...- FEEDING TUBE (G-TUBE) CONTINUOUS FEEDING
Patient has a gastrostomy tube with continuous feedings.
Is at risk for complications from gastro-feeding tube.
These include aspiration, intolerance to formula, nausea,
vomiting, diarrhea, in...- 0B-GYN PRECLAMPSIA
Patient presents with edema (swelling of the hands and
face present upon arising), Weight gain in excess of 2
pounds per week of sudden onset, over 1 to 2 days
. Headaches
Note: Some swelling of...- ACTIVITY
ACTIVITY PURSUIT PATTERN: Leisure Activity Deficit...- ACTIVITY DEFCIT DUE TO ISOLATION
DIVERSIONAL ACTIVITY DEFICIT
Decreased stimulation from or interest or engagement in
recreational or leisure activities.
Indifference to social interactions spends less than 1/3
of time en...- ACTIVITY INTOLERANCE
Patient is at risk for activity intolerance due to:
Deconditioned status
Presence of circulatory problems
Presence of respiratory problems
History of previous intolerance...- ACTIVITY OVERACTIVE
DIVERSIONAL ACTIVITY
Highly involved resident whose health may be in jeopardy
secondary to failure to slow down.
...- ACTIVITY POTENTIAL FOR SOCIAL ISOLATION
DIVERSIONAL ACTIVITY DEFICIT
Potential for social isolation as resident is unable to
participate in activities due to medical condition,
physical and cognitive deficits
...- ACUTE BRONCHITIS
Patient has a diagnosis of Bronchitis
At risk for impaired gas exchange
At risk for fluid volume deficit
...- ADLS BATHING THE CONFUSED RESIDENT
ADL: Self Performance Deficit
(bathing & hygiene) related to confusion and combatative
behavior at times....- ADLS DRESSING THE CONFUSED RESIDENT
ADL-SELF PERFORMANCE
DEFICIT: dressing related to confusion...- ADLS FEEDING THE CONFUSED RESIDENT
ADL-SELF PERFORMANCE
DEFICIT (feeding) related to confusion
...- ADLS GROOMING THE CONFUSED MALE RESIDENT
ADL-SELF PERFORMANCE
DEFICIT (grooming) related to confusion...- ADLS HAIR CARE IN CONFUSED RESIDENT
ADL-Self Performance Deficit
(hair care) related to confusion
...- ADLS MAINTENANCE WITH RESTORATIVE SERVICES
ADL: Self Care Performance
Deficit due to: (example right sided weakness due to
recent CVA.
Resident needs assist with the following: (example)
Set up for feeding
Limited assist with bathing a...- ADLS PREFORMANCE MAINTAINENCE
Resident has a deficit with ADL preformance due to
Current level of function is the following:
Needs assist with the following:...- ADLS REHAB OT AND PT POST HOSP
ADL: Self Performance Deficit due to recent
hospitalization for:
Resident needs the following assistance:...- ADLS REHAB OT AND PT POST HOSP FILL IN
ADL:Self Performance
Deficit due to recent hospitalization for
Resident needs the following assistance:
...- ADLS REHAB OT AND PT POTENTIAL
ADL: Self Care Performance
Deficit due to recent hospitalization for
Resident needs the following assistance:
...- ADLS REHAB WITH OT AND PT
ADL FUNCTION
Self care deficit due to dx of
Resident needs the following assistance:
...- ADLS REHAB WITH OT AND PT AND ST
ADL: Self Performance
Deficit due to dx of
Resident needs the following assistance:...- ADLS TOILETING THE CONFUSED FEMALE RESIDENT
ADL-Self Performance Deficit
(Toileting) related to confusion
...- ADLS TOILETING THE CONFUSED MALE RESIDENT
ADL: Self Performance Deficit
(Toileting) related to confusion
...- ADLS GROOMING THE CONFUSED FEMALE RESIDENT
ADL-SELF PERFORMANCE
DEFICIT (grooming) related to confusion...- ADLS REHAB WITH OT AND PT
ADL: Self Performance
Deficit due to dx of
Resident needs the following assistance:...- ADLS TOTAL CARE WITH ORAL FEEDINGS
ADL: Self Performance deficit due to dx of
Resident has cognitive as well as physical deficits.
Resident requires total care from staff for all bathing,
grooming, personal hygiene, bed mobili...- ADLS TOTAL CARE WITH TUBE FEEDING
ADL FUNCTION
Self care deficit due to dx of
Resident has cognitive as well as physical deficits.
Resident requires total care from staff for all bathing,
grooming, personal hygiene, bed m...- ADULT FAILURE TO THRIVE
Patient has been diagnosed with failure to thrive.
Patient is exhibiting weight loss, anorexia, poor
nutritional status,inactivity and progressive functional
deterioration both physically and c...- AIDS-PNEUMOCYSTIS CARINII PNEUMONIA
Patient has AIDS and has contracted
Pneumocystis carinii pneumonia. At risk for
respiratory failure....- AIDS-PULMONARY COMPLICATIONS
Patient is at risk for an ineffective airway
clearance,impaired gas exchange and
respiratory failure due to AIDS complications
of infection, malignancy, increased
secretions,poor activity intolera...- ALCOHOL WITHDRAWAL
Patient is being detoxed from alcohol
Patient is at risk for seizures, irregular heart rhythmn,
and other life threatening complications.
