Indonesian Nursing Diagnosis Standards (SDKI)

 

 

Category: Physiological

 

Subcategory: Respiration

 

D.0001 Ineffective Airway Clearance.

 

Definition:inability to clear secretions or airway obstruction to maintain a patent airway.

 

Reason :

Physiological :

1. Airway spasm.

2. Airway hypersecretion.

3. Neuromuscular dysfunction.

4. Foreign body in the airway.

5. The presence of an artificial airway.

6. Retained secretions.

7. Hyperplasia of the airway wall.

8. The infection process.

9. Allergic response.

10. Effects of pharmacological agents (eg anesthetics).

Situational:

1. Active smoking.

2. Passive smoking.

3. Exposure to pollutants.

 

Major Symptoms and Signs:

Subjective : not available.

Objective :

1. Cough is not effective

2. unable to cough.

3. Excess sputum.

4. Wheezing, wheezing and/or dry rhonchi.

5. Meconium in the airway in neonates.

 

Minor Symptoms and Signs.

Subjective :

Dyspnea.

It's hard to talk.

orthopnea.

Objective :

Nervous.

Cyanosis.

Decreased breath sounds.

Respiratory rate changes.

Breathing patterns change.

 

Related Clinical Conditions

1.     Gullian Barre syndrome.

2.     Multiple sclerosis.

3.     Myasthenia gravis.

4.     Diagnostic procedures (eg bronchoscopy, transesophageal echocardiography [TEE] ).

5.     Central nervous system depression.

6.     Head injury

7.     stroke

8.     Quadriplegia

9.     Meconium aspiration syndrome

10.  Respiratory tract infection.

 

D.0002 Ventilator Weaning Disorder

 

Definition:inability to adapt with reduced mechanical ventilator assistance which can inhibit and prolong the weaning process.

 

Reason :

 

ReasonPhysiological :

1. Hypersecretion of the airway.

2. Insufficient energy.

3. Impaired respiratory effort (eg pain when breathing, weakness of respiratory muscles, sedation effect.)

ReasonPsychological :

1. Anxiety.

2. Feelings of helplessness.

3. Lack of exposure to information about the weaning process.

4. Decreased motivation.

Situational:

1 Inadequate social support

2 Inaccuracy in the speed of the weaning process

3 history of repeated failures in weaning attempts

4 history of ventilator dependence more than 4 days

 

MAJOR SYMPTOMS AND SIGNS.

Subjective : Not available.

Objective :

1. Respiratory rate increases.

2. Use of accessory muscles of breathing.

3. Shortness of breath (gasping).

4. Breathing efforts and ventilator support are out of sync.

5. Shallow Breath.

6. Agitation.

7. Abnormal arterial blood gas values.

 

MINOR SYMPTOMS AND SIGNS.

Subjective :

1. Tired.

2. Worried the machine is damaged.

3. Increased focus on breathing.

Objective:

1. Auscultation of inspiratory sounds decreased.

2. Abnormal skin color (eg pallor, cyanosis).

3. Abdominal paradoxical breathing.

4. Diaphoresis.

5. Fearful facial expressions.

6. Blood pressure increases.

7. Pulse rate increases.

8. Decreased consciousness.

 

RELATED CLINICAL CONDITIONS:

1. Head Injury.

2. Coronary artery bypass graft (CABG).

3. Breathing Failure.

4. Cardiac Arrest.

5. Heart transplant.

6. Bronchopulmonary dysplasia.

 

D0003 Gas Exchange Disorder.

 

DEFINITION:

Excess or lack of oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

 

REASON :

1. Ventilation-perfusion imbalance.

2. Alveolar-capillary membrane changes.

 

Major Symptoms and Signs:

Subjective :

1. Dyspnea.

Objective :

1. PCO2 increases / decreases.

2. PO2 decreases.

3. Tachycardia.

4. Arterial pH increases/decreases.

5. Additional breath sounds.

 

Minor Symptoms and Signs

Subjective :

1. Dizziness.

2. Blurred vision.

Objective :

1. Cyanosis.

2. Diaphoresis.

3. Restless.

4. Nostril breath.

5. Abnormal breathing pattern (fast/slow, regular/irregular, deep/shallow).

6. Abnormal skin color (eg pale, bluish).

7. Decreased consciousness.

 

RELATED CLINICAL CONDITIONS:

1. Chronic obstructive pulmonary disease (COPD).

2. Congestive heart failure.

3. Asthma.

4. Pneumonia.

5. Pulmonary tuberculosis.

6. Hyaline membrane disease.

7. Asphyxia.

8. Persistent pulmonary hypertension of newborn (PPHN).

9. Prematurity.

10.Infection of the respiratory tract.

 

D.0004 Impaired Spontaneous Ventilation.

 

Definition:Decreased energy reserves resulting in the individual not being able to breathe adequately.

 

Reason :

1. Metabolic disorders.

2. Respiratory muscle fatigue

 

Major Symptoms and Signs

subjective :

1. Dispenda.

objective :

1. The use of the upper muscles is increased.

2. Tidal volume decreases.

3. PCO2 increase.

4. PO2 decreases.

5.SaO2 decreases.

 

Minor Symptoms and Signs

subjective : not available.

Objective :

1. Restless.

2. Tachycardia.

 

Related Clinical Conditions:

1. Chronic obstructive pulmonary disease (COPD).

2. Asthma.

 

D.0005 Ineffective Breathing Pattern

 

Definition:

Inspiration and/or expiration that does not provide adequate ventilation

 

Reason :

1. Depression of the respiratory center

2. Impaired respiratory effort (eg pain with breathing, respiratory muscle weakness)

3. Chest wall deformity.

4. Breastbone deformity.

5. Neuromuscular disorders.

6 Neurological disturbances (eg positive electroencephalogram [EEG], head injury, seizure disorder).

7. Neurological maturity.

8. Decreased energy.

9. Obesity.

10. Position of the body that inhibits lung expansion.

11. Hypoventilation syndrome.

12. Damage to the innervation of the diaphragm (damage to the CS nerve and above).

13. Injury to the spinal cord.

14. Effects of pharmacological agents.

15. Anxiety.

 

Major Symptoms and Signs ::

Subjective :

1. Dyspnea

Objective :

1. Use of accessory muscles of respiration.

2. The expiratory phase is prolonged.

3. Abnormal breathing pattern (eg tachypnea, bradypnea, Kussmaul Cheyne-Stokes hyperventilation).

 

Minor Symptoms and Signs:

Subjective: 1. Orthopnea

Objective :

1. Pursed-lip breathing.

2. Nostril breathing.

3. Anterior-posterior thoracic diameter increases

4. Minute ventilation decreased

5. Vital capacity decreases

6. Decreased expiratory pressure

7. Decreased inspiratory pressure

8. Chest excursion changed

 

D.0006 Aspiration Risk.

 

The risk of experiencing the entry of gastrointestinal secretions, oropharyngeal secretions, liquid or solid objects into the tracheobronchial tract due to dysfunction of the protective mechanisms of the airways.

 

RISK FACTOR:

1. Decreased level of consciousness.

2. Decreased gag reflex and / or cough.

3. Swallowing disorders.

4. Dysphagia.

5. Impaired physical mobility.

6. Increased gastric residue.

7. Increased intragastric pressure.

8. Decreased gastrointestinal motility.

9. Incompetent lower esophageal sphincter.

10. Slowed gastric emptying.

11. A nasogastric tube is attached.

12. Attached tracheostomy or endotracheal tube.

13. Trauma/surgery of neck, mouth, and/or face.

14. Effects of pharmacological agents.

15. Immaturity of coordination of sucking, swallowing and breathing.

 

Related Clinical Conditions:

1. Head Injury.

2. Strokes.

3. Spinal cord injury.

4. Guillain Barre Syndrome.

5. Parkinson's disease.

6. Drug and alcohol poisoning.

7. Enlargement of the uterus.

8. Myesthenia gravis.

9. Tracheoesophageal fistula.

10. Esophageal stricture.

11. Multiple sclerosis.

12. Labiopalatoskizis.

13. Esophageal atresia.

14. Laryngomalacia.

15. Prematurity.

 

Subcategory: Circulation

 

D.0007 Impaired Spontaneous Circulation.

 

Definition:Inability to maintain adequate circulation to support life.

 

Reason :

1. Electrical abnormalities of the heart.

2. Abnormalities of cardiac structure.

3. Decreased ventricular function.

 

Major Symptoms and Signs:- Subjective:

1. Not responding.

Major Symptoms and Signs:– Objectives:

1. Pulse rate <50 beats/minute or >150 beats/minute.

2. Systolic blood pressure <60 mmHg or >200 mmHg.

3. Nasa frequency <6 times/minute or >30 times/minute.

4. Decreased awareness or unconsciousness.

 

Minor Symptoms and Signs– Subjective : (not available)

Minor Symptoms and Signs– Objectives:

1. Body temperature <34.5 degrees Celsius.

2. No urine production in 6 hours.

3. Oxygen saturation <85%.

4. The ECG shows lethal arrhythmias (eg Ventricular Tachycardia [VT], Ventricular Fibrillatio [VF], Asystole, Pulseless Electrical Activity [PEA] ).

5. ECG showing major arrhythmia (eg type 2 AV block, total AV block, tachyarrhythmia/bradyarrhythmia, Supraventricular Tachycardia [SVT], Ventricular Extrasystole [VES], Ventricular Extrasystole [VES], symptomatic).

6. ETCO2 <35 mmHg.

 

Related Clinical Conditions.

1. Cardiac arrest.

2. Bradycardia.

3. Tachycardia.

4. Acute coronary syndrome.

5. Heart Failure.

6. Cardiomyopathy.

7. Myocarditis.

8. Dysrhythmias.

9. Trauma.

10. Bleeding (eg gastrointestinal bleeding, aortic rupture, intracranial hemorrhage).

11. Poisoning.

12. Overdose.

13. Sink.

14. Pulmonary embolism.

 

D.0008 Decreased Cardiac Output.

 

Inadequate heart pumping blood to meet the body's metabolic needs.

 

Reason :

1. Changes in heart rhythm.

2. Changes in heart rate.

3. Changes in contractility.

4. Change of preload.

5. Changed afterload.

 

Major Symptoms and Signs:Subjective :

1. Changes in heart rhythm: Palpitations.

2. Changes in preload: tired.

3. Changes afterload: Dyspnea.

4. Changes in contractility: Paroxysmal nocturnal dyspnea (PND); orthopnea; Cough.

 

Major Symptoms and Signs:Subjective :

 

Changes in heart rhythm:

– Bradycardial / Tachycardia.

– ECG features arrhythmias or conduction disturbances.

Preload changes:

– Edema,

- jugular vein distention

- Central venous pressure (CVP) increased / decreased,

- Hepatomegaly.

Afterload changes.

- Blood pressure increases / decreases.

- Peripheral pulse palpable weak.

– Capillary refill time > 3 seconds

– Oliguria.

– Pale skin color and/or cyanosis.

Contractility changes

– S3 and/or S4 heart sounds are heard.

– Ejection fraction (EF) decreased.

 

Related Clinical Conditions:

Congestive heart failure.

Acute coronary syndrome.

Mitral stenosis.

Mitral regurgitation.

Aortic stenosis.

Aortic regurgitation.

Pulmonary stenosis.

Tricuspid regurgitation.

Pulmonary stenosis.

Pulmonary regurgitation.

arrhythmia.

Congenital heart disease.

 

D.0009 Ineffective Peripheral Perfusion.

 

Definition:Decreased blood circulation at the capillary level which can interfere with the body's metabolism.

 

Reason:

Hyperglycemia

Decreased hemoglobin concentration

Increased blood pressure

Lack of fluid volume

Decreased arterial and/or venous flow

Lack of exposure to information about aggravating factors (eg smoking, monotonous lifestyle, trauma, obesity, salt intake, immobility)

Lack of exposure to information about the disease process (eg diabetes mellitus, hyperlipidemia)

Lack of physical activity.

 

Major Symptoms and Signs– Subjective : (Not available).

Major Symptoms and Signs– Objectives:

Capillary refill >3 seconds.

Peripheral pulse decreased or not palpable.

Akral feels cold.

Pale skinned people.

Decreased skin turgor.

 

Minor Symptoms and Signs– Subjective:

paresthesia.

Extremity pain (intermittent claudication).

 

Minor Symptoms and Signs– Objectives:

Edema.

Slow wound healing.

Ankle-brachial index < 0.90.

Femoral Bruits.

 

Related Clinical Conditions.

 

Thrombophlebitis.

Diabetes mellitus.

Anemia.

Congenital heart failure.

Congenital heart defects/

Arterial thrombosis.

Varicose veins.

Deep vein thrombosis.

Compartment syndrome.

 

D.0010 Risk of Impaired Spontaneous Circulation.

 

Definition:

At risk for inability to maintain adequate circulation to support life.

 

Risk Factor:

Lack of fluid volume.

hypoxia.

Hypothermia.

Hypokalemia/hyperkalemia.

Hypoglycemia/hyperglycemia.

Acidosis.

Taxin (eg poisoning, drug overdose).

Cardiac tamponade.

Tension pneumothorax.

Cardiac thrombosis.

Pulmonary thrombosis (pulmonary embolism).

 

Related Clinical Conditions:

Bradycardia.

tachycardia.

Acute coronary syndrome.

Heart failure.

Cardiomyopathy.

Myocarditis.

dysrhythmia.

Trauma.

Bleeding (eg gastrointestinal bleeding, aortic rupture, intracranial hemorrhage).

Poisoning.

Overdose.

Sink.

Pulmonary embolism.

 

D.0011 Risk of Decreased Cardiac Output.

 

Definition:

At risk of experiencing inadequate cardiac pumping to meet the body's metabolic needs.

 

Risk Factor:

Afterload changes.

Changes in heart rate.

Changes in heart rhythm.

Contractility changes.

Preload changes.

 

Related Clinical Conditions.

Congestive heart failure

Acute coronary syndrome.

Cardiac valve disorders (aortic, pulmonary, tricuspid, or mitral stenosis / regurgitation).

Atrial/ventricular septal defects.

arrhythmia.

 

D.0012 Risk of Bleeding.

 

Definition:

At risk of experiencing blood loss, both internal (occurs inside the body) and external (Occurs to the outside of the body).

