A
Abdominal Distention
Dysfunctional Gastrointestinal Motility r/t decreased perfusion of intestines, medication effect
Nausea r/t irritation of gastrointestinal tract
Imbalanced Nutrition: less than body requirements r/t nausea, vomiting
Acute Pain r/t retention of air, gastrointestinal secretions
Abdominal Pain
Dysfunctional Gastrointestinal Motility r/t decreased perfusion, medication effect
Acute Pain r/t injury, pathological process
Abdominal Surgery
Constipation r/t decreased activity, decreased fluid intake, anesthesia, opioids
Dysfunctional Gastrointestinal Motility r/t medication or anesthesia effect, trauma from surgery
Acute Pain r/t surgical procedure
Ineffective peripheral Tissue Perfusion r/t immobility, abdominal surgery
Risk for Infection: Risk factor: invasive procedure
Readiness for enhanced Knowledge: expresses an interest in learning
See Surgery, Perioperative Care; Surgery, Postoperative Care; Surgery, Preoperative Care
Abdominal Trauma
Disturbed Body Image r/t scarring, change in body function, need for temporary colostomy
Ineffective Breathing Pattern r/t abdominal distention, pain
Deficient Fluid Volume r/t hemorrhage
Dysfunctional Gastrointestinal Motility r/t decreased perfusion
Acute Pain r/t abdominal trauma
Risk for Bleeding: Risk factor: trauma and possible rupture of abdominal organs
Risk for Infection: Risk factor: possible perforation of abdominal structures
Ablation, Radiofrequency Catheter
Risk for decreased Cardiac tissue perfusion: Risk factor: catheterization of heart
Abortion, Induced
Compromised family Coping r/t unresolved feelings about decision
Acute Pain r/t surgical intervention
Chronic low Self-Esteem r/t feelings of guilt
Chronic Sorrow r/t loss of potential child
Risk for Bleeding: Risk factor: trauma from abortion
Risk for delayed Development: Risk factors: unplanned or unwanted pregnancy
Risk for Infection: Risk factors: open uterine blood vessels, dilated cervix
Risk for Post-Trauma Syndrome: Risk factor: psychological trauma of abortion
Risk for Spiritual Distress: Risk factor: perceived moral implications of decision
Readiness for enhanced Knowledge: expresses an interest in learning
Abortion, Spontaneous
Disturbed Body Image r/t perceived inability to carry pregnancy, produce child
Disabled family Coping r/t unresolved feelings about loss
Ineffective Coping r/t personal vulnerability
Interrupted Family Processes r/t unmet expectations for pregnancy and childbirth
Fear r/t implications for future pregnancies
Acute Pain r/t uterine contractions, surgical intervention
Situational low Self-Esteem r/t feelings about loss of fetus
Chronic Sorrow r/t loss of potential child
Risk for Bleeding: Risk factor: trauma from abortion
Risk for Post-Trauma Syndrome: Risk factor: psychological trauma of abortion
Risk for Spiritual Distress: Risk factor: loss of fetus
Readiness for enhanced Knowledge: expresses an interest in learning
Abruptio Placentae <36 Weeks
Anxiety r/t unknown outcome, change in birth plans
Death Anxiety r/t unknown outcome, hemorrhage, or pain
Interrupted Family Processes r/t unmet expectations for pregnancy and childbirth
Fear r/t threat to well-being of self and fetus
Impaired Gas Exchange: placental r/t decreased uteroplacental area
Acute Pain r/t irritable uterus, hypertonic uterus
Impaired Tissue Integrity: maternal r/t possible uterine rupture
Risk for Bleeding: Risk factor: separation of placenta from uterus causing bleeding
Risk for disproportionate Growth: Risk factor: uteroplacental insufficiency
Risk for Infection: Risk factor: partial separation of placenta
Risk for disturbed Maternal/Fetal Dyad: Risk factors: trauma of process, lack of energy of mother
Risk for Shock: Risk factors: separation of placenta from uterus
Readiness for enhanced Knowledge: expresses an interest in learning
Abscess Formation
Impaired Tissue Integrity r/t altered circulation, nutritional deficit or excess
Readiness for enhanced Knowledge: expresses an interest in learning