Patient is at risk for injury due to sensorimotor d...- ALLERGIES - ALLERGIC RHINITIS
Patient has a diagnosis of Allergic Rhinitis. Patient is
at risk for altered level of comfort due to sneezing,
watery eyes, itching, nasal discharge and difficulty
breathing....- ALOPECIA DUE TO CHEMOTHERAPY
Patient has a negative self image due to hair loss from
chemotherapy...- ALTERED NUTRITION RELATED TO ALZHEIMERS
NUTRITIONAL STATUS
Potential for diminished nutrition.
Resident refuses to eat or eats very little due to
Alzheimers Dementia....- ALTERED SENSORY PERCEPTION
Patient has recently had vision loss and is experiencing
altered sensory perception resulting in depression and
denial....- ALTERED TISSUE PERFUSION
Patient has altered tissue perfusion due to:...- ALZHEIMERS - MOOD AND BEHAVIOR PROBLEMS
Patient/resident/client has a diagnosis of Alzheimers
disease and exhibits mood and behavior problems as a
result.
Patient/resident/client experiences mood changes for no
apparent reason, can g...- ALZHEIMERS DEMENTIA
Resident has a diagnosis of Alzheimers Dementia.
Resident is at risk for injury, malnutrition, dehydration,
constipation, insomnia, incontinence, depression, and lack
of coping skills....- ALZHEIMERS DISEASE -AGITATION DUE TO COGNITIVE DEFICITS
Impaired level of cognitive function due to Alzheimers
disease. Patient/resident/client fails to recognize
familiar persons, places and things.
Patient asks repetitive questions or makes repetit...- Alzheimers- Risk for injury
Resident has been diagnosed with Alzheimers.
At risk for injury due to cognitive deficits, impaired
judgment, impaired safety awareness....- Alzheimers-Confusion
...- AMPUTATION OF LOWER EXTREMITY
Patient has had a (right, left, bilateral) amputation
(below knee, above knee) due to
PVD
Infection
trauma
malignancy
Patient is at risk for infection, sepsis, necrosis,
unrelieved phantom...- ANASARCA - GROSS EDEMA
Patient is exhibiting symptom of anasarca, widespread
swelling of the skin due to effusion of fluid into the
extracellular space.
Defining characteristics include rapid increase in weight
ove...- ANEMIA (IRON DEFICIENCY)
Resident has a diagnosis of Iron Deficiency Anemia....- ANGINA
Patient has a diagnosis of Angina. At risk for
complications of myocardial infarction and /or sudden
death....- ANOREXIA
Lack of appetite despite basic caloric need
Loss of appetite , which after a few weeks may lead to
malnutrition
...- ANOREXIA NERVOSA
Patient has anorexia nervosa, imbalanced nutrition less
than body requirements
Patient is at risk for malnutrition, fluid and electrolyte
disturbancespotassium depletion, cardiac
arrhythmia,n...- ANTI COAGULANT THERAPY - RISK FOR BLEEDING
Patient is on anti coagulant therapy (name of drug) for
(name of disease, condition)
Patient is at risk for bleeding....- ANTIBIOTIC RESISTANT INFECTION
Patient has an antibiotic resistant infection....- ANTICOAGULANT THERAPY
Patient is receiving anticoagulant therapy. At risk for
hemorrhage....- ANXIETY DUE TO DIAGNOSIS OF CANCER
Patient is exhibiting signs and symptoms of anxiety due to
a recent diagnosis of cancer. (May list specific symptoms
here.)...- APPENDECTOMY WITH COMPLICATIONS
Patient is at risk for infection from rupture of appendix.
Had appendectomy....- ARTHRITIS/ DJD
Patient has a diagnosis of Arthritis/ DJD. At risk for
pain. limited mobility and deformity of joint....- ASTHMA
Patient has a diagnosis of Asthma.
At risk for complications of status
asthmaticus, pneumonia, atelectasis,
dehydration, dysrrhythmias, cor pulmonale,
respiratiory failure and death....- AT RISK FOR INJURY DUE TO POOR IMPULSE CONTROL
Patient has a dignosis of (put in appropriate dx).
Patient is at risk for injury due to poor impulse control....- ATOPIC DERMATITIS
Patient has a diagnosis of atopic dermatitis. Is at risk
for skin infections and impaired sleep patterns....- ATRIAL FIBRILLATION
Rapid Irregular Pulse...- BAD PUMP (BENADRYL, ATIVAN, DECADRON) FOR NAUSEA AND VOMITING
Patient has terminal cancer with metastasis and is having
severe nausea. Is currently being treated with the BAD
Pump. Patient is at risk for dehydration, nutritional
deficiencies and physical ...- BEHAVIOR DUE TO AGITATION
BEHAVIOR;
resulting into agitation
(Negativism, constant requests for attention, complaining, and whining)
...- BEHAVIOR NON COMPLIANT WITH FACILITY SMOKING POLICY
At risk for injury due to non compliance with facility smoking policy. ...- BEHAVIOR NONCOMPLIANCE
Resident is non compliant with treatment program.
Resident is non compliant with daily bathing, hygiene, grooming and other ADLS. ...- BEHAVIOR DUE TO SPLITTING STAFF
MOOD AND BEHAVIOR: related to mood swings, angry outbursts
and attempts to cause
tension between staff,...- BEHAVIOR DUE TO COMBATIVENESS
BEHAVIOR:
Risk of Violence related to confusion and fear from brain
dysfunction (hitting, pushing,
scratching, pinching, or biting)
...- BEHAVIOR DUE TO DRUG SEEKING
BEHAVIOR: related to
Drug-Seeking Behavior.
