for each partner; Satisfaction with physical or emotional need fulfillment for each partner; Satisfaction with complementary relation between partners; Mutual respect between partners; Autonomy or collaboration between partners; Understanding of partner's functional deficit, e.g., physical, social, psychological

RELATIONSHIP, RISK FOR INEFFECTIVE

Diagnostic Division: Ego Integrity

Definition: Vulnerable to developing a pattern that is insufficient for providing a mutual partnership to provide for each other's needs.

RISK FACTORS

Stressors; developmental crisis; Substance abuse; Unrealistic expectations; Ineffective communication skills; History of domestic violence; Alteration in cognitive functioning in one partner; Incarceration of one partner

RELIGIOSITY, IMPAIRED

Diagnostic Division: Ego Integrity

Definition: Impaired ability to exercise reliance on beliefs and/or participate in rituals of a particular faith tradition.

NOTE: [NANDA-I] recognizes that the term “religiosity” may be culture specific; however, the term is useful in the U.S. and is well-supported in the U.S. literature.

RELATED FACTORS

Developmental and Situational

Aging; end-stage life crisis; Life transition (actual and risk)

Physical

Illness; Pain

Psychological Factors

Ineffective coping strategies; insufficient or ineffective social support; Anxiety; fear of death; Depression (risk); Personal crisis; insecurity; History of religious manipulation

Sociocultural

Cultural or environmental barrier to practicing religion; Insufficient social integration or sociocultural interaction

Spiritual

Spiritual crises; Suffering

DEFINING CHARACTERISTICS

Subjective

Distress about separation from faith community; Desire to reconnect with previous belief pattern or customs; Questioning of religious belief patterns or customs; Difficulty adhering to prescribed religious beliefs and rituals, e.g., ceremonies, regulations, clothing, prayer, services, holiday observances

RELIGIOSITY, READINESS FOR ENHANCED

Diagnostic Division: Ego Integrity

Definition: A pattern of reliance on religious beliefs and/or participation in rituals of a particular faith tradition, which can be strengthened.

DEFINING CHARACTERISTICS

Subjective

Expresses desire to enhance belief patterns or religious customs used in the past; Expresses desire to enhance participation in religious experiences or practices, e.g., ceremonies, regulations, clothing, prayer, services, holiday observances; Expresses desire to enhance religious options, use of religious materials; Expresses desire to enhance connection with a religious leader; Expresses desire to enhance forgiveness

RELIGIOSITY, RISK FOR IMPAIRED

Diagnostic Division: Ego Integrity

Definition: Vulnerable to an impaired ability to exercise reliance on beliefs and/or participate in rituals of a particular faith tradition, which may compromise health.

NOTE: [NANDA-I] recognizes that the term “religiosity” may be culture specific; however, the term is useful in the U.S. and is well-supported in the U.S. literature.

RISK FACTORS

Developmental

Life transitions

Environmental

Lack of transportation; Barriers to practicing religion

Physical

Illness; Hospitalization; Pain

Psychological

Ineffective coping/caregiving; Ineffective support; Depression; Lack of security

Sociocultural

Lack of social interaction; Social isolation; Cultural barrier to practicing religion

Spiritual

Suffering

RELOCATION STRESS SYNDROME

Diagnostic Division: Ego Integrity

Definition: Physiological and/or psychosocial disturbance following transfer from one environment to another.

RELATED FACTORS

Move from one environment to another; significant environmental change (risk); Compromised health status (risk); deficient mental competence (risk); History of loss; powerlessness; Insufficient support system; insufficient predeparture counseling; unpredictability of experience; Social Isolation; language barrier; Impaired psychosocial functioning; ineffective coping strategies; [Increased confusion, cognitive impairment]

DEFINING CHARACTERISTICS

Subjective

Anxiety, e.g., separation; Anger; Insecurity; Worry; Fear; Loneliness; Depression; Unwillingness to move; Concern about relocation; Alteration in Sleep pattern

Objective

Increase in verbalization of needs; Pessimism; frustration; Increase in physical symptoms or illness; Withdrawal; aloneness; alienation; Loss of identity or self-worth; low self-esteem; dependency; Increased confusion or cognitive impairment

RELOCATION STRESS SYNDROME, RISK FOR

Diagnostic Division: Ego Integrity

Definition: Vulnerable to physiological and/or psychosocial disturbance following transfer from one environment to another, which may compromise health..

