Nursing Diagnosis with Related Factors

NURSING NURSIN G DIAGNOSIS ACTIVITY INTOLERANCE

RELATED FACTORS y y y

ACTIVITY INTOLERANCE; RISK FOR

y y

ACTIVITY PLANNING, INEFFECTIVE AUTONOMIC DYSREFLEXIA

Bedrest complete exhaustion imbalance between oxygen supply and demand immobility Lifestyle

Head

Injury

Subarachnoid H emorrhage Guillain-Barre Syndrome

AUTONOMIC DYSREFLEXIA, RISK FOR

Medication

y

or perceived threat to physi cal and emoti onal integrity Changes in r ol e function Intrusive diagnostic a nd surgical tests and procedures Changes in environm ent and routines Threat or perceived threat t o self -conc -concept Threat to ( or change in) s ocioeconom ic status Situational and maturational crises Interpersonal con f licts

y

Environmental

y

ANXIETY

y y y y y

ANXIETY, DEATH

y

y y y y y y

AIRWAY CLEARANCE, INEFFECTIVE

y y y y y y y y y y

y y

ASPIRATION, RISK FOR

y y y

ALLERGY RESPONSE, LATEX

side effects

Threat

Smoking smoke inhalation second-hand smok e Obstructed Airway Airway spasm retained secretions excessive mucus presenc e of artifi cial airway f oreign body in airway secretions in bronchi exudates in alveoli Physi ological Neuromusc ular dysfuncti on hyperplasia of br onchial wall s; chronic obstructive pulmonary disease; i nfec tion; asthma; allergic airways

Impaired gag ref lex Poor De ntition Alteration In Consciousness Impaired Airway Defense Mechanisms Poor oral hygie ne

y y

No

immune mechanism response

ALLERGY RESPONSE, RISK FOR LATEX y y y y

ATTACHMENT, RISK FOR IMPAIRED y y

BLEEDING,

RISK FOR y y

BEHAVIOR,

Inability of parents to meet personal needs Anxiety ass ociated with the pare nt role Substa nc e abuse Premature i nfant; i ll infant/c hild who is unable to effectively initiate pare ntal con tact due to altered behavioral organization Separation; physical barriers Lack of privacy

RISK-PRONE HEALTH

y y y

Inadequate comprehension self -efficacy; Multiple stressors; Inadequate social support Low socioeconom ic status Negative attitudes t oward health care Low

y y y y y

BODY

IMAGE, DISTURBED

y y y y y

y

y

y

y

BOWEL

INCONTINENCE

y

y y y

BREASTFEEDING,

EFFECTIVE

y y y y y

Maternal-infa nt

y y y y y y y

y

INTERRUPTED

y y y y y y y y

BREATHING

PATTERN, INEFFECTIVE

breast structure Normal i nfant oral structure Gestational age >34* weeks Infa nt eagerness to breastfeed s/s MER Adequate infant output (f or day of PP age) Maternal knowledge/confidence/support Verbalization of satisfaction  BF pr ocess

y

y

BREASTFEEDING,

Normal

y

y

INEFFECTIVE

Change in st ool consistency (diarrhea, (diarrhea, constipation, fecal  impaction) abnormal motility (metabolic ( metabolic disorders, inflammatory bowel  disease, infectious disease, drug induced motility disorders, food  intolerance) defects in rectal vault functi on (low rectal compliance from ischemia, fibrosis, radiation, infectious proctitis, Hirschprung's disease, local or infiltrating neoplasm, severe rectocele ) sphincter dysfuncti on (obstetric or traumatic induced  incompetence, fistula or abscess, prolapse, third degree hemorrhoids, pseudodyssynergia of the pelvic muscles) neurologi cal disorders i mpacting gastrointestinal motility, rectal vault functi on and sphincter function (cerebro vascular accident, spinal injury, traumatic brain injury, central nervous system tumor, advanced stage dementia, encephalopathy, profound  mental retardation, multiple sclerosis, myelodysplasia and related  neural tube defects, gastroparesis of diabetes mellitus, heavy  metal poisoning, chronic alcoholism, infectious or autoimmune neurological disorders, myasthenia gravis)