...- BEHAVIOR DUE TO FLUSHING OBJECTS IN TOILET
BEHAVIOR: related to flushing linens, towels, and belongings in toilet...- BEHAVIOR DUE TO HOARDING AND THEFT
BEHAVIOR;related to theft and/or hoarding objects
...- BEHAVIOR RELATED TO AGITATION
BEHAVIOR; agitation resulting In (restlessness, pacing,
and trying to get to a different
place.
...- BEHAVIOR RELATED TO ANTISOCIAL BEHAVIOR
BEHAVIOR: related to lifelong pattern of irresponsible
behavior with disregard for rights
and safety of others...- BEHAVIOR RELATED TO DISROBING
BEHAVIOR:
related to inappropriate sexual behavior (disrobing)
...- BEHAVIOR RELATED TO GROPING
BEHAVIOR: related to inappropriate sexual behavior
(groping other patients or staff)
...- BEHAVIOR RELATED TO MASTURBATION
BEHAVIOR:
related to inappropriate sexual behavior (masturbating in
view of others)
...- BEHAVIOR RELATED TO NARCISSTIC BEHAVIOR
BEHAVIOR: related to grandiose and entitled behavior...- BEHAVIOR RELATED TO SUNDOWNING
BEHAVIOR:
Sleep Pattern Disorder related to sundowning and insomnia
...- BEHAVIOR WITH ATTENTION SEEKING
COGNITIVE & BEHAVIOR:
attention-seeking behavior....- BEHAVIOR WITH VERBAL ABUSE
BEHAVIOR: related to verbal accusations and insults,
screaming, cursing, temper
outbursts, or making strange noises)
...- BEHAVIOR- RISK FOR INJURY DUE TO WANDERING
Patient tends to endanger self by disengaging the
wheelchair alarm and attempts to go OOF unassisted....- BEHAVIOR-PHYSICALLY ABUSIVE
Resident becomes physically abusive to other
residents when she becomes agitated...- BLADDER INCONTINENCE - RETRAINING
Patient is incontinent of urine due to (put in diagnosis
or cause if known)....- BLOOD TRANSFUSION
Patient is scheduled to receive a blood transfusion due to
diagnosis of (put in diagnosis)
Patient is at risk for acute transfusion reactions which
include allergic, febrile nonhemolytic, acute h...- BOWEL INCONTINENCE - RETRAINING
Patient is incontinent of bowels due to (put in diagnosis
or condition if known)
Patient is at risk for skin impairment and psychological
problems due to fecal incontinence....- C-DIFF - DEHYDRATION
Patient is at risk for fluid volume deficit due to
diagnosis of C-Diff....- C-DIFF- SPREAD OF INFECTION & ALTERED COMFORT
Patient has a dx of C-Diff. At risk for altered level of
comfort and spread of infection....- CANCER RELATED FATIGUE
Patient is experiencing fatigue related to cancer and/or
treatment of cancer...- CARBON MONOXIDE POISONING
Impaired gas exchange due to carbon monoxide poisoning....- CARDIOMEGALY
Patient has a diagnosis of cardiomegaly. Is at risk for
congestive heart failure and arrhythmias....- CAREGIVER ROLE STRAIN
Caregiver is experiencing difficulty in performing family
caregiver role. Caregiver is preoccupied with care
routine, is apprehensive regarding ability to perform
care, is at risk for social is...- CELLILITIS
Cracks and breaks in skin resulting red swollen areas of
the skin with pain and
elevated body temperature
Complications that could result in amputations
Poor hygiene resulting in infection...- CELLULITIS IMPAIRED PHYSICAL MOBILITY
Patient has a dx of cellulitis on (put in location such as
left lower extremity). Patient has impaired physical
mobility due to pain (add any other symptoms)....- CENTRAL ADRENAL INSUFFICIENCY
Adrenal occurs when a lack of secretion of cortticotropion releasing hormone (CRH) from
the hypothalamus or of adrencorticatropic hormone (ACTH) from the pituitardy leads to
hypofunction of the ad...- CEREBRAL DEGENERATION
Patient has a diagnosis of cerebral degeneration. Is at
risk for decreased quality of life....- CEREBRAL PALSY
Patient has a diagnosis of Cerebral Palsy. Child is at
risk for complications such as seizures, speech and
communication problems, mental retardation and visual
deficits, hearing loss, swallowi...- CESAREAN DELIVERY- POST OP CARE
Patient has successfully delivered a healthy
infant via Cesarian section. She is at risk
for post op complications of: pain, fluid
volume deficit, infection, hemorrhage,
thrombophlebitis, ileus, ...- CESAREAN DELIVERY- PRE OP CARE
Patient has been evaluated and it has been
determined that she needs a Cesarean delivery
due to (put in reason such as mal position,
malpresentation, previous uterine surgery,
fetal distress,abrup...- CHEMO BRAIN
Patient is receiving chemotherapy and is having difficulty
concentrating, word finding, multitasking, being organized,
has short term memory impairment and a short attention
span.
...- CHEMOTHERAPY - CYTOXAN (CYCLOPHOSPHAMIDE)
Patient has a diagnosis of cancer and is receiving Cytoxan.
Patient is at risk for altered level of comfort due to
side effects....- CHEMOTHERAPY - TAXOL
Patient has a diagnosis of cancer and is receiving Taxol.