 

Risk Factor:

aneurysm.

Gastrointestinal disorders (eg ulcers, polyps, varicose veins).

Impaired liver function (eg hepatitis cirrhosis).

Pregnancy complications (eg premature rupture of membranes, placenta previa/abruption, multiple pregnancies).

Post partum complications (eg uterine atony, retained placenta).

Coagulation disorders (eg thrombocytopenia),

Effects of pharmacological agents.

Surgical action.

Trauma.

Lack of exposure to information about prevention of bleeding prevention.

violent process.

 

Related Clinical Conditions.

aneurysm.

Disseminated intravascular coagulation.

Impaired liver function (eg hepatitis cirrhosis).

Pregnancy complications (eg premature rupture of membranes, placenta previa/abruption, multiple pregnancies).

Post partum complications (eg uterine atony, retained placenta).

Coagulation disorders (eg thrombocytopenia).

Effects of pharmacological agents.

Surgical Action.

Trauma.

Lack of exposure to information about bleeding prevention.

malignant process,

 

Related Clinical Conditions:

aneurysm.

Disseminated intravascular coagulation.

Liver Cirrhosis.

Stomach ulcer.

Varicose veins.

Thrombocytopenia.

The membranes rupture prematurely.

Placenta previa/abrupsio.

Uterine atony.

Placental Retention.

Surgical action.

Cancer.

Trauma.

 

D.0013 Risk of Ineffective Gastrointestinal Perfusion.

 

Definition:

At risk for decreased gastrointestinal circulation.

 

Risk Factor:

Acute gastrointestinal bleeding

Abdominal trauma

Abdominal compartment syndrome

Abdominal aortic aneurysm

Gastroesophageal varices

Decreased left ventricular performance

Coagulopathy (eg sickle cell anemia, disseminated intravascular coagulopathy)

Decreased hemoglobin concentration

Abnormal prothrombin mass and/or partial thromboplastin time

Liver dysfunction (eg cirrhosis, hepatitis)

Renal dysfunction (eg polycystic kidney, renal artery stenosis, renal failure)

Gastrointestinal dysfunction (eg duodenal or gastric ulcer, ischemic colitis, ischemic pancreatitis)

Hyperglycemia

Hemodynamic instability

Effects of pharmacological agents

>60 years old

Side effects of action (cardiopulmunary bypass, anesthesia, gastric surgery)

 

Related Clinical Conditions

Gastroesophageal varices

Abdominal aortic aneurysm

Diabetes mellitus

Liver cirrhosis

Acute gastrointestinal bleeding

Congestive heart failure

Diminished intravascular coagulation

Duodenal ulcer or gastric ulcer

Ischemic colitis

Ischemic pancreatitis

Polycystic kidney

Renal artery stenosis

Kidney failure

Abdominal compartment syndrome

Abdominal trauma

Anemia

Heart Surgery

 

D.0014 Risk of Ineffective Myocardial Perfusion.

 

Definition:

At risk for decreased coronary artery circulation which can interfere with myocardial metabolism.

 

 

 

Risk Factor:

Hypertension.

Hyperlipidemia.

Hyperglycemia.

Hypoxaemia.

hypoxia.

Lack of fluid volume.

Heart Surgery.

Substance abuse.

Coronary artery spasm.

Increased C-reactive protein.

Cardiac tamponade.

Effects of pharmacological agents.

Family history of cardiovascular disease.

Lack of exposure to information aboutRisk Factormodifiable (eg smoking, sedentary lifestyle, obesity).

 

Related Clinical Conditions:

Cardiac surgery.

Cardiac tamponade.

Acute coronary syndrome.

Diabetes mellitus.

Hypertension

 

Information :

This diagnosis is made in patients who are not yet at risk for cardiac pumping disorders. If the patient is already at risk for cardiac pumping disorders, it is preferable to establish a risk diagnosis for decreased cardiac output.

 

D.0015 Risk of Ineffective Peripheral Perfusion.

 

Definition:…

At risk of experiencing a decrease in blood circulation at the caliper level which can interfere with the body's metabolism

 

Risk Factor

Hyperglycemia

Sedentary lifestyle

Hypertension

Smoke

Endovascular procedures

Trauma

Lack of exposure to information about aggravating factors (eg smoking, sedentary lifestyle, obesity, immobility)

 

Related Clinical Conditions

Atherosclerosis

Raynaud's disease

Arterial thrombosis

Leriche's syndrome

Aneurysm

Buerger's disease

Varicose veins

Diabetes mellitus

Hypotension

Kanke

 

D.0016 Risk of Ineffective Renal Perfusion.

 

Definition:…

At risk of decreased blood circulation to the kidneys

 

 

Risk Factor

Lack of fluid volume

Vascular embolism

Vasculitis

Hypertension

Kidney dysfunction

Hyperglycemia

Malignancy

heart surgery

Cardiopulmonary bypass

Hypoxaemia

Hypoxia

Metabolic acidosis

Trauma

Abdominal compartment syndrome

Burns

Sepsis

Systemic inflammatory response syndrome

Elderly

Smoke

Substance abuse

 

Related Clinical Conditions

Diabetes mellitus

Hypertension

Atherosclerosis

Shock

Malignancy

Burns

heart surgery

Renal disease (eg polycystic kidney, renal artery stenosis, renal failure, glomerulonephritis, interstitial nephritis, bilateral cortical necrosis, polynephritis)

Trauma

 

D.0017 Risk of Ineffective Cerebral Perfusion.

 

Definition:…

At risk of decreased blood circulation to the brain

 

Risk Factor

 

Abnormal prothrombin mass and/or partial thromboplastin time

Decreased left ventricular performance

Aortic atherosclerosis

Arterial dissection

atrial fibrillation

Brain tumor

Carotid Stenosis

atrial myxoma

Cerebral aneurysm

Coagulopathy (eg sickle cell anemia)

Dilated cardiomyopathy

Coagulation (eg sickle cell anemia)

Embolism

Head injury

Hypercholesterolemia

Hypertension

Infective endocarditis

Mechanical prosthetic valve

Mitral Stenosis

Brain neoplasm

Acute myocardial infarction

Sick sinus syndrome

Substance abuse

Button therapy

Side effects of the procedure (eg bypass surgery)

 

Related Clinical Conditions

stroke

Head injury

Aortic atherosclerosis

Acute myocardial infarction

Arterial dissection

Embolism

Infective endocarditis

atrial fibrillation

Hypercholesterolemia

Hypertension

Dilated cardiomyopathy

Disseminated intravascular coagulation

atrial myxoma

Brain neoplasm

Akinetic left ventricular segment

Sick sinus syndrome

Carotid stenosis

Mitral Stenosis

hydrocephalus

Brain infections (eg meningitis, encephalitis, cerebral abscess)

Subcategory: Nutrients/Fluids

 

D.0018 Overweight.

 

Definition:

Excessive or abnormal fat accumulation that is not appropriate for age and gender

 

Reason

Lack of daily physical activity

Excess sugar consumption

Eating disorders

Eating disorders

Excess alcohol consumption

Energy use is less than intake

Frequent snacking

Often eats oily/fatty food

Hereditary factors (eg adipose tissue distribution, energy expenditure, lipoprotein lipase activity, lipid synthesis, liposis)

Use of formula or mixed foods (in infants)

Low calcium intake (in children)

Weight gain rapidly (during childhood, during infancy, including the first week, first 4 months, and first year)

Solid food as the main food source at the age of <5 months

 

Major Symptoms and Signs

Subjective(not available)

Objective

BMI >25 kg/m2 (in adults) or body weight and length more than the 95th percentile (in children <2 years) or BMI at the 85-95th percentile (in children 2-18 years)

 

Minor Symptoms and Signs

Subjective(not available)

Objective

Triceps skinfold thickness >25 mm

 

Related Clinical Conditions

Genetic disorders

heredity

Hypothyroid

Maternal diabetes mellitus

 

D.0019 Nutritional Deficit :

 

Insufficient nutritional intake to meet metabolic needs

 

Reason

Inability to swallow food

Inability to digest food

Inability to absorb nutrients

Increased metabolic needs

Economic factors (e.g. insufficient finances)

Psychological factors (eg, stress, aversion to eating)

 

Major Symptoms and Signs

Subjective : (not available)

Objective :

1. Weight loss of at least 10% below the ideal range.

 

Minor Symptoms and Signs

Subjective :

Quickly full after eating

Abdominal cramps/pain

Decreased appetite.

Objective :

Hyperactive bowel sounds

Weak masticatory muscles

Weak swallowing muscles

Pale mucous membranes

Sprue

Serum albumin is down

Excessive hair loss

Diarrhea

 

Related Clinical Conditions:

stroke

Parkinson

Mobius syndrome

Cerebral palsy

Cleft lip

Cleft palate

Amyotropic lateral sclerosis

Neuromuscular damage

Burns

Cancer

Infection

AIDS

Crohn's disease

Enterocolitis

cystic fibrosis

 

D.0020 Diarrhea.

 

Definition:

Frequent, soft and unformed stools.

 

 

 

Reason

Physiological

Gastrointestinal inflammation.

Gastrointestinal irritation.

infection process.

malabsorption.

Psychological

Worry.

High stress levels.

Situational

Exposure to contaminants.

Exposure to toxins.

Laxative abuse.

Substance abuse.

Treatment program (thyroid agents, analgesics, stool softeners, ferrosultate, antacids, cimetidine and antibiotics).

Changes in water and food.

Bacteria in water.

 

Major Symptoms and Signs

 

Subjective(not available).

Objective

More than three bowel movements in 24 hours.

Soft or liquid stools.

 

Minor Symptoms and Signs

Subjective

Urgency.

Abdominal pain/cramping.

Objective

Peristalsis frequency increases.

Hyperactive bowel sounds.

 

Related Clinical Conditions

Colon cancer.

Divericulitis.

Intestinal irritation.

Crohn's disease.

Peptic ulcer.

gastritis.

Colon spasm.

Ulcerative colitis.

Hyperthyroidism.

Typhoid fever.

Malaria.

Sigelosis.

Cholera.

Dysentery.

Hepatitis.

 

D.0021 Gastrointestinal Motility Dysfunction.

 

Definition:

Increased, decreased, ineffective or lack of gastrointestinal perstatic activity.

 

Reason

Enteral intake

Food intolerance

Immobilization

Container food

Malnutrition

Surgery

Effects of pharmacological agents (eg narcotics/opiates, antibiotics, laxatives, anesthetics)

aging process

Worry

 

Major Symptoms and Signs

Subjective

Reveals flatus non-existent

Abdominal pain/cramps

Objective

Peristaltic sounds change (absent, hypoactive, or hyperactive)

 

Major Symptoms and Signs

Subjective

Feeling nauseous

Objective

Gastric residue increases/decreases

Gag

Regurgitation

Fast gastric emptying

Abdominal distension

Diarrhea

Stool is dry and hard to come out

hard stool

 

Related Clinical Conditions

Abdominal or bowel surgery

Malnutrition

Worry

bile cancer

Cholecystectomy

Gastrointestinal infection

Gastroesophageal reflux disease (GERD)

Perioneal dialysis

Radiation therapy

Multiple organ dysfunction syndrome

 

D.0022 Hypervolemia.

 

Definition:Increased intravascular, interstitial, and/or intracellular fluid volume.

 

Reason

Disruption of regulatory mechanisms

Excess fluid intake

Excess sodium intake

impaired venous return

Effects of pharmacological agents (eg corticosteroids, chlorpropamide, tolbutamide, vincristine, tryptilinescarbamazepine)

 

Major Symptoms and Signs

Subjective

Orthopnea

dyspnea

Paroxysmal nocturnal dyspnea (PND)

Objective

Anasarca and/or peripheral edema

Weight gain in a short time

Increased Jugular Venous Pressure (JVP) and/or Cental Venous Pressure (CVP)

Positive hepatojugular reflex

 

Minor Symptoms and Signs

 

Subjective(not available)

Objective

Jugular venous distention

There is an extra breath

Hepatomegaly

Hb/Ht levels go down

Oliguria

Intake is more than output (positive fluid balance)

Lung congestion

 

Related Clinical Conditions

Kidney disease: acute/chronic renal failure, nephrotic syndrome

Hypoalbuminemia

Congestive heart failure

Hormonal disorders

Liver disease (eg cirrhosis, ascites, liver cancer)

Peripheral venous disease (eg varicose veins, venous thrombus, phlebitis)

Immobility

 

D.0023 Hypovolemia.

 

Definition:Increased intravascular, interstitial, and/or intracellular fluid volume.

 

Reason

 

Active fluid loss

Regulatory mechanism failure

Increased capillary permeability

Lack of fluid intake

Evaporation

 

Major Symptoms and Signs

Subjective(not available)

Objective

Increased pulse rate

Weak pulse

Decreased blood pressure

Pulse pressure narrows

Narrow skin turgor

Dry mucous membranes

Decreased urine volume

Increased hematocrit

 

Minor Symptoms and Signs

Subjective

Feeling weak

Complaining thirst

Objective

Decreased venous filling

Mental status changed

Increased body temperature

Increased urine concentration

sudden weight loss

 

Related Clinical Conditions

Addison's disease

Trauma/bleeding

Burns

AIDS

Crohn's disease

Gag

Diarrhea

Ulcerative Colitis

Hypoalbuminemia

 

D.0024 Neonatal jaundice.

 

Definition:

The skin and mucous membranes of the neonate turn yellow after 24 hours of birth due to unconjugated bilirubin entering the circulation

 

Reason

Abnormal weight loss (>7-8% in breastfed newborns, >15% in moderate-bodied infants)

Diet is not well established

Difficult transition to extra uterine life

Age less than 7 days

Delayed excretion of feces (maconium)

 

Major Symptoms and Signs

Subject(not available)

Objective

Abnormal blood profile (hemolysis, total serum bilirubin >2mg/dL, total serum bilirubin in the high-risk range for age at time-specific normogens)

Yellow mucous membrane

yellow skin

Yellow sclera

 

Minor Symptoms and Signs

Subjective(not available)

Objective(not available)

 

Related Clinical Conditions

Neonates

Premature baby

 

D.0025 Readiness to Improve Fluid Balance.