Infa nt anomaly infant receiving su pplemental feedings with artifi cial nipple interrupti on in breastfeeding knowledge deficit maternal ambivalenc e maternal anxiety maternal breast anom al y nonsupportive famil y; non supportive partner poor infant ref lex prematurity; previ ous breast surgery previous history of breastfeeding failure

y

BREASTFEEDING,

Psychosocial biophysi cal cognitive/perceptual cultura l spiritual, or developm ental changes illness trauma or injury surgery illness treatment

y y y y y y

separation RT illness of either, prematurity/i mmaturity, etc. Short- term contraindications to breastfeedi ng Need to wean a bru ptly Maternal employm ent Inf lammatory pr ocess: viral or ba cterial Hypoxia Neuromusc ular impair ment Pain Musc ulosk eletal i mpair ment Tracheobronchial obstruction Perception or cog nitive i mpair ment Anxiety Decreased energy and fatigue Decreased lung expa nsion Extremes of weight or age

y y

BODY

TEMPERATURE, RISK FOR IM BALANCED

y y y y

y

Increased or decreased ventricular fill ing (preload) Alteration in afterload Impaired con tractility Alteration in heart rate, rhythm, a nd con ducti on Decreased oxygenation  Cardiac muscl e disease Unclear personal values/bel iefs Perceived threat t o value system Lack of experience/interferenc e with decision making Lack of relevant i nf or mation Mul tiple/divergent s ources of inf ormati on Moral obligati ons require perf or ming/not perf orming acti ons Moral pri ncipl es/rul es/values support mutually inconsistent courses of acti on Support system deficit [Age, developmental state] [Family system; Sociocul tura l factors] [Cognitive/ emotional /behavioral level of fu nctioning]

y

Change

y y

CARDIAC OUTPUT, DECREASED

y y y y y y y y y

CONFLICT, DECISIONAL (SPECIFY)

Dehydration Illness and/or trauma, especially affecting te mperature regulation center Drugs Environment: exposure to hot or cold temp eratures Inappropriate clo thing Inactivity or vigorous activity

y y

y y y

COPING, DEFENSIVE y y y y

COPING, INEFFECTIVE y y y y y y y y

CONSTIPATION

y y y y

y y

CONSTIPATION, PERCEIVED

y

y

CONSTIPATION, RISK FOR

y

y

in or loss of body part Diagnosis of serious illness Recent change in health status Unsatisfactory support system Inadequate psychological resources (poor self -esteem, l ack of  motivation) Personal vuln erability Inadequate copi ng method Situational crises Maturational crises Inadequate fiber intake Immobility/inadequate physi cal ac tivity Inadequate f l uid intake Pain on defecati on Change in r outine (diet i ntak e) Abuse of laxatives Delaying defecation when urge is present Use of pres cri bed consti pating medications ( narcotic a nalgesic, iron, a ntacid and anticholinergic)

Altered thought proc ess Family health beliefs Knowledge deficit about nor mal pr ocesses

diminished defecation ref l ex associated with: o suppression of urge t o defecate because of lack of  privacy and reluc tance to use bedpa n o decreased gravity filling of lower rectum resulting from horizontal positioning; k n wea e ed abdomi nal muscles associated with generalized loss of  muscle tone resulting from pr olonged immobility; decreased gastrointestinal motility associated with decreased activity a nd the increased sympathetic nervous syste m activity that occ urs with a nxiety.

CONFUSION, ACUTE

y y y

CONFUSION, RISK FOR ACUTE

y y y y y y y y

CONFUSION, CHRONIC

y y y y y

y

Sternotomy (mediastinal (mediastinal incision) or donor site (leg (leg or arm incision) Myocardial ische mia (acute (acute MI, angina) Tissue inf lammation, edema f ormation Intraoperative nerve trauma

y

Caregiver expresses

y

y

COMFORT, IMPAIRED

60 years of age Dementia alcohol abuse abuse; delirium uncontrolled pain multiple morbidities and medications Alzheimers disease (dementia of the Alzheimers type) Multiinfarct dementia Cerebr ovasc ular accident (CVA) Acquired i mmune deficiency disease Chronic hepatic enc ephalop athy Chronic drug int oxicati on Chronic subdura l hemat oma Parkinsons disease Huntingt ons c horea Creutzfel dt-Jakob disease

