Nursing diagnosis – NEONATAL JAUNDICE

ShareNEONATAL  JAUNDICE 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 biliru- bin in the circulation DEFINING CHARACTERISTICS • Neonate age 1–7 days • Yellow orange skin • Yellow sclerae • Yellow mucous membranes • Abnormal blood profile (hemolysis; total [...]

Nursing diagnosis – DECREASED INTRACRANIAL ADAPTIVE CAPACITY

ShareADAPTIVE  CAPACITY 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 nonnoxious stimuli DEFINING CHARACTERISTICS • Baseline ICP    10 mm Hg • Disproportionate increase in ICP following single nursing maneuver • Elevated [...]

Nursing diagnosis – INSOMNIA

ShareINSOMNIA DEFINITION A disruption in the amount and quality of sleep that impairs func- tioning DEFINING CHARACTERISTICS • Observed changes in affect • Reports difficulty falling asleep • Observed lack of energy, diffi- and staying asleep culty concentrating • Reports dissatisfaction with • Increased work or school sleep absenteeism • Reports early morning awak- • [...]

Nursing diagnosis – RISK FOR PERIOPERATIVE POSITIONING INJURY

ShareRISK  FOR  PERIOPERATIVE-POSITIONING INJURY DEFINITION At risk for inadvertent anatomical and physical changes as a result of posture on equipment used during an invasive/surgical procedure RISK FACTORS • Disorientation • Muscle weakness • Edema • Obesity • Emaciation • Sensory–perceptual • Immobilization disturbances from anesthesia ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.) • Activity/exercise • [...]

Nursing diagnosis – RISK FOR INJURY

ShareDEFINITION At risk for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources RISK FACTORS External Internal • Biological: Community immu- • Abnormal blood profile: nization level; microorganisms Altered clotting factors; • Chemical: Cosmetics; drugs, decreased hemoglobin; leuko- pharmaceutical agents; dyes; alcohol, nicotine, preservatives; poisons cytosis/leucopenia; sickle cell; thalassemia; [...]

Nursing diagnosis – RISK FOR INFECTION

ShareRISK  FOR  INFECTION DEFINITION At risk for being invaded by pathogenic organisms RISK FACTORS • Altered immune function • Pharmaceutical agents • Amniotic membrane rupture • Inadequate primary (such as • Chronic disease skin) or secondary (such as • Environmental exposure to inflammatory response) pathogens defenses • Invasive procedures • Malnutrition • Lack of knowledge [...]

Nursing diagnosis – INEFFECTIVE INFANT FEEDING PATTERN

ShareINEFFECTIVE  INFANT  FEEDING  PATTERN DEFINITION Impaired ability of an infant to suck or coordinate the suck/swallow response resulting in inadequate oral nutrition for metabolic needs DEFINING CHARACTERISTICS • Inability to coordinate sucking, swallowing, and breathing • Inability to initiate or sustain effective suck RELATED FACTORS • Anatomic abnormality • Oral hypersensitivity • Neurological delay or [...]

Nursing diagnosis – READINESS FOR ENHANCED ORGANIZED INFANT BEHAVIOR

ShareREADINESS  FOR  ENHANCED  ORGANIZED INFANT  BEHAVIOR DEFINITION A pattern of modulation of the physiologic and behavioral systems of functioning (such as autonomic, motor, state-organizational, self- regulatory, and attentional–interactional systems) in an infant that is satisfactory but that can be improved DEFINING CHARACTERISTICS • Use of some self-regulatory behaviors • Definite sleep–wake states • Responsiveness to [...]

Nursing diagnosis – RISK FOR DISORGANIZED INFANT BEHAVIOR

ShareRISK FOR DISORGANIZED INFANT BEHAVIOR DEFINITION Risk for alteration in integration and modulation of the physiologi- cal and behavioral systems of functioning (such as autonomic, motor, state-organizational, self-regulatory, and attentional–interac- tional systems) RISK FACTORS • Environmental overstimulation • Oral or motor problems • Invasive or painful procedures • Pain • Lack of containment or • [...]

Nursing diagnosis – DISORGANIZED INFANT BEHAVIOR

ShareDISORGANIZED  INFANT  BEHAVIOR DEFINITION Disintegrated physiological and neurobehavioral responses of infant to the environment DEFINING CHARACTERISTICS • Attention–interaction system—abnormal response to sensory stimuli (e.g., difficulty soothing, inability to sustain alert status) • Motor-system—altered primitive reflexes; finger splaying; jittery, uncoordinated movement; increased or decreased tone; startles, tremors, or twitches • Physiological—arrhythmias, bradycardia, or tachycardia; desatura- tion; [...]