RISK FACTORS

Move from one environment to another; significant environmental change (risk); Compromised health status (risk); deficient mental competence (risk); History of loss; powerlessness; Insufficient support system; insufficient predeparture counseling; unpredictability of experience; Social Isolation; language barrier; Impaired psychosocial functioning; ineffective coping strategies; [Increased confusion, cognitive impairment]

RENAL PERFUSION, RISK FOR INEFFECTIVE

Diagnostic Division: Circulatory

Definition: Vulnerable to a decrease in blood circulation to the kidney, which may compromise health.

RISK FACTORS

Alteration in metabolism; diabetes mellitus; Renal disease, e.g., polycystic kidney, renal artery stenosis, failure; bilateral cortical necrosis; exposure to nephrotoxin; glomerulonephritis; interstitial nephritis; polynephritis; Burns; infection; systemic inflammatory response syndrome (SIRS); Cardiac surgery; vascular embolism; vasculitis; Abdominal compartment syndrome; Extremes of age; female gender; Hypertension; malignant hypertension; hypovolemia; hypoxemia; Malignancy; Smoking; substance abuse; Trauma; treatment regimen

RESILIENCE, IMPAIRED

Diagnostic Division: Ego Integrity

Definition: Decreased ability to sustain a pattern of positive responses to an adverse situation or crisis.

RELATED FACTORS

Community violence; exposure to violence; Demographics that increase changes of maladjustment; ethnic minority status; Economically disadvantaged; perceived vulnerability; Female gender; large family size; Inconsistent parenting; parental mental illness; psychological disorder; Low intellectual ability; low maternal educational level; Insufficient impulse control; substance abuse

DEFINING CHARACTERISTICS

Subjective

Depression, guilt, isolation or social isolation, low self-esteem, shame; Lower perceived health status; Renewed elevation of distress; Decreased interest in academic activities, vocational activities

Objective

Using maladaptive coping skills, i.e., drug use, violence, etc.

RESILIENCE, READINESS FOR ENHANCED

Diagnostic Division: Ego Integrity

Definition: A pattern of positive responses to an adverse situation or crisis, which can be strengthened.

DEFINING CHARACTERISTICS

Subjective

Expresses desire to enhance: communication skills, relationships with others; Expresses desire to enhance use of: coping skills, conflict management strategies; Expresses desire to enhance: resilience, self-esteem; Expresses desire to enhance: involvement in activities, own responsibility for action, sense of control; Expresses desire to enhance: goal-setting, progress toward goal; Expresses desire to enhance: support system, available resources, use of resources; Expresses desire to enhance: environmental safety

Objective

Demonstrates positive outlook; Exposure to crisis

RESILIENCE, RISK FOR IMPAIRED

Diagnostic Division: Ego Integrity

Definition: Vulnerable to decreased ability to sustain a pattern of positive responses to an adverse situation or crisis, which may compromise health.

RISK FACTORS

Chronicity of existing crisis; Multiple coexisting adverse situations; New crisis, e.g., unplanned pregnancy, loss of housing, death of family member

ROLE CONFLICT, PARENTAL

Diagnostic Division: Social Interaction

Definition: Parental experience of role confusion and conflict in response to crisis.