y y

COMFORT, READINESS FOR ENHANCED CONTAMINATION CONTAMINATION, RISK FOR y y

CAREGIVER ROLE STRAIN

y

y

y y

CAREGIVER ROLE STRAIN, RISK FOR

y y y

y

COMMUNICATION, IMPAIRED VERBAL y y y y

COMMUNICATION, READINESS FOR ENHANCED

y y y y

CONFLICT, PARENTAL ROLE y y y y y y y y

COPING, INEFFECTIVE COMMUNITY

difficulty in perf or ming patient care of  patient care Caregiver w orries that ow n health will suffer because of  caregiving Caregiver states that f ormal and inf or mal support syste ms are inadequate Caregiver regrets that caregivi ng res ponsibility does not allow time f or other ac tivities Caregiver expresses proble ms in cop ing with patients behavior Caregiver expresses negative feel ing a bout patient or relationshi p Caregiver neglects patient care  Caregiver abuses patient Brain injury that adversely affects the trans mission, reception or interpretati on of language or other f orms of communication Structural problem (e.g., cleft palate, laryngectomy, tracheostomy, intubation, or wired jaws) Cultural difference (e.g., (e.g., speaks different language) Dyspnea Fatigue  Sens ory c hallenge involving hearing or vision Caregiver ver balizes anger with res ponsibility

y

Change in marita l status home care of a c hild with s pecial needs interrupti ons of fa mily life due t o home care regimen (e.g., treatments, caregivers, lack of respite) intimidation with invasive mo dalities (e.g., (e.g., intubation) intimidation with restri ctive modalities (e.g., (e.g., isolation) separation from child due to c hronic illness specialized care center Change in or loss of body part Diagnosis of serious illness Recent change in health status Unsatisfactory support system Inadequate psychological resources ( poor  poor self-esteem, lack of 

y y y y

COPING, READINESS FOR ENHANCED COMMUNITY

y y y y y y y y y y

COPING, COMPROMISED FAMILY

y y

y y y y y y y y

COPING, DISABLED FAMILY y y y y y y

COPING, READINESS FOR ENHANCED FAMILY

y

y y y

DISUSE SYNDROME, RISK FOR

y y y y

DIVERSIONAL ACTIVITY, DEFICIENT

y y y

DECISION MAKING, READINESS FOR ENHANCED

y

Overwhelmi ng stress

y

Threat

y y y y y y

DIGNITY, RISK FOR COMPROMISED HUMAN DISTRESS, MORAL

y

of unpleasant reality Fear of deaths Fear of separation Fear of lo ss of autonomy Anxiety Lack of competency i n using effective coping mec hanis ms Lack of contr ol of life situation Lack of emotional support fr om others Multiple negative factors

y y y y

DIARRHEA

Situational crisis temporary fa mily dis organization and rol e changes Highl y ambivalent family rel ationship Prolonged disease a nd disa bility progression that exhausts the supportive capacity of SO Client pr oviding little support in turn f or SO SO with chronically unexpressed feelings of guilt Anxiety Hostility despair Needs sufficiently gratified t o ena ble goals of self -actualization to surface Adaptive tas ks effectively addressed to enable goals of self actualization to surfac e [Developm ental stage, situational crises/supports] Unconciousness Neuromusc ular Impairment Musc ulosk eletal con dition Immobility Traction/casts/splints Monotonous environment Long-term hospital ization Lack of motivation with signs of de pression Skeletal-m uscular impairments

y

y

DENIAL, INEFFECTIVE

motivation) Personal vuln erability Inadequate copi ng method Situational crises Maturational crises Social supports available Resources avail able f or problem solving Community has a sense of power to manage stress ors Coexisti ng situati ons affec ting the sig nificant pers on developm ental crises the significant person may be facing exhaustion of supportive capacity of significant people inadequate inf or mation by a primary person inadequate understanding of inf ormati on by a pri mary person incorrect inf or mation by a pri mary person lack of reciprocal support little suppo rt pr ovided by client, in tur n, f or pri mary person prolonged disease that exhausts supportive capacity of significant people situational crises the significant person may be facing temporary fa mily dis organization temporary fa mily role changes temporary preoccupation by a significant person

y y y

Dietary alteration Stress/anxiety Inf lammation/irritati on of the bowel drug side effects ood spoiled f oo tube feeding