Abuse, Spouse, Parent, or Significant Other
Anxiety r/t threat to self-concept, situational crisis of abuse
Impaired verbal Communication r/t psychological barriers of fear
Compromised family Coping r/t abusive patterns
Defensive Coping r/t low self-esteem
Dysfunctional Family Processes r/t inadequate coping skills
Insomnia r/t psychological stress
Post-Trauma Syndrome r/t history of abuse
Powerlessness r/t lifestyle of helplessness
Chronic low Self-Esteem r/t negative family interactions
Risk for self-directed Violence: Risk factor: history of abuse
Accessory Muscle Use (to Breathe)
Ineffective Breathing Pattern (See Breathing Pattern, ineffective, Section III)
See Asthma; Bronchitis; COPD (Chronic Obstructive Pulmonary Disease); Respiratory Infections, Acute Childhood
Accident Prone
Adult Failure to Thrive r/t fatigue
Acute Confusion r/t altered level of consciousness
Ineffective Coping r/t personal vulnerability, situational crises
Ineffective Impulse Control (See Impulse Control, ineffective, Section III)
Achalasia
Ineffective Coping r/t chronic disease
Acute Pain r/t stasis of food in esophagus
Impaired Swallowing r/t neuromuscular impairment
Acidosis, Metabolic
Acute Confusion r/t acid-base imbalance, associated electrolyte imbalance
Impaired Memory r/t effect of metabolic acidosis on brain function
Imbalanced Nutrition: less than body requirements r/t inability to ingest, absorb nutrients
Risk for Electrolyte Imbalance: Risk factor: effect of metabolic acidosis on renal function
Risk for Injury: Risk factors: disorientation, weakness, stupor
Risk for decreased Cardiac tissue perfusion: Risk factor: dysrhythmias from hyperkalemia
Risk for Shock: Risk factors: abnormal metabolic state, presence of acid state impairing function
Acidosis, Respiratory
Activity Intolerance r/t imbalance between oxygen supply and demand
Impaired Gas Exchange r/t ventilation-perfusion imbalance
Acne
Disturbed Body Image r/t biophysical changes associated with skin disorder
Ineffective Self-Health Management r/t deficient knowledge (medications, personal care, cause)
Impaired Skin Integrity r/t hormonal changes (adolescence, menstrual cycle)
Acromegaly
Activity Intolerance (See Activity Intolerance, Section III)
Ineffective Airway Clearance r/t airway obstruction by enlarged tongue
Disturbed Body Image r/t changes in body function and appearance
Impaired physical Mobility r/t joint pain
Risk for unstable blood Glucose level: Risk factor: abnormal physical health status
Activity Intolerance, Potential to Develop
Risk for Activity Intolerance (See Activity Intolerance, risk for, Section III)
Acute Abdominal Pain
Deficient Fluid Volume r/t air and fluids trapped in bowel, inability to drink
Acute Pain r/t pathological process
Acute Alcohol Intoxication
Ineffective Breathing Pattern r/t depression of the respiratory center from excessive alcohol intake
Acute Confusion r/t central nervous system depression
Dysfunctional Family Processes r/t abuse of alcohol
Risk for Aspiration: Risk factor: depressed reflexes with acute vomiting
Acute Back Pain
Anxiety r/t situational crisis, back injury
Constipation r/t decreased activity, effect of pain medication
Ineffective Coping r/t situational crisis, back injury
Impaired physical Mobility r/t pain
Readiness for enhanced Knowledge: expresses an interest in learning
Addison’s Disease
Activity Intolerance r/t weakness, fatigue
Disturbed Body Image r/t increased skin pigmentation
Deficient Fluid Volume r/t failure of regulatory mechanisms
Imbalanced Nutrition: less than body requirements r/t chronic illness
Risk for Injury: Risk factor: weakness
Readiness for enhanced Knowledge: expresses an interest in learning
Adenoidectomy
Acute Pain r/t surgical incision
Ineffective Airway Clearance r/t hesitation or reluctance to cough as a result of pain, fear
Nausea r/t anesthesia effects, drainage from surgery
Acute Pain r/t surgical incision
Risk for Aspiration: Risk factors: postoperative drainage, impaired swallowing
