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
Minor Symptoms and Signs
Subjective
It's hard to
express love
Objective
Symptoms of severe
anxiety
Poor eye contact
Unresponsive
facial expressions
Not cooperative in
playing and making friends with peers
age-inappropriate
behavior
Related
Current Condition
Mental retardation
autistic disorder
Attention
deficit/hyperactivity discover (ADHD)
Behavioral
disorders
Oppositional
Defant Disorder
Tourette's
Disorder
Separation anxiety
disorder
Down syndrome
D.0119 Verbal
Communication Disorder
Definition:
Decrease,
slowdown, or lack of ability to receive, process, send, and/or use the button
system.
Reason
Decreased cerebral
circulation
Neuromuscular
disorders
Hearing disorders
Musculoskeletal
disorders
Plate failure
Physical barriers
(e.g. trcheostomy, intubation, cricothyrodectomy
Individual
barriers (eg fear, anxiety, feeling embarrassed, emotional, lack of privacy)
Psychological
barriers (eg psychotic disorders, impaired self-concept, low self-esteem,
emotional disturbances)
environmental
barriers (e.g. insufficient information, absence of close people, cultural
incompatibility, foreign language)
Minor Symptoms and Signs
Subjective
(not available)
Objective
Unable to speak or
hear
Shows an
inappropriate response
Minor Symptoms and Signs
Subjective
(not available)
Objective
Aphasia
Dysphasia
Apraxia
dyslexia
knight
Afonia
Dislalia
Pelo
stutter
No eye contact
Difficult to
understand communication
Difficult to
maintain communication
Difficulty using
facial or body expressions
Unable to use
facial or body expressions
Difficult to
compose sentences
Improper
verbalization
It's hard to put
into words
Disorientation of
people, space, time
Vision deficit
delusions
Related Clinical Conditions
stroke
Head injury
facial trauma
Increased
intracranial pressure
Chronic hypoxia
Tumor
Myasthenia gravis
Multiple Sclerosis
Mescular dystrophy
Alzheimer's
disease
Quadriplegia
Labiopalatoskizis
Laryngeal
infection
Jaw fracture
Schizophrenia
delusions
paranoid
Autism
D.0120 Family
Process Disorder
Definition:
Changes in family
relationships or functioning
Reason
Changes in the
health status of family members
Family financial
changes
Changes in family
social status
Changes in
interaction with the community
Development crisis
Developmental
transition
Switching of
decision makers in the family
Prebuh family role
Situational crisis
Situational
transition
Major Symptoms and Signs
Subjective
(not available)
Objective
the family is not
able to adapt to the situation
Unable to
communicate openly among family members
Minor Symptoms and Signs
Subjective
family is not able
to express feelings freely
Objective
Families are
unable to meet the physical/emotional/spiritual needs of family members
Families are
unable to seek or receive assistance appropriately
Related Clinical Conditions
Hostpitalisai
Chronic disease
conditions
Surgical procedure
Traumatic injury
Substance abuse
Alzheimer's
disease
Pregnancy
D.0121 Social
Isolation
Definition:
Inability to
develop close, warm, open, and interdependent relationships with others
Reason
developmental
delay
inability to have
satisfying relationships
incompatibility of
interests with developmental stage
non-conformance of
values with norms
non-conformance of
social behavior with norms
changes in
physical appearance
mental status
changes
inadequate
personal resources (eg overt dysfunction, poor self-control)
Major Symptoms and Signs
Subjective
Feel like being
alone
Feeling unsafe in
public
Objective
Withdraw
Not
interested/refused to interact with other people or the environment
Minor Symptoms and Signs
Subjective
Feeling different
from others
Feeling engrossed
in your own mind
Feeling that you
don't have a clear goal
Objective
flat affect
sad affect
History rejected
Showing hostility
Unable to meet
other people's expectations
Disabled
conditions
Action is
meaningless
No eye contact
Late development
Not excited /
lethargic
Related Clinical Conditions
Alzheimer's
disease
AIDS
Tuberculosis
Conditions that
cause impaired mobility
Psychiatric
disorders (eg major depression and schizophrenia)
D.0122 Readiness
to Improve Parenthood
Definition:
The pattern of
providing an environment for children or family members that is sufficient to
facilitate growth and development and can be improved
Major Symptoms and Signs
Subjective
Expressing desire