DENTITION, IMPAIRED

y

allergy

y

Ineffective oral hygeine

y y y

DEATH SYNDROME, RISK FOR SUDDEN INFANT

y y y

DEVELOPMENT, RISK FOR DELAYED

y y

ENERGY FIELD, DISTURBED

ELECTROLYTE IMBALANCE, RISK FOR ENVIRONMENTAL INTERPRETATION SYNDROME, IMPAIRED FATIGUE

y

y y

y y

y

y y y y y y y

FEEDING PATTERN, INEFFECTIVE INFANT

y y y

FLUID BALANCE, READINESS FOR ENHANCED

y y y y

y y y y y

y y y

FLUID VOLUME, DEFICIENT [ISOTONIC]

Innate origi n (e.g., sudde n noise, height , pain, loss of physical support) Innate releasers (neurotrans mitters) Phobic sti mulus Learned response (e.g ., con diti oni ng, modeling from or identification with others); Unfamiliarity with e nvironmental experience(s) Separation from support syste m i n potentially stressful situation (e.g., hospitalization, hospital procedures [/treatments]) Language barrier Sensory i mpairment Depression Apathy Fatigue Prematurity Neurological impairm ent/delay Oral hypersensitivity Prolonged NPO Anatomic a bnormality

y y

[FLUID VOLUME, DEFICIENT HYPER/HYPOTONIC]

Dementia (Alzhei mer's disease) multiinfarct dementia

y

y

FAILURE TO THRIVE, ADULT

Slowing or blocki ng of energy f lo lows secon dary to: maturational factors: age-related developmental crisis or difficulties pathophysiologi c fa ctors: illness, injury, pregnancy; situational   factors: anxiety, fear, grieving, pain; treatment-related factors: chemotherapy, immobility, labor and delivery, perioperative experience

y

y

FEAR

Inadequate prenata l care Placental a bnormalities Low weight gain during pregna ncy Their first pregna ncy at younger than 20 years of age Anemia History of sexually trans mitted diseases or urinary tract i nfec tions

y y y

y y

Hypertonic dehydration: uncontrolled diabetes mell itus/insipidus, HHNC, increased inta ke of hypertonic f luids/IV therapy , inability to respon d to thirst ref lex/inadequate free water supplementation (high-os molarity enteral feeding f ormulas), renal insufficiency/failure]; [Hypotonic dehydration: chronic illness/maln utrition, excessive use of hypot onic IV solutions Active f luid v olume loss [ e.g., hemorrhage, gastric intubation, diarrhea, w ounds abdominal cancer burns fistulas ascites (third s pacing) use of hy perosmotic radiopaque contrast agents] Failure of regul atory mechanisms [e.g ., fever/thermoregulatory response, renal tubule damage] [Impaired access/intake/absorption of f luids] Abuse of alco hol [/addictive substances]

y y

FAMILY PROCESSES, PROCESSES, DYSFUNCTIONAL DYSFUNCTIONAL

y y y y y y

FAMILY PROCESSES, INTERRUPTED y y y y y

FAMILY PROCESSES, READINESS FOR ENHANCED

y

FALLS, RISK FOR

y y y y

FLUID VOLUME RISK FOR IMBALANCE

y y y y

+FLUID

VOLUME, RISK FOR IMBALANCED

GRIEVING y y y y y y

y y

GRIEVING, RISK FOR COMPLICATED

y y

y y y

y

GLUCOSE, RISK FOR UNSTABLE BLOOD

y y y y y y y y

y

GAS EXCHANGE, IMPAIRED

y

y y

GROWTH, RISK FOR DISPROPORTIONATE

Extremes

of age/weight of f luid thr ough abnormal routes (e.g., indwelling tubes) Knowledge deficiency Factors inf luencing f luid needs (e.g., hypermetabolic states) Medications (e .g ., diuretics) Excessive lo sses thr ough nor mal r outes (e.g ., diarrhea) Deviations affecti ng access/intake/absor ption of f l uids Loss

y y

GRIEVING, COMPLICATED

Family hist ory of alcoholism/resistance to treatment Inadequate copi ng skills Addictive personality Lack of problem-s olving ski lls Biochemical inf l uences Genetic predisposition Situational transition/crises Developm ental transition/crises [e.g., loss or gain of a family member, adol escenc e, l eaving home f or college] Shift i n health status of a family m ember Family roles shift Power shift of fami ly m embers Modification in fami ly fina nces/social status Interaction with community

