Author Archive

Nursing diagnosis – GRIEVING

ShareGRIEVING DEFINITION A normal complex process that includes emotional, physical, spiri- tual, social, and intellectual responses and behaviors by which indi- viduals, families, and communities incorporate an actual, anticipated, or perceived loss into their daily lives DEFINING CHARACTERISTICS • Altered communication patterns • Change in eating, sleep and dream patterns, activity level, or libido • [...]

Nursing diagnosis – RISK FOR UNSTABLE BLOOD GLUCOSE

ShareRISK  FOR  UNSTABLE  BLOOD  GLUCOSE DEFINITION At risk for variation of blood glucose/sugar levels from the normal range RISK FACTORS • Deficient knowledge of • Lack of adherence to diabetes diabetes management management • Developmental level • Physical activity level • Dietary intake • Physical/mental health status • Inadequate blood glucose • Pregnancy monitoring • [...]

Nursing diagnosis – RISK FOR DYSFUNCTIONAL GASTROINTESTINAL MOTILITY

ShareRISK  FOR  DYSFUNCTIONAL GASTROINTESTINAL  MOTILITY DEFINITION Risk for increased, decreased, ineffective, or lack of peristaltic activity within the gastrointestinal system RISK FACTORS • Abdominal surgery • Gastroesophageal reflux • Diabetes disease (GERD) • Prematurity • Unsanitary food preparation • Decreased gastrointestinal • Anxiety circulation • Lifestyle • Pharmaceutical agents (e.g., • Immobility narcotics, antibiotics, proton [...]

Nursing diagnosis – DYSFUNCTIONAL GASTROINTESTINAL MOTILITY

ShareDYSFUNCTIONAL  GASTROINTESTINAL MOTILITY DEFINITION Increased, decreased, ineffective, or lack of peristaltic activity within the gastrointestinal system DEFINING CHARACTERISTICS • Nausea • Abdominal pain • Vomiting • Absence of flatus • Abdominal distension • Hard, dry stool • Change in bowel sounds • Difficulty passing stool (e.g., absent, hypoactive, hyperactive) • Diarrhea • Abdominal cramping • [...]

Nursing diagnosis – IMPAIRED GAS EXCHANGE

ShareIMPAIRED  GAS  EXCHANGE DEFINITION Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane DEFINING CHARACTERISTICS • Abnormal pH and arterial • Headache upon awakening blood gases levels • Hypoxia and hypoxemia • Abnormal respiratory rate, • Increased or decreased carbon rhythm, and depth dioxide levels • Confusion • Irritability/Restlessness • Cyanosis [...]

Nursing diagnosis – RISK FOR IMBALANCED FLUID VOLUME

ShareRISK  FOR  IMBALANCED  FLUID  VOLUME DEFINITION At risk for a decrease, increase, or rapid shift from one to the other of intravascular, interstitial, and/or intracellular fluid. This refers to body fluid loss, gain, or both RISK FACTORS • Receiving apheresis • Intestinal obstruction • Abdominal surgery • Sepsis • Traumatic injury • Pancreatitis • Burns [...]

Nursing diagnosis – RISK FOR DEFICIENT FLUID VOLUME

ShareRISK  FOR  DEFICIENT  FLUID  VOLUME DEFINITION At risk for experiencing vascular, cellular, or intracellular dehydration RISK FACTORS • Conditions  that  influence  fluid • Knowledge deficit related to needs (e.g., hypermetabolic state) fluid volume • Excessive loss of fluid from • Loss of fluid through abnor- normal routes (e.g., diarrhea) mal routes (e.g., drainage • Extremes [...]

Nursing diagnosis – EXCESS FLUID VOLUME

ShareEXCESS  FLUID  VOLUME DEFINITION Increased isotonic fluid retention DEFINING CHARACTERISTICS • Altered mental status or respiratory pattern • Anasarca • Azotemia • Changes in blood pressure, pulmonary artery pressure, urine specific gravity, and electrolyte levels • Crackles • Decreased Hb and HCT levels • Dyspnea • Edema • Increased central venous pressure (CVP) • Intake [...]

Nursing diagnosis – DEFICIENT FLUID VOLUME

ShareDEFICIENT  FLUID  VOLUME DEFINITION Decreased intravascular, interstitial, or intracellular fluid; water loss alone without change in sodium DEFINING CHARACTERISTICS • Changes in mental status • Decreased pulse volume and pressure, urine output, and venous filling • Dry skin and mucous membranes • Increased body temperature, HCT, pulse rate, and urine concen- tration • Low blood [...]

Nursing diagnosis – READINESS FOR ENHANCED FLUID BALANCE

ShareREADINESS  FOR  ENHANCED FLUID  BALANCE DEFINITION A pattern of equilibrium between fluid volume and chemical compo- sition of body fluids that is sufficient for meeting physical needs and can be strengthened DEFINING CHARACTERISTICS • Verbalization of willingness to enhance fluid balance • Stable weight • Moist mucous membranes • Food and fluid intake adequate for [...]