RELATED FACTORS

Parent-child separation; Intimidation by invasive modalities, e.g., intubation; by restrictive modalities, e.g., isolation; Home care of a child with special needs; Living in nontraditional setting, e.g., foster, group, or institutional care; Change in marital status; [conflicts of the role of single parent]; Interruptions in family life due to home-care regimen, e.g., treatments, caregivers, lack of respite

DEFINING CHARACTERISTICS

Subjective

Perceived inadequacy to provide for child's needs, e.g., physical, emotional; Concern about change in parental role; concern about family, e.g., functioning, communication, health; Perceived loss of control over decisions relating to child; Guilt; frustration; anxiety; fear

Objective

Disruption in caregiver routines; Reluctance to participate in usual caregiver activities

ROLE PERFORMANCE, INEFFECTIVE

Diagnostic Division: Social Interaction

Definition: A pattern of behavior and self-expression that does not match the environmental context, norms, and expectations.

NOTE: There is a typology of roles, e.g., sociopersonal [friendship, family, marital, parenting, community]; home management; intimacy [sexuality, relationship building]; leisure, exercise, or recreation; self-management; socialization [developmental transitions], community contributor; and religious, that can help to understand ineffective Role Performance.

RELATED FACTORS

Knowledge

Insufficient role model; Insufficient role preparation, e.g., role transition, skill rehearsal, validation; Low educational level; Unrealistic role expectations

Physiological

Alteration in body image; neurological deficit; physical illness; low self-esteem; Mental health issue, e.g., depression, psychosis, personality disorder, substance abuse; Fatigue; pain

Social

Insufficient role socialization; Young age; developmental level inappropriate for role expectation; Insufficient resources, e.g., financial, social, knowledge; economically disadvantaged; Stressors; conflict; high demands of job schedule; [Family conflict]; domestic violence; Insufficient support system; insufficient rewards; Inappropriate linkage with the healthcare system

DEFINING CHARACTERISTICS

Subjective

Alteration in role perception; change in self-/other's perception of role; Change in usual pattern of responsibility or in capacity to resume role; Insufficient opportunity for role enactment; Role dissatisfaction; role denial; Discrimination; powerlessness

Objective

Insufficient knowledge of role requirements; Ineffective adaptation to change; inappropriate developmental expectations; Insufficient confidence, motivation, self-management, or skills; Ineffective coping strategies; ineffective role performance; Inadequate external support for role enactment; Role strain, conflict, confusion, or ambivalence; [failure to assume role]; Uncertainty; anxiety; depression; pessimism; Domestic violence; harassment; system conflict

ROLE STRAIN, CAREGIVER

Diagnostic Division: Social Interaction

Definition: Difficulty in performing family/significant other caregiver role.

RELATED FACTORS

Care Receiver Health Status

Alteration in cognitive functioning; Chronic illness; illness severity; increase in care needs; unpredictability of illness trajectory; unstable health condition; Codependency; dependency; substance abuse; Problematic behavior; psychiatric disorder

Caregiving Activities

Around-the-clock care responsibilities; change in nature or complexity of care activities; Duration of caregiving; unpredictability of care situation; Excessive caregiving activities; recent discharge home with significant care needs

Caregiver Health Status

Alteration in cognitive functioning; physical conditions; Codependency; substance abuse; Ineffective coping strategies; insufficient fulfillment of others' or self-expectations; unrealistic care receiver expectations

Socioeconomic

Alienation or social isolation; Competing role commitments; Insufficient recreation

Caregiver–Care Receiver Relationship

Abusive or violent relationship; pattern of ineffective relationships; Care receiver's condition inhibits conversation; unrealistic care receiver expectations

Family Processes

Pattern of ineffective family coping or family dysfunction

Resources

Caregiver is not developmentally ready for caregiver role; insufficient time; Difficulty accessing assistance, support, or community resources; insufficient knowledge about community resources; insufficient community services, e.g., respite, recreation, social support; insufficient transportation; Financial crisis, e.g., debt, insufficient finances; Insufficient emotional resilience, social support, time, or energy; Insufficient physical environment or equipment for providing care