Patient is at risk for altered comfort level due to side
effects....- CHEMOTHERAPY- ALTERED NUTRITION
Patient is receiving chemotherapy and is at risk for
altered nutrition, less than body requirements due to
anorexia, nausea and vomiting...- CHEMOTHERAPY- FATIGUE
Patient is experiencing fatigue related to effects of
chemotherapy....- CHEMOTHERAPY-BODY IMAGE DISTURBANCE
Patient is receiving chemotherapy and is experiencing a
body image disturbance due to alopecia...- CHEST PAIN
Patient has been admitted with a diagnosis of chest pain....- CHF - PATIENT TEACHING
Patient has knowledge deficit regarding his/her diagnosis
of congestive heart failure...- CHLAMYDIA
Patient has a knowledge deficit regarding the
transmission, complications and treatment of Chlamydia.
Patient is at risk for infection, PID....- CHOLECYSTECTOMY
Patient had a cholecystectomy due to acute and chronic
cholecystitis
Patient is at risk for complications of hemorrhage,
infection, bile duct injury and thrombophlebitis...- CHOLECYSTITIS - GALLBLADDER ATTACKS
Patient was admitted with cholecystitis
Patient has acute pain, is at risk for altered nutrition,
less than body requirements, fluid volume deficit and
infection...- CHOLELITHIASIS - GALLSTONES
Patient has been admitted with gallstones.
Patient has acute pain and is at risk for fluid volume
deficit, infection and altered nutrition less than body
requirements ...- CHRONIC IDIOPATHIC PSEUDO OBSTRUCTION
Impaired Verbal Communication
Powerlessness due to inability to communicate
Alteration in Bowel Elimination
Risk for Infection
...- CHRONIC LOW SELF ESTEEM
Patient has long standing negative self-evaluation/
feelings about self or self capabilities.
Patient displays lack of eye contact, is nonassertive/
passive, overly conforming, indecisive, self ne...- CHRONIC RENAL DISEASE
Patient has a diagnosis of chronic renal disease which is
slowly progressive. At risk for severe kidney failure
resulting in end stage renal disease....- CIRRHOSIS OF THE LIVER
Patient has a diagnosis of Cirrhosis of the liver.
Patient is at risk for malnutrition, injury, breathing
problems due to acites, skin impairments, infection and
encephalopathy....- COGNITIVE CHRONIC CONFUSION
COGNITIVE; Confusion, chronic...- COGNITIVE AND BEHAVIOR RELATED TO PARANOIA
Cognitive & Behavior: related to (paranoia) life long
pattern of suspicion, mistrust, and fear of others...- COGNITIVE AND BEHAVIOR RELATED TO WANDERING
COGNITIVE AND BEHAVIOR:
related to Wandering...- COGNITIVE AND COMMUNICATION
COGNITIVE AND COMMUNICATION
Altered level of cognitive function due to dx of (put in
diagnosis).
Resident has memory problems, impaired decision making
skills and impaired ability to compr...- COGNITIVE AND DISEASE RELATED TO HALLUCINATIONS
COGNITIVE & DISEASE & HEALTH CONDITION related to
hallucinations
...- COGNITIVE DEFICIT
COGNITIVE
Altered level of cognitive function. Resident has memory
problems, impaired decision making skills and impaired
ability to comprehend
...- COGNITIVE ON FEAR OF BATH
COGNITIVE: Fear of Bathing...- COLITIS
Patient has a diagnosis of Colitis. Patient is
experiencing a fluid volumn deficit due to diarrhea and
is also having abdominal pain.
Patient is at risk for the following complications: bowe...- COLOSTOMY
Patient has a new colostomy. Additionally patient had a
left ovarian mass resection and left iliac vein repair.
had abdominal surgical eviseration in hospital....- COLOSTOMY CARE IN LONG TERM CARE SETTING
Patient has a colostomy and is not able to do
self care.
At risk for complications such as skin
impairment fluid volume deficit,gas,
constipation and nutritional imbalance...- COMMUNICATION DEFICIT DUE TO HARD OF HEARING
COMMUNICATION
Impaired ability to communication related to resident is
hard of hearing.
...- COMMUNICATION AND COGNITIVE DEFICIT
Impaired verbal communication due to diagnosis of Dementia.
(Could also substitute brain injury)...- COMMUNICATION DEFICIT DUE TO APHASIA
COMMUNICATION
Altered level of communication related to a dx of Aphasia.
...- CONFUSION WITH PICKING BEHAVIOR
Periods of confusion which includes picking at objects or
seeing people (not present)...- CONGESTIVE HEART FAILURE
Resident has a diagnosis of Congestive Heart Failure....- CONJUNCTIVITIS
Resident/Patient has a dx of Conjunctivitis....- CONSTIPATION
Patient has a history of chronic constipation.
Patient has potential for constipation due to decreased
mobility, diminished appetite, poor fluid and fiber
intake, cognitive deficits and takes d...- CONTRACTURES
Potential for development of contractures due to limited
mobilty, limited range of motion and loss of voluntary
muscle control....- COPD CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Patient has a diagnosis of COPD. Potential for side
effects for brochodilators, anxiety
from dyspnea, diminished ability to perform ADLS and high
risk for respiratory infections....- COPING INABILITY OF FAMILY
Inability to Cope with illness of patient...- CORONARY ARTERY DISEASE
Patient has been diagnosed with coronary artery disease.
Is at risk for atherosclerosis, hypertension, angina and
myocardial infarction....- CRITICAL DILANTIN LEVEL
Patient has been diagnosed with a seizure disorder and put
on Dilantin (Phenytoin) therapy.
