Nursing Diagnosis – Code 00103 Impaired swallowing (1986, 1998)

Domain 2. Nutrition Class 1. Ingestion

Impaired swallowing

Definition Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function.

Defining Characteristics

First Stage: Oral ■ Abnormal oral phase of swallow study ■ Choking prior to swallowing ■ Coughing prior to swallowing ■ Drooling ■ Food falls from mouth ■ Food pushed out of mouth ■ Gagging prior to swallowing ■ Inability to clear oral cavity ■ Incomplete lip closure ■ Inefficient nippling
■ Inefficient suck ■ Insufficient chewing ■ Nasal reflux ■ Piecemeal deglutition ■ Pooling of bolus in lateral sulci ■ Premature entry of bolus ■ Prolonged bolus formation ■ Prolonged meal time with insufficient consumption ■ Tongue action ineffective in forming bolus
Second Stage: Pharyngeal ■ Abnormal pharyngeal phase of swallow study ■ Alteration in head position ■ Choking ■ Coughing ■ Delayed swallowing ■ Fevers of unknown etiology ■ Food refusal
■ Gagging sensation ■ Gurgly voice quality ■ Inadequate laryngeal elevation ■ Nasal reflux ■ Recurrent pulmonary infection ■ Repetitive swallowing

Third Stage: Esophageal

■ Abnormal esophageal phase of swallow study ■ Acidic-smelling breath ■ Bruxism ■ Difficulty swallowing ■ Epigastric pain ■ Food refusal ■ Heartburn ■ Hematemesis ■ Hyperextension of head ■ Nighttime awakening
■ Nighttime coughing ■ Odynophagia ■ Regurgitation ■ Repetitive swallowing ■ Reports “something stuck” ■ Unexplained irritability surrounding mealtimes ■ Volume limiting ■ Vomiting ■ Vomitus on pillow

Related Factors

Congenital Deficits

■ Behavioral feeding problem ■ Conditions with significant hypotonia ■ Congenital heart disease ■ Failure to thrive ■ History of enteral feeding
■ Mechanical obstruction ■ Neuromuscular impairment ■ Protein-energy malnutrition ■ Respiratory condition ■ Self-injurious behavior ■ Upper airway abnormality

Neurological Problems

■ Achalasia ■ Acquired anatomic defects ■ Brain injury (e.g., cerebrovascular impairment, neurological illness, trauma, tumor) ■ Cerebral palsy ■ Cranial nerve involvement ■ Developmental delay ■ Esophageal reflux disease ■ Laryngeal abnormality
■ Laryngeal defect ■ Nasal defect ■ Nasopharyngeal cavity defect ■ Neurological problems ■ Oropharynx abnormality ■ Prematurity ■ Tracheal defect ■ Trauma ■ Upper airway anomaly

Nursing Diagnosis – Code 00234 Risk for overweight (2013; LOE 2.2)

Domain 2. Nutrition Class 1. Ingestion

Risk for overweight

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

Risk Factors
■ ADULT: BMI approaching 25 kg/m2 ■ Average daily physical activity is less than recommended for gender and age ■ CHILD < 2 years: Weight-forlength approaching 95th percentile ■ CHILD 2–18 years: BMI approaching 85th percentile, or 25 kg/m2 (whichever is smaller) ■ Children who are crossing BMI percentiles upward ■ Children with high BMI percentiles ■ Consumption of sugarsweetened beverages ■ Disordered eating behaviors (e.g., binge eating, extreme weight control) ■ Disordered eating perceptions ■ 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)
■ Economically disadvantaged ■ Energy expenditure below energy intake based on standard assessment (e.g., WAVE assessment*) ■ Excessive alcohol consumption ■ Fear regarding lack of food supply ■ Formula- or mixed-fed infants ■ Frequent snacking ■ Genetic disorder ■ Heritability of interrelated factors (e.g., adipose tissue distribution, energy expenditure, lipoprotein lipase activity, lipid synthesis, lipolysis) ■ High disinhibition and restraint eating behavior score ■ High frequency of restaurant or fried food ■ Higher baseline weight at beginning of each pregnancy ■ Low dietary calcium intake in children ■ Maternal diabetes mellitus ■ Maternal smoking ■ Obesity in childhood ■ Parental obesity ■ Portion sizes larger than recommended ■ Premature pubarche ■ Rapid weight gain during childhood
■ Sedentary behavior occurring for >2 hours/day ■ Shortened sleep time ■ Sleep disorder ■ Solid foods as major food source at <5 months of age
■ Rapid weight gain during infancy, including the first week, first 4 months, and first year