to increase parenthood
Objective
There appears to
be emotional support and understanding in the child or family member
Symptoms
Minor Signs
Subjective
Children or other
family members express satisfaction in the home environment
Child or family
member expresses realistic expectations
Objective
Physical and
emotional needs of children/family members are met
Related Clinical Conditions
Health improvement
behavior
D.0123 Readiness
to Improve Family Process
Definition:
Patterns of family
function that are sufficient to support the welfare of family members and can
be improved
Major Symptoms and Signs
Subjective
Expresses a desire
to improve family dynamics
Objective
Shows the function
of the family in meeting the physical, social and psychological needs of family
members
demonstrate
activities to support the safety and growth of family members
The role of the
family is flexible and appropriate to the stage of development
Shows respect for
family members
Major
Signs Symptoms
Subjective
(not available)
Objective
The family shows
an interest in carrying out positive activities of daily living
see what the
family's ability to recover from difficult conditions is
Looks a balance
between autonomy and togetherness
Family member
boundaries are maintained
positive
relationship with the community
Families adapt to
change
Related Clinical Conditions
Chronic health
conditions (eg asthma, diabetes mellitus, systemic lupus, multiple sclerosis,
AIDS)
Mental disorders
(eg affective disorders, attention disorders, Down syndrome)
D.0124 Tensions of
the Caregiver Role
Definition:
Difficulty in
carrying out the role of caregiver in the family
Reason
The severity of
the recipient's illness
chronic illness of
care recipients
Caregivers do not
get enough rest and recreation time
competition for
the role of caregiver
Inadequate
physical environment in providing care
Family or
caregiver away from other relatives
Complexity and
number of caregiver activities
Major Symptoms and Signs
Subactive
Worried that the
client will be hospitalized again
Worried about
continuing client care
concerned about
the inability of the caregiver to care for the client
Objective
(not available)
Minor Symptoms and Signs
Subjective
(not available)
Objective
Difficulty doing
and completing the task of caring for clients
Related Clinical Conditions
Chronic conditions
(eg severe head injury, spinal cord injury, developmental delay)
Conditions of progressive
weakness (eg, muscular dystrophy, multiple sclerosis, dementia, Alzheimer's
disease, terminal COPD, renal failure, renal dialysis)
Substance abuse
End of life (near
death)
Psychiatric
conditions (eg personality disorders, schizophrenia)
D.0125 Ineffective
Role Performance
Definition:
Behavioral
patterns that change or are not in accordance with expectations, norms and the
environment.
Reason
Unrealistic role
expectations
Physical barriers
Low self esteem
Body image changes
Inadequate support
system (support system)
Stress
Role change
Economic factors
Major Symptoms and Signs
Subjective
Feeling confused
about playing the role
Feeling
unfulfilled
Feeling
dissatisfied in carrying out the role
Objective
Role conflict
Inadequate
adaptation
Coping strategies
are not effective
Symptoms Minor
Signs
Subjective
Feeling anxious
Objective
Depression
Lack of social
support
Lack of
responsibility in carrying out the role
Related Clinical Conditions
Malignant disease
of reproductive organs
Chronic Condition
Major surgery
Substance abuse
spinal cord injury
Chronic fatigue
syndrome
Major depression
D.0126 Achieving
the Role of Being a Parent
Definition:
There is an
interactive process between family members (husband and wife, family members
and babies) which is indicated by optimal baby development.
Major Symptoms and Signs
Subjective : (not
available) .
Objective
1.Bounding
attachments are optimal.
2. Positive
behavior of being a parent
3. Interact with
each other in caring for babies
Minor Symptoms and Signs
Subjective
1. Expressing
satisfaction with the baby.
Objective
1. Perform visual
tactile or auditory stimulation of the baby.
Related Clinical Conditions
Maternal health
status.
Baby's health
status.
D.0127 Risk of
Attachment Disorder
Definition:
At risk of
experiencing impaired interaction between parents or those closest to the
baby/child which can affect the process of honing, caring, and nurturing.