At risk for critical dilantin level....- CROHNS DISEASE - NUTRITIONAL DEFICIT
Patient has been diagnosed with Crohns disease and is at
risk for nutritional imbalance less than body requirements
related to malabsorption, diarrhea, nausea, vomiting,
anorexia and poor intake...- CROHNS DISEASE - RISK FOR FLUID VOLUME DEFICIT
Patient has been diagnosed with Crohns Disease and is at
risk for fluid volume deficit due to severe diarrhea,
vomiting and poor intake due to nausea. Patient may also
experience fever....- CVA - CEREBROVASCULAR ACCIDENT
Patient has been diagnosed with a CVA. At risk for
impaired mobility, cognitive deficits, aspiration
pneumonia, contractures, depression. deep vein thrombosis,
dysphagia, incontinence and impai...- DECREASED CARDIAC OUTPUT
Patient has decreased cardiac output due to a diagnosis of
_______________(put in diagnosis such as CHF, MI,
digitalis toxicity, cardiac arrhythmias)...- DECUBITUS ULCER STAGE 2
Resident has a superficial skin break (or blister) on (put
location). Dimensions are (give dimensions).
At risk for further skin impairment or deterioration of
the stage 2....- DEHYDRATION DUE TO VOMITING.
Patient has been vomiting due to (here put in reason if
know, such as gastritis, viral infection, food poisioning,
chemotherapy, bacterial infection of GI tract,
pancreatitis, hepatitis, fecal i...- DELIRIUM
DELIRIUM Related to the Dx of...- DEMENTIA/ORGANIC BRAIN SYNDROME
Resident has a diagnosis of Dementia. Is at risk for
malnutrition, injury, incontinence, constipation,
insomnia, depression, emotional distress, coping
deficiency....- DENTAL
Resident has poor oral hygiene, caries and missing teeth....- DENTAL CARE
Patient at risk for tooth decay and mucous membrane disease...- DIABETES - INEFFECTIVE MANAGEMENT OF THERAPY REGIMEN
Patient has a new diagnosis of Diabetes and
patient/familiy are experiencing difficulty with
management of therapy regimen....- DIABETES - KNOWLEDGE DEFICIT
Patient has a diagnosis of Diabetes Mellitus and is not
well informed regarding the nutritional management of the
disease....- DIABETES MELLITUS
DIABETES MELLITUS
Potential for complications such as hyper/hypoglycemia
related to dx of Diabetes Mellitus.
...- DIABETIC FOOT CARE KNOWLEDGE DEFICIT
Patient has a diagnosis of Diabetes Mellitus and is at
risk for skin impairment due to a lack of knowledge
concerning proper diabetic foot care....- DIABETIC NEUROPATHY RISK FOR INJURY
Patient is at risk for injury from falls.
Patient has Diabetes Mellitus with neuropathy. She walks
with a limp and has an unsteady gait....- DIARRHEA - FLUID VOLUME DEFICIT
Patient is at risk for fluid volume deficit due to
diarrhea....- DIFFICULTY SWALLOWING MEDICATIONS.
Patient has difficulty swallowing medications.
Patient is at risk for choking and resistance to taking
prescribed medications as ordered....- DISCHARGE PLANNING
• Risk for Relocation Stress Syndrome -Physiological or psychosocial disturbances
caused by change from one environment to another such as admission, transfer or
discharge
• Anxiety
• Coping
...- DISTURBED BODY IMAGE
Patient has a distorted body image related to an eating
disorder. Patient is underweight with diagnosis of
bulimia.
Patient is at risk for altered nutrition less than body
requirements....- DIVERSIONAL ACTIVITY COGNITIVE DEFICIT
Patient has a diversional activity deficit due to severe
cognitive deficits. Is unable to actively participate in
facility programs....- DIVERSIONAL ACTIVITY DEFICIT APATHY
ACTIVITY PURSUIT PATTERN:
Diversional Activity Deficit due to lack of motivation
with signs of depression, apathy,
longterm institutionalization, monotonous environ- ment,
physical impairme...- DIVERSIONAL ACTIVITY DEFICIT WEAKNESS
DIVERSIONAL ACTIVITY
DEFICIT.
Activity intolerance due to complaints of fatigue,
weakness.
Decreased physical endurance....- DIVERTICULITIS
Patient has a diagnosis of diverticulitis. Is at risk for
complications such as infection, hemorrhage, fistula
formation, peritonitis and sepsis....- DIVERTICULOSIS
Patient has a diagnosis of Diverticulosis. Patient is at
risk for constipation, abdominal pain or diarrhea....- DNR - RISK FOR DECISIONAL CONFLICT
Patient has declared a desire for a natural death and has
requested a Do Not Resuscitate Order for both in patient
and outpatient care.
Patient is at risk for decisional conflict due to family ...- DVT- POTENTIAL FOR DUE TO MORBID OBESITY
Patient is at risk for DVT due to morbid obesity.
....- EDENTULOUS PATIENT
Patient is edentulous. At risk for weight loss, choking
and malnutrition....- END OF LIFE CAREPLAN
Patient is terminally ill and has experienced decline in
ADLS, weight loss and may experience skin breakdown and
dehydration. Patient is at risk for altered level of
comfort due to pain, spirit...- END STAGE RENAL DISEASE
Patient has a diagnosis of end stage renal disease, has
irreversible kidney damage and
must have dialysis (or kidney transplant) in order to
survive. At risk for the following:
fluid overloa...- END STAGE RENAL DISEASE - PEDIATRIC
Child has a diagnosis of end stage renal disease, has
irreversible kidney damage and must have dialysis or
transplant in order to survive. At risk for fluid
overload, electrolyte imbalance, acc...- ENDOSCOPY
Patient is scheduled for an endoscopy. At risk for
anxiety due to lack of knowledge.