Nursing Diagnosis – Code 00233 Overweight (2013; LOE 2.2)

Domain 2. Nutrition Class 1. Ingestion

Overweight

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

Defining Characteristics

■ ADULT: BMI > 25 kg/m2 ■ CHILD < 2 years: Weight-forlength > 95th percentile
■ CHILD 2–18 years: BMI > 85th but <95th percentile, or 25 kg/m2 (whichever is smaller)

Related Factors
■ Average daily physical activity is less than recommended for gender and age ■ Consumption of sugar- sweetened beverages ■ Disordered eating behaviors (e.g., binge eating, extreme weight control) ■ Disordered eating perceptions ■ Economically disadvantaged ■ Energy expenditure below energy intake based on standard assessment (e.g., WAVE assessment*) ■ Excessive alcohol consumption ■ Fear regarding lack of food supply ■ Formula- or mixed-fed infants ■ Frequent snacking ■ Genetic disorder
■ Heritability of interrelated factors (e.g., adipose tissue distribution, energy expenditure, lipoprotein lipase activity, lipid synthesis, lipolysis) ■ High disinhibition and restraint eating behavior score ■ High frequency of restaurant or fried food ■ Low dietary calcium intake in children ■ Maternal diabetes mellitus ■ Maternal smoking ■ Obesity in childhood ■ Parental obesity ■ Portion sizes larger than recommended ■ Premature pubarche ■ Rapid weight gain during childhood ■ Rapid weight gain during infancy, including the first week, first 4 months, and first year ■ Sedentary behavior occurring for >2 hours/day
■ Shortened sleep time ■ Sleep disorder ■ Solid foods as major food source at <5 months of age

Nursing Diagnosis – Code 00232 Obesity (2013; LOE 2.2)

Domain 2. Nutrition Class 1. Ingestion

Obesity

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

Defining Characteristics

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

Related Factors

■ Average daily physical activity is less than recommended for gender and age ■ Consumption of sugarsweetened beverages ■ Disordered eating behaviors ■ Disordered eating perceptions ■ Economically disadvantaged ■ Energy expenditure below energy intake based on standard assessment (e.g., WAVE assessment*) ■ Excessive alcohol consumption ■ Fear regarding lack of food supply ■ Formula- or mixed-fed infants ■ Frequent snacking ■ Genetic disorder
■ Heritability of interrelated factors (e.g., adipose tissue distribution, energy expenditure, lipoprotein lipase activity, lipid synthesis, lipolysis) ■ High disinhibition and restraint eating behavior score ■ High frequency of restaurant or fried food ■ Low dietary calcium intake in children ■ Maternal diabetes mellitus ■ Maternal smoking ■ Overweight in infancy ■ Parental obesity ■ Portion sizes larger than recommended ■ Premature pubarche ■ Rapid weight gain during childhood ■ Rapid weight gain during infancy, including the first week, first 4 months, and first year
■ Sedentary behavior occurring for >2 hours/day ■ Shortened sleep time ■ Sleep disorder ■ Solid foods as major food source at <5 months of age

 

Nursing Diagnosis – Code 00002 Imbalanced nutrition: less than body requirements (1975, 2000)de

Domain 2. Nutrition Class 1. Ingestion

Imbalanced nutrition: less than body requirements

Definition Intake of nutrients insufficient to meet metabolic needs.

Defining Characteristics

■ Abdominal cramping ■ Abdominal pain ■ Alteration in taste sensation ■ Body weight 20% or more below ideal weight range ■ Capillary fragility ■ Diarrhea ■ Excessive hair loss ■ Food aversion ■ Food intake less than recommended daily allowance (RDA) ■ Hyperactive bowel sounds ■ Insufficient information ■ Insufficient interest in food ■ Insufficient muscle tone
■ Misinformation ■ Misperception ■ Pale mucous membranes ■ Perceived inability to ingest food ■ Satiety immediately upon ingesting food ■ Sore buccal cavity ■ Weakness of muscles required for mastication ■ Weakness of muscles required for swallowing ■ Weight loss with adequate food intake