Nursing diagnosis – RISK FOR URGE URINARY INCONTINENCE

ShareRISK  FOR  URGE  URINARY  INCONTINENCE DEFINITION At risk for involuntary loss of urine associated with a sudden, strong sensation or urinary urgency RISK FACTORS • Effects of medication, caffeine, • Detrusor muscle instability or alcohol with impaired contractility • Detrusor hyperreflexia from • Ineffective toileting habits cystitis, urethritis, tumors, renal calculi, central nervous system disorders [...]

Nursing diagnosis – URGE URINARY INCONTINENCE

ShareURGE  URINARY  INCONTINENCE DEFINITION Involuntary passage of urine occurring shortly after a strong sense of urgency to void DEFINING CHARACTERISTICS • Bladder contraction or spasm • Increased or decreased volume • Frequency • Nocturia • Inability to reach toilet in time • Urgency RELATED FACTORS • Alcohol intake • Decreased bladder capacity • Atrophic urethritis [...]

Nursing diagnosis – STRESS URINARY INCONTINENCE

ShareSTRESS  URINARY  INCONTINENCE DEFINITION Sudden leakage of urine with activities that increase intra-abdominal pressure DEFINING CHARACTERISTICS • Dribbling with increased abdominal pressure • Frequency • Urgency RELATED FACTORS • Degenerative changes in pelvic • Intrinsic urethral sphincter muscles deficiency • High intra-abdominal pressure • Weak pelvic muscles ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.) • [...]

Nursing diagnosis – REFLEX URINARY INCONTINENCE

ShareREFLEX  URINARY  INCONTINENCE DEFINITION Involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached DEFINING CHARACTERISTICS • Complete emptying (with lesion above pontine micturition center) or incomplete emptying (with lesion above sacral micturition center) of bladder • Either inability to sense full bladder, urge to void, or voiding, or ability [...]

Nursing diagnosis – DISTURBED PERSONAL IDENTITY

ShareDISTURBED  PERSONAL  IDENTITY DEFINITION Inability to maintain an integrated and complete perception of self DEFINING CHARACTERISTICS • Disturbed body image • Contradictory personal traits • Fluctuating feelings about self • Ineffective role performance • Gender confusion • Ineffective coping • Unable to distinguish between • Uncertainty about ideological inner and outer stimuli and cultural values [...]

Nursing diagnosis – HYPOTHERMIA

ShareHYPOTHERMIA DEFINITION Body temperature below normal range DEFINING CHARACTERISTICS • Body temperature below normal range • Cool, pale skin • Cyanotic nail beds • Increased blood pressure, heart rate, and capillary refill time • Piloerection • Shivering RELATED FACTORS • Aging • Exposure to cool environment • Consumption of alcohol • Illness • Damage to [...]

Nursing diagnosis – HYPERTHERMIA

ShareHYPERTHERMIA DEFINITION Body temperature elevated above normal range DEFINING CHARACTERISTICS • Fever • Flushed, warm skin • Increased heart and respiratory rate • Seizures RELATED FACTORS • Anesthesia • Increased metabolic rate • Decreased perspiration • Illness • Dehydration • Medications • Exposure to hot environment • Trauma • Inappropriate clothing • Vigorous activity ASSESSMENT [...]

Nursing diagnosis – HOPELESSNESS

ShareHOPELESSNESS DEFINITION Subjective state in which an individual sees few or no available alter- natives or personal choices available and is unable to mobilize energy on own behalf DEFINING CHARACTERISTICS • Decreased appetite, affect, response to stimuli, verbalization • Increased or decreased sleep • Lack of involvement in self-care • Nonverbal cues, such as closing [...]

Nursing diagnosis – READINESS FOR ENHANCED HOPE

ShareREADINESS  FOR  ENHANCED  HOPE DEFINITION A pattern of expectations and desires that is sufficient for mobilizing energy on one’s own behalf and can be strengthened DEFINING CHARACTERISTICS Expresses desire to enhance: • Ability to set personal goals • Belief in possibilities • Congruency of expectations with desires • Hope • Interconnectedness with others • Problem [...]

Nursing diagnosis – IMPAIRED HOME MAINTENANCE

ShareIMPAIRED  HOME  MAINTENANCE DEFINITION Inability to independently maintain a safe growth-promoting imme- diate environment DEFINING CHARACTERISTICS • Difficulty in maintaining home in a comfortable environment • Outstanding debts or financial crises • Request for assistance with home maintenance • Disorderly surroundings • Unwashed or unavailable cooking equipment, clothes, or linens • Accumulation of dirt, food [...]