At risk for complication of perforation of structure being
scoped, bleeding or infection....- EXPRESSIVE COMMUNICATION DEFICIT
Client has impaired communication manifested
by an expressive communication deficit related
to developmental disability...- FACIAL FRACTURES WITH WIRED JAWS
Patient has jaws wired due to facial fractures.
At risk for aspiration and airway obstruction.
At risk for impaired communication...- FALLS RESULTING IN FRACTURE
FALLS:
Recent fall resulting in fx
of
Had ORIF. Hx of falls the past 30 days as well as the
past 31-180 days. Dx of...- FEAR RELATED TO UNFAMILIARITY DUE TO VISION LOSS
Patient has recently lost sight and is exhibiting signs of
fear and maladjustment to condition....- FEEDING TUBE COMPLICATIONS
FEEDING TUBE
Potential for complications from gastrostomy feeding
tube. These include aspiration,
intolerance to diet, nausea, vomiting, diarrhea, dyspnea,
s/sx of infection, irritation of...- FEEDING TUBE NASOGASTRIC CONTINUOUS FEEDING
Potential for complications from nasogastric feeding
tube. These include aspiration,
intolerance to diet, nausea, vomiting, diarrhea, dyspnea
and irritation of the nares....- FEEDING TUBE TEACHING FOR DISCHARGE.
The patient is on continuous feeding with a pump. Patient
is being discharged home with a family caregiver.
Caregiver has a knowledge deficit regarding patients
feeding tube....- FEEDING TUBE VIA GASTRO FEEDINGS BOLUS
FEEDING TUBE
Potential for complications from feeding tube. These
include aspiration, intolerance to diet, nausea, vomiting,
diarrhea, dyspnea, s/s of infection, irritation of stoma
site
...- FLUID VOLUME DEFICIT
Patient has fluid volume deficit due to:...- FLUID VOLUME EXCESS
Patient has excessive fluid volume (hypervolemia) due to
(put in diagnosis such as Congestive heart failure,
nephrotic syndrome, cirrhosis of the liver ect)....- GASTRIC OUTLET OBSTRUCTION
Patient has a diagnosis of gastric outlet obstruction due
to (put in cause)
At risk for bleeding, pain, nausea and vomiting...- GASTROESOPHAGEAL REFLUX DISEASE (GERD)
Patient has a diagnosis of GERD. At risk for esophagitis,
pneumonia, esophageal stricture, ulceration and possible
fistula, Barretts esophagus which increases the risk of
adenocarcinoma and asp...- GASTROINTESTINAL HEMORRHAGE ( GI BLEED)
Patient has a dx of GI bleed. At risk for shock....- GOUT
Patient has a diagnosis of gout.
Patient is at risk for activity intolerance,
acute pain impaired physical mobility and
impaired nutrition, more than body requirements
Assessment: Acute gout, u...- GROOMING SELF CARE DEFICIT
Patient has impaired ability to perform or complete
dressing and grooming activities for self due to a
diagnosis of Dementia....- H PYLORI
H.Pylori bacteria is present in the stomach causing
peptic ulcers
Excessive gastric acids irritate gastric lining
Noncompliance with needed Lifestyle Changes
...- HEAD INJURY
Patient has sustained a closed head injury.
At risk for increased ICP, pain, hyperthermia,altered
tissue perfusion, impaired motor and sensory function,...- HEMOLYTIC ANEMIA
Patient has a diagnosis of hemolytic anemia.
At risk for activity intolerance, altered nutrition, less
than body requirements and self care deficit due to
weakeness....- Hepatitis C
At risk for altered nutrition, less than body requirements
due to anorexia, nausea & vomiting...- HEPATITIS C
Patient is at risk for activity intolerance due to
generalized weakness, fatigue. lack of endurance...- HEPATITIS C
Patient has a diagnosis of Hepatitis C. Patient is at risk
for altered nutrition, pain and altered level of comfort,
infection,anxiety, altered level of activity...- HERPES ZOSTER - SHINGLES
Patient is at risk for altered comfort level due to pain
from shingles. Also may experience headache and fever.
At risk for complications from infection....- HPOTHYROIDISM
Resident has a diagnosis of Hypothyroidism....- HUGHES SYNDROME
...- HYPERCHOLESTEROLEMIA
Patient has a diagnosis of hypercholesterolemia and is at
risk for heart attack and cardiac disease.
Patient has a knowledge deficit about causes, prevention
and treatment of hypercholesterolem...- HYPEREMESIS
Patient is having hyperemesis.
Patient is at risk for fluid volume deficit, altered
nutrition, less than body requirements, weight loss,
anxiety and weakeness....- HYPERKALEMIA
Patient has been diagnosed with hyperkalemia.
Complications include dangerous cardiac arrhythmias
including cardiac arrest....- HYPERLIPIDEMIA
Patient has been diagnosed with hyperlipidemia. At risk
for atherosclerosis, coronary heart disease...- HYPERSEXUALITY AND PARAPHILIA
Patient exhibits inappropriate sexual behaviors
Physical harm and medical risk for other
...- HYPERTENSION
Resident has a diagnosis of hypertension. Potential for
complications such as renal
failure, congestive heart failure, stroke, cardiovascular
arteriosclerotic disease
and retinopathy....- HYPERTHERMIA
Patient has a body temperature of >39 C, hot flushed skin,
increased pulse and respirations, hypotension,
diaphoresis, possible dehydration and electroylte
imbalance.