Risk Factor
Worries about playing
the role of a parent.
Separation between
mother and baby/child due to hospitalization.
Physical barriers
(eg incubator, baby warmer).
Inability of
parents to meet the needs of the baby/child.
Treatment in
isolation.
Prematurity.
Substance abuse.
Conflict in the
relationship between parents and children.
uncoordinated
infant behavior.
Related Clinical Conditions
Hospitalization.
Prematurity.
Chronic disease in
parents or children.
Mental
retardation.
Maternal
complications.
Pain during
pregnancy and childbirth.
Post perfume
blues.
D.0128 Risk of
Ineffective Parenting Process.
Definition:
At risk of
experiencing the process of pregnancy, childbirth and after giving birth
including care for a newborn that is not in accordance with the context of
norms and expectations.
Risk Factor
Domestic violence.
Unwanted/planned
pregnancy.
Lack of exposure
to information about childbirth/caregiving.
Maternal
inequality.
Psychological
distress.
Drug abuse.
Inadequate
management of discomfort during labour.
Access to health
services is difficult to reach.
Lack of
interest/proactivity in the labor process.
The baby's
condition does not match expectations.
Environmental
insecurity for babies.
Related Clinical Conditions
Fetal growth
disorders.
Maternal physical
and psychological health problems.
Category:
Environment
Subcategory:
Security and Protection
D.0129 Impaired
Skin/Tissue Integrity
Definition:
Damage to skin
(dermis and/or epidermis) or tissues (mucous membranes, cornea, fascia,
muscles, tendons, bones, cartilages, joint capsules and/or ligaments
Reason
1. Circulation
changes
2. Changes in
nutritional status (excess or deficiency)
3.Excess/lack of
fluid volume
4. Decreased
mobility
5.Irritative
chemicals
6.Extreme ambient
temperature
7. Mechanical
factors (eg stress on bony prominences, friction)
8.Radiation
therapy side effects
9.Moisture
10.The aging
process
11. peripheral
neuropathy
12. Pigmentation
changes
13. Hormonal
changes
14.Less exposure
to information about efforts to maintain/protect network integrity
Major Symptoms and Signs
Subjective
Objective
(not available)
1.Tissue and/or skin damage
Minor Symptoms and Signs
Subjective
Objective
(not available)
1.Pain
2.Bleeding
3.Redness
4. Hermatoma
Related Clinical Conditions
1.Immobilization
2. Congestive
heart failure
3. Kidney failure
4.Diabetes
mellitus
5.
Immunodeficiency (eg AIDS)
Information
Specified to be
skin or tissue
The skin is only
limited to the dermis and epidermis, while the tissue includes not only the
skin but also the mucosa, cornea, fascia, muscles, tendons, bones, cartilages,
joint capsules and/or ligaments.
D.0130
Hyperthermia
Definition:…
Body temperature
rises above the body's normal range
Reason
Dehydration
Exposed to hot
environment
Disease process
(eg infection, cancer)
Incompatibility of
clothing with ambient temperature
Increased
metabolic rate
Trauma response
Excessive activity
Use of incubator
Major Symptoms and Signs
Subjective
(not available)
Objective
Body temperature
above normal value
Minor Symptoms and Signs
Subjective
(not available)
Objective
red skin
Seizures
Tachycardia
Tachypnea
Skin feels warm
Related Clinical Conditions
Infectious process
Hyperthyroid
stroke
Dehydration
Trauma
Prematurity
D.0131 Hypothermia
Definition:…
Body temperature
is below the normal range of the body
Reason
Hypothalamic
damage
Alcohol
consumption
Extreme body
weight
Lack of
subcutaneous fat
Exposure to low
ambient temperature
Malnutrition
Use of thin
clothes
Decreased
metabolic rate
Not active
Heat transfer (eg
conduction, convection, evaporation, radiation)
Trauma
aging process
Effects of
pharmacological agents
Lack of exposure
to information about prevention of hypothermia
Major Symptoms and Signs
Subjective
(not available)
Objective
Skin feels cold
Shivering
Body temperature
below normal value
Minor Symptoms and Signs
Subjective
(not available)
Objective
Acrocyanosis
Bradycardia
Cyanotic nail bed
Hypoglycemia
Hypoxia
Capillary refill
> 3 seconds
Oxygen consumption
increases
Decreased
ventilation
Piloerection
Tachycardia
Peripheral
Vasoconstruction
Cutis memorata (in
neonates)
D.0132 Violent
Behavior
Definition:…
Anger that is
expressed excessively and uncontrollably verbally to the point of injuring
others and/or damaging the environment.