Anticipat ory loss of significant other/sig nificant object (e .g., possessions,  job, status , home, parts a nd processes of body) Death of significant other Loss of significant object Death/sudden death of a significant other Emotional instabil ity Lack of social support [Loss of significant object (e.g., possessions , job, status, home, idea ls, parts a nd processes of the bodya mputation, paralysis, chronic/terminal illness] Death of a significant other Emotional instabil ity Lack of social support [Loss of significant object (e.g., possessions , job, status, home, parts and processes of body)] Lack of acc epta nce of diagnosis Deficient knowledge of diabetes ma nage ment (e .g., action plan) Lack of diabetes ma nageme nt/adherence to diabetes manage ment (e.g., action plan) Inadequate blood glucose monitoring Medication ma nagement Dietary i ntake Weight gain/loss; Ra pid growth periods Pregnancy Physi cal health status/activity level Stress; Mental health status Developm ental l evel Ventilation-p erfusion imbalanc e [as in altered blood f lo (e.g., low (e.g.,  pulmonary embolus, increased vascular resistance), vasospasm, heart failure, hypovolemic shock] Alveolar-capillary membrane cha nges (e.g., (e.g., acute adult  respiratory distress syndrome) chronic conditions such as: as: restrictive/obstructive lung disease, pneumoconiosis, respiratory depressant drugs, brai n injury, asbestosis/silicosis] [Altered oxygen supply (e.g., (e.g., altitude sickness)] [Altered oxygen-carrying ca pacity of blood ( e.g., e.g., sickle cell/other  anemia, carbon monoxide poisoning)]

y y

Inadequate careta king

y y y y y

GROWTH AND DEVELOPMENT, DELAYED

y y y y

y y

HOPE, READINESS FOR ENHANCED HOPELESSNESS

y y y y y y y y y

HEALTH MAINTENANCE, INEFFECTIVE

y y y y y y y y y y y

HOME MAINTENANCE, IMPAIRED

y y y y y

y y y

HYPERTHERMIA

y y y y y y y y

y y y

HYPOTHERMIA

y y y y y y y

[Physi cal/e motional neglect or a buse] Indifference Inconsistent responsiveness Multiple caretak ers Separation from sig nificant others Environmental/stimul ation deficiencies Effects of physi cal disabi lity [handica ppi ng conditi on] Prescribed dependenc e [insuffi cient exp ectati ons f or self -c -care] [Physi cal/e motional illness (chronic, (chronic, traumatic), e.g., chronic inf lammat ory disease, pituitary tumors, impaired nutrition/ metabolism, greater-than-nor mal energy requirements; prolonged/ painful treatments; prolonged/repeated hos pitalizations] [Sexual a buse] [Substance use/abuse] Prolonged a ctivity restri ction, creati ng isolation Failing or deteriorating physiologi c con dition Long-term stress Abandonment Lost belief in transc endent values [/God] Deficient communication skills [written, verbal, gestural] Unachieved developm ental tasks Inability t o make appropriate  j udgments Perceptual/cog nitive i mpair ment Diminished/lack of gross motor skills Diminished/lack of fine motor skill s Ineffective i ndividual/family coping Compl icated grieving Spiritua l distress Insufficient resource (e.g., equipment, finances) [Lack of psychos ocial supports] Disease Injury Insufficient fa mily organization/planning Insufficient fina nces Impaired functioning Lack of role modell ing Unfa miliarity with neighborh ood resources Deficient knowledge Inadequate support systems Exposure t o hot environment Inappropriate clo thing Vig orous activity Dehydration Decreased perspiration Medications Anesthesia Increased metabolic rate Illness Trauma Exposure t o cool or cold e nvironment [ prolonged exposure, e.g., homeless, immersion in cold water/near-drowning; induced  hypothermia/cardiopulmonary bypass] bypass] Inadequate clothing Evaporation from skin in cool environment Decreased ability t o shiver Aging [or very young] young] [Debilitating] ebilitating] illness Trauma Damage to hypothala mus Malnutrition Decreased metabolic rate Inactivity

+HEALTH BEHAVIOR, +HEALTH

y

Consumption

y

Medications[ Drug

of alco hol overdose] overdose]