 

Definition:

The equilibrium pattern between the volume of fluids and the chemical composition of body fluids that is sufficient to meet physical needs and can be increased.

 

Major Symptoms and Signs

Subjective

Expresses a desire to improve fluid balance

Objective

Moist mucous membrane

Adequate food and fluid intake for daily needs

Good network turgor

No signs of edema or dehydration

Symptoms and Minor

Subjective

(not available)

Objective

Clear yellow urine with specific gravity in the normal range

Urine output according to intake

Stable weight

 

Related Clinical Conditions

heart failure

Irritable bowel syndrome

Addison's disease

Entral or parenteral feeding

 

D.0026 Nutritional Enhancement Readiness.

 

Definition:

The pattern of nutritional intake is sufficient to meet metabolic needs and can be increased.

 

 

 

Major Symptoms and Signs

 

Subjective

 

Expresses a desire to improve nutrition

 

 

Objective

 

Eat regularly and adequately

 

 

Minor Symptoms and Signs

 

Subjective

 

Express knowledge about healthy food and fluid choices

Follow appropriate nutritional intake standards (e.g. food pyramid, American Diabetic Association guidelines or other guidelines)

 

 

Objective

 

Safe preparation and storage of food and beverages

Attitude towards food and drink is in accordance with health goals

 

 

Related Clinical Conditions

Health improvement behavior

 

D.0027 Blood Glucose Level Instability.

 

Definition:

Variations in nail blood glucose levels/drops from the normal range.

 

Reason

Hyperglycemia

Pancreatic Dysfunction

insulin resistance

Impaired blood glucose tolerance

Fasting blood glucose disorders

Hypoglycemia

Use of insulin or oral gynecologic drugs

Hyperinsulinemia (eg insulinoma)

Endocrinnopathies (eg adrenal or pituitary damage)

Liver dysfunction

Chronic kidney dysfunction

Effects of pharmacological agents

Neoplasm surgery

Inherited metabolic disorders (eg lysosomal storage disorders, galactosemia, glycogen storage disorders)

 

Major Symptoms and Signs

Subjective

Hypoglycemia

 

Sleepy

Dizzy

Hyperglycemia

Palpitations

Complaining hungry

Objective

Hypoglycemia

Coordination disorders

Low blood/urine glucose levels

Hyperglycemia

High blood/urine glucose levels

 

Minor Symptoms and Signs

Subjective

Hypoglycemia

Palpitations

Stifling hunger

Hyperglycemia

dry mouth

Thirst increases

 

Objective

Hypoglycemia

Shaky

Decreased consciousness

Weird behavior

Slur talk

Sweating

Hyperglycemia

 

Related Clinical Conditions

Diabetes mellitus

Diabetic ketoacidosis

Hypoglycemia

Hyperglycemia

Gestational diabetes

Use of corticosteroids

Total Parental Nutrition (TPN)

 

D.0028 Effective Breastfeeding.

 

Definition:

 

Breastfeeding directly from the breast to infants and children that can meet nutritional needs.

 

 

 

Reason

 

Physiological

 

Adequate oxytocin and protactin hormones

Breasts enlarge, alveoli begin to fill with milk

There is no abnormality in the breast structure

Protruding nipples

term baby

There is no deformity in the baby's mouth

 

 

Situational

 

Treat join

Adequate family and health support

Cultural factors

 

 

Major Symptoms and Signs

 

Subjective

 

Mothers feel confident during the breastfeeding process

 

 

Objective

 

Baby attaches to mother's breast properly

Mother is able to position the baby correctly

Baby urinate more than 8 times in 24 hours

Baby's weight increases

Milk dripping / gushing

Adequate breast milk supply

Nipples don't blister after the second week

 

 

Minor Symptoms and Signs

 

Subjective

 

(not available)

 

 

 

Objective

 

Baby sleeping after feeding

Mother's breasts are empty after breastfeeding

Baby is not fussy and cries after feeding

 

 

Related Clinical Conditions

 

Mother's health status is good

Baby's health status is good

D.0029 Breastfeeding Ineffective.

 

Definition:

A condition where the mother and baby experience dissatisfaction or difficulty in the breastfeeding process.

 

Reason

Physiological

Inadequate milk supply

Neonatal obstruction (eg prematurity, cleft palate)

Maternal breast anomalies (eg inverted nipples)

Inadequate oxytocin reflex

Inadequate baby sucking reflex

Swollen breasts

History of breast surgery

Twin birth

Situational

No care join

Lack of exposure to information about the importance of breastfeeding and/or breastfeeding methods

Lack of family support

Cultural factors

 

Major Symptoms and Signs

Subjective

Maternal fatigue

Maternal anxiety

Objective

Baby unable to attach to mother's breast

Breast milk does not hatch/spout

Baby urinate less than 8 times in 24 hours

Persistent pain and/or blisters after the second week

 

Minor Symptoms and Signs

Subjective(not available)

Objective

Inadequate baby intake

Baby sucks not continuously

Baby cries while breastfeeding

Babies are fussy and cry continuously in the first hours after feeding

Refuse to suck

 

Related Clinical Conditions

Breast abscess

mastitis

Carpal tunnel syndrome

 

Information

 

*) Carpal tuner syndrome is one of the problems in breastfeeding where the mother's hand feels painful and uncomfortable. Mothers have difficulty in positioning their babies for breastfeeding.

 

D.0030 Obesity.

 

Definition:

Excess or abnormal fat accumulation that is not appropriate for age and gender, and exceeds the condition of being overweight

 

Reason

Lack of daily physical activity

Excess sugar consumption

Eating disorders

Eating Perception Disorder

Excess alcohol consumption

Energy use is less than intake

Frequent snacking

Often eat oily/fatty food

Hereditary factors (eg adipose tissue distribution, energy expenditure, lipoprotein lipase activity, lipid synthesis, lipolysis)

Use of formula or mixed food in infants

Low calcium intake in children

Weight gain rapidly (during childhood. during infancy, including the first week, first 4 months, and first year)

Solid food as the main food source at the age of <5 months.

 

Major Symptoms and Signs

Subjective(not available)

Objective

BMI >27kg/m (in adults) or more than the 95th percentile for age and sex (in children)

 

Minor Symptoms and Signs

Subjective(not available)

Objective

Guess the triceps skin fold >25 mm

 

Related Clinical Conditions

Genetic disorders

heredity

Hypothyroid

Maternal diabetes mellitus

 

D.0031 Risk of Overweight.

 

Definition:

At risk of excessive or abnormal fat accumulation that is not appropriate for age and gender

 

Risk Factor

Lack of daily physical activity

Excess sugar consumption

Eating disorders

eating perception disorder

Excess alcohol consumption

Energy use is less than intake

Frequent snacking

Often eats oily/fatty food

Hereditary factors (eg adipose tissue distribution, energy expenditure, lipoprotein lipase activity, lipid synthesis, lipolysis)

Use of formula or mixed food in infants

Low calcium intake in children

Weight gain rapidly (During childhood, during infancy, including the first week, first 4 months, and first year)

Solid food as the main food source at the age of <5 months.

 

Related Clinical Conditions

genetic disorders

Hypothyroid

Gestational diabetes mellitus

Less active lifestyle

 

D.0032 Risk of Nutritional Deficit.

 

Definition:

At risk of experiencing insufficient nutritional intake to meet metabolic needs.

 

Risk Factor

Inability to swallow food

Inability to digest food

Inability to absorb nutrients

Increased metabolic needs

Economic factors (eg insufficient finance)

Psychological factors (eg stress, reluctance to eat)

 

Related Clinical Conditions

stroke

Parkinson

Mobius Syndrome

Cerebral palsy

Cleft lip

Cleft palate

Amyotropic lateral sclerosis

Neuromuscular damage

Burns

Cancer

Infection

AIDS

Crohn's disease

Enterocolitis

cystic fibrosis

 

D.0033 Risk of Gastrointestinal Motility Dysfunction.

Definition:

 

Risk of increased, decreased or ineffective peristatic activity of the gastrointestinal system.

 

 

 

Risk Factor

 

Abdominal surgery

Decreased gastrointestinal circulation

Food intolerance

Gastrointestinal reflux

Hyperglycemia

Immobility

aging process

Gastrointestinal infection

Effects of pharmacological agents (eg antibiotics, laxatives, narcotics/opiates)

Prematurity

Worry

Stress

Lack of sanitation in food preparation

 

 

Related Clinical Conditions

 

Abdominal surgery

Decreased gastrointestinal circulation

Food intolerance

Gastrointestinal reflux

Hyperglycemia

Immobility

aging process

Gastrointestinal infection

Effects of pharmacological agents (eg antibiotics, laxatives, narcotics/opiates)

Maturity

Anxiety

Stress

Lack of sanitation in food preparation

 

 

Related Clinical Conditions

 

Abdominal or bowel surgery

Malnutrition

Anemia

Worry

bile cancer

Cholecystectomy

Gastrointestinal infection

Gastroesophageal reflux disease (GERD)

Peritoneal dialysis

Radiation therapy

Multiple organ dysfunction syndrome

0034 Risk of Hypovolemia.

 

Definition:

 

At risk for decreased intravascular, interstitial and/or intracellular fluid volume.

 

 

 

Risk Factor

 

Active fluid loss

Impaired absorption of fluids

Elderly

Overweight

Hypermetabolic state

Regulatory mechanism failure

Evaporation

Lack of fluid intake

Effects of pharmacological agents

 

 

Related Clinical Conditions

 

Addison's disease

Trauma/bleeding

Burns

AIDS

Crohn's disease

Gag

Diarrhea

Ulcerative Colitis

D.0035 Neonatal Jaundice Risk.

 

Definition:

 

There is a risk of yellowing of the skin and mucous membranes of the neonate after 24 hours of birth due to unconjugated bilirubin entering the circulation.

 

 

 

Risk Factor

 

Abnormal weight loss >7-8% in breastfed newborns, >15% in term infants)

Poor diet

Difficulty transitioning to extra uterine life

Age less than 7 days

Delay in passing stool (meconium)

Prematurity (<37 weeks)

 

 

Related Clinical Conditions

 

Neonates

Premature baby

0036 Risk of Fluid Imbalance.

 

Definition:

 

risk of decreased, increased or accelerated fluid transfer from intravescular, interstitial or intracellular.

 

 

 

Risk Factor

 

Major surgical procedures

Trauma/surgery

Burns

Apheresis

Intestinal obstruction

Pancreatic inflammation

Kidney and gland diseases

Intestinal dysfunction

 

 

Related Clinical Conditions

 

Major surgical procedures

Kidney and gland diseases

Bleeding

Burns

D.0037 Risk of Electrolyte Imbalance.

 

Definition:

 

At risk for changes in serum electrolyte levels

 

 

 

Risk Factor

 

Fluid imbalance (eg dehydration and water intoxication)

Excess fluid volume

Impaired regulatory mechanisms (eg diabetes)

Side effects of the procedure (eg surgery)

Diarrhea

Gag

Kidney dysfunction

Endocrine regulation dysfunction

 

 

Related Clinical Conditions

 

Kidney failure

Anorexia nervosa

Diabetes mellitus

Crohn's disease

Gastroenteritis

Pancreatitis

Head injury

Cancer

Multiple trauma

Burns

Sickle cell anemia

D0038 Risk of Blood Glucose Level Instability.

 

Definition:

 

Risk for variations in blood glucose levels from the normal range.

 

 

 

Risk Factor

 

Lack of exposure to information about diabetes management

Inaccuracy of blood glucose monitoring

Lack of adherence to diabetes management plan

Uncontrolled medication management

Snack

Fast growth period

Excessive stress

Weight gain

Unable to accept diagnosis

 

 

Related Clinical Conditions

 

Diabetes mellitus

diabetic ketoacidosis

Hypoglycemia

Gestational diabetes

Use of corticosteroids

Parental nutrition

D.0039 Risk of Shock.

 

Definition:

 

At risk for insufficient blood flow to body tissues, which can result in life-threatening cellular dysfunction.

 

 

 

Risk Factor

 

Hypoxaemia

Hypoxia

Hypotension

Lack of fluid volume

Sepsis

Systemic inflammatory response syndrome (SIRS)

 

 

Related Clinical Conditions

 

Bleeding

Multiple trauma

Pheumothorax

Myocardial Infarction

Cardiomyopathy

spinal cord injury

Anaphylaxis

Sepsis

Disseminated intravascular coagulation

Systemic inflammatory response syndrome (SIRS)

 

 

Information

 

This diagnosis is made in a life-threatening emergency and interventions are directed at saving lives.

Subcategory: Elimination

D.0040 Impaired Urinary Elimination.

 

Definition:

 

Urinary elimination dysfunction

 

 

 

Reason

 

Decreased bladder capacity

Bladder irritation

Decreased ability to recognize signs of bladder disorders

Effects of medical and diagnostic measures (eg kidney surgery, urinary tract surgery, anesthesia, and drugs)

Pelvic muscle weakness

Inability to access the toilet (eg immobility)

Environmental barriers

Inability to communicate need for elimination

Incomplete bladder outlet (eg congenital urinary tract anomaly)

Immaturity (in children < 3 years old)

 

 

Major Symptoms and Signs

 

Subjective

 

Urge Urination (Urgency)

Urine hatching (dribbling)

Frequent urination

nocturia

bedwetting

Enuresis

 

 

objective

 

Bladder distension

Incomplete voiding (hesitancy)

Increased residual urine volume

 

 

Minor Symptoms and Signs

 

Subjective

 

(not available)

 

 

 

Objective

 

(not available)

 

 

 

Related Clinical Conditions

 

Kidney and urinary tract infections

Hyperglycemia

Trauma

Cancer

Spinal cord injury/tumor/infection

Diabetic neuropathy

Alcoholic neuropathy

stroke

Parkinson

Multiple sclerosis

Alpha adrenergic drugs

 

 

Information

 

This diagnosis is still general in nature to be enforced in the clinic, on the contrary, this diagnosis is more specific in incontinence or retention. However, this diagnosis can be used if nurses have not succeeded in identifying factorsReasonincontinence or urinary retention.

D.0041 Fecal incontinence.