Reason
Inability to
control angry impulses
Environmental
stimulus
Interpersonal
conflict
Mental status
changes
Drop out of
medicine
Substance/alcohol
abuse
Major Symptoms and Signs
subjective
Threaten
Swearing with
harsh words
Loud noise
Talk curtly
Objective
Attacking others
Hurt
yourself/others
Damaging the
environment
Aggressive/angry
behavior
Minor Symptoms and Signs
Subjective
(not available)
Objective
Bulging eyes or
sharp eyes
Hands clenched
Jaws clenched
Red face
Stiff posture
Related Clinical Conditions
Attention
deficit/hyperactivity disorder (ADHD)
Behavioral
disorders
Oppositional
defiant disorder
Tourette's
Disorder
Delirium
Dementia
amnestic disorder
D.0133
Postoperative Recovery Delay
Definition:
Extend the number
of postoperative days to start and perform daily activities.
Reason
American Society
of Anesthesiologists (ASA) physical status classification score >3
Hyperglycemia
Edema at the
surgical site
Extensive
(extensive) surgical procedures
Extreme age
History of delayed
wound healing
Mobility disorders
Malnutrition
Obesity
Periodontal wound
infection
Persistent
nausea/vomiting
Postoperative
emotional response
Postoperative
lengthening
Postoperative
psychological disorders
Surgical
contamination
Trauma to the
surgical wound
Effects of
pharmacological agents
Major Symptoms and Signs
Subjective
Objective
1. Complaining
discomfort 1. The surgical wound area is open
2. Prolonged
healing time
Minor Symptoms and Signs
Subjective
Objective
1. Loss of
appetite 1. Mobility disorders
2. Unable to
continue work
3. Starting a
pending job
4. Need help with
self-care
Related Clinical Conditions
Major surgery
Trauma requiring
surgical intervention
Postoperative
Bleaching
D.0134 Allergic
Risk
Definition:…
At risk of
experiencing an exaggerated simulated immune response due to exposure to
allergens.
Risk Factor
Food (e.g.
avocado, banana, kiwi, nuts, seafood, tropical fruit, mushrooms)
Exposure to
allergens (eg chemicals, pharmacological agents)
Exposure to environmental
allergens (eg dust, pollen)
Insect sting
Related Clinical Conditions
Conditions of
decreased immunity
Surgical history
Previous history
of allergies
Asthma
D.0135 Suicide
Risk
Definition:
Risk of self-harm
to end life
Risk Factor
Behavioral
disorders (e.g. sudden euphoria after depression, gun-seeking behavior, buying
large amounts of drugs, making inheritances)
Demographics (eg
elderly, divorced status, widow/widower, low economy, unemployment)
Physical
impairment (eg chronic pain, terminal illness)
Social problems
(eg grieving, helplessness, hopelessness, loneliness, loss of important
relationships, social isolation)
Psychological
disorders (e.g. childhood abuse, previous history of suicide, homosexual youth,
psychiatric disorders, psychiatric illness, substance abuse)
Related Clinical Conditions
Acute/chronic
brain syndrome
Hormonal imbalance
(eg premenstrual syndrome, postpartum psychosis)
Substance abuse
Post-traumatic
stress disorder (PTSD)
Chronic/terminal
disease (eg cancer)
D.0136 Risk of
Injury
Definition:
At risk of
physical harm or damage that causes a person to no longer be fully healthy or
in good condition
Risk Factor
External
Exposure to
pathogens
Exposure to toxic
chemicals
Exposure to
nosocomial agents
Transportation
Inconvenience
Internal
Abnormal blood
profile
Changes in
affective orientation
Sensation change
Autoimmune
dysfunction
Biochemical
dysfunction
Tissue hypoxia
Failure of the
body's defense mechanisms
Malnutrition
Changes in
psychomotor function
Changes in
cognitive function
Related Clinical Conditions
Seizures
syncope
Vertigo
Visual disturbance
Hearing disorders
Parkinson's
disease
Hypotension