RISK-PRONE

MANAGEMENT, INEFFECTIVE SELF

IDENTITY, DISTURBED PERSONAL IMMUNIZATION STATUS, READINESS FOR ENHANCED INFANT BEHAVIOR, DISORGANIZED

be developed

y

To

y

[Organic brain syndrom e]

y

[Poor ego differentiation, as in schizophrenia]

y

[Panic/dissociative states]

y

[Biochemical body change]

y

Prenatal Conge nital/genetic dis orders; Teratogeni c exposure; [E xposure to drugs/substa nces] Postnatal Prematurity; Oral/motor pr oblems; Feedi ng intoleranc e; Malnutrition; Invasive procedures; Pain Individual Gestational /postconceptual age; Immature neurologi cal system; Illn ess; [Infection]; [Hypoxia/birth asphyxia] Environmental Physi cal environment i nappropriate ness; Sensory inappropriateness/overstimulation/de privati on; Lack of con tainment withi n environment

INFANT BEHAVIOR, READINESS FOR ENHANCED ORGANIZED INFANT BEHAVIOR, RISK FOR DISORGANIZED

Caregiver Cue misreadi ng; Cue knowledge deficit; Environmental sti mulation contribution Prematurity Pain y y

y

Pain

y

Oral/motor

y y y y y y

y y y

INFANT FEEDING PATTERN, INEFFECTIVE

y y y y y

INFECTION, RISK FOR

y

y

y y y y y y y y y

problems oversti mulation Lack of contai nment/ boundaries Invasive/ painful procedures Prematurity [Immaturity of the central nervous system generic problems that al ter neurologi c and/or physi ologi c functi oning conditions resulting in hypoxia a nd/or birth asphyxia] [Malnutriti on; infecti on Environmental

drug addiction] [Environmental events or conditions suc h as separation from parent, exposure to lo ud noise, exc essive handling, bright lights] Prematurity Neurological impairm ent/delay Oral hypersensitivity Prolonged NPO Anatomic a bnormality Inadequate pri mary defenses (broken (broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids, change in pH secretions, altered peristalsis) Inadequate secondary defenses (e.g., (e.g., decreased hemoglobin, leukopenia, suppressed inflammatory response) Inadequate acquired i mmunity; Immunosuppression Tissue destruction Increased environm ental exposure Invasive procedures Chronic disease Malnutrition Trauma Pharmaceuti cal agents (e.g., (e.g., immunosuppressants, [antibiotic therapy])

y y y

INJURY, RISK FOR y

y y y y y

INJURY, RISK FOR PERIOPERATIVE POSITIONING

y y y y

INSOMNIA

y y y y y y y y y

y y y

y

INTRACRANIAL ADAPTIVE CAPACITY, DECREASED

y y y y

KNOWLEDGE, DEFICIENT [LEARNING NEED] (SPECIFY)

y y y y y y y y

Rupture of amniotic m embran es Insufficient knowledge to avoid exposure to path ogens Internal Physi cal (e.g., broke n ski n, altered mobi lity); Tissue hypoxia; Malnutrition; A bnormal blood profile (e.g., leukocytosis/leukop enia, altered clo tting factors, thrombocytop enia, sickle c ell, thalassemia, decreased hemoglobin); Bioche mical dysfunction; S ens ory dysfu nction; Integrative/effector dysfunction; Immune/autoi mmune dysfunction; Developmental age (physiologi cal, psychosocial); Psychologi cal (affective, orie ntation) External Biological (e.g., imm unization l evel of community, microorganism); Chemical (e.g., pollutants, poisons, drugs, pharmaceutical agents, alcohol, nicotine, preservatives, cosmetics, dyes); Nutriti onal (e.g., vitami ns, f oo ood types); Physi cal (e.g., design, structure, a nd arrangement of comm unity, building, and/or equipm ent), mode of tra nsport or tra nsportation; Huma n (e.g., nosocomial agents, staffing patterns; cognitive, affective , and psychomotor factors)