 

 

Definition:

 

Lower motor nervous system damage

Decreased muscle tone

Cognitive impairment

Laxative abuse

Loss of control of the rectal sphincter

Postoperative pullthrough and closomy closure

Inability to reach the restroom

Chronic diarrhea

Excessive stress

 

 

Major Symptoms and Signs

 

Subjective

 

Unable to control the discharge of faeces

Unable to delay defecation

 

 

Objective

 

Faeces come out little by little and often

 

 

Minor Symptoms and Signs

 

Subjective

 

(not available)

 

 

 

Objective

 

Smell of feces

Reddish perineal skin

 

 

Related Clinical Conditions

 

Spina bifida

Anal atresia

Hirschsprung's disease

Definition:

 

Uncontrolled and continuous urine output without distension or a feeling of fullness in the bladder

 

 

 

Reason

 

Reflex arch neuropathy

Neurological dysfunction

Impaired detrusor contraction reflex

Trauma

Spinal cord damage

Anatomical abnormalities (eg. fistula)

 

 

Major Symptoms and Signs

 

Subjective

 

Constant urine output without distention

Nocturia more than 2 times during sleep

 

 

Objective

 

(not available)

 

 

 

Minor Symptoms and Signs

 

Subjective

 

Urinating involuntarily

Unaware of urinary incontinence

 

 

Objective

 

(not available)

 

 

 

Related Clinical Conditions

 

Head injury

Trauma

Tumor

spinal cord infection

Urinary fistula

D.0043 Functional Urinary Incontinence.

 

 

Definition:

 

Uncontrolled loss of urine due to bladder overdistention.

 

 

 

Reason

 

spinger block

Damage or inadequate afferent pathways

Urinary outlet obstruction (eg, faecal impaction, effects of pharmacological agents)

Inadequate detrusor (eg under stressful or uncomfortable conditions, deconditioned voiding)

 

 

Major Symptoms and Signs

 

Subjective

 

Residual volume of urine after urinating or complaints of little urine leakage

nocturia

 

 

Objective

 

Bladder distension (not related toReasonacute reversible) or distended bladder with frequent, scanty urination or dribbling

 

 

Minor Symptoms and Signs

 

(not available)

 

 

 

Objective

 

Residual urine 100 ml or more

 

 

Related Clinical Conditions

 

Asthma

Allergy

Neurological disease: spinal cord injury/tumor/infection

Head injury

Multiple Sclerosis

Nerve myelination

Diabetic neuropathy

Alcoholic neuropathy

Urethral stricture/bladder neck

Enlargement of the prostate

Perinatal swelling

 

D.0044 Excessive Urinary Incontinence.

 

Definition:

Uncontrolled urine output due to difficulty and not being able to reach the toilet in a timely manner

 

Reason

Inability or decline to recognize signs of urination

Decreased bladder tone

Monility Barriers

Psychological factors: decreased attention to signs of urge to urinate (depression, confusion, delirium)

Environmental barriers (toilet far, bed too high, new environment)

Sensory and motor loss (in geriatrics)

Visual disturbance

 

Major Symptoms and Signs

Subjective

Wetting before reaching or during attempts to reach the toilet

Objective

(not available)

 

Minor Symptoms and Signs

Subjective

Bedwetting in the morning

Able to empty bladder completely

 

Related Clinical Conditions

Head injury

Alcoholic neuropathy

Parkinson's disease

Myelinated disease

Multiple Sclerosis

stroke

Progressive dementia

Depression

 

D.0045 Reflex Urinary Incontinence.

 

Definition:

Uncontrolled urine output when a certain bladder volume is reached

 

Reason

Impaired inplus conduction above the reflex arc

Tissue damage (eg radiation therapy)

 

Major Symptoms and Signs

Subjective

Not experiencing the sensation of urinating

Dribbling

Frequent urination

Hesitnacy

nocturia

Enuresis

Objective

Increased residual urine volume

 

Minor Symptoms and Signs

Subjective(not available)

Objective(not available)

 

Related Clinical Conditions

Spinal cord injury/tumor/infection

Cystitis

Pelvic surgery

Multiple Sclerosis

Bladder or pelvic cancer

Parkinson's disease

Dementia

 

D.0046 Stress Urinary Incontinence.

 

Definition:

Sudden and uncontrollable leakage of urine due to increased intra-abdominal pressure

 

Reason

Intrinsic weakness of the urethral sphincter

Changes degenerating / non degenerating pelvic muscles

Estrogen deficiency

Increased intra-abdominal pressure

Pelvic muscle weakness

 

Major Symptoms and Signs

Subjective

Complaining of <50 ml of urine when increased abdominal pressure (eg when standing, sneezing, laughing, running, or lifting heavy objects)

Objective(not available)

 

Minor Symptoms and Signs

Subjective

Incomplete urine output

urgency of urination

Increased frequency of urination

Objective

Abdominal overdistention

 

Related Clinical Conditions

Obesity

Pregnancy/delivery

menopause

Urinary tract infection

Abdominal surgery

prostate surgery

Alzheimer's disease

spinal cord injury

 

D.0047 Urinary Incontinence Urinary Incontinence.

 

Definition:

Uncontrollable loss of urine shortly after a strong urge to urinate

 

Reason

Irritation of bladder contraction receptors

Decreased bladder capacity

Detrusor hyperactivation with impaired bladder contractility

Effects of pharmacological agents (eg diuretics)

 

Major Symptoms and Signs

Subjective

Strong urge to urinate accompanied by incontinence

Objective(not available)

 

Minor Symptoms and Signs

Subjective(not available)

Objective(not available)

 

Related Clinical Conditions

History of pelvic and/or vaginal inflammatory disease

History of urinary catheter descent

Infections of the bladder and/or urethra

Neurogenic disorder/tumor/infection

Parkinson's disease

Diabetic neuropathy

Abdominal surgery

 

D.0048 Increased Readiness of Urinary Elimination.

 

Definition:

Pattern of urinary system function sufficient to meet the need for enhanced elimination

 

Major Symptoms and Signs

Subjective

Expresses a desire to increase urinary elimination

Objective

Normal amount of urine

Characteristics of normal urine

 

Minor Symptoms and Signs

Subjective(not available)

Objective

Adequate fluid intake

 

Related Clinical Conditions

spinal cord injury

multiple sclerosis

Pregnancy

Pelvic trauma

Abdominal surgery

prostate disease

 

D.0049 Constipation.

 

Definition:

Decreased normal defecation accompanied by difficult and incomplete faeces and dry and profuse stools

 

Reason

Physiological

Decreased gastrointestinal motility

Inadequate tooth growth

Inadequate diet

Insufficient fiber intake

Insufficient fluid intake

Aganglionic (eg Hircsprung's disease)

Abdominal muscle weakness

Psychological

Confucius

Depression

Emotional disturbance

Situational

Changes in eating habits (eg type of food, meal schedule)

Inadequate toileting

Daily physical activity less than recommended

Laxative abuse

Effects of pharmacological agents

Irregular bowel habits

The habit of holding back the urge to defecate

Environmental changes

 

Major Symptoms and Signs

Subjective

Defecation less than 2 times a week

Excretion of old and difficult faeces

Objective

hard stool

Decreased intestinal peristalsis

 

Minor Symptoms and Signs

Subjective

Straining during defecation

Objective

Abdominal distension

Common Weaknesses

Palpable rectal mass

 

Related Clinical Conditions

Spinal cord lesions/injury

Spina bifida

stroke

Multiple Sclerosis

Parkinson's disease

Dementia

Hyperparathyroidism

Hypoparathyroidism

Electrolyte imbalance

hemorrhoids

Obesity

Post bowel obstruction surgery

Pregnancy

Enlargement of the prostate

Rectal abscess

Anorectal fissure

Anorectal stricture

Rectal prolapse

Rectal ulcer

Rectocele

Tumor

Hircsprung's disease

Fecal impaction

 

D.0050 Urinary Retention.

 

Definition:

Incomplete emptying of the bladder

 

Reason

increased urethral pressure

Damage to the reflex arc

Springter block

Neurological dysfunction (eg trauma, neurological disease)

Effects of pharmacological agents (eg atropine, belladonna, psychotropics, antihistamines, opiates)

 

Major Symptoms and Signs

Subjective

Sensation of fullness in the bladder

Objective

dysuria/anuria

Bladder distension

 

Minor Symptoms and Signs

Subjective

Dribbling

Objective

 

Excessive incontinence

Urine residue

 

Related Clinical Conditions

Benign prostatic hyperplasia

Perineal swelling

spinal cord injury

Rectocele

Tumors in the urinary tract

 

D.0051 Urinary Incontinence Risk.

 

Definition:

At risk for uncontrolled urination.

 

Risk Factor

Side effects of drugs, coffee and alcohol

detrussor hyperreflex

Central nervous system disorders

Impaired bladder contraction: uncontrolled sphincter relaxation

Ineffective voiding habits

Small bladder capacity

 

Related Clinical Conditions

Urinary tract and/or kidney infection/tumor/stones

Central nervous system disorders

 

D.0052 Risk of Constipation.

 

Definition:

At risk for decreased normal frequency of defecation accompanied by difficulty and incomplete expulsion of feces.

 

Risk Factor

Physiological

Decreased gastrointestinal motility.

Inadequate dentition.

Inadequate diet.

Inadequate fiber intake.

Insufficient fluids.

Aganglionic (eg Hircsprung's disease).

Abdominal muscle weakness.

Psychological

Confucianism.

Depression.

Emotional disturbance.

Situational

Changes in eating habits (eg type of food, meal schedule).

Inadequate toileting.

Daily physical activity is less than recommended.

Laxative abuse.

Effects of pharmacological agents.

Irregular bowel habits.

The habit of holding back the urge to defecate.

Environmental changes.

 

Related Clinical Conditions

Lesions/injuries to the spinal cord.

Spina bifida.

strokes.

Multiple sclerosis.

Parkinson's disease.

dementia.

Hyperparathyroidism.

Hypoparathyroidism.

Subcategory: Activities and Rest

 

D.0053 Disorganized Infant Behavior.

 

Definition:

Disintegration of the baby's physiological and neurobehavioral responses to the environment

 

Reason

Physical environment limitations

Sensory imprecision

The advantages of sensory stimulation

Sensory system immaturity

Prematurity

Invasion procedure

Malnutrition

Motor disorders

Congenital abnormalities

Genetic disorders

Teratogenic exposure

 

Major Symptoms and Signs

Subjective

(not available)

Objective

Extremity hyperextension

Fingers stretched or hands grasping

Abnormal response to sensory stimuli

Uncoordinated movement

 

Minor Symptoms and Signs

Subjective

(not available)

Objective

Cry

Unable to inhibit the surprised response

Irritability

Reflex disorder

Changed motor tone

Hand on face

Nervous

Tremor

jerk

Arrhythmia

Bradycardia or tachycardia

Saturation decreased

Don't want to breastfeed

Changed skin color

 

Related Clinical Kindis

Hospitalization

Invasive procedures

Prematurity

Neurological Disorder

Respiratory disorders

Cardiovascular disorders

 

0054 Impaired Physical Mobility.

 

 

 

Definition:

Limitations in the physical movement of one or more extremities independently

 

Reason

Damage to the integrity of bone structure

Metabolic changes

Physical infirmity

Decreased muscle control

Decreased muscle mass

Decreased muscle strength

Developmental delay

Joint stiffness

Contracture

Malnutrition

Musculoskeletal disorders

Neuromuscular disorders

Body mass index above the 75th percentile for age

Effects of pharmacological agents

Movement restriction program

Painful

Lack of exposure to information about physical activity

Worry

Cognitive impairment

Reluctance to move

Sensoriperception disorders

 

Major Symptoms and Signs

Subjective

Complains of difficulty moving extremities

Objective

Decreased muscle strength

Decreased range of motion (ROM)

 

Minor Symptoms and Signs

Subjective

Pain when moving

Reluctant to move

Feeling anxious when moving

Objective

Stiff joints

Uncoordinated movement

Limited movement

Physically weak

 

Related Clinical Conditions

stroke

spinal cord injury

Trauma

Fracture

Osteoarthritis

Ostemalacia

Malignancy

 

D.0055 Sleep Pattern Disorder.

 

Definition:

Impaired sleep quality and quantity due to external factors

 

Reason :

Environmental barriers (eg ambient humidity, ambient temperature, lighting, noise, unpleasant odors, monitoring/inspection/action schedule)

Lack of sleep control

Lack of privacy

Physical restraint

No sleeping partner

Not familiar with sleeping equipment

 

Major Symptoms and Signs:

Subjective

Complaining about sleeplessness

Complaining often awake

Complaining not satisfied with sleep

Complaining about changing sleep patterns

Complaining that rest is not enough

Objective(not available)

 

Minor Symptoms and Signs

Subjective Objective

Complains of decreased ability to function (not available)

 

Related Clinical Conditions

Pain/colic

Hyperthyroidism

Worry

Chronic obstructive pulmonary disease

Pregnancy

Post partum period

postoperative condition

 

D.0056 Activity Intolerance.

 

Definition:

Insufficient energy to carry out daily activities

 

Reason

Imbalance between oxygen supply and demand

bed rest

Weakness

Immobility

Monotonous lifestyle

 

Major Symptoms and Signs

Subjective

Complaining tired

Objective

heart rate increased >20% of healthy condition

 

Minor Symptoms and Signs

Subjective

Dyspnea during/after activity

Feeling uncomfortable after activities

Feeling weak

Objective

Blood pressure changes >20% from resting

ECG picture shows arrhythmia during/after activity

The ECG shows ischemia

Cyanosis

 

Related Clinical Conditions

Anemia

Congestive heart failure

Coronary heart disease

heart valve disease

Arrhythmia

Chronic obstructive pulmonary disease (COPD)

Metabolic disorders

Musculoskeletal disorders

 

D.0057 Fatigue.

 

 

Definition:

Decreased physical and mental work capacity that does not recover with rest.