Vestibular nerve
disorders
Mental retardation
D.0137 Risk of
Injury to Mother
Definition:
Risk of experiencing
harm or physical damage to the mother during pregnancy until the delivery
process
Risk Factor
The size of the
fetus
Fetal malposition
(posterior position)
Labor induction
Long time labor |,
|| and |||
uterine
dysfunction
Effects of
surgical methods/interventions during labor
Lack of support
from family and parents
Inadequate
observation and anticipation
Delay in decision
making and management
Inadequate
prenatal screening and care
Excessive anxiety
during labor
History of injury
in previous deliveries
Maternal age
(<15 years or >35 years)
parity a lot
Hormonal changes
Changes in body
posture
ruptured membranes
Infectious process
co-morbidities
Contraction
problems
Related Clinical Conditions
lordosis body
position
Fatigue
ruptured membranes
Decreased
hemoglobin levels
D.0138 Risk of
Injury to Fetus
Definition:
Risk of
experiencing harm or physical damage to the fetus during pregnancy and
childbirth
Risk Factor
The size of the
fetus
Fetal malposition
Labor induction
Long time labor |,
|| and |||
uterine
dysfunction
Excessive anxiety
about labor
Previous birth
history
Maternal age
(<15 years or >35 years)
parity a lot
Effects of
surgical methods/interventions during labor
Pain in the
abdomen
Pain in the birth
canal
Use of birthing
aids
Fatigue
Smoke
Effects of
pharmacological agents
Cultural influence
Unhealthy diet
Economic factors
Alcohol
consumption
Exposure to
teratogenic agents
Related Clinical Conditions
premature rupture
of membranes (KPSW)
Infection
Comorbidities: asthma,
hypertension, sexually transmitted diseases, AIDS
Contraction
problems
Effect of
treatment on mother
D.0139 Risk of
Impaired Skin/Tissue Integrity
Definition:
At risk for damage
to skin (dermis, and/or epidermis) or tissues (mucous membranes, cornea,
fascia, muscles, tendons, bones, cartilages, joint capsules and/or ligaments)
Risk Factor
Circulation
changes
Changes in
nutritional status (excess or deficiency)
Fluid volume
deficit/excess
Decreased mobility
Initiative
chemicals
Extreme ambient
temperature
Mechanical factors
(eg compression, friction) or electrical factors (electrodiathermy,
high-voltage electrical energy)
Radiation therapy
Humidity
aging process
Peripheral
neuropathy
Hormonal changes
Emphasis on bony
prominences
Lack of exposure
to information about efforts to maintain/protect network integrity
Related Clinical Conditions
Immobility
Congestive heart
failure
Kidney failure
Diabetes mellitus
Immunodeficiency
(eg AIDS)
Cardiac
catheterization
Information
Specified to be
skin or tissue
Skin is only
limited to the dermis and epidermis, while tissue includes not only skin but
also mucosa, cornea, fascia, muscle, tendon, bone, cartilage, joint capsule
and/or ligaments.
D.0140 Risk of
Hypothermia
Definition:
At risk for
thermoregulation failure which can result in body temperature being below the
normal range
Risk Factor
Extreme body
weight
Hypothalamic
damage
Alcohol
consumption
Lack of
subcutaneous fat layer
Low ambient
temperature
Malnutrition
Use of light
clothing
Decreased
metabolic rate
Radiation therapy
Not active
Heat transfer
(e.g. conduction, convection, evaporation, radiation)
Trauma
Prematurity
aging
Newborn baby
low birth weight
Lack of exposure
to information about prevention of hypothermia
Effects of pharmacological
agents
Related Clinical Conditions
Extreme body
weight
Dehydration
Lack of physical
mobility
D.0141
Perioperative Hypothermia Risk
Definition:
At risk of
experiencing a sudden drop in body temperature below 36 degrees Celsius that
occurs one hour before surgery to 24 hours after surgery.