Disorientati on sens ory/perc eptual disturba nces due to a nesthesia Immobilization Muscle weakn ess [Pre-existing musculoskeletal con ditions] Obesity Emaciation Edema [Elderl y] Intake of stimulants/alco hol Medications Gender-related hormonal shifts Stress (e.g., (e.g., ruminative presleep pattern) Depression Fear Anxiety Grief  Impairment of normal sleep pattern (e.g., travel, shift work,  parental responsibilities, interruptions for interventions) Inadequate sleep hygiene (current  (current ) Activity pattern (e.g., timing, amount ) Physi cal discomf ort (e.g., (e.g., body temperature, pain, shortness of  breath, cough, gastroesophageal reflux, nausea, incontinence/urgency ) Environmental fac tors (e.g., (e.g., ambient noise, daylight/darkness exposure, ambient temperature/humidity, unfamiliar setting) Brain injuries Sustained increase i n ICP equal to 10 t o 15 mm Hg Decreased c erebral perfusion pressure 50 to 60 mm Hg Systemic hypotensi on with intracranial hypertensi on Lack of exposure Inf ormation misinterpretation Unfa miliarity with i nf ormati on resources Lack of recall Cognitive limitation Lack of interest in learning [Request f or no inf ormation] [Inacc urate/incomplete inf or mation presented]

KNOWLEDGE (SPECIFY), READINESS FOR ENHANCED LIFESTYLE, SEDENTARY

y

y y

LIVER FUNCTION, RISK FOR IMPAIRED

y

Lack of

interest/motivation/resourc es (time, (time, money, companionship, facilities) Lack of trai ning f or accompl ish ment of physi cal exercise Deficient knowledge of health benefits of physi cal exercise Vira l infection (e.g., hepatitis A, hepatitis B, hepatitis C, EpsteinBarr )

y

HIV

y

Hepat otoxic

y

LONELINESS, RISK FOR

y y y y y y

MEMORY, IMPAIRED

y y y y y y y y y

MOBILITY, IMPAIRED BED

y y y y y

y y y y y y y y y y y y y y

MOBILITY, IMPAIRED PHYSICAL

y y y y y y y y y y y y y y

MOBILITY, IMPAIRED WHEELCHAIR

y y y y y y y y y y y

co-infection (e.g., acetaminophen, statins) medications (e.g., Substa nc e abuse (e.g., (e.g., alcohol, cocaine)

Affecti onal deprivati on Physi cal isolation Cathectic deprivati on Social isolation [Problems of attachment f or c hildren] [Chaotic family relationships] Hypoxi Anemia Fluid a nd electrolyte imbalance Decreased cardiac output Neurological distur bances [e.g., brai n injury/concussion] Excessive environm en tal disturbanc es [Manic state, fugue, traumati c eve nt] [Substance use/abuse] [Effects of medications]; [Age] Neuromusc ular/musculo sketal impair men t Insufficient muscle strength Decon diti oning Obesity Environmental constraints (i .e., bed size/typ e, treat ment equipment, restrai nts) Pain Sedating medications Deficient knowledge Cognitive i mpair ment Sedentary l ifestyle Activity i ntoleranc e Disuse Decon diti oning Decreased endurance Limited cardiovasc ular endurance Decreased muscl e strength/con trol/mass Joint stiff ness Contracture Loss of integrity of bon e structures Pain/discomf ort Neuromusc ular/musculo skel etal impairment Sensori perc eptual/cognitive i mpair ment Developm ental delay Depressive moo d state Anxiety Malnutrition Altered c ellular metabolism Body mass index above 75th age-appropriate percentile Deficient knowledge regarding val ue of physical activity Cultural beliefs regarding age-appropriate activity Lack of environm ental supports (e.g., (e.g., physical or social) Prescribed movem ent restrictions; Medications Reluctance t o initiate movem en t Neuromusc ular/musculo sketal impair ments (e.g., (e.g., contractures) Insufficient muscle strength Limited enduranc e Decon diti oning Obesity Impaired vision Pain Depressed moo d Cognitive i mpair ment Deficient knowledge Environmental constraints (e.g., (e.g., stairs, inclines, uneven surfaces, unsafe obstacles, distances, lack of assistive devices or persons, wheelchair type)