 

Sleep disturbance

Monotonous lifestyle

Physiological conditions (eg chronic illness, terminal illness, anemia, malnutrition, pregnancy)'

Long-term care/treatment program

Negative life events

Stress—too much

Depression

Major Symptoms and Signs

 

Subjective

 

Feeling energy is not white even though you have slept

Feeling sleep deprived

Complaining tired

 

 

Objective

 

Unable to maintain routine activities

Looking sluggish

 

 

Minor Symptoms and Signs

 

Subjective

 

Feeling guilty for not being able to carry out responsibilities

decreased libido

 

 

Objective

 

Increased need for rest

 

 

Related Clinical Conditions

 

Anemia

Cancer

Hypothyroidism/Hyperthyroidism

AIDS

Depression

Menopause

 

 

Information

 

The diagnosis of fatigue is a subjective feeling that is not resolved by rest and nursing interventions are not focused on increasing endurance, but on helping clients adapt to the conditions they are experiencing. Meanwhile, Activity Intolerance is focused on increasing the client's tolerance and endurance for activities.

 

D.0058 Improved Sleep Readiness.

 

Definition:

A natural and periodic pattern of loss of consciousness that allows adequate rest, maintains a desired lifestyle and can be improved.

 

Major Symptoms and Signs

Subjective

Expresses a desire to improve sleep

Expressing the feeling of being well rested after sleeping

Objective

The amount of sleep in accordance with the growth of development

 

Minor Symptoms and Signs

Subjective

Not using sleeping pills

Objective

Adopt a bedtime routine that improves sleep habits

 

Related Clinical Conditions

Postoperative recovery

Chronic pain

Pregnancy (prenatal/postnatal period)

Sleep apnea

 

D.0059 Risk of Infant Behavioral Disorganization.

 

Definition:

At risk for disintegrating the baby's physiological and neurobehavioral responses to the environment.

 

Risk Factor

The advantages of sensory stimulation

Prematurity

Invasive procedures

Motor disorders

Congenital abnormalities

Genetic disorders

 

Related Clinical Conditions

Hospitalization

Invasive procedures

Prematurity

Neurological disorders

Congenital disorders

Cardiovascular disorders

 

D.0060 Activity Intolerance Risk.

 

Definition:

At risk of experiencing insufficient energy to carry out daily activities

 

Risk Factor

Circulation disorders

Infirm physical status

Past history of activity intolerance

No experience with an activity

Respiratory disorders

 

Related Clinical Conditions

Anemia

Congestive heart failure

heart valve disease

Arrhythmia

Chronic obstructive pulmonary disease (COPD)

Metabolic disorders

Musculoskeletal disorders

Subcategory: Neurosensory

 

D.0061 Autonomic dysreflexia.

 

Definition:

A spontaneous, life-threatening response of the sympathetic nervous system to noxious stimuli resulting from spinal cord injury at T7 or above.

 

Subjective

Headache

Objective

Systolic blood pressure increased >20%

Red patches on the skin over the injury site

Diaphoresis over the injury site

Pale below the injury site

Bradycardia and/or tachycardia

 

Minor Symptoms and Signs

Subjective

Chest pain

Blurred vision

Conjunctival congestion

Nasal congestion

paresthesia

Metallic sensation in the mouth

Objective

Shivering

Horner's syndrome

Pilomotor reflex

Pupillary dilation

Penile erection

Cement emission

 

Related Clinical Conditions

spinal cord injury

Fracture

Deep vein thrombosis

 

D.0062 Memory Impairment.

 

Definition:

Inability to remember some information or behavior.

 

cause

Inadequate intellectual stimulation

Circulation disorders to the brain

Impaired fluid and/or electrolyte volume

aging process

Hypoxia

Neurological disturbances (eg positive EEG, head injury, seizure disorder)

Effects of pharmacological agents

Substance abuse

Psychological factors (eg anxiety, depression, excessive stress, grieving, sleep disturbances)

Environmental distraction

 

Major Symptoms and Signs

Subjective

 

Report an experience overflow

Unable to learn new skills

Unable to remember factual information

Not being able to remember certain behaviors that have been done

Unable to remember events

Objective

Unable to perform previously learned abilities

 

Minor Symptoms and Signs

Subjective

forgot to do the behavior at the scheduled time

Feel easy to forget

Objective

(not available)

 

Related Clinical Conditions

 

stroke

Head injury

Seizures

Alzheimer's disease

Depression

Alcohol intoxication

Substance abuse

 

D.0063 Swallowing Disorders.

 

Definition:

Abnormal swallowing function due to deficits in oral, pharyngeal or esophageal structure or function.

 

Reason

Cerebrovascular disorders

Cranial nerve disorders

Cerebral Paralysis

Achalasia

Laryngeal abnormalities

Oropharyngeal abnormalities

Upper airway anomalies

Congenital anatomic defects

laryngeal defect

Nasal defects

Nasopharyngeal cavity defects

Tracheal defect

Gastroesophageal reflux

Mechanical obstruction

prematurity

 

Major Symptoms and Signs.

Subjective

Complaining difficult to swallow

Objective

Cough before swallowing

Cough after eating or drinking

Choking

Food left in the oral cavity

 

Minor Symptoms and Signs

Subjective

Oral

(not available)

 

 

Pharynx

Refuse to eat

Esophagus

Complaining about waking up at night

Epigastric pain

Objective

Oral

Bolus coming in too fast

Nasal reflux

Unable to clean the oral cavity

Food falls out of mouth

Food is pushed out of the mouth

Difficult to chew

Vomiting before swallowing

Long formed bolus

Long meal time

The food portion is not finished

Abnormal oral phase

Drooling

Pharynx

Gag

Head position is not elevated

Swallow repeatedly

Esophagus

Hematemesis

Nervous

Regurgitation

Odynophagia

Bruxism

 

Related Clinical Conditions

stroke

Muscular dystrophy

Poliomyelitis

Cerebral palsy

Prkinson's disease

Guillain Barre Syndrome

Myasthenia gravis

Amyotropic lateral sclerosis

Brain neoplasm

Vocal cord paralysis

Damage to cranial nerves V, VII, IX, XI

Esophagitis

 

D.0064 Acute Confusion

 

Definition:

Reversible disturbance of consciousness, attention, cognition, and perception, lasts suddenly and briefly.

 

Reason.

 

Delirium

Dementia

Sleep-wake cycle fluctuations

More than 60 years old

Substance abuse

 

Major Symptoms and Signs

Subjective

Lack of motivation to initiate/complete goal-oriented behavior

Lack of motivation to initiate/complete directed behavior.

 

objective'

Cognitive function fluctuations

Fluctuations in level of consciousness

Psychomotor activity fluctuations

 

Minor Symptoms and Signs

Subjective

Misperception

Objective

hallucination

Nervous

 

Related Clinical Conditions

Head injury

stroke

Alzheimer's disease

Substance abuse

Dementia

Delirium

 

D.0065 Chronic Confusion

 

Definition:

Irreversible, long-lasting, and/or progressive impairment of consciousness, attention, cognition and perception

 

Reason

Brain injury (eg cerebrovascular damage, neurological disease, trauma, tumor)

Korsakoff's Psychosis

Multi-infarct dementia

 

Major Symptoms and Signs

Subjective

Lack of motivation to initiate/complete goal-oriented behavior

Lack of motivation to initiate/complete directed behavior

Objective

Cognitive function changes progressively

Changes in short and/or long term memory

Interpretation changed

Disrupted social function

Response to stimulus changes

 

Minor Symptoms and Signs

Subjective

Misperception

Objective

Organic brain disorder

 

Related Clinical Conditions

 

Head injury

Brain tumor

stroke

Alzheimer's disease

Substance abuse

Multi-infarct dementia

 

D.0066 Decreased Intracranial Adaptive Capacity

 

Definition:

Disruption of intracranial dynamic mechanisms in compensating for stimuli that can reduce intracranial capacity

 

 

 

Reason

Space-occupying lesion (eg space-occupying lesion – due to tumor, abscess)

Metabolic disorders (eg due to hyponatremia, uremic encephalopathy, hepatic encephalopathy, diabetic ketoacidosis, septicemia)

Cerebral edema (eg due to head injury [epidural hematoma, subdural hematoma, subarachnoid hematoma, intracerebral hematoma], hemorrhagic stroke, hypoxia, ischemic encephalopathy, postoperatively)

Increased venous pressure (eg due to cerebral venous sinus thrombosis, heart failure, jugular or superior vena cava thrombosis/obstruction)

Obstruction of cerebrospinal fluid flow (eg hydrocephalus)

Idiopathic intracranial hypertension

 

Major Symptoms and Signs

Subjective

Headache

Objective

Blood pressure increases with a widening pulse pressure

Bradycardia

Irregular breathing pattern

Decreased level of consciousness

Pupil response slowed or not the same

Impaired neurological reflexes

 

Minor Symptoms and Signs

 

Subjective

 

(not available)

Objective

Nervous

Agitation

Vomiting (without nausea)

Looks lethargic/weak

Impaired cognitive function

Intracranial pressure (ICP) >20mmHg

Papilledema

Deceleration (extension) posture

 

Related Clinical Conditions

Head injury

Cerebral ischemia

Cerebral tumors

hydrocephalus

Cranial hematoma

arteriovenous formation

Cerebral vasogenic or cytotoxic edema

hyperemia

Obstruction of venous flow

 

D.0067 Risk of Peripheral Neurovascular Dysfunction

 

Definition:

At risk for impaired circulation, sensation and movement in the extremities.

 

Risk Factor

Hyperglycemia

Vascular obstruction

Fracture

Immobilization

Mechanical stresses (eg tournket, cast, bandage, restraint)

Orthopedic surgery

Trauma

Burns

 

Related Clinical Conditions

 

Diabetes mellitus

Vascular obstruction

Fracture

Orthopedic surgery

Trauma

Burns

 

D.0068 Risk of Acute Confusion.

 

Definition:

At risk for disturbances of consciousness, attention, cognition and perception that are reversible and occur in a short period of time.

 

Risk Factor

Age above 60 years

Changes in cognitive function

Changes in the sleep-wake cycle

Dehydration

Dementia

History of stroke

Impaired metabolic function (eg azotemia, decreased hemoglobin, electrolyte imbalance, increased blood urea nitrogen [BUN/creatinine])

Mobility disorders

Improper use of restraints

Infection

Malnutrition

Painful

Pharmacological gene effects

Sensory Deprivation

Substance abuse

 

Related Clinical Conditions

Head injury

stroke

Alzheimer's disease

Substance abuse

dementia

Subcategory: Reproduction and Sexuality

 

D.0069 Sexual Dysfunction

 

Definition:

Changes in sexual function during the sexual response phase in the form of desire, arousal, orgasm, and/or relaxation that are felt to be unsatisfactory, meaningless or inadequate.

 

Reason

Changes in body function/structure (eg pregnancy, new birth, drugs, surgery, anomalies, disease processes, trauma, radiation)

Biopsychosocial changes in sexuality

Lack of role models

Role models can't influence

Lack of privacy

absence of partner

misinformation

Sexual harassment (e.g. violent relationships)

Value conflict

Physical abuse (eg domestic violence)

Less exposed to information

 

Major Symptoms and Signs

Subjective

Revealing changed sexual activity

Expressing sexual excitement changes

Feeling unsatisfactory sexual relationship

Revealing changing sexual roles

Complaining about decreased sexual desire

Reveal changed sexual function

Complaining of pain during sexual intercourse (dyspareunia)

Objective

(not available)

 

Minor Symptoms and Signs

Subjective

Expressing interest in changing partners

Complaining about limited sexual intercourse

Looking for information about the ability to achieve sexual satisfaction

Objective

(not available)

 

Related Clinical Conditions

Endocrine, urinary, neuromuscular, musculoskeletal, cardiovascular disorders

Genital trauma

Pelvic surgery

Cancer

Menopause

Psychiatric disorders such as mania, major depression, dementia, personality disorders, substance abuse or use, anxiety disorders, and schizophrenia.

 

D.0070 – Childbirth Readiness

 

Definition:

The pattern of preparing, maintaining and strengthening the process of pregnancy and childbirth as well as the care of newborns.

 

Major Symptoms and Signs

Subjective

Expresses a desire to adopt an appropriate lifestyle for childbirth.

Expresses a desire to apply management of symptoms of discomfort during labour.

Expressing self-confidence during childbirth.

 

Minor Symptoms and Signs

Subjective

(not available).

Objective

Demonstrate proactive behavior during labor preparation.

 

Related Clinical Conditions

Mother's health status is healthy.

Fetal health status is healthy.

 

D.0071 Ineffective Sexual Patterns.

 

Definition:

An individual's concern about having risky sexual intercourse causes health changes.

 

Reason :

lack of privacy,

absence of a partner,

sexual orientation conflict,

fear of pregnancy,

Fear of being infected with a sexually transmitted disease

Relationship barriers with partner

Lack of exposure to information about sexuality.

 

Major Symptoms and Signs

Subjective

Complains of difficulty performing sexual activity,

Reveal changed sexual activity,

Disclosing changed sexual behavior,

Sexual orientation changes.

Objective(not available).

 

Minor Symptoms and Signs

Subjective

Revealing a relationship with a changed partner.

Objective

Value conflict.

 

Related Clinical Conditions

Mastectomy.

Hysterectomy.

Cancer.

Conditions that cause paralysis.

Sexually transmitted diseases (eg syphilis, gonorrhea, AIDS).