DEFINING CHARACTERISTICS

Subjective

Caregiving Activities

Apprehensiveness about: future ability to provide care or well-being of care receiver if unable to provide care; apprehensiveness about future health or institutionalization of care receiver; to provide care

Caregiver Health Status—physiological

Fatigue; gastrointestinal distress; headache, rash, weight change; Hypertension; cardiovascular disease; diabetes

Caregiver Health Status—emotional

Alteration in sleep pattern; Anger, emotional vacillation; depression; frustration, impatience; nervousness; Insufficient time to meet personal needs; stressors

Caregiver Health Status—socioeconomic

Changes in leisure activities; low work productivity; refuses career advancement

Caregiver–Care Receiver Relationship

Difficulty watching care receiver with illness; Grieving changes or uncertainty in relationship with care receiver

Family Processes

Concern about family members; family conflict

Objective

Caregiving Activities

Difficulty performing/completing required tasks; Preoccupation with care routine; Dysfunctional change in caregiving activities

Caregiver Health Status—emotional

Anger, emotional vacillation; depression; frustration, impatience; nervousness; Somatization; Ineffective coping strategies

Caregiver Health status—socioeconomic

Low work productivity; refusal of career advancement; social isolation

Family Processes

Family conflict

NOTE: [Authors' note: The presence of this problem may encompass other numerous problems/high-risk concerns such as deficient Diversional Activity, Insomnia, Fatigue, Anxiety, ineffective Coping, compromised/disabled family Coping, decisional Conflict, ineffective Denial, Grieving, Hopelessness, Powerlessness, Spiritual Distress, ineffective Health Maintenance, impaired Home Maintenance, ineffective Sexuality Pattern, readiness for enhanced family Coping, interrupted Family Processes, Social Isolation. Careful attention to data gathering will identify and clarify the client's specific needs, which can then be coordinated under this single diagnostic label]

ROLE STRAIN, RISK FOR CAREGIVER

Diagnostic Division: Social Interaction

Definition: Vulnerable to difficulty in performing the family/significant other caregiver role, which may compromise health.

RISK FACTORS

Illness severity of the care receiver; alteration in cognitive functioning in care receiver; psychological disorder in care receiver; care receiver exhibits bizarre or deviant behavior; Care receiver discharged home with significant needs; prematurity; congenital disorder; developmental delay; Unpredictable illness trajectory; instability in care receiver's health; Substance abuse; codependency; Extended duration of caregiving required; inexperience with caregiving; caregiving task complexity; excessive caregiving activities; Caregiver health impairment; psychological disorder in caregiver; Partner is caregiver, female; Caregiver is not developmentally ready for caregiver role [e.g., a young adult needing to provide care for middle-aged parent]; developmental delay of caregiver; Stressors; caregiver's competing role commitments; Inadequate physical environment for providing care; Family or caregiver isolation; Insufficient caregiver respite or recreation; Ineffective family adaptation; pattern of family dysfunction prior to the caregiving situation; Ineffective caregiver coping pattern; Pattern of ineffective relationship between caregiver and care receiver; Exposure to violence; presence of abuse, e.g., physical, psychological, sexual

SELF-CARE, READINESS FOR ENHANCED

Diagnostic Division: Teaching/Learning

Definition: A pattern of performing activities for oneself that helps to meet health-related goals, which can be strengthened.

DEFINING CHARACTERISTICS

Subjective

Expresses desire to enhance independence in maintaining: life/health/personal development/well-being; Expresses desire to enhance: Self-care; Knowledge of strategies for self-care; Responsibility for self-care

NOTE: Note: Based on the definition and defining characteristics of this ND, the focus appears to be broader than simply meeting routine basic ADLs and addresses independence in maintaining overall health, personal development, and general well-being.

SELF-CARE DEFICIT, BATHING

Diagnostic Division: Hygiene

Definition: Impaired ability to perform or complete bathing activities for self.