Risk Factor
Surgical
procedure.
A combination of
regional and general anesthesia.
American Society
of Anesthesiologists (ASA) score >1.
Low pre-operating
temperature (<36'C).
Low weight.
Diabetic neuropathy.
Cardiovascular
complications.
Low ambient
temperature.
Heat transfer (eg
high volume unwarmed infusion, >2 liter unwarmed irrigation).
D.0142 Risk of
Infection.
Definition:
There is an
increased risk of being attacked by pathogenic organisms.
Risk Factor
Chronic disease
(eg diabetes mellitus).
Effects of the
invasion procedure.
Malnutrition.
Increased exposure
to environmental pathogenic organisms.
Inadequate primary
body defenses:
peristalsis
disorders,
Impaired skin
integrity,
Changes in pH
secretion,
Decreased ciliary
action,
old ruptured
membranes,
premature rupture
of membranes,
Smoke,
static body
fluids.
Inadequate
secondary body defenses:
Decreased
homolobin,
immunosuppression,
leukopenia,
suppression of the
inflammatory response,
Inadequate
vaccination.
Related Clinical Conditions
AIDS.
Burns.
Obstructive lung
disease.
Diabetes mellitus.
invasion action.
Conditions of use
of steroid therapy.
Drug abuse.
premature rupture
of membranes (KPSW).
Cancer.
Kidney failure.
Immunosuppression.
lymphedema.
Leukocytopedia.
Liver disfunction.
D.0143 Fall Risk.
Definition:
There is a risk of
physical damage and health problems due to falls.
Risk Factor
Age >65 years
(in adults) or <2 years (in children).
Fall history.
Lower limb
prosthesis (artificial).
Use of walking
aids.
Decreased level of
consciousness.
Changes in
cognitive function.
Unsafe environment
(eg slippery, dark, unfamiliar environment).
Postoperative
conditions.
Orthostatic
hypotension.
Changes in blood
glucose levels.
Anemia.
Decreased muscle
strength.
Hearing disorders.
Balance disorders.
Visual
disturbances (eg glaucoma, cataract, detachment, retina, optic neuritis).
Neuropathy.
Effects of
pharmacological agents (eg sedation, alcohol, general anaesthesia).
Related Clinical Conditions
Osteoporosis.
seizures.
cebrovascular
disease.
Cataract.
Glaucoma.
dementia.
Hypotension.
Amputation.
Intoxication.
preeclampsia.
D.0144 Risk of
Pressure Wound
Definition:
At risk for
localized injury to skin and/or tissue, usually bony prominences due to
pressure and/or friction.
Risk Factor
Braden Q scale
score < 16 (child) or Braden scale score < 18 (adult)
Changes in
cognitive function
Sensation change
ASA (American in
Sensation Anethesiologist) score <2
Anemia
Decreased mobility
decreased albumin
levels
Decreased tissue
oxygenation
Decreased tissue
perfusion
Dehydration
Potato skin
Edema
1-2'C Peningkatan
increase in skin temperature
Long periods of
immobilization on hard surfaces (eg 22 hour surgical procedure)
Age >65 years
Over weight
Leg fracture
History of stroke
History of
pressure sores
Trauma history
Hyperthermia
Incontinence
Inadequate
nutrition
Low RAPS (Risk
Assisment Preddure Score) score
NYHA (New York
Heart Association) functional classification <2
Effects of
pharmacological agents (eg general anesthetics, vasopressors, antidepressants,
norepinephrine)
Physical
immobilization
Emphasis over bony
prominences
decrease in
triceps skinfold thickness
Scaly skin
Skin surface
friction
Related Clinical Conditions
Anemia
Congestive heart
failure
Trauma
stroke
Malnutrition
Obesity
Leg fracture
Spinal cord and/or
head injury
Immobilization
D.0145 Risk of
Self Mutilation
Definition:
Risk of
intentional self-injury causing physical damage to obtain tension relief.