Related Factors

■ Biological factors ■ Economically disadvantaged ■ Inability to absorb nutrients ■ Inability to digest food
■ Inability to ingest food ■ Insufficient dietary intake ■ Psychological disorder

Nursing Diagnosis – Code 00107 Ineffective infant feeding pattern (1992, 2006; LOE 2.1)

Domain 2. Nutrition Class 1. Ingestion

Ineffective infant feeding pattern

Definition Impaired ability of an infant to suck or coordinate the suck/swallow

Defining Characteristics

■ Inability to coordinate sucking, swallowing, and breathing ■ Inability to initiate an effective suck
■ Inability to sustain an effective suck

Related Factors

■ Neurological delay ■ Neurological impairment (e.g., positive EEG, head trauma, seizure disorders) ■ Oral hypersensitivity
■ Oropharyngeal defect ■ Prematurity ■ Prolonged nil per os (NPO) status

Nursing Diagnosis – Code 00106 Readiness for enhanced breastfeeding (1990, 2010, 2013; LOE 2.2)

Domain 2. Nutrition Class 1. Ingestion

Readiness for enhanced breastfeeding

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

Defining Characteristics

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

Nursing Diagnosis – Code 00105 Interrupted breastfeeding (1992, 2013; LOE 2.2)

Domain 2. Nutrition Class 1. Ingestion

Interrupted breastfeeding

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.

Defining Characteristics

■ Nonexclusive breastfeeding

Related Factors

■ Contraindications to breastfeeding (e.g., pharmaceutical agents) ■ Hospitalization of child ■ Infant illness
■ Maternal employment ■ Maternal illness ■ Maternal–infant separation ■ Need to abruptly wean infant ■ Prematurity

Nursing Diagnosis – Code 00104 Ineffective breastfeeding (1988, 2010, 2013; LOE 2.2)

Domain 2. Nutrition Class 1. Ingestion

Ineffective breastfeeding

Definition Difficulty providing milk to an infant or young child directly from the breasts, which may compromise nutritional status of the infant/child.

Defining Characteristics

■ Inadequate infant stooling ■ Infant arching at breast ■ Infant crying at the breast ■ Infant crying within the first hour after breastfeeding ■ Infant fussing within one hour of breastfeeding ■ Infant inability to latch on to maternal breast correctly ■ Infant resisting latching on to breast ■ Infant unresponsive to other comfort measures
■ Insufficient emptying of each breast per feeding ■ Insufficient infant weight gain ■ Insufficient signs of oxytocin release ■ Perceived inadequate milk supply ■ Sore nipples persisting beyond first week ■ Sustained infant weight loss ■ Unsustained suckling at the breast

Related Factors

■ Delayed lactogenesis II ■ Inadequate milk supply ■ Insufficient family support ■ Insufficient opportunity for suckling at the breast ■ Insufficient parental knowledge regarding breastfeeding techniques ■ Insufficient parental knowledge regarding
importance of breastfeeding
■ Interrupted breastfeeding ■ Maternal ambivalence ■ Maternal anxiety ■ Maternal breast anomaly ■ Maternal fatigue ■ Maternal obesity ■ Maternal pain ■ Oropharyngeal defect ■ Pacifier use ■ Poor infant sucking reflex ■ Prematurity ■ Previous breast surgery ■ Previous history of breastfeeding failure
■ Short maternity leave ■ Supplemental feedings with artificial nipple

 

Nursing Diagnosis – Code 00216 Insufficient breast milk (2010; LOE 2.1)

Domain 2. Nutrition Class 1. Ingestion

Insufficient breast milk

Definition Low production of maternal breast milk.

Defining Characteristics

Infant

■ Constipation ■ Frequent crying ■ Frequently seeks to suckle at breast ■ Prolonged breastfeeding time ■ Refuses to suckle at breast
■ Suckling time at breast appears unsatisfactory ■ Voids small amounts of concentrated urine ■ Weight gain <500 g in a month

Mother

■ Absence of milk production with nipple stimulation ■ Delay in milk production
■ Expresses breast milk less than prescribed volume

Related Factors

Infant

■ Ineffective latching on to breast ■ Ineffective sucking reflex ■ Insufficient opportunity for suckling at the breast
■ Insufficient suckling time at breast ■ Rejection of breast
Mother

■ Alcohol consumption ■ Insufficient fluid volume ■ Malnutrition
■ Pregnancy ■ Smoking ■ Treatment regimen