Nursing diagnosis – FEAR

ShareFEAR DEFINITION Response to a perceived threat that is consciously recognized as a danger DEFINING CHARACTERISTICS • Behaviors involving aggression, avoidance, impulsivness, increased alertness, and narrowed focus of the source of fear • Cognitive effects such as decreased self-assurance, productivity, and ability to problem solve • Feelings of alarm, apprehension, increased tension, panic, and terror [...]

Nursing diagnosis – FATIGUE

ShareFATIGUE DEFINITION An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at usual level DEFINING CHARACTERISTICS • Decreased libido or performance • Disinterest in surroundings • Drowsiness • Failure of sleep to restore energy • Lack of energy • Guilt for not meeting responsibilities • Inability to maintain usual routines [...]

Nursing diagnosis – READINESS FOR ENHANCED FAMILY PROCESSES

ShareREADINESS  FOR  ENHANCED FAMILY  PROCESSES DEFINITION A pattern of family functioning that is sufficient to support the well- being of family members and can be strengthened DEFINING CHARACTERISTICS • Activities support the growth of family members • Activities support the safety of family members • Balance exists between autonomy and cohesiveness • Boundaries of family [...]

Nursing diagnosis – INTERRUPTED FAMILY PROCESSES

ShareINTERRUPTED  FAMILY  PROCESSES DEFINITION Change in family relationship or functioning DEFINING CHARACTERISTICS Changes in: • Assigned tasks • Availability for affective responses and/or emotional support • Communication patterns • Effectiveness in completing assigned tasks • Expressions of conflict within family and/or community resources • Expressions of isolation from community resources • Intimacy • Participation in [...]

Nursing diagnosis – DYSFUNCTIONAL FAMILY PROCESSES ALCOHOLISM

ShareDYSFUNCTIONAL  FAMILY  PROCESSES: ALCOHOLISM DEFINITION Psychosocial, spiritual, and physiological functions of the family unit are chronically disorganized, which leads to conflict, denial of prob- lems, resistance to change, ineffective problem solving, and a series of self-perpetuating crises DEFINING CHARACTERISTICS • Alcohol abuse; agitation; blaming; broken promises • Deficient knowledge about alcoholism • Denial of problems; [...]

Nursing diagnosis – RISK FOR FALLS

ShareRISK  FOR  FALLS DEFINITION Increasing susceptibility to falling that may cause physical harm RISK FACTORS Adult • Patient verbalizes faintness • Age   65 years when extending neck • Lives alone • Difficulties with hearing or • Environmental hazards (e.g., vision cluttered environment; poor lighting) • Incontinence Child • Presence of lower limb pros- • Age   [...]

Nursing diagnosis – ADULT FAILURE TO THRIVE

ShareADULT  FAILURE  TO  THRIVE DEFINITION Progressive functional deterioration of a physical and cognitive nature. The individual’s ability to live with multisystem diseases, cope with ensuing problems, and manage his/her care are remarkably diminished DEFINING CHARACTERISTICS • Cognitive decline, as evidenced by problems with responding appropriately to environmental stimuli and decreased perception • Consumption of limited [...]

Nursing diagnosis – IMPAIRED ENVIRONMENTAL INTERPRETATION SYNDROME

ShareIMPAIRED  ENVIRONMENTAL INTERPRETATION  SYNDROME DEFINITION Consistent lack of orientation to person, place, time, or circumstances over more than 3 to 6 months necessitating a protective environment DEFINING CHARACTERISTICS • Chronic confusion • Consistent state of disorientation to environment • Inability to reason, concentrate, or follow simple instructions • Loss of occupation or social function resulting [...]

Nursing diagnosis – DISTURBED ENERGY FIELD

ShareDISTURBED  ENERGY  FIELD Disruption of the flow of energy surrounding a person’s being that results in disharmony of body, mind, and/or spirit DEFINING CHARACTERISTICS Perceptions of changes in patterns of energy flow, such as changes in • Hearing (tones, words). • Perception of movement (wave spike, tingling, dense, flowing). • Temperature. • Sight (image, color). [...]

Nursing diagnosis – RISK FOR ELECTROLYTE IMBALANCE

ShareRISK  FOR  ELECTROLYTE  IMBALANCE DEFINITION At risk for change in serum electrolyte levels that may compromise health RISK FACTORS • Fluid imbalance (e.g., dehydra- • Renal dysfunction tion, water intoxication) • Endocrine dysfunction • Treatment-related side effects • Impaired regulatory mechanisms (e.g., medications, drains) (e.g., diabetes insipidus, syn- • Diarrhea drome of inappropriate • Vomiting [...]