 

D.0072 Risk of Sexual Dysfunction

 

Definition:

At risk of experiencing changes in sexual function during the sexual response phase in the form of desire, arousal, orgasm and relaxation which are considered unsatisfactory, meaningless/inadequate

 

Risk Factor

Biological

Neurological disorders

Urological disorders

Endocrine disorders

Malignancy

Gynecological factors (eg pregnancy, postpartum)

Effects of pharmacological agents

Psychological

Depression

Worry

Psychological/sexual abuse

Drug/substance abuse

Situational

Relationship conflict

Lack of privacy

Deviant partner's sexual pattern

No partner

Inadequate education

Conflict of personal values ​​in family, culture and religion

 

Related Clinical Conflict

Diabetes mellitus

Heart disease (eg hypertension, coronary heart disease)

Lung disease (eg TB, COPD, asthma)

stroke

Pregnancy

Cancer

Endokurin, urinary, neuromuscular, cardiovascular musculoskeletal disorders

Genital trauma

Pelvic dissection

Cancer

Menopause

Psychiatric disorders such as mania, major depression, dementia, personality disorders, substance abuse, anxiety disorders, and schizophrenia

 

D.0073 Risk of Unwanted Pregnancy

 

Definition:

At risk of having an unwanted pregnancy either because of the wrong timing or because the pregnancy was not wanted

 

Risk Factor

Rape

Incest (incest)

Mental disorders

Failure to use contraceptives

Domestic Violence (KDRT)

Not using contraception

Socio-economic factors

 

Related Clinical Conditions

Sexually transmitted disease

Mental disorders

Failure to use contraceptives

Domestic Violence (KDRT)

 

Category: Psychological

Subcategory: Pain and Comfort

 

D.0074 Disturbance of Comfort

 

Definition:

Feelings of less pleasure, relief and perfection in the physical, psychospiritual, environmental and social dimensions

 

Reason

Symptoms of disease

Lack of situational/environmental control

Inadequate resources eg (eg financial, social and knowledge support)

Lack of privacy

Disruption of environmental stimuli

Side effects of therapy (eg medication, radiation, chemotherapy)

Impaired pregnancy adaptation

 

Major Symptoms and Signs

Subjective

complaining of discomfort

Objective

Nervous

 

Minor Symptoms and Signs

Subjective

Complaining about sleeplessness

Unable to relax

Complaining cold/hot

Feeling itchy

Complaining about nausea

Complaining tired

Objective

Showing symptoms of distress

Looks moaning/crying

Elimination pattern changed

Changed body posture

Irritability

 

Related Clinical Conditions

 

Chronic disease

Malignancy

Psychological distress

Pregnancy

 

Information

 

The diagnosis of discomfort disorder is established when discomfort occurs without tissue injury. If discomfort occurs due to tissue damage, the recommended diagnosis is acute or chronic pain.

 

D.0075 Post Partum Discomfort

 

Definition:

Uncomfortable feelings related to the condition after giving birth

 

Reason

Perineal trauma during labor and delivery

Uterine involution, the process of returning the size of the uterus to its original size

Freezing of the breast where the alveoli begin to fill with milk

Lack of support from family and health workers

Incorrect sitting position

Cultural factors

 

Major Symptoms and Signs

Subjective

Complaining uncomfortable

Objective

Looks like crying

There are uterine contractions

Lika epislotomi

Swollen breasts

 

Minor Symptoms and Signs

Subjective(not available)

Objective

Increased blood pressure

Increased pulse rate

Excessive sweating

cry/moan

Haemorroid

 

Related Clinical Conditions

Postpartum conditions

 

D.0076 Nausea

 

Definition:

An uncomfortable feeling in the back of the throat or stomach that can lead to vomiting.

 

Reason

Biochemical disturbances (eg uremia, diabetic ketoacidosis)

Disorders of the esophagus

gastric distension

Stomach irritation

Pamcreas disorders

Spleen capsule stretch

Lolized tumor (eg acoustic neuroma, primary or secondary brain tumor, skull base bone metastases)

increased intra-abdominal pressure (eg intra-abdominal malignancy)

Increased intracranial pressure

Increased intraorbital pressure (eg glaucoma)

Motion sickness

Pregnancy

Bad smell

Bad taste of food/drink

Stimulus of sight is not pleasant

Psychological factors (eg anxiety, fear, stress)

Effects of pharmacological agents

Toxic effect

 

Major Symptoms and Signs

Subjective

Complaining about nausea

Feeling like throwing up

Not interested in eating

Objective(not available)

 

Minor Symptoms and Signs

Subjective

Feeling sour in the mouth

Hot/cold sensation

Swallow often

Objective

Salva increases

Pale

Diaphoresis

Tachycardia

Dilated pupils

 

Related Clinical Conditions

Meningitis

Labrinitis

Uremia

Diabetic ketoacidosis

Peptic ulcer

Esophageal disease

intra-abdominal tumor

Meniere's disease

Acoustic neuroma

Brain tumor

Cancer

Glaucoma

 

D.0077 Acute Pain

 

Definition:

Sensory or emotional experience related to actual or functional tissue damage, of sudden or late onset and of mild to severe intensity lasting less than 3 months.

 

Reason

Physiological injuring agents (eg infarcts, lakemias, neoplasms)

Chemical injuring agents (eg burns, chemical irritants)

Agents of physical injury (eg abscess, amputation, burns, cuts, heavy lifting, surgical procedures, trauma, overexertion)

 

Major Symptoms and Signs

Subjective(not available)

Objective

Looks grim

Be protective (eg alert, pain avoidance position)

Nervous

Increased pulse rate

Hard to sleep

 

Symptoms and Minor

Subjective(not available)

Objective

Increased blood pressure

breathing pattern changes

change in appetite

disturbed thought process

Withdraw

Focus on yourself

Diaphoresis

 

Related Clinical Conditions

Surgical conditions

Traumatic injury

Infection

Acute coronary syndrome

Glaucoma

 

D.0078 Chronic Pain

 

Definition:

Sensory or emotional experience associated with actual or functional tissue damage, of sudden or late onset and of mild to severe and constant intensity, lasting more than 3 months.

 

Reason.

Chronic musculoskeletal conditions

Nervous system damage

Nerve suppression

Tumor infiltration

Imbalance of neurotransmitters, neuromodulators, and receptors

Immune disorders (eg HIV-associated neuropathy, varicella-zoster virus)

Metabolic dysfunction

History of static work position

Increase in body mass index

post-traumatic conditions

Emotional stress

History of abuse (eg physical, psychological, sexual)

History of drug/substance abuse

 

Major Symptoms and Signs

Subjective

Complaining of pain

Feeling depressed (depressed)

Objective

Looks grim

Nervous

Unable to complete activities

 

Minor Symptoms and Signs

Subjective

Feeling afraid of getting injured again

Objective

Be protective (eg position to avoid pain)

Alert

Sleep patterns change

Anorexia

Narrowed focus

Focus on yourself

 

Related Clinical Conditions

Chronic conditions (eg rheumatoid arthritis)

Infection

Spinal cord injury

Post-traumatic conditions

Tumor

 

D.0079 Childbirth Pain

 

Definition:

Sensory and emotional experiences that vary from pleasant to unpleasant associated with childbirth

 

Reason :

1. Cervical dilatation

2. Fetal expulsion

 

Mayaor Symptoms and Signs:

 

Subjective Objective

1. Complaining looking for

.Grinding facial expression

2.Perineum feels depressed 2.Position to relieve pain

3. Uterus feels rounded

 

Minor Symptoms and Signs

 

Subjective Objective

1.Nausea

1.Blood pressure increases

2. Decreased/increased appetite

2. Pulse rate increases

3. Increased muscle tension

4. Sleep patterns change

5. Urinary function changes

6.Diaphoresis

7. Behavioral disorders

8. Expressive behavior

9. Dilated pupils

10. Vomit

11.Focus on yourself

 

Related Clinical Conditions

Labor process

Childbirth pain

 

Subcategory: Ego Integrity

 

D.0080 Anxiety.

 

Definition:

Emotional conditions and subjective experiences of objects that are not clear and specific due to the anticipation of danger that allows individuals to take action to deal with threats.

 

Reason.

Situational crisis.

Needs not met.

Maturational crisis.

Threats to self-concept.

Threats to death.

Fear of failure.

Family system dysfunction.

The parent-child relationship is unsatisfactory.

Hereditary factors (easily agitated temperament from birth)

Substance abuse.

Exposure to environmental hazards (eg toxins, pollutants, etc.).

Lack of exposure to information.

 

Major Symptoms and Signs.

Subjective.

Feeling confused.

Worry about the consequences.

It's hard to concentrate.

Objective.

Looks restless.

Looks tense.

Hard to sleep

 

Minor Symptoms and Signs.

Subjective.

Complains of dizziness.

anorexia.

Palpitations.

Feeling helpless.

Objective.

Breathing rate increases.

The pulse rate increases.

Increased blood pressure.

Diaphoresis.

Tremos.

The face looks pale.

The voice vibrates.

Poor eye contact.

Frequent urination.

Oriented to the past.

 

Related Clinical Conditions.

Chronic Disease.

Acute illness

Hospitalization

Operation plan

The condition of the disease diagnosis is not clear

Neurological disease

Growth stage

 

D.0081 Grieving.

 

Definition:

 

The psychosocial response shown by the client due to loss (person, object, function, status, body part or relationship).

 

Reason.

The death of a significant person or family.

Anticipate the death of a family or significant person.

Loss (object, job, function, status, body part, social relationship).

Anticipation of loss (object, occupation, status function, body part, social relations).

 

Major Symptoms and Signs.

Subjective.

Feeling sad.

Feeling guilty or blaming others.

Don't accept loss.

Feeling hopeless.

objective.

cry.

Sleep patterns change.

Unable to concentrate

 

Minor Symptoms and Signs.

Subjective.

Nightmares or dream patterns change.

Feeling useless.

phobia.

Objective

Angry.

Looks panicked.

Impaired immune function.

 

Related Clinical Conditions.

Death of a family member or close person.

Amputation.

Spinal cord injury.

Perinatal loss conditions.

Terminal disease (eg cancer).

Breaking labor relations.

 

D.0082 Spiritual Distress

 

Definition:

Disturbances in beliefs or value systems in the form of difficulty feeling the meaning and purpose of life through relationships with self, other people, the environment or God.

 

Reason.

Towards death.

Chronic disease conditions.

Death of a close person.

Lifestyle changes.

Lonely.

Self isolation.

Social compassion.

Socio-cultural disorders.

Increased dependence on others.

Unexpected life events.

 

Major Symptoms and Signs.

Subjective.

Declare his life is not / less meaningful.

Complaining can not accept (less surrender).

Feel guilty.

Feeling alienated.

Saying has been ignored

Objective.

Refuse to interact with the closest person/spiritual leader.

Inability to be creative (eg singing, listening to music, writing).

Coping is not effective.

Not interested in nature / spiritual order.

 

Related Clinical Conditions.

Chronic disease (eg rheumatoid, multiple sclerosis).

Terminal illness (eg cancer).

Mental retardation.

Loss of body parts.

Sudden infant death syndrome (SIDS).

Stillbirth, fetal death, miscarriage.

infertility.

Psychiatric disorders.

 

D.0083 Body Image Disorder

 

Definition:

Changes in perception of an individual's appearance, structure and physical function

 

Reason

Changes in body structure/shape (eg amputation, trauma, burns, obesity, acne)

Changes in body function (eg disease process, pregnancy, paralysis)

Changes in cognitive function

Incompatibility of culture, belief or value system

Developmental transition

Psychosocial disorders

Effects of action/treatment (eg surgery, chemotherapy, radiation therapy)

 

Major Symptoms and Signs

Subjective

Reveal mess/loss of body parts

Objective

Loss of body part

Changes/lost function/structure of the body

 

Minor Symptoms and Signs

Subjective

Do not want to reveal disability / loss of body parts

Expressing negative feelings about body changes

Expressing concern at rejection/reaction of others

Reveal lifestyle changes

Objective

Hiding/showing body parts excessively

Avoid seeing and/or touching body parts

Excessive focus on body changes

Nonverbal responses to changes and body perceptions

Focus on past appearances and strengths

Social relationships change

 

Related Clinical Conditions

Mastectomy

Amputation

Pimple

Visible scars or burns

Obesity

Hyperpigmentation in pregnancy

Psychiatric disorders

Neoplasm therapy program

Chemically induced alopecia

 

D.0084 Self-Identity Disorder

 

Definition:

Unable to maintain the integrity of the perception of self-identity.

 

Reason

Social role disorder

Non-fulfillment of developmental tasks

Neurological disorders

Inadequate sensory stimulation

 

Major Symptoms and Signs

Subjective

Changes in self-perception

Confused by cultural values, life goals, gender, and/or ideal values

Fluctuating feelings about yourself

Objective

Inconsistent behavior

ineffective relationship

Coping strategies are not effective

Ineffective role performance

 

Minor Symptoms and Signs

Subjective(not available)

Objective(not available)

 

Related Clinical Conditions

 

autistic disorder

Disorders of sexual orientation

Disorders of the adolescent developmental period

 

D.0085 Impaired Sensory Perception

 

Definition:

Changes in perception of stimulation both internal and external accompanied by a reduced, exaggerated or distorted response

 

Reason

Visual disturbance

Hearing disorders

olfactory disorders

Disturbance of touch

Cerebral hypoxia

Substance abuse

Elderly

Exposure to environmental toxins

 

Major Symptoms and Signs

Subjective

Hear a whisper or see a shadow

Feeling something through the senses of touch, smell, touch, or taste

Objective

Sensory distortion

Inappropriate response

Acting as if you saw, heard, tasted, touched, or smelled something

 

Minor Symptoms and Signs

Subjective

Expressing upset

Objective

alone

Daydream

Poor concentration

Disorientation of time, place, person or situation

Suspect

look in one direction

Back and forth

Speak for yourself

 

Related Clinical Conditions

Glaucoma

Cataract

Refractive errors (myopia, hyperopia, astigmatism, presbyopia)

Ocular trauma

Trauma to cranial nerves II, III, IV due to stroke, intracranial aneurysm, trauma/brain tumor)

Ocular infection

Presnicus

Hearing aid malfunction

Delirium

Dementia

amnestic disorder

terminal illness

Psychotic disorders

 

D.0086 Chronic Low Self-Esteem

 

Definition:

Evaluation or negative feelings about oneself or the client's abilities such as meaningless, worthless, helpless that lasts for a long time and continuously

 

Reason

Being exposed to a traumatic situation

Repeat failure

Lack of acknowledgment from others

Ineffective coping with loss

Psychiatric disorders

Repeated negative reinforcement

Cultural incompatibility

 

Major Symptoms and Signs

Subjective

Negative self-assessment (e.g. useless, helpless)

Feeling ashamed/guilty

Feeling unable to do anything

Underestimating problem-solving skills

Feeling of not having positive strengths or abilities

Exaggerating negative self-assessments

Refuse positive self-assessments

Objective

Reluctant to try new things

Walk down

Lowered body posture

 

Minor Symptoms and Signs

Subjective

Feeling difficult to concentrate

Hard to sleep

Expressing the decision

Objective

Poor eye contact

Lethargic and unmotivated

Speak slowly and quietly

Passive

Non-assertive behavior

Looking for reinforcement excessively

Depend on other people's opinion

Hard to make a decision

 

Related Clinical Conditions

Traumatic injury

Surgery

Pregnancy

stroke

Substance abuse

Dementia

Chronic disease

Unpleasant experience

 

D.0087 Situational Low Self-Esteem

 

Definition:

Evaluation or negative feelings about oneself or the client's abilities in response to the current situation.