Risks/Related factors: ex...- HYPONATREMIA
Patient has a diagnosis of Hyponatremia related to (put in
cause such as vomiting, diarrhea, burns, surgery, fluid
overload, SIADH). ...- HYPOTENSION
Patient has hypotension (systolic below 90 and diastolic
below 60).
at risk for complications such as shock, organ failure and
wide spread ischemia...- HYPOTHERMIA
Patient has shivering, lethargy, cyanotic nail beds, cool
skin, hypertension, slow capillary refill,arrhythmias,
body temperature < 35 degrees C. (95F).
Risk/related factors include prolonged e...- IDIOPATHIC THROMBOCYTOPENIA PURPURA
Patient has been diagnosed with idiopathic
thrombycytopenia purpura.
Patient is at risk for complications of:
spontaneous cerebral hemorrhage
severe epistaxis
hemorrhage from GI tract or urinar...- ILEOSTOMY
Patient had recent surgery for colo-rectal cancer and now
has an ileostomy.
Patient is at risk for impaired skin integrity and body
image disturbance....- IMMUNOSUPRESSION DUE TO SIDE EFFECTS OF CHEMOTHERAPY
Patient is receiving (put in name of drugs)
Patient is at risk for infection due to immunosupression
side effect of the drugs....- IMPAIRED ADJUSTMENT
Patient has inability to modify lifestyle/behavior in a
manner consistent with changes in health status.
Patient denies change of health status.
Failure to take actions to prevent further heal...- IMPAIRED COPING SKILLS DUE TO LOSS OF INDEPENDENCE
Patient is elderly, confused, malnourished, unable to
continue living independently and having difficulty coping
with loss of independence. Placement will be forthcoming....- IMPAIRED MOBILITY
Patient has impaired mobility due to:
List impairments....- IMPAIRED PHYSICAL MOBILITY OF CHILD
Child has limitation in independent, purposeful physical
movement of the body or of one or more extremities due to
delayed developmental disability.
Caregiver/parents display a lack of knowle...- IMPAIRED SPONTANEOUS VENTILLATION
Patient has impaired spontaneous ventilation.
Patient is at risk for injury related to
machine malfunction, accidental
disconnect,increased secretions, inability to
breath unassisted ...- INADEQUATE AIRWAY CLEARANCE
Patient experiences difficulty with airway clearance due
to:
inadequate cough
decreased mobility, fatigue
thick, vicous secretions.
tracheal/pharyngeal edema
side effects from medications su...- INAPPROPRIATE BEHAVIORS
Patient is exhibiting inappropriate behaviors.
Patient can be physically and verbally abusive to staff,
screams and yells out when frustrated....- INAPPROPRIATE SEXUAL BEHAVIOR
Patient exchanging sexual favors for money in a long term
care facility
Patient is delusional that staff and other patients are
part of a conspiracy and are being paid by other patients
for he...- INCARCERATED SCHIZOPHRENIC
Schizophrenic patient is legally committed for
incarceration for life.
...- INCONTINENCE OF BLADDER AND BOWELS
Patient has incontinence of bladder/bowel
Incontinence is intermittent or chronic (delete incorrect
choice)
Incontinence type is stress, overflow, functional or mixed
type. (delete incorrect cho...- INDWELLING CATHETER SUPRAPUBIC
Resident has an indwelling suprapublic catheter and is at
risk for complications of infection...- INDWELLING FOLEY CATHETER
Patient has altered pattern of urinary elimination and has
an indwelling catheter. Patient is at risk for UTI....- INEFFECTIVE BREATHING PATTERN- SLEEP APNEA
Ineffective breathing pattern related to Obstructive Sleep
Apnea Syndrome.
Patient is DD with dx of Obstructive Sleep Apnea. A CPAP
was not ordered due to compliance issues....- INEFFECTIVE COPING DUE TO LOSS OF VISION
Patient has recently loss sight and is in denial about
loss....- INEFFECTIVE COPING SKILLS
Patient has ineffective coping skills related to (put in
diagnosis )and inadequate support system....- INEFFECTIVE ROLE PERFORMANCE
Patient is exhibiting patterns of behavior and self
expression that do not match the environmental context,
norms and expectation.
Patient is (Put in specific behaviors and diagnosis
relevant...- INEFFECTIVE THERMOREGULATION
Ineffective thermoregulation related to immaturity of
neuroendrocrine system. Characteristics include decreased
body temperature, hypoglycemia, decreased respirations,
bradycardia, restlessness...- INFLUENZA
Patient has influenza and is at risk for:
Fluid volume deficit due to vomiting and diarrhea
Altered comfort level due to malaise, pain, fever and
nausea...- INSOMNIA
Resident has been experiencing difficulty with sleeping.
wakes up frequently during the night, has difficulty
initially falling asleep, wakes up very early in the
morning and cannot fall back asl...- INSUFFECIENT BREATHING CAPACITY
Insufficient Breathing Capacity due to the Dx of...- INTERMITTANT CLEAN CATHETERIZATION CARE PLAN
Patient has a diagnosis of (put dx here) and requires
intermittant clean catherizations.
At risk for infections....- INTESTINAL OBSTRUCTION
Patient has been diagnosed with intestinal obstruction.
At risk for pain due to abdominal distension and increased
peristalsis.
At risk for fluid volume deficit due to vomiting and
decrease in i...- KIDNEY STONES
Patient has diagnosis of kidney stones.
...- KIDNEY STONES-PAIN
Altered comfort level due to pain from kidney stone...- LEFT SIDED HEART FAILURE - ACTIVITY INTOLERANCE
Patient has a dx of left sided heart failure.