y

y

NAUSEA

Treatment Gastric irritati on; Gastric distention; P harmac euti cals [ e.g ., analgesicsaspiri n/nonsterodial a nti-inf lammatory drugs/opioids, anesthesia, a ntivira ls f or HIV , steroids, a ntibiotics, chemotherapeutic agents]; [Radiati on therapy/ex posure] Biophysical Biochemical disorders (e.g., (e.g., uremia, diabetic ketoacidosis,  pregnancy ); L ocalized tumors (e.g., (e.g., acoustic neuroma, primary or  secondary brain tumors, bone metastases at base of skull ); Intraabdominal tumors; Toxins (e.g., (e.g., tumor-produced peptides, abnormal metabolites due to cancer ); Es ophageal/pancreatic disease; Liver/splenetic capsule stretc h; Gastric distention [e.g., delayed gastric emptying, pylo ri c intestinal obstruction, external compression of the stomach, other organ enlargement that slo ws stomach functioning (squashed (squashed stomach syndrome)]; Gastric irritation [e.g., pharyngea l and/or peritoneal inf lammation]; Motion sickness; Ménières disease; Labyrinthitis; I ncreased intracranial pressure; Meni ngitis

Situational Noxious odors/taste; Unpleasant visual stim ulation; Pain; Psychologi cal factors; Anxiety; Fear Brain injury from: Cerebr ovasc ular pr oblems Neurological illness Trauma Tumor Left hemipl egia fr om c erebr ovascular accident of the right hemisphere Hemianopsia Health Care Plan Duration; Cost; Intensity; C ompl exity; Fi na ncial f lexibility of plan y

y

NEGLECT, UNILATERAL

y y y y

y

NONCOMPLIANCE [ADHERENCE, INEFFECTIVE] (SPECIFY)

y

y

y

y

NUTRITION: LESS THAN BODY REQUIREMENTS, IMBALANCED

y y y y y

NUTRITION: MORE THAN BODY REQUIREMENTS, IMBALANCED NUTRITION: READINESS FOR ENHANCED NUTRITION: RISK FOR MORE THAN BODY REQUIREMENTS, REQUIREMENTS, IMBALANCED

y y

Individual factors Personal/developm ental abil ities; K nowledge/skill relevant to the regimen behavior; Motivational f orces; Individuals value system; Health beliefs; Cultural inf luences; Spiritual values; Significant others; [Altered thought processes such as depression, paranoia]; [Difficulty changing behavior, as in addictions]; [Denial]; [Issues of  secondary gain] Health System Individual health coverage; Credibility of provider; Client-provider relationships; Provider con tinuity/regular f ollo ollow-up; Provider reimbursement; Comm unication/teaching skills of the provider; Access/ convenience of care; Satisfacti on with care Network Involvement of members in health plan; Social value regarding plan; Perceived beliefs of significant others Inability t o i ngest/digest f oo ood Inability t o a bsor b nutrients Biological/psychologi cal/economic factors [Increased metabolic dema nds, e.g., burns] [Lack of inf ormati on, misinf or mation, misconceptions] Excessive in take

in relationship to metabolic need

Underlying cause is ofte n compl ex and may be difficult to diagnose/treat

y y y y

y

Dysfunctional eating patterns ood with other activities Pairi ng f oo Eating in res ponse to exter nal cues other tha n hunger (e.g., ti me of day, social situation) Eating in res ponse to i nternal c ues other tha n hunger (such as anxiety)

y y y y

y y y y y

y

ORAL MUCOUS MEM BRANE, IMPAIRED

y y y y y y y y

y

y y y y

y y y y y y y y

Concentrating

f oo ood intak e at end of day obesity Rapid tra nsition acr oss growth percentiles in children ood as ma jor f oo ood source bef ore 5 months Reported use of solid f oo of age Higher baseline weight at beginni ng of each preg nancy Observed use of f oo ood as reward/comf ort measure [Frequent/repeated dieting] [Alteration in usual activity patterns/sedentary lifestyle] [Ma jority of f oo oods consumed are concentrated, high-c alorie/fat sources] [Lower socioeconomic status] Parental

Dehydration NPO f or more than 24 hours Malnutrition Decreased salivation Medication side effects Diminished hormone levels (women) Mouth breathing Deficient knowledge of appropriate oral hygie ne Ineffective oral hygiene; Barriers to oral self care/professional care; Mechanical factors (e.g., ill-fitting dentures; braces; tubes [endotrachial, nasogastric], surgery in oral  cavity ) Loss of supportive structures Trauma Cleft lip or palate (e.g., alcohol, tobacco, acidic Chemical irritants (e.g.,  foods, regular use of inhalers or other noxious agents) Chemotherapy Immunosuppression Immunocompromised Decreased platelets Infection Radiation therapy Stress Depression