 

Reason

Changes in body image

Changes in social roles

Inadequate understanding

Behavior inconsistent with values

Repeated life failure

History of loss

Rejection history

Developmental transition

 

Major Symptoms and Signs

Subjective

Negative self-assessment (eg useless, helpless)

Feeling ashamed/guilty

Exaggerating negative self-assessments

Exaggerating positive self-assessments

Objective

Speak slowly and quietly

Refuse to interact with other people

Walk down

Lowered body posture

 

Minor Symptoms and Signs

Subjective

Difficult to concentrate

Objective

Poor eye contact

Lethargic and unmotivated

Passive

Unable to make a decision

 

Related Clinical Conditions

Traumatic injury

Surgery

Pregnancy

Newly diagnosed condition (eg diabetes mellitus)

stroke

Substance abuse

Dementia

Unpleasant experience

 

D.0088 Despair

 

Definition:

The condition of the individual who views the existence of limitations or the unavailability of alternative solutions to the problems at hand.

 

Reason

Long term stress

Decreased physiological condition

Losing faith in spiritual power

Loss of faith in important values

Long-term activity restriction

Exile

 

 

Major Symptoms and Signs

Subjective

Expressing despair

Objective

Passive behavior

 

 

Minor Symptoms and Signs

Subjective

Hard to sleep

Decreased appetite

Objective

Flat affect lacks initiative

Leaving the interlocutor

Leaving the interlocutor

Less involved in maintenance activities

Shrugging in response to the other person

 

Related Clinical Conditions

Chronic disease

terminal illness

Incurable disease

 

D.0089 Readiness to Improve Self-Concept

 

Definition:

A pattern of self-perception that is sufficient to feel prosperous and can be improved.

 

Major Symptoms and Signs

Subjective

Expresses a desire to improve self-concept

Express satisfaction with self, role performance, body image and personal identity.

Objective

(not available)

 

Minor Symptoms and Signs

Subjective

Feel confident

Accept the advantages and limitations

Objective

Action according to the feelings and thoughts expressed

 

Related Clinical Conditions

Health improvement behavior

 

D.0090 Readiness to Improve Family Coping

 

Definition:

The pattern of adaptation of family members in dealing with situations experienced by clients effectively and shows the desire and readiness to improve the health of families and clients.

 

Major Symptoms and Signs

Subjective

Family members set goals to promote a healthy lifestyle

Family members set goals to improve health

Objective

(not available)

Subjective

Family members identify experiences that optimize well-being

Family members seek to explain the impact of the crisis on development

Family members express interest in making contact with others experiencing the same situation

 

Related Clinical Conditions

Genetic disorders (eg Down syndrome, cystic fibrosis)

Traumatic injury (eg amputation, spinal injury)

Chronic conditions (eg asthma, AIDS, Alzheimer's disease)

 

D.0091 Community Coping Enhancement Readiness

 

Definition:

Adaptation patterns from solving community problems that are satisfactory to meet the demands or needs of the community, and can be improved for the management of current and future problems

 

Major Symptoms and Signs

Subjective

Active planning by the community regarding stressor prediction

Active troubleshooting by the community when faced with a problem

Objective

There are adequate resources to cope with the stressor

 

Minor Symptoms and Signs

Subjective

Agree that the community is responsible for implementing stress

Communicating positively among community members

Communicating positively among the community

Objective

Programs available for recreation

Programs available for relaxation/Relax

 

Related Clinical Conditions

Reducing the rate of illness, accident or violence

 

D.0092 Helplessness

 

Definition:

 

The perception that one's actions will not significantly affect the outcome; a perception that lacks control over the current situation in the future

 

Reason

Complex or long-term care/treatment program

The environment does not support treatment/treatment

Unsatisfactory interpersonal interaction

 

Major Symptoms and Signs

Subjective

Expresses frustration or inability to carry out previous activities

Objective

Depend on others

 

Minor Symptoms and Signs

Subjective

Feeling alienated

Expressing doubts about the job performance of the role

Expressing lack of control

Expressing shame

Feeling depressed (depression)

Objective

Not participating in treatment

Exile

 

Related Clinical Conditions

Unexpected or new diagnosis

Traumatic event

Diagnosis of chronic disease

Diagnosis of terminal illness

Inpatient

 

D.0093 Family Coping Disability

 

Definition:

 

Reason

Ambivalent family relationship

Different coping patterns between clients and close people

Family resistance to complex care/treatment

 

 

Major Symptoms and Signs

Subjective

Feeling neglected

Objective

Not meeting the needs of family members

Intolerant

Ignoring family members

Subjective

Too worried about family members

Feeling depressed (depression)

Objective

Attacking behavior (aggression)

Instigating behavior (agitation)

Not committed

Showing psychosomatic symptoms

Rejecting behavior

Treatment that ignores the client's basic needs

Neglecting treatment/medication

Hostile behavior

Individualistic behavior

Efforts to build a meaningful life disturbed

Disrupted healthy behavior

Increased dependency of family members

The reality of the health of family members is disturbed

 

Related Clinical Conditions

Alzheimer's disease

AIDS

Disorders that cause permanent paralysis

cancer

Chronic disease (eg cancer, arthritis, rheumatoid)

substance abuse

Family crisis

Unresolved family conflict

 

D.0094 Defensive Coping

 

Definition:

Projected self-evaluation to protect oneself from threats to self-esteem

 

Reason

Conflict between self-perception and value system

Fear of failure

Fear of being humiliated

Fear of the impact of the situation at hand

Lack of trust in others

Lack of confidence

Lack of support system support (support system)

Unrealistic expectations

 

Major Symptoms and Signs

Subjective

Blaming others

Denying there is a problem

Denying self weakness

Rationalize failure

Objective

Hypersensitivity to criticism

 

Minor Symptoms and Signs

Subjective

Underestimating others

Objective

Throwing responsibility

Hostile laughter

Superior attitude towards others

Unable to distinguish reality

Lack of interest in taking care/treatment

Difficulty building or maintaining relationships

 

Related Clinical Conditions

Chronic disease

Substance abuse

Attention-deficit/hyperactivity disorder (ADHD)

Behavioral disorders

Oppositional Defiant Disorder

Delirium

Dementia

amnestic disorder

 

D.0095 Ineffective Community Coping

 

Definition:

The pattern of adaptation of community activities and unsatisfactory problem solving to meet the demands or needs of the community.

 

Reason

Exposure to disasters (natural or man-made)

Disaster history (natural or man-made)

Inadequate resources for problem solving

Inadequate community resources (eg rest, recreation, social support)

No community system

 

Major Symptoms and Signs

Subjective

Expressing Community Powerlessness

Objective

The community doesn't live up to the expectations of its members

Community conflict is increasing

Incidence of community problems is increasing (eg homicide, bullying, harassment, unemployment, poverty, mental illness)

 

Minor Symptoms and Signs

Revealing community vulnerabilities

High disease rate

Few opportunities or locations for community interaction

 

Related Clinical Conditions

High incidence of violence

High disease rate

Few opportunities or locations for community interaction

 

D.0096 Coping Ineffective

 

Definition:

inability to assess and respond to stressors and/or inability to use available resources to deal with problems

 

Reason

Lack of confidence in your ability to solve problems

Inadequate support system

Inadequate coping system

Environmental disorder or chaos

Insufficient preparation to deal with stressors

Family system dysfunction

Situational crisis

Maturational crisis

Personality vulnerability

Uncertainty

 

Major Symptoms and Signs

Subjective

Expressing unable to solve problems

Objective

Not able to fulfill the expected role (age appropriate)

Using inappropriate coping mechanisms

 

Minor Symptoms and Signs

 

Subjective

Unable to meet basic needs

Chronic worry

Objective

Substance abuse

Manipulating others to fulfill one's own desires

Unassertive behavior

Lack of social participation

 

Related Clinical Conditions

Critical care condition

Attention Deficit/Hyperacity Disorder

Behavioral disorders

Oppositional Defiant Disorder

Separation anxiety disorder

Delirium

Dementia

amnestic disorder

Substance intoxication

break up

 

D.0097 Decline in Family Coping

 

Definition:

Inadequate or ineffective support, comfort, assistance, and motivation of the closest person (family member or significant other) needed by the client to manage or overcome his health problem

 

Reason

Accompanying situations that affect those closest to you

The developmental crisis faced by those closest to us

Fatigue of the closest people in providing support

Family disorganization

Changes in family roles

There is no information for the closest people

Lack of mutual support

There is not enough support given by the client to those closest to him

Close people are less exposed to information

wrong or do not understand the information obtained by the closest person

The closest people are too focused on conditions outside the family

A chronic illness that depletes the support ability of those closest to you

Situational crisis experienced by the closest people

 

Major Symptoms and Signs

Subjective

The client complains/worries about the response of the closest person to health problems

Objective

 

The closest person withdraws from the client

Limited communication with the closest person to the client

 

Minor Symptoms and Signs

Subjective

The closest person states that they are less exposed to information about efforts to solve client problems

Objective

The help from the closest people showed unsatisfactory results

the closest person has protective behavior that is not in accordance with the ability / independence of the client

 

Related Clinical Conditions

Alzheimer's disease

AIDS

Disorders that cause permanent paralysis

Cancer

Chronic disease (eg, cancer, rheumatoid arthritis)

Substance abuse

 

D.0098 Disclaimer Ineffective

 

Definition:

Efforts to deny the understanding or meaning of an event consciously or unconsciously to reduce anxiety/fear that can cause health problems

 

Reason

worry

Fear of death

fear of losing independence

Fear of separation

Ineffective coping strategies

Distrust of problem solving ability

Threat to unpleasant reality

 

Major Symptoms and Signs

Subjective

Does not admit to experiencing symptoms or danger (despite the fact that it is otherwise)

Objective

Delaying seeking help from health services

 

Minor Symptoms and Signs

Subjective

admit that you are not afraid of death

Claiming not to be afraid of chronic disease

Not admitting that disease has an impact on lifestyle

Objective

Do your own treatment

Diverting the source of symptoms to other organs

Behave nonchalantly when talking about eventsReasonstress

Shows inappropriate affect

 

Associated Clinical Conditions

Chronic disease

Substance intoxication

Hopeless

Alzheimer's disease

terminal illness

 

D.0099 Health behaviors tend to be risky

 

Definition:Impaired ability to change lifestyle/behavior to improve health status.

 

Reason

 

Less exposed to information

Inadequate social support

Low self-efficacy

Low socio-economic status

Too much stress

Negative attitude towards health services

Unhealthy lifestyle choices (eg smoking, excessive alcohol consumption)

 

Major Symptoms and Signs

Subjective

(not available)

Objective

Indicates against changes in health status

Crows do prevention of health problems

Shows efforts to improve terminal health status

 

Symptoms and Minor Signs

Subjective

(not available)

Objective

Failed to achieve optimal control

 

Related Clinical Conditions

New condition diagnosed disease

Conditions of new lifestyle changes due to disease

Brain tumor

Substance abuse

Personality and psychotic disorders

Postpartum depression/psychosis

 

D.0100 Risk of Spiritual Distress

 

Definition:

At risk of experiencing disruption of beliefs or value systems in individuals or groups in the form of strength, hope and meaning in life

 

 

Risk Factor

Life change

Environmental changes

Natural disasters

Chronic pain

Physical pain

Substance abuse

Worry

Changes in religious rituals

change in spiritual practice

Spiritual conflict

Depression

Inability to forgive

Lost

Low self esteem

Bad relationship

Racial conflict

Parting with the support system

Stress

 

Related Clinical Conditions

Chronic Disease (eg rheumatoid arthritis, multiple sclerosis)

Terminal illness (eg cancer)

Mental retardation

Loss of extremity

sudden infant death syndrome (SIDS)

Stillbirth, Fetal death, miscarriage

infertility

 

D.0101 Risk of Chronic Low Self-esteem

 

Definition:

At risk of experiencing negative evaluations or feelings about yourself or the client's abilities that lasts for a long time and continuously.

 

Risk Factor

Psychiatric disorders

Repeat failure

Cultural discrepancy

spiritual distress

ineffective coping with loss

Lack of love

Lack of involvement in the group/community

Lack of respect from others

Inability to show feelings

Feelings of not being supported by others

traumatic experience

 

Related Clinical Conditions

Chronic disease

Degenerative disease

Behavioral disorders

Developmental disorders

Mental disorders

Substance abuse

Mood disorders

Trauma

Post surgery

Loss of body function

 

D.0102 Situational Low Self-Esteem Risk

 

Definition:

At risk of experiencing negative evaluations or feelings of self or client's abilities in response to the current situation.

 

Risk Factor

Disturbed self-image

dysfunction

social role disorder

Expectations are not realistic

Lack of understanding of the situation

Decreased control over the environment

Physical illness

Behavior not in accordance with local values

Failure

Feelings of helplessness

History of loss

Abandonment history

Rejection history

History of abuse (eg physical, psychological, sexual)

Developmental transition

 

Related Clinical Conditions

Traumatic injury

Surgery

Pregnancy

Newly diagnosed condition (eg diabetes mellitus)

stroke

Substance abuse

Dementia

 

D.0103 Risk of Powerlessness

 

Definition:

The perception that one's actions will not significantly affect the outcome; perception of lack of control over current or future situations.

 

Risk Factor

Long-lasting or unpredictable course of the disease

Low self-esteem lasts a long time

Low economic status

Inability to solve problems

no problem support

Progressive debilitating disease

Socializing

stigmatized condition

Stigma disease

Less exposed to information

worry

 

Related clinical conditions

Unexpected or new diagnosis

Traumatic event

Chronic disease diagnosis

Diagnosis of terminal illness

Inpatient

 

D.0104 Post Traumatic Syndrome

 

Definition:

Ongoing maladaptive response to traumatic events.