At risk for activity intolerance related to
imbalance between oxygen supply and demand....- LEFT SIDED HEART FAILURE-IMPAIRED GAS EXCHANGE
Patient has a dx of left sided heart failure
At risk for impaired gas exchange...- LIVER FAILURE - ALTERED NUTRITION
Altered nutrition, less than body requirements due to
anorexia, nausea and decreased metabolism of nutrients by
the liver....- LIVER FAILURE - BREATHING IMPAIRMENT
Patient has ineffective breathing pattern related to
pressure on diaphragm from acites, decreased lung
expansion and pleural effusion from excessive fluid volume....- LIVER FAILURE - IMPAIRED SKIN
Patient has impaired skin integrity related to acites,
edema and pruritus. Potential for broken areas....- LIVER FAILURE - KNOWLEDGE DEFICIT
Patient has knowledge deficit resulting in poor
therapeutic regimen management demonstrated by non
compliance and unhealthy life style with history of both
alchol and substance abuse....- LIVER FAILURE - RISK OF INFECTION
Patient is at risk for infection due to leukopenia,
altered resistance to disease....- LIVER FAILURE - SELF CARE DEFICIT
Patient has a self care deficit due to weakness and
fatigue....- LIVER FAILURE -RISK OF ENCEPHALOPATHY
Patient is at risk for hepatic encephalopathy due to build
up of ammonia and aromatic amino acids....- LUPUS ERYTHEMATOSUS
Patient has a diagnosis of Lupus and is at risk for acute
exacerbation with symptoms of fever, pain, joint
inflammation, altered nutritional status, limited
mobility, fatigue and impaired skin i...- LUPUS-FATIGUE
Patient has a diagnosis of Lupus and has fatigue related
to disease process. Patient has altered level of comfort
due to fatigue and is unable to maintain ususal
routine and activities of daily ...- LUPUS-IMPAIRED SKIN INTEGRITY
Patient has a diagnoses of Lupus erythematosus. Patient is
at risk for the skin related manifestations of "butterfly
rash" with erythema and edema, Alopecia, discoid lesions,
ring shaped lesions...- LUPUS-PAIN
Patient has diagnosis of Lupus. Patient has altered level
of comfort due to pain....- MANIC BEHAVIOR RELATED TO BIPOLAR DISORDER
Poor impulse control causing risk for violence
hyperactivity, recklessness, racing thoughts,
distractability, grandiosity, and poor
concentration resulting in intrusive and irrational speech
...- MECHANICAL VENTILATION-ANXIETY
Patient has anxiety related to dependence on
mechanical ventilation, inability to
communicate, possible machine malfunction and
fear of death...- MECHANICAL VENTILATION-NUTRITION
Patient is receiving mechanical ventilation.
Potential for nutrition less than body
requirements due to inability to consume food PO...- MESENTERIC ARTERY DISEASE - ACUTE
Problem: Insufficient Tissue Perfusion to the Intestines, Spleen and Liver...- MESENTERIC ARTERY DISEASE -CHRONIC
Problem: Insufficient Tissue Perfusion to the Intestines, Spleen and Liver...- MIGRAINE HEADACHES
Prevention of H/A
Pain
Inability to avoid triggers for H/A...- MITRAL VALVE PROLAPSE
Patient has decreased cardiac output due to a diagnosis oF Mitral Valve Prolapse
Regurgitation
Ineffective Breathing
Increased agitation and confusion...- MONITOR FOR HEMODIALYSIS PATIENT
DIALYSIS DEPENDENT
Resident has ESRD, is Hemodialysis dependent and is at
risk for complications from
Hemodialysis. Complications include bleeding, graft
clotting and infection....- MOOD GRIEVING DUE TO TERMINAL ILLNESS
MOOD, PSYCHOSOCIAL WELL BEING, EMOTION STATUS
Grieving due to dx of terminal illness. Resident is
exhibiting social isolation, withdrawal,
denial, anger, change in eating habits, change in sle...- MOOD REFUSES THERAPY AND VERVALLY ABUSIVE
MOOD AND BEHAVIOR
Resident displays anger with self and others, is verbally
abusive and is resistive to care at times.
Often refuses to participate in therapy. He has an hx of
depression an...- MOOD - GRIEF DUE TO TERMINAL ILLNESS
Patient/resident/client has been diagnosed with a terminal
illness.(may insert dx here). Has been exhibiting
withdrawl, social isolation, denial, anger, change in
eating habits, change in sleep...- MOOD AND BEHAVIOR
Resident displays repetitive verbalizations, self
deprecation, repetitive physical movements and mood
persistence. Has a history of Depression....- MOOD AND BEHAVIOR RELATED TO SPIRITUAL NEEDS
MOOD AND BEHAVIOR: Spiritual Distress & Suffering
...- MOOD AND BEHAVIOR DUE TO HOPELESSNESS
MOOD AND BEHAVIOR;
Feelings of Hopelessness related to depression
...- MOOD AND BEHAVIOR DUE TO ANXIETY
MOOD AND BEHAVIOR:
Anxiety : Exhibits s/s of anxiety to times per
day/ week...- MOOD AND BEHAVIOR DUE TO BORDERLINE BEHAVIOR AND SUICIDAL IDEA
MOOD AND BEHAVIOR: related to mood swings, angry
outbursts, attempts to cause tension between staff, poor
impulse control, and suicidal gestures and other attempts
to harm self.
...- MOOD AND BEