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NANDA Nursing Diagnosis, Lecture notes of Nursing

NANDA NURSING DIAGNOSIS. Last updated August 2009, *=new diagnosis 2009-2011. Activity/Rest-ability to engage in necessary/desired activities of life (work ...

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NANDA NURSING DIAGNOSIS Last updated August 2009, *=new diagnosis 2009-2011
Activity/Rest-ability to engage in
necessary/desired activities of life (work and
leisure) and to obtain adequate sleep/rest
Activity intolerance
Activity intolerance, risk for
Disuse syndrome, risk for
Divisional activity, deficit
Fatigue
Insomnia
Mobility: bed, impaired
Mobility: physical, impaired
Mobility: wheelchair, impaired
Sedentary lifestyle
Sleep deprivation
*Sleep pattern disturbed
Sleep, readiness for enhanced
Transfer ability, impaired
Walking, impaired
Circulation- ability to transport oxygen and
nutrients necessary to meet cellular needs
*Bleeding, risk for
Cardiac output, decreased
*Tissue perfusion, decreased cardiac
tissue, risk for
*Tissue perfusion, ineffective,
cerebral, risk for
*Tissue perfusion, ineffective, renal,
risk for
*Tissue perfusion, ineffective
gastrointestinal, risk for
Tissue perfusion, ineffective,
peripheral
*Shock, risk for
Ego Integrity- ability to develop and use
skills and behaviors to integrate and
manage life experiences
Anxiety
Anxiety, death
Body image, disturbed
Coping, community, ineffective
Coping, community, readiness for
enhanced
Coping, defensive
Coping, family, compromised
Coping, family, disabled
Coping, family, readiness for enhanced
Coping, (individual), readiness for
enhanced
Coping, ineffective
Denial, ineffective
Energy field disturbance
Fear
Grieving
Grieving, complicated
Grieving, risk for complicated
Health behavior, risk prone
Human dignity, risk for compromised
Personal identity, disturbed
Post trauma syndrome
Post trauma syndrome, risk for
Power, readiness for enhanced
Powerlessness
Powerlessness, risk for
Rape-trauma syndrome
Relocation stress syndrome
Relocation stress syndrome, risk for
*Resilience, impaired individual
*Resilience, readiness for enhanced
*Resilience, risk for compromised
Self concept, readiness for enhanced
Self-esteem, chronic low
Self-esteem, situational low
Self-esteem, risk for situational low
Sorrow, chronic
Stress, overload
Endo
Blood glucose, risk for unstable
Elimination- ability to excrete waste
products
Bowel incontinence
Constipation
Constipation, risk for
Constipation, perceived
Diarrhoea
*Motility, dysfunctional
gastrointestinal
*Motility, risk for dysfunctional
gastrointestinal
Urinary elimination, readiness for
enhanced
Urinary elimination, impaired
Urinary incontinence, functional
Urinary incontinence, overflow
Urinary incontinence, reflex
Urinary incontinence, stress
Urinary incontinence, urge
Urinary incontinence, risk for urge
Urinary retention
Food/fluid- ability to maintain intake of and
utilize nutrients and liquids to meet
physiological needs
Breastfeeding, effective
Breastfeeding, ineffective
Breastfeeding, interrupted
*Electrolyte imbalance, risk for
Failure to thrive, adult
Fluid balance, readiness for enhanced
Fluid volume, deficient
Fluid volume, deficient risk for
Fluid volume excess
Fluid volume, imbalanced, risk for
Infant feeding pattern, ineffective
Nutrition: imbalanced, less than body
requirements
Nutrition: imbalanced, more than body
requirements
Nutrition: imbalanced, risk for more
than body requirements
Nutrition, readiness for enhanced
Oral mucous membrane, impaired
Swallowing, impaired
Gastro
*Jaundice, neonatal
Liver function, impaired, risk for
Nausea
Growth and development
Dentition, impaired
Development delayed, risk for
Growth, disproportionate, risk for
Growth and development, delayed
Health promotion/Education
Health maintenance, ineffective
Health management, self, ineffective
Health-seeking behaviors (specify)
Immunization status, readiness for
enhanced
Knowledge deficient (specify)
Knowledge (specify), readiness for
enhanced
Therapeutic regime management:
family ineffective
Hygiene- ability to perform activities of
daily living
*Neglect, self
Self care, readiness for enhanced
Self-care deficit, feeding
Self-care deficit, bathing
Self-care deficit, dressing
Self-care deficit, toileting
Life Principles
*Activity planning, ineffective
Decisional conflict
Decision making, readiness for
enhanced
Moral distress
Noncompliance (specify)
Hope, readiness for enhanced
Hopelessness
Religiosity, impaired
Religiosity, readiness for enhanced
Religiosity, risk for impaired
Spiritual distress
Spiritual distress, risk of
Spiritual well being, readiness for
enhanced
Neurosensory- ability to perceive, integrate
and respond to internal and external cues
Autonomic dysreflexia
Autonomic dysreflexia, risk for
Communication, impaired verbal
Communication, readiness for
enhanced
Confusion, acute
Confusion, acute, risk for
Confusion, chronic
Environmental interpretation
syndrome, impaired
Infant behavior, disorganized
Infant behavior, disorganized, risk for
Infant behavior, organized, readiness
for enhanced
Intracranial adaptive capacity,
decreased
Memory, impaired
Neurovascular dysfunction, peripheral
risk for
Sensory perception disturbed
(specify):visual, auditory, kinesthetic,
gustatory, tactile, olfactory
Unilateral neglect
Pain/discomfort- ability to control
internal/external environment to maintain
comfort
*Comfort, impaired
Comfort, readiness for enhanced
Pain, acute
Pain, chronic
Respiration- ability to provide and use
oxygen to meet physiological needs
Airway clearance, ineffective
Aspiration, risk for
Breathing pattern, ineffective
Gas exchange, impaired
Spontaneous ventilation, impaired
Ventilatory weaning response,
dysfunctional (DVWR)
Safety- ability to provide safe, growth-
promoting environment
Body temperature, imbalanced, risk for
Contamination
Contamination, risk for
Falls, risk for
Home maintenance, ineffective
Hyperthermia
Hypothermia
Infection, risk for
Injury, risk for
*Maternal/fetal dyad, risk disturbed
Latex allergy response
Latex allergy response, risk for
Perioperative positioning injury, risk
for
Poisoning, risk for
Protection, ineffective
Self mutilation
Self mutilation, risk for
Skin integrity, impaired
Skin integrity, impaired, risk for
Sudden infant death syndrome, risk for
Suffocation, risk for
Suicide, risk for
Surgical recovery, delayed
Thermoregulation, ineffective
Tissue integrity, impaired
Trauma, risk for
*Trauma, risk for vascular
Violence, self-directed risk for
Violence, other-directed, risk for
Wandering
Sexuality (component of ego integrity and
Social interaction)- Ability to meet
requirements/characteristics of male/female
role
*Childbearing process, readiness for
enhanced
Sexual dysfunction
Sexuality patterns, ineffective
Social Interaction- ability to establish and
maintain relationships
Attachment, parent/infant/child, risk
for impaired
Care giver role strain
Care giver role strain, risk for
Family processes, dysfunctional
Family processes, interrupted
Family processes, readiness for
enhanced
Loneliness, risk for
Parenting, impaired
Parenting, readiness for enhanced
Patenting, risk for impaired
*Relationships, readiness for enhanced
Role conflict, parental
Role performance, ineffective
Social interaction, impaired
Social isolation
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NANDA NURSING DIAGNOSIS

Last updated August 2009, *=new diagnosis 2009-

Activity/Rest-

ability to engage in necessary/desired activities of life (work andleisure) and to obtain adequate sleep/rest •^ Activity intolerance •^ Activity intolerance, risk for •^ Disuse syndrome, risk for •^ Divisional activity, deficit •^ Fatigue •^ Insomnia •^ Mobility: bed, impaired •^ Mobility: physical, impaired •^ Mobility: wheelchair, impaired •^ Sedentary lifestyle •^ Sleep deprivation •^ *Sleep pattern disturbed •^ Sleep, readiness for enhanced •^ Transfer ability, impaired •^ Walking, impaired Circulation-

ability to transport oxygen and nutrients necessary to meet cellular needs •^ *Bleeding, risk for •^ Cardiac output, decreased •^ *Tissue perfusion, decreased cardiactissue, risk for •^ *Tissue perfusion, ineffective,cerebral, risk for •^

*Tissue perfusion, ineffective, renal,risk for

-^ *Tissue perfusion, ineffectivegastrointestinal, risk for •^ Tissue perfusion, ineffective,peripheral •^ *Shock, risk for Ego Integrity-

ability to develop and use skills and behaviors to integrate andmanage life experiences •^ Anxiety •^ Anxiety, death •^ Body image, disturbed •^ Coping, community, ineffective •^ Coping, community, readiness forenhanced •^ Coping, defensive •^ Coping, family, compromised •^ Coping, family, disabled •^ Coping, family, readiness for enhanced •^ Coping, (individual), readiness forenhanced •^ Coping, ineffective •^ Denial, ineffective •^ Energy field disturbance •^ Fear •^ Grieving •^ Grieving, complicated •^ Grieving, risk for complicated •^ Health behavior, risk prone •^ Human dignity, risk for compromised

-^ Personal identity, disturbed •^ Post trauma syndrome •^ Post trauma syndrome, risk for •^ Power, readiness for enhanced •^ Powerlessness •^ Powerlessness, risk for •^ Rape-trauma syndrome •^ Relocation stress syndrome •^ Relocation stress syndrome, risk for •^ *Resilience, impaired individual •^ *Resilience, readiness for enhanced •^ *Resilience, risk for compromised •^ Self concept, readiness for enhanced •^ Self-esteem, chronic low •^ Self-esteem, situational low •^ Self-esteem, risk for situational low •^ Sorrow, chronic •^ Stress, overload Endo •^ Blood glucose, risk for unstable Elimination-

ability to excrete waste products •^ Bowel incontinence •^ Constipation •^ Constipation, risk for •^ Constipation, perceived •^ Diarrhoea •^ *Motility, dysfunctionalgastrointestinal •^ *Motility, risk for dysfunctionalgastrointestinal •^ Urinary elimination, readiness forenhanced •^ Urinary elimination, impaired •^ Urinary incontinence, functional •^ Urinary incontinence, overflow •^ Urinary incontinence, reflex •^ Urinary incontinence, stress •^ Urinary incontinence, urge •^ Urinary incontinence, risk for urge •^ Urinary retention Food/fluid-

ability to maintain intake of and utilize nutrients and liquids to meetphysiological needs •^ Breastfeeding, effective •^ Breastfeeding, ineffective •^ Breastfeeding, interrupted •^ *Electrolyte imbalance, risk for •^ Failure to thrive, adult •^ Fluid balance, readiness for enhanced •^ Fluid volume, deficient •^ Fluid volume, deficient risk for •^ Fluid volume excess •^ Fluid volume, imbalanced, risk for •^ Infant feeding pattern, ineffective

-^ Nutrition: imbalanced, less than bodyrequirements •^ Nutrition: imbalanced, more than bodyrequirements •^ Nutrition: imbalanced, risk for morethan body requirements •^ Nutrition, readiness for enhanced •^ Oral mucous membrane, impaired •^ Swallowing, impaired Gastro •^ *Jaundice, neonatal •^ Liver function, impaired, risk for •^ Nausea Growth and development •^ Dentition, impaired •^ Development delayed, risk for •^ Growth, disproportionate, risk for •^ Growth and development, delayed Health promotion/Education •^ Health maintenance, ineffective •^ Health management, self, ineffective •^ Health-seeking behaviors (specify) •^ Immunization status, readiness forenhanced •^ Knowledge deficient (specify) •^ Knowledge (specify), readiness forenhanced •^ Therapeutic regime management:family ineffective • Hygiene-

ability to perform activities of daily living •^ *Neglect, self •^ Self care, readiness for enhanced •^ Self-care deficit, feeding •^ Self-care deficit, bathing •^ Self-care deficit, dressing •^ Self-care deficit, toileting Life Principles •^ *Activity planning, ineffective •^ Decisional conflict •^ Decision making, readiness forenhanced •^ Moral distress •^ Noncompliance (specify) •^ Hope, readiness for enhanced •^ Hopelessness •^ Religiosity, impaired •^ Religiosity, readiness for enhanced •^ Religiosity, risk for impaired •^ Spiritual distress •^ Spiritual distress, risk of •^ Spiritual well being, readiness forenhanced

Neurosensory-

ability to perceive, integrate and respond to internal and external cues •^ Autonomic dysreflexia •^ Autonomic dysreflexia, risk for •^ Communication, impaired verbal •^ Communication, readiness forenhanced •^ Confusion, acute •^ Confusion, acute, risk for •^ Confusion, chronic •^ Environmental interpretationsyndrome, impaired •^ Infant behavior, disorganized •^ Infant behavior, disorganized, risk for •^ Infant behavior, organized, readinessfor enhanced •^ Intracranial adaptive capacity,decreased •^ Memory, impaired •^ Neurovascular dysfunction, peripheralrisk for •^ Sensory perception disturbed(specify):visual, auditory, kinesthetic,gustatory, tactile, olfactory •^ Unilateral neglect Pain/discomfort-

ability to control

internal/external environment to maintaincomfort •^ *Comfort, impaired •^ Comfort, readiness for enhanced •^ Pain, acute •^ Pain, chronic Respiration-

ability to provide and use oxygen to meet physiological needs •^ Airway clearance, ineffective •^ Aspiration, risk for •^ Breathing pattern, ineffective •^ Gas exchange, impaired •^ Spontaneous ventilation, impaired •^ Ventilatory weaning response,dysfunctional (DVWR) Safety-

ability to provide safe, growth- promoting environment •^ Body temperature, imbalanced, risk for •^ Contamination •^ Contamination, risk for •^ Falls, risk for •^ Home maintenance, ineffective •^ Hyperthermia •^ Hypothermia •^ Infection, risk for •^ Injury, risk for •^ *Maternal/fetal dyad, risk disturbed •^ Latex allergy response •^ Latex allergy response, risk for

•^ Perioperative positioning injury, riskfor •^ Poisoning, risk for •^ Protection, ineffective •^ Self mutilation •^ Self mutilation, risk for •^ Skin integrity, impaired •^ Skin integrity, impaired, risk for •^ Sudden infant death syndrome, risk for •^ Suffocation, risk for •^ Suicide, risk for •^ Surgical recovery, delayed •^ Thermoregulation, ineffective •^ Tissue integrity, impaired •^ Trauma, risk for •^ *Trauma, risk for vascular •^ Violence, self-directed risk for •^ Violence, other-directed, risk for •^ Wandering Sexuality (component of ego integrity and Social interaction)-

Ability to meet

requirements/characteristics of male/femalerole •^ *Childbearing process, readiness forenhanced •^ Sexual dysfunction •^ Sexuality patterns, ineffective Social Interaction-

ability to establish and

maintain relationships •^ Attachment, parent/infant/child, riskfor impaired •^ Care giver role strain •^ Care giver role strain, risk for •^ Family processes, dysfunctional •^ Family processes, interrupted •^ Family processes, readiness forenhanced •^ Loneliness, risk for •^ Parenting, impaired •^ Parenting, readiness for enhanced •^ Patenting, risk for impaired •^ *Relationships, readiness for enhanced •^ Role conflict, parental •^ Role performance, ineffective •^ Social interaction, impaired •^ Social isolation

Activity/Rest Activity intolerance:

insufficient

physiological or psychological energy toendure or complete required or desired dailyactivities Activity intolerance, risk for:

at risk for

experiencing insufficient physiological orpsychological energy to endure or completerequired or desired daily activities Disuse syndrome, risk for:

at risk for

deterioration of body systems as the result ofprescribed or unavoidable musculoskeletalinactivity Diversional activity, deficient:

decreased

stimulation from or interest or engagementin recreational or leisure activities Fatigue:

an overwhelming, sustained sense of exhaustion and decreased capacity forphysical mental work at usual level Insomnia:

a disruption in amount and quality of sleep that impairs function Mobility: bed, impaired:

limitation of

independent movement from one bedposition to another Mobility: physical, impaired:

limitation in

independent, purposeful physical movementfor the body or of one or more extremities Mobility: wheelchair, impaired:

limitation

of independent operation of wheelchairwithin the environment Sedentary lifestyle:

reports a habit of life

that is characterized by a low physicalactivity level Sleep deprivation:

prolonged periods

without sleep (sustained natural, periodicsuspension of relative unconscious) *Sleep pattern disturbed:

time-limited

interruptions of sleep amount and qualitydue to external factors Sleep, readiness for enhanced:

a pattern of

natural, periodic suspension ofconsciousness that provides adequate rest,sustains a desired lifestyle, and can bestrengthened Transfer ability, impaired:

limitation of

independence movement between twonearby surfaces

Walking, impaired:

limitation of

independent movement within theenvironment on foot (or artificial limb) *Circulation Bleeding, risk for:

at risk for a decrease in

blood volume that may compromise health Cardiac output, decreased:

inadequate

blood pumped by the heart to meetmetabolic demands of the body *Tissue perfusion, decreased cardiactissue, risk for:

risk for a decrease in cardiac (coronary) circulation *Tissue perfusion, ineffective, cerebral,risk for:

risk for

decrease cerebral tissue circulation *Tissue perfusion, ineffective, renal, riskfor:^ at risk for a decrease in bloodcirculation to the kidney that maycompromise health *Tissue perfusion, ineffective,gastrointestinal, risk for:

at risk for

decrease I gastrointestinal circulation Tissue perfusion, ineffective, peripheral: decrease in blood circulation to theperipheries that may compromise health *Shock, risk for:

at risk fro an inadequate

blood flow to the body’s tissues which maylead to life-threatening cellular dysfunction Ego Integrity Anxiety:

vague, uneasy feeling of discomfort or dread accompanied by anautonomic response, with the source oftennonspecific or unknown to the individual; afeeling of apprehension caused byanticipation of danger. It is an alerting signalthat warns of impending danger and enablesthe individual to take measures to deal withthreat. Anxiety, death:

vague uneasy feeling of discomfort or dread generated byperceptions of a real or imagined threat toone’s existence Body image, disturbed:

confusion in

mental picture of one’s physical self Coping, community, ineffective:

pattern of

community activities (for adaptation andproblem solving) that is unsatisfactory formeeting the demands or needs of thecommunity

Coping, community, readiness forenhanced:

pattern of community activities for adaptation and problem solving that isunsatisfactory for meeting the demands orneeds of the community but that can also beimproved for management or current andfuture problems/stressors Coping, defensive:

repeated projection of

falsely positive self-evaluations based onself-protective pattern that defends againstperceived threats to positive self regard Coping, family, compromised:

usually

supportive primary person (family memberor close friend) provides insufficient,ineffective, or compromised support,comfort, assistance, or encouragement thatmay be needed to manage or masteradaptive tasks related to heath challenge Coping, family, disabled:

behavior of

significant person (family member or otherprimary person) that disables his or hercapacity to effectively address tasksessential to either person’s adaptation tohealth challenges Coping, family, readiness for enhanced: effective management of adaptive tasks byfamily member involved with client’s healthchallenge, who now exhibits desire andreadiness for enhanced health and growthwith regard to self in relation to client Coping, (individual), readiness forenhanced:

pattern of cognitive and behavioral efforts to manage demands that issufficient for wellbeing and can bestrengthened Coping, ineffective:

inability to form a

valid appraisal of internal or externalstressors, inadequate choices of practicalresponses, and/or to access or use availableresources Denial, ineffective:

conscious or

unconscious attempt to disavow anxiety theknowledge or meaning of an event, toreduce anxiety/fear, but leading to thedetriment of health Energy field disturbed:

a disruption of the

flow of energy surrounding a person’sbeing, which results in a disharmony ofmind and spirit Fear:

response to perceived threat that is consciously recognized as a danger

Grieving:

a normal complex process that includes emotional, physical, spiritual,social and intellectual responses andbehaviors by which individuals, families andcommunities incorporate an actual,anticipated or perceived loss into their dailylives Grieving, complicated:

a disorder that

occurs after the death of a significant other,in which the experience of distressaccompanying bereavement fails to follownormative expectations and manifest infunctional impairment Grieving, risk for complicated

: a t risk for

a disorder that occurs after the death of asignificant other, in which the experience ofdistress accompanying bereavement fails tofollow normative expectations and manifestin functional impairment Health behavior, risk prone:

impaired

ability to modify lifestyle/behaviors in amanner consistent with a change in healthstatus Human dignity, risk for compromised:

at

risk for perceived loss of respect and honor Personal identity, disturbed:

inability to

maintain an integrated and completeperception of self Post trauma syndrome:

sustained

maladaptive response to a traumatic,overwhelming event Post trauma syndrome, risk for:

at risk for

sustained maladaptive response to atraumatic, overwhelming event Power, readiness for enhanced:

a pattern

of participating knowingly in change that issufficient for well-being and can bestrengthened Powerlessness:

perception that one’s own actions will not significantly affect anoutcome, perceived lack of control overcurrent situation or immediate happening Powerlessness, risk for:

at risk for

perceived lack of control over a situationand/or one’s ability to significantly affect anoutcome Rape-trauma syndrome:

sustained

maladaptive response to forced, violentsexual act (penetration may not actuallyoccur) against victim’s will and consent

Relocation stress syndrome:

physiological

and/or psychological disturbances that resultfrom transfer from one environment toanother Relocation stress syndrome, risk for:

at

risk for physiological and/or psychologicaldisturbances that result from transfer fromone environment to another *Resilience, impaired individual: decreased ability to sustain a pattern ofpositive responses to an adverse situation orcrisis *Resilience, readiness for enhanced:

a

pattern of positive responses to an adversesituation or crisis that can be strengthened tooptimize human potential *Resilience, risk for compromised:

at risk

for decreased ability to sustain a pattern ofpositive responses to an adverse situation orcrisis Self-concept readiness for enhanced

: a

pattern of perceptions or ideas about the selfthat is sufficient for well-being and can bestrengthened Self-esteem, chronic low:

long-standing

negative self-evaluations/feelings about selfor self-capabilities Self-esteem, situational low:

development

of a negative perception of self-worth inresponse to a current situation Self-esteem, risk for situational low:

at

risk for developing negative perception ofself-worth in response to a current situation Sorrow, chronic:

cyclical, recurring and

potentially progressive pattern of pervasivesadness that is experienced (by parent, orcaregiver, or individual with chronic illnessor disability) in response to continual lossthroughout the trajectory of an illness ordisability Stress, overload:

excessive amounts and

types of demands that require action Endo Blood glucose, risk for unstable:

risk for

variation of blood glucose/sugar levels fromthe normal range

Religiosity, readiness for enhanced:

ability

to increase reliance on religious beliefsand/or participate in rituals of a particularfaith tradition Religiosity, risk for impaired:

at risk for an

impaired ability to exercise reliance onbeliefs and/or participate in rituals of aparticular faith tradition Spiritual distress:

impaired ability to

experience and integrate meaning andpurpose in life through the individual’sconnectedness with self, others, art, music,literature, nature or a power greater thanoneself Spiritual distress, risk of:

at risk for an

impaired ability to experience and integratemeaning and purpose in life through theindividual’s connectedness with self, others,art, music, literature, nature or a powergreater than oneself Spiritual well being, readiness forenhanced:

ability to experience and integrate meaning and purpose in lifethrough connectedness with self, others, art,music, literature, nature, or a power greaterthan oneself that can be strengthened Neuro Autonomic dysrelexia:

life threatening,

uninhibited sympathetic response of thenervous system to a noxious stimulus afterspinal cord injury at T7 or above Autonomic dysreflexia, risk for:

at risk for

life threatening, uninhibited response of thesympathetic nervous system; post-spinalshock; in an individual with spinal cordinjury or lesion at T6 or above (has beendemonstrated in clients with injuries at T7 orT8) Communication, impaired verbal: decreased, delayed or absent ability toreceive, process, transmit, and use a systemof symbols Communication, readiness for enhanced: pattern of exchanging information and ideaswith others that is sufficient for meetingone’s needs and life’s goals and can bestrengthened Confusion, acute:

abrupt onset of reversible

disturbances of consciousness, attention,cognition and perception that develop over ashort period of time

Confusion, acute, risk for:

at risk for

reversible disturbances of consciousness,attention, cognition, and perception thatdevelop over a short period of time Confusion, chronic:

irreversible, long-

standing, and/or progressive deterioration ofintellect and personality characterized bydeceased ability to interpret environmentalstimuli and decreased capacity forintellectual thought processes, andmanifested by disturbances of memory,orientation, and behavior Environmental interpretation syndrome,impaired:

consistent lack of orientation to time/place/person/circumstances over morethan 3-6 months necessitating a protectiveenvironment Infant behavior, disorganized: disintegrated physiological andneurobehavioral responses to theenvironment Infant behavior, disorganized, risk for: risk for alteration in integrating andmodulation of the physiological andneurobehavioral systems of functioning (i.e.autonomic, motor, state, organization, self-regulatory, and attentional-interactionalsystems) Infant behavior, organized, readiness forenhanced:

a pattern of modulation of the physiological and behavioral systems offunctioning (i.e. autonomic, motor, state,organization, self-regulatory, andattentional-interactional systems) in aninfant that is satisfactory but that can beimproved Intracranial adaptive capacity, decreased: intracranial fluid dynamic mechanisms thatnormally compensate for increases inintracranial volumes are compromised,resulting in repeated disproportionateincreases in intracranial pressure (ICP) inresponse to a variety of noxious and non-noxious stimuli Memory, impaired:

inability to remember

or recall bits of information or behavioralskills Neurovascular dysfunction, peripheralrisk for:

at risk of disruption in circulation, sensation or motion of an extremity

Sensory perception, disturbed (auditory,gustatory, kinesthetic, olfactory, tactile,visual):

change in the amount or patterning of incoming stimuli accompanied by adiminished, exaggerated, distorted, orimpaired response to such stimuli (auditory-hearing) (gustatory- taste) (kinesthetic-muscle sense) (olfactory- smell) (tactile-touch) (visual- see) Unilateral neglect:

impaired sensory and

motor response, mental representation andspatial attention of the body, and thecorresponding environment characterized byinattention to one side and over attention tothe opposite side. Left side neglect is moresevere than persistent right side neglect *Pain/discomfort Comfort, impaired:

perceived lack of

ease, relief and transcendence in physical,psychospiritual, environmental and socialdimensions Comfort, readiness for enhanced:

a

pattern of ease, relief and transcendence inphysical, psychospiritual environmentaland/or social dimensions that can bestrengthened Pain, acute:

unpleasant sensory and emotional experience arising from actual orpotential tissue damage or described interms of such damage; sudden or slow onsetof any intensity from mild to severe withanticipated or predictable end and a durationof less than 6 months Pain, chronic:

unpleasant sensory and emotional experience arising from actual orpotential tissue damage or described interms of such damage; sudden or slow onsetof any intensity from mild to severe,constant or recurring without an anticipatedor predictable end and a duration of morethan 6 months Respiration Airway clearance, ineffective:

inability to

clear secretions or obstructions from therespiratory tract to maintain a clear airway Aspiration, risk for:

at risk for entry of

gastrointestinal secretions, oropharyngealsecretions, solids or fluids into thetracheobronchial passages Breathing pattern, ineffective:

inspiration

and/or expiration that does not provideadequate ventilation

Gas exchange, impaired:

excess or deficit

in oxygenation and/or carbon dioxideelimination at the alveolar-capillarymembrane Spontaneous ventilation, impaired: decreased energy reserve result in anindividual’s ability to maintain breathingadequate to support life Ventilatory weaning response,dysfunctional (DVWR):

inability to adjust

to lowered levels of mechanical ventilatorsupport that interrupts and prolongs theweaning process Safety Body temperature, imbalanced, risk for: at risk for failure to maintain bodytemperature within normal range Contamination:

exposure to environmental contaminates in doses sufficient to causeadverse health effects Contamination, risk for:

accentuated risk

of exposure to environmental contaminantsin doses sufficient to cause adverse healtheffects Falls, risk for:

increased susceptibility to falling that may cause physical harm Home maintenance ineffective:

inability to

independently maintain a safe and growth-promoting immediate environment Hyperthermia:

body temperature elevated above normal range Hypothermia:

body temperate below normal range Infection, risk for:

at increased risk for

being invaded by pathogenic organisms Injury, risk for:

at risk of injury as a result of the interaction of environmentalconditions interacting with the individual’sadaptive and defensive resources *Maternal/fetal dyad, risk disturbed:

at

risk for disruption of symbioticmaternal/fetal dyad as a result of comorbidor pregnancy related complications Latex allergy response:

a hypersensitive

reaction to natural latex rubber products

Latex allergy response, risk for:

risk of

hypersensitive reaction to natural latexrubber products Perioperative positioning injury, risk for: at risk for inadvertent anatomical andphysical changes as a result of posture orequipment used during an invasive/surgicalprocedure Poisoning, risk for:

accentuated risk for

accidental exposure to, or ingestion of, drugsor dangerous products in doses sufficient tocause poisoning Protection, ineffective:

deceased in the

ability to guard self from internal or externalthreats such as illness or injury Self mutilation:

deliberate self-injurious behavior causing damage with the intent ofcausing on-fatal injury to attain relief oftension Self mutilation, risk for:

at risk of

deliberate self-injurious behavior causingdamage with the intent of causing on-fatalinjury to attain relief of tension Skin integrity, impaired:

altered epidermis

and/or dermis Skin integrity, impaired, risk for:

at risk

for skin being adversely altered Sudden infant death syndrome, risk for: presence of risk factors for sudden death ofan infant under 1 year of age Suffocation, risk for:

accentuated risk of

accidental suffocation (inadequate airavailable for inhalation) Suicide, risk for:

at risk for self-inflicted,

life-threatening injury Surgical recovery, delayed:

extension of

number of postoperative days required toinitiate and perform activities that maintainlife, health, and well-being Thermoregulation, ineffective: temperature fluctuation betweenhypothermia and hyperthermia Tissue integrity, impaired:

damage to

mucous membrane, corneal, integumentaryor subcutaneous tissue

Trauma, risk for:

accentuated risk of

accidental tissue injury (eg: wound, burn,fracture) *Trauma, risk for vascular:

at risk for

damage to a vein and its surrounding tissuesrelated to the presence of a catheter and/orinfused solutions Violence, self-directed risk for:

at risk for

behaviors in which an individualdemonstrates that he or she can bephysically, emotionally, and/or sexuallyharmful to self Violence, other-directed, risk for:

at risk

for behaviors in which an individualdemonstrates that he or she can bephysically, emotionally, and/or sexuallyharmful to others Wandering:

meandering, aimless or repetitive locomotion that exposes theindividual to harm; frequency incongruentwith boundaries, limits or obstacles *Sexuality (component of ego integrity and Social interaction) Childbearing process, readiness forenhanced:

a pattern of preparing for, maintaining and strengthening a healthypregnancy an childbirth process and care ofnewborn Sexual dysfunction:

the state in which an

individual experiences a change in sexualfunction during sexual response phases ofdesire, excitation, and/or orgasm, which isviewed as unsatisfying, unrewarding,inadequate Sexuality patterns, ineffective:

expressions

of concern regarding own sexuality Social Interaction Attachment, parent/infant/child, risk forimpaired:

disruption of the interactive process between parent/significant other andinfant/child that fosters the development of aprotective and nurturing reciprocalrelationship Care giver role strain:

difficulty in

performing family caregiver role Care giver role strain, risk for:

caregiver

is vulnerable for felt difficulty in performingfamily caregiver role

Family processes, dysfunctional: psychosocial, spiritual and physiologicalfunctions of the family unit are chronicallydisorganized, which leads to conflict, denialof problems, resistance to change,ineffective problem solving and a series ofself-perpetuating crises Family processes, interrupted:

change in

family relationships and/or functioning Family processes, readiness for enhanced: a pattern of family functioning that issufficient to support the well-being of familymembers and can be strengthened Loneliness, risk for:

at risk of experiencing

discomfort associated with a desire or needfor more contact with others Parenting, impaired:

inability of primary

caretaker to create, maintain or regain anenvironment that promotes optimum growthand development of the child Parenting, readiness for enhanced:

pattern

of providing environment for children orother dependent person/s that is sufficient tonurture growth and development and can bestrengthened Parenting, risk for impaired:

risk for

inability of primary caretaker to create,maintain, or regain an environment thatpromotes optimum growth and developmentof the child *Relationships, readiness for enhanced:

a

pattern of mutual partnership that issufficient to provide each other’s needs andcan be strengthened Role conflict, parental:

parent experience

of role confusion and role in response tocrisis Role performance, ineffective:

patterns of

behavior and self-expression that do notmatch the environmental context, norms andexpectations Social interaction, impaired:

insufficient

or excessive quantity or ineffective qualityof social exchange Social isolation:

aloneness experienced by the individual and perceived as imposed byothers and as a negative or threatened state Readiness to enhance = willingness to strengthen or improve