 

Reason

Disaster

War

history of victims of violent behavior

Accident

murder witness

 

Major Symptoms and Signs

Subjective

Over-revealing or avoiding talking about the traumatic event

Feeling anxious

Reminiscing about a traumatic event

Objective

The memory of the past is disturbed

Repeated nightmares

Repeated fear

Avoid activities, places or people that generate the traumatic event

 

Minor Symptoms and Signs

Subjective

Don't trust other people

Blame yourself

Objective

Decreased interest in interacting with others

Confusion or dissociation

Impaired realistic interpretation

It's hard to concentrate

overly vigilant

Disturbed lifestyle

Disturbed sleep

Self-destructive (e.g. alcohol consumption, substance use, attempted suicide, criminal activity)

 

Related Clinical Conditions

Victims of violence

Post-traumatic stress disorder (PTSD)

Victims of natural disasters

Multiple personality disorder

Victims of sexual violence

Victims of war

Multiple injuries (traffic accident)

Subcategory: Growth and Development

 

D.0106 Developmental Disorder

 

Definition:

The condition of the individual experiencing impaired ability to grow and develop according to the age group.

 

Reason

Physical disability effect

Environmental limitations

Response inconsistency

abandonment

Separated from parents and/or closest people

Stimulus deficiency

 

Major Symptoms and Signs

Subjective

(not available)

Objective

Inability to perform age-specific skills or behaviors (physical, language, motor, psychosocial)

Impaired physical growth

 

Minor Symptoms and Signs

Subjective

(not available)

Objective

Unable to perform age-appropriate self-care

flat affect

Slow social response

Limited eye contact

Decreased appetite

Sluggish

Easy to get angry

Regression

Disturbed sleep patterns (in infants)

 

Related Clinical Conditions

 

hypothyroidism

Failure to thrive syndrome (Failure to Thrive Syndrome)

Leukemia

Growth hormone deficiency

Dementia

Delirium

Congenital heart defects

Chronic disease

Personality disorders (personality disorders)

 

D.0107 Risk of Developmental Disorder.

 

Definition:

At risk of developing disorders according to their age group.

 

Risk Factor

Inadequate nutrition.

Inadequate prenatal care.

Delay in prenatal care.

pregnant under 15 years.

pregnant age over 35 years.

unplanned pregnancy.

Unwanted pregnancy.

Endocrine disorders.

Prematurity.

Genetic/congenital disorders.

Brain damage (eg bleeding during the postnatal period, abuse, accidents).

Chronic disease.

Infection.

Side effects of therapy (eg chemotherapy, radiation therapy, pharmacologic agents.

Abuse (eg, physical, psychological, sexual).

Hearing disorders.

Visual disturbances.

Substance abuse.

Learning disability.

Adopted child.

Disaster incident.

Weak economy.

 

Related Clinical Conditions

Hypothyroidism.

Failure to thrive syndrome (Failure to Thrive Syndrome).

Leukemia.

Growth hormone deficiency.

dementia.

Delirium.

Congenital heart defects.

Personality disorders (personality disorders).

 

D.0108 Risk of Impaired Growth.

 

Definition:

At risk of experiencing disorders to grow according to their age group.

 

Risk Factor

Inadequate nutrition.

Chronic disease.

Uncontrolled appetite.

Prematurity.

Exposure to teratogens.

Inadequate maternal nutrition.

infection process.

Maternal infectious process.

Maladaptive eating behavior.

Substance abuse.

Genetic/congenital disorders.

Abuse (eg physical, psychological, sexual).

Weak economy.

 

Related Clinical Conditions

Hypothyroidism.

Failure to thrive syndrome (Failure to Yhrive Syndrome).

Leukemia.

Growth hormone deficiency.

dementia.

Delirium.

Congenital heart defects.

Chronic disease.

Personality disorder (personality disorder

 

D.0105 Delusions

 

Definition:

False beliefs about the contents of the mind that are maintained strongly or continuously but are not in accordance with reality.

 

Reason

Biological factors: Genetic/hereditary disorders, neurological disorders (eg limbic system disorders, basal ganglia disorders, brain tumors).

Psychodynamic factors (eg social isolation, hypersensitivity).

maladaptation.

Excessive stress.

 

Major Symptoms and Signs

Reveal the content of delusions.

Objective

Shows behavior according to the contents of the delusion.

The content of thought does not match reality.

The content of the conversation is difficult to understand.

 

Minor Symptoms and Signs

Subjective

Find it difficult to concentrate.

Feeling worried.

Objective

Excessive suspicion.

Excessive caution.

Talk too much.

Opposition or hostility.

Face tense.

Sleep patterns change.

Unable to make a decision.

Flight of ideas.

Decreased work productivity.

Unable to take care of yourself.

Withdraw.

 

Related Clinical Conditions

Schizophrenia

limbic system disorders

Basal ganglia disorders

Brain tumor

Depression

 

Category: Behavior

Subcategory: Personal Hygiene

 

D.0109 Self-Care Deficit.

 

Definition:

Unable to perform or complete self-care activities

 

Reason

 

Musculoskeletal disorders

Neuromuscular disorders

Weakness

Psychological and/or psychotic disorders

Decreased motivation/interest

 

Major Symptoms and Signs

Subjective

Refusing to do self-care

Objective

Unable to bathe/put on clothes/eat/to the toilet/makeup independently

Lack of interest in self-care

 

Minor Symptoms and Signs

Subjective

(not available)

Objective

(not available)

 

Related Clinical Conditions

stroke

spinal cord injury

Depression

Rheumatoid arthritis

Mental retardation

Delirium

Dementia

amnestic disorder

Schizophrenia and other psychotic disorders

Disrupted appraisal function

Information

This diagnosis is specified as one or more of:

Bath

Dress up

Eat

Subcategory: Counseling and Learning

 

D.0110 Community Health Deficit

 

Definition:

Have a health problem orRisk Factorthat can interfere with the welfare of a group.

 

Reason

Barriers to access to health care providers

Limited resources

The program does not have sufficient budget

The program is not or less supported by the community

The community is not satisfied with the program being run

The program does not have an optimal evaluation plan

The program does not have sufficient outcome data

Programs do not address all community health problems

 

Major Symptoms and Signs

Subjective

(not available)

 

Objective

There are no programs to improve welfare for the community

There are no programs available to prevent community health problems

No programs available to reduce community health problems

There are no programs available to address community health problems

 

Associated Clinical Conditions

HIV/AIDS

Substance abuse

Sexually transmitted disease

pregnancy out of wedlock

Malnutrition

Upper respiratory tract infection (ARI)

Server Acute Respiratory Syndrome (SARS)

 

D.0111 Knowledge Deficit

 

Definition:

Absence or lack of cognitive information related to a particular topic

 

Reason

Cognitive limitation

Impaired cognitive function

The mistake of following the advice

Less exposed to information

Lack of interest in learning

Not able to remember

Ignorance of finding sources of information

 

Major Symptoms and Signs

Subjective

(not available)

Objective

Showing inappropriate behavior

Shows a wrong perception of the problem

 

Minor Symptoms and Signs

Undergo proper inspection

Displays excessive behavior (eg apathy, hostility, agitation, hysteria)

 

Related Clinical Conditions

The new clinical condition faced by the client

Acute illness

Chronic disease

Information

 

This diagnosis is specified based on certain topics, namely:

Healthy lifestyle

Self safety

Children's physical safety

Pregnancy and childbirth

Maternal health after delivery

Preconception maternal health

Psychomotor skills

Energy conservation

Toilet training

Rheumatoid arthritis management

Asthma management

Weight management

dementia management

Depression management

dysrhythmia management

Heart failure management

Management of lipid disorders

Eating disorder management

Hypertension management

Cancer management

Pain management

Management of osteoporosis

Acute disease management

peripheral arterial disease management

Management of kidney disease

Heart disease management

Chronic disease management

Management of chronic obstructive pulmonary disease

Pneumonia management

Disease process management

Multiple sclerosis management

Stroke management

Stroke management

Management of coronary heart disease

Medication

Body mechanics

Breast-feed

Bottle feeding

Baby/child nutrition

Fall prevention

Cancer prevention

Prevention of conception

Stroke prevention

Thrombus prevention

Substance use control

Increased fertilization

The role of being a parent

Baby care

Foot care

Ostomy care

Healthy behavior

Activity program

diet program

Exercise program

Action procedure

Safe sex

Sexuality

Stimulation of babies and children

 

D.0112 Readiness to Improve Health Management

 

Definition:

Patterns of setting and integrating health programs into daily life that are sufficient to meet health goals and can be improved

 

Major Symptoms and Signs

Subjective

Express a desire to manage health problems and their prevention

Objective

the choice of finding symptoms of an unexpected health problem or illness

 

Minor Symptoms and Signs

Subjective

Expressing the absence of significant obstacles in integrating the established programs to address health problems

Describing a decreaseRisk Factoroccurrence of health problems

Objective

No unexpected symptoms of health problems or illnesses were found

 

Related Clinical Conditions

Diabetes mellitus

Congestive heart disease

Chronic obstructive pulmonary disease

Asthma

Multiple Sclerosis

Systemic lupus

HIV positive

AIDS

Prematurity

 

D.0113 Readiness to Increase Knowledge

 

Definition:

The development of cognitive information related to a specific topic is sufficient to meet health goals and can be improved.

 

Major Symptoms and Signs

Subjective

Expressing interest in learning

Explain knowledge about a topic

Describe previous experiences that are relevant to the topic

Objective

Behavior according to knowledge

 

Minor Symptoms and Signs

Subjective

(not available)

Objective

(not available)

 

Related Clinical Conditions

Health improvement behavior

 

D.0114 Non-compliance

 

Definition:

The behavior of the individual and/or the care giver does not follow the treatment/treatment plan agreed with the health worker, resulting in ineffective treatment/treatment results.

 

Reason

Disabilities (eg memory loss, sensory/motor deficits)

Side effects of treatment/treatment programs

Cost of financing the treatment/treatment program

Non-therapeutic environment

Complex and/or prolonged therapy program

Barriers to accessing health services (eg impaired mobility, transportation problems, absence of people caring for children at home, unpredictable weather

The therapy program is not covered by insurance

Inadequate understanding (secondary to cognitive deficits, anxiety, visual/hearing impairment, fatigue, lack of motivation)

 

Major Symptoms and Signs

Subjective

Refuse to undergo treatment/medication

Refusing to follow instructions

Objective

behavior not following the treatment/treatment program

Perlikau not carry out the recommendation

 

Minor Symptoms and Signs

Subjective

(not available)

Objective

The signs/symptoms of illness/health problems are still present or increasing

It appears that when the disease/health problem persists or increases

 

Related Clinical Conditions

New condition diagnosed disease

Chronic disease conditions

health problems that require lifestyle changes

 

D.0115 Ineffective Family Health Management.

 

Definition:

The pattern of handling health problems in the family is not satisfactory for restoring the health conditions of family members.

 

Reason

The complexity of the health care system.

Complexity of care/treatment programs.

Decision conflict.

Economy crisis.

Lots of demands.

Family conflict.

 

Major Signs and Symptoms

Subjective

Disclosing does not understand the health problems suffered.

Expressing difficulty carrying out the applied treatment.

Objective

Symptoms of illness in family members are getting worse.

Family activities to address health problems are not appropriate.

 

Minor Symptoms and Signs

Subjective

(not available).

Objective

Failing to take action to reduceRisk Factor.

 

Related Clinical Conditions

COPD.

Multiple sclerosis.

Rheumatoid arthritis.

Chronic Pain.

Substance abuse.

Terminal stage renal/liver failure.

 

D.0116 Ineffective Health Management.

 

Definition:

The pattern of regulation and integration of the handling of health problems into the habits of daily life is not satisfactory to achieve the expected health status.

 

Reason

The complexity of the health care system.

the complexity of the treatment/treatment program.

Decision-making conflicts.

Lack of exposure to information.

Economy crisis.

Excessive demands (eg individual, deficient).

Family conflict.

Ineffective family health care patterns.

Insufficient directions for action.

Lack of social support.

 

Major Symptoms and Signs

Subjective :

Expressing difficulties in undergoing a treatment/treatment program.

Objective :

Failing to take action to reduceRisk Factor.

Failed to implement the treatment/treatment program.

Activities of daily living are not effective in meeting health goals.

 

Minor Symptoms and Signs

Subjective : (not available).

Objective : (not available).

 

Related Clinical Conditions

Chronic conditions (eg cancer, chronic obstructive pulmonary disease, multiple sclerosis, arthritis, chronic kidney, liver or heart failure).

A new diagnosis that requires lifestyle changes.

 

D.0117 Health Care Ineffective

 

Definition:

Inability to identify, manage, and/or find help to maintain health.

 

Reason

Cognitive barriers.

Lack of completeness of the grieving process.

Inadequate communication skills.

lack of fine/gross motor skills.

inability to make accurate judgments.

inability to cope with problems (individual or family).

insufficient resources (eg finances, facilities).

Perceptual disturbances.

Failure to fulfill developmental tasks.

 

Major Symptoms and Signs

Subjective

(not available).

Objective

Lack of showing adaptive behavior to environmental changes.

Does not show an understanding of healthy behavior.

Unable to carry out healthy behavior.

 

Minor Symptoms and Signs

Subjective

(not available).

Objective

Have a history of poor health seeking behavior.

Lack of interest in improving healthy behavior.

Does not have a support system (support system).

 

Related Clinical Conditions

Chronic conditions (eg multiple sclerosis arthritis, chronic pain).

Brain injury.

strokes.

Paralysis.

Spinal cord injury.

Laryngectomy.

dementia.

Alzheimer's disease.

Developmental delay.

 

 

 

 

Category: Relational

Subcategory: Social Interaction

 

D.0118 Social Interaction Disorder

 

Definition:

Insufficient or excess quantity and/or quality of social relations

 

Reason

Speech deficiency

Developmental/maturation barriers

Nearest absence

Neurological changes (e.g., preterm delivery, fetal distress, rapid or prolonged labor)

Family system dysfunction

Environmental disorder or chaos

Child abuse or neglect

Unsatisfactory parent-child relationship

Negative role model

Impulsive

Opposing behavior

Aggressive Behavior

Reluctance to part with the closest person

 

Major Symptoms and Signs

Subjective

Feeling uncomfortable in social situations

Feeling difficult to receive or communicate feelings

Objective

Less responsive or interested in other people

Not interested in making emotional and physical contact