Risk for Bleeding: Risk factors: surgical incision
Risk for imbalanced Nutrition: less than body requirements: Risk factors: reluctance to swallow
Readiness for enhanced Knowledge: expresses an interest in learning
Adjustment Disorder
Anxiety r/t inability to cope with psychosocial stressor
Risk-prone Health Behavior r/t assault to self-esteem
Disturbed personal Identity r/t psychosocial stressor (specific to individual)
Situational low Self-Esteem r/t change in role function
Impaired Social Interaction r/t absence of significant others or peers
Adolescent, Pregnant
Anxiety r/t situational and maturational crisis, pregnancy
Disturbed Body Image r/t pregnancy superimposed on developing body
Ineffective Coping r/t situational and maturational crisis, personal vulnerability
Ineffective Denial r/t fear of consequences of pregnancy becoming known
Interrupted Family Processes r/t unmet expectations for adolescent, situational crisis
Delayed Growth and Development r/t pregnancy
Deficient Knowledge r/t pregnancy, infant growth and development, parenting
Ineffective Role Performance r/t pregnancy
Situational low Self-Esteem r/t feelings of shame and guilt about becoming or being pregnant
Impaired Social Interaction r/t self-concept disturbance
Social Isolation r/t absence of supportive significant others
Risk for impaired Attachment: Risk factor: anxiety associated with the parent role
Risk for delayed Development: Risk factor: unplanned or unwanted pregnancy
Risk for urge urinary Incontinence: Risk factor: pressure on bladder by growing uterus
Risk for disturbed Maternal/Fetal Dyad: Risk factors: immaturity, substance use
Readiness for enhanced Childbearing Process: reports appropriate prenatal lifestyle
Readiness for enhanced Knowledge: expresses an interest in learning
Adoption, Giving Child Up for
Ineffective Coping r/t stress of loss of child
Interrupted Family Processes r/t conflict within family regarding relinquishment of child
Grieving r/t loss of child, loss of role of parent
Insomnia r/t depression or trauma of relinquishment of child
Social Isolation r/t making choice that goes against values of significant others
Chronic Sorrow r/t loss of relationship with child
Risk for Spiritual Distress: Risk factor: perceived moral implications of decision
Readiness for enhanced Spiritual Well-Being: harmony with self regarding final decision
Adrenocortical Insufficiency
Deficient Fluid Volume r/t insufficient ability to reabsorb water
Ineffective Protection r/t inability to tolerate stress
Delayed Surgical Recovery r/t inability to respond to stress
Advance Directives
Death Anxiety r/t planning for end-of-life health decisions
Grieving r/t possible loss of self, significant other
Affective Disorders
See specific disorder: Depression (Major Depressive Disorder); Dysthymic Disorder; Manic Disorder, Bipolar I, Seasonal Affective Disorder
Aggressive Behavior
Fear r/t real or imagined threat to own well-being
Risk for other-directed Violence (See Violence, other-directed, risk for, Section III)
Aging
Death Anxiety r/t fear of unknown, loss of self, impact on significant others
Impaired Dentition r/t ineffective oral hygiene
Adult Failure to Thrive r/t depression, apathy, fatigue
Grieving r/t multiple losses, impending death
Hearing Loss r/t exposure to loud noises, aging
Impaired individual Resilience r/t aging, multiple losses
Sleep deprivation r/t aging-related sleep-stage shifts
Ineffective Thermoregulation r/t aging
Vision Loss r/t aging (see care plan on Evolve)
Readiness for enhanced family Coping: ability to gratify needs, address adaptive tasks
Readiness for enhanced Knowledge: specify need to improve health
Readiness for enhanced Nutrition: need to improve health
Readiness for enhanced Relationship: demonstrates understanding of partner’s insufficient function
Readiness for enhanced Sleep: need to improve sleep
Readiness for enhanced Urinary Elimination: need to improve health
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