RELATED FACTORS

Alteration in cognitive functioning; perceptual impairment; Weakness; fatigue; decrease in motivation; anxiety; Neuromuscular or musculoskeletal impairment; Environmental barrier; [mechanical restrictions such as cast, splint, traction, ventilator]; Pain; discomfort; Inability to perceive body part or spatial relationship [bathing]; Impaired mobility or transfer ability [toileting]

DEFINING CHARACTERISTICS

Objective

Impaired ability to: access bathroom, access water source, dry body, gather bathing supplies, regulate bath water, wash body

SELF-CARE, DEFICIT, DRESSING

Diagnostic Division: Hygiene

Definition: Impaired ability to perform or complete dressing activities for self.

RELATED FACTORS

Alteration in cognitive functioning; Anxiety; Perceptual disorders; Weakness

DEFINING CHARACTERISTICS

Objective

Impaired ability to: choose clothing, gather clothing, pick up clothing, put clothing on upper or lower body, fasten clothing; Impaired ability to: put on/remove various items of clothing, e.g., shirt, socks, shoes; Impaired ability to: use zipper or assistive device, maintain appearance

SELF-CARE, DEFICIT, FEEDING

Diagnostic Division: Hygiene

Definition: Impaired ability to perform or complete self-feeding activities.

RELATED FACTORS

Alteration in cognitive functioning; Perceptual disorders; Neuromuscular/musculoskeletal impairment; Decrease in motivation; Discomfort; Environmental barriers; Fatigue; Pain; Anxiety; Weakness

DEFINING CHARACTERISTICS

Objective

Impaired ability to: prepare food, open containers; Impaired ability to: handle utensils, get food onto utensil, bring food to the mouth, use assistive device, pick up cup; Impaired ability to: manipulate food in mouth, chew food, swallow food or swallow sufficient amount of food, self-feed a complete meal in an acceptable manner

SELF-CARE, DEFICIT, TOILETING

Diagnostic Division: Activity/Rest

Definition: Impaired ability to perform or complete self-toileting activities.

NOTE: Specify level of independence using a standardized functional scale.

RELATED FACTORS

Alteration in cognitive functioning; Perceptual disorders; Neuromuscular/musculoskeletal impairment; Decrease in motivation; Discomfort; Environmental barriers; Fatigue; Pain; Anxiety; Weakness

DEFINING CHARACTERISTICS

Objective

Impaired ability to: reach toilet, manipulate clothing for toileting, sit on or rise from toilet, complete toilet hygiene, flush toilet

SELF-CONCEPT, READINESS FOR ENHANCED

Diagnostic Division: Ego Integrity

Definition: A pattern of perceptions or ideas about the self, which can be strengthened.

DEFINING CHARACTERISTICS

Subjective

Expresses desire to enhance self-concept, role performance; Acceptance of strengths, limitations; Confidence in abilities; Satisfaction with thoughts about self, sense of worth; Satisfaction with body image, personal identity

Objective

Actions congruent with verbal expressions.

SELF-ESTEEM, CHRONIC LOW

Diagnostic Division: Ego Integrity

Definition: Long-standing negative self-evaluation/feelings about self or self-capabilities.

RELATED FACTORS

Repeated negative reinforcement, failures; Receiving insufficient affection, approval from others; Inadequate belonging; insufficient group membership; Inadequate respect from others; Cultural or spiritual incongruencies; Exposure to traumatic situation; Ineffective coping with loss; Psychiatric disorder

DEFINING CHARACTERISTICS

Subjective

Shame; guilt; Underestimation of ability to deal with situation; Rejection of positive feedback

Objective

Hesitant to try new experiences; Repeatedly unsuccessful in life events; Exaggerates negative feedback about self; Overly conforming; dependent on others' opinions; Poor eye contact; Nonassertive or indecisive behavior; passivity; Excessive seeking of reassurance

SELF-ESTEEM, SITUATIONAL LOW

Diagnostic Division: Ego Integrity

Definition: Development of a negative perception of self-worth in response to a current situation.