Risk Factor
Adolescent
development
autistic
individual
Personality
disorder
hereditary disease
Abuse (eg
physical, psychological, sexual)
Interpersonal
relationship disorder
Family divorce
Developmental
delay
History of self-injurious
behavior
Threat of losing
meaningful relationships
Inability to
express tension verbally
Inability to solve
problems
Low self esteem
Intolerable
increase in tension
Related Clinical Conditions
Personality
disorder
Organic mental
disorder
Autism
Schizophrenia
Major depression
Dissociative
Identify Disorder (DID)
Sexual masochism
Affective disorder
or mania
History of abuse
D.0146 Risk of
Violent Behavior
Definition:
Risk of physical,
emotional and/or sexual harm to self or others.
Risk Factor:
Delusional/delusional
thoughts.
Be suspicious of
other people.
hallucination.
Planning to commit
suicide.
Family system
dysfunction.
Cognitive
impairment.
Disorientation or
confusion.
Cognitive
impairment.
Perception of the
environment is not accurate.
Depression nature.
History of
violence against animals.
Neurological
disorders.
Disorganized
environment.
Child abuse or
neglect.
History or threats
of violence against self or others or destruction of property of others.
Impulsive.
Related Clinical Conditions:
Physical,
psychological or sexual abuse.
Organic brain
syndrome (eg Alzheimer's disease).
Behavioral
disorders.
Oppositional
defiant disorder.
Depression.
Panic attack.
Tourette's
disorder.
Delirium.
dementia.
Amnestic Disorder.
hallucination.
Suicide attempt.
Abnormalities of
brain neurotransmitters.
D.0147 Risk of
Delayed Postoperative Recovery
Definition:
At risk for a
prolonged number of postoperative days to start and perform daily activities
Risk Factor
1. American Society
of Anesthesiologists (ASA) physical status classification score >3
2. Hyperglycemia
3. Edema at the
surgical site
4. Extensive
(extensive) surgical procedures
5. Extreme age
6, History of
slowed wound healing
7. Impaired
mobility
8. Mainutrition
9. obesity
10. Perioperative
wound infection
11.
Nausea/vomiting persistent
12. Postoperative
emotional response
13. Extend the
operation process
14. Postoperative
psychological disorders
15. Surgical
contamination
16. Surgical wound
trauma
17. Effects of pharmacological
agents
Related Clinical Conditions
1. Major surgery
2 . Trauma
requiring surgical intervention
D.0148 Risk of
Ineffective Thermoregulation
Definition:
At risk for
failure to maintain body temperature within normal ranges.
Risk Factor
1. acute brain
injury.
2. dehydration.
3. Clothing that
is not suitable for the ambient temperature.
4. increased body
surface area to body weight ratio
5. Oxygen demand
increases
6. Changes in
metabolic rate
7. Disease process
(eg infection).
8. Extreme environmental
temperature.
9. Inadequate
supply of subcutaneous fat.
10. The aging
process.
11. Extreme body
weight.
12. Effects of
pharmacological agents (eg sedation).
Related Clinical Conditions
1.Acute brain
injury.
2. dehydration.
3. trauma.
D.0149 Ineffective
Thermoregulation
Definition:failure to maintain body temperature
within the normal range.
Reason :
1. stimulation of
the hypothalamic thermoregulatory center.
2. environmental
temperature fluctuations.
3. Disease
processes such as infection.
4. Aging Process.
5. Dehydration.
6. Incompatibility
of clothing for ambient temperature.
7. Increased
oxygen demand.
8. Changes in
metabolic rate.
9. Extreme
environmental temperature.
10. Inadequate
supply of subcutaneous fat.
11. Extreme body
weight.
12. Effects of
pharmacological agents (eg sedation).
Major Symptoms and Signs:
Subjective : (not
available)
Objective :
1. Cool/warm skin.
2. Shivering.
3. Flukuatif body
temperature.
Minor Symptoms and Signs:
Subjective : (not
available)
Objective :
1.Piolerection.
2. Capillary
refill >3 seconds.
3. Blood pressure
increases.
4. Pale.
5. The frequency
of breathing increases.
6.Tachycardia.
7. Seizures.
8. Skin redness.
9. Cyanotic nail
bed.
Related Clinical Conditions:
Spinal cord
injury.
infection/species.
Surgery.
Acute brain
injury.
Trauma.
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