RELATED FACTORS

Developmental transition; Functional impairment; alteration in body image; History of loss; Alteration in social role; Pattern of failure; history of rejection; inadequate recognition; Behavior inconsistent with values

DEFINING CHARACTERISTICS

Subjective

Helplessness; purposelessness; Underestimates ability to deal with situation

Objective

Situational challenge to self-worth; Self-negating verbalizations; Indecisive or nonas-sertive behavior

SELF-ESTEEM, RISK FOR CHRONIC LOW

Diagnostic Division: Ego Integrity

Definition: Vulnerable to long-standing negative self-evaluating/feelings about self or self-capabilities, which may compromise health.

RISK FACTORS

Repeated negative reinforcement, failures; Receiving insufficient affection, approval from others; Inadequate belonging; insufficient group membership; Inadequate respect from others; Cultural or spiritual incongruencies; Exposure to traumatic situation; Ineffective coping with loss; Psychiatric disorder

SELF-ESTEEM, RISK FOR SITUATIONAL LOW

Diagnostic Division: Ego Integrity

Definition: Vulnerable to developing a negative perception of self-worth in response to a current situation, which may compromise health.

RISK FACTORS

Alteration in body image; physical illness; Alteration in social role; history of abandonment; Behavior inconsistent with values; unrealistic self-expectations; Decrease in control over environment; Developmental transition; functional impairment; History of neglect or rejection; history of abuse, e.g., physical, psychological, sexual; Inadequate recognition; pattern of failure; pattern of helplessness

SELF-MUTILATION

Diagnostic Division: Safety

Definition: Deliberate self-injurious behavior causing tissue damage with the intent of causing nonfatal injury to attain relief of tension.

RELATED FACTORS

Absence of family confidant; disturbance in interpersonal relationships; Adolescence; ineffective communication between parent and adolescent; eating disorder; Alteration in body image; impaired or low self-esteem; Autism; childhood illness or surgery; developmental delay; Borderline personality or character disorder; depersonalization; dissociation; psychotic disorder; emotional disorder; labile behavior (risk); Family divorce; family history of substance abuse or self-destructive behavior; violence between parental figures; Feeling threatened with loss of significant relationship; loss of significant relationship(s) (risk); History of childhood abuse, e.g., physical, psychological, sexual; History of self-directed violence; irresistible urge for self-directed violence or to cut self; Impulsiveness; ineffective coping strategies; inability to express tension verbally; mounting tension that is intolerable; requires rapid stress reduction; Incarceration; Isolation from peers; peers who self-mutilate; Living in nontraditional setting, e.g., foster, group, or institutional care; Negative feeling, e.g., depression, rejection, self-hatred, separation anxiety, guilt, depersonalization; perfectionism; Loss of control over problem-solving (risk); pattern of inability to plan solutions or to see long-term consequences; history of manipulation to obtain nurturing relationship with others; Sexual identity crisis; Substance abuse

DEFINING CHARACTERISTICS

Subjective

Self-inflicted burn; Ingestion or inhalation of harmful substance

Objective

Cuts or scratches on body; Picking at wound; Biting; Abrading; Insertion of object into body orifice; Hitting; Severing or Constricting a body part

SELF-MUTILATION, RISK FOR

Diagnostic Division: Safety

Definition: Vulnerable to deliberate self-injurious behavior causing tissue damage with the intent of causing nonfatal injury to attain relief of tension.

RISK FACTORS

Absence of family confidant; disturbance in interpersonal relationships; Adolescence; ineffective communication between parent and adolescent; eating disorder; Alteration in body image; impaired or low self-esteem; Autism; childhood illness or surgery; developmental delay; Borderline personality or character disorder; depersonalization; dissociation; psychotic disorder; emotional disorder; labile behavior (risk); Family divorce; family history of substance abuse or self-destructive behavior; violence between parental figures; Feeling threatened with loss of significant relationship; loss of significant relationship(s) (risk); History of childhood abuse, e.g., physical, psychological, sexual; History of self-directed violence; irresistible urge for self-directed violence or to cut self; Impulsiveness; ineffective coping strategies; inability to express tension verbally; mounting tension that is intolerable; requires rapid stress reduction; Incarceration; Isolation from peers; peers who self-mutilate; Living in nontraditional setting, e.g., foster, group, or institutional care; Negative feeling, e.g., depression, rejection, self-hatred, separation anxiety, guilt, depersonalization; perfectionism; Loss of control over problem-solving (risk); pattern of inability to plan solutions or to see long-term consequences; history of manipulation to obtain nurturing relationship with others; Sexual identity crisis; Substance abuse

SELF-NEGLECT

Diagnostic Division: Hygiene

Definition: A constellation of culturally framed behaviors involving one or more self-care activities in which there is a failure to maintain a socially accepted standard of health and well-being (Gibbons, Lauder, & Ludwick, 2006).

RELATED FACTORS

Stressor; psychiatric/psychotic disorder; Frontal lobe dysfunction; deficient executive function; alteration in cognitive functioning; Capgras syndrome; Functional impairment; learning disability; Lifestyle choice; substance abuse; malingering; Inability to maintain control; fear of institutionalization

DEFINING CHARACTERISTICS

Objective

Insufficient personal or environmental hygiene; Nonadherence to health activity

SEXUAL DYSFUNCTION

Diagnostic Division: Sexuality

Definition: A state in which an individual experiences a change in sexual function during the sexual response phases of desire, excitation, and/or orgasm, which is viewed as unsatisfying, unrewarding, or inadequate.

RELATED FACTORS

Inadequate role model; absence of significant other (SO); Absence of privacy; Misinformation or insufficient knowledge about sexual function; Vulnerability; Presence of abuse, e.g., physical, psychological, sexual; psychosocial abuse, e.g., controlling, manipulation, verbal abuse; Alteration in body function or structure (due to pregnancy, surgery, medication, anomaly, disease, trauma, radiation, etc.); Value conflict

DEFINING CHARACTERISTICS

Subjective

Change in sexual role; Perceived sexual limitation; Alteration in sexual activity, excitation, or satisfaction; decrease in sexual desire; Undesired change in sexual function; Seeks confirmation of desirability; Change in self-interest/interest toward others

SEXUALITY PATTERN, INEFFECTIVE

Diagnostic Division: Sexuality

Definition: Expressions of concern regarding own sexuality.

RELATED FACTORS

Insufficient knowledge or skill deficit about alternatives related to sexuality; Absence of privacy; Impaired relationship with a significant other (SO); absence of SO; Inadequate role model; Conflict about sexual orientation or variant preference; Fear of pregnancy or sexually transmitted infection

DEFINING CHARACTERISTICS

Subjective

Alteration in relationship with SO; Alteration in/difficulty with sexual activity or behavior; Change in sexual role; Value conflict

SHOCK, RISK FOR

Diagnostic Division: Circulation

Definition: Vulnerable to an inadequate blood flow to the body's tissues that may lead to life-threatening cellular dysfunction, which may compromise health.

RISK FACTORS

Hypotension; Hypovolemia; Hypoxemia, hypoxia; Infection, sepsis, systemic inflammatory response syndrome

SITTING, IMPAIRED

Diagnostic Division: Safety

Definition: Limitation of ability to independently and purposefully attain and/or maintain a rest position that is supported by the buttocks and thighs in which the torso is upright.

RELATED FACTORS

Alteration in cognitive functioning; psychological disorder; Impaired metabolic functioning; malnutrition; sarcopenia; Insufficient endurance; Neurological disorder; Orthopedic surgery; Pain; Prescribed posture; self-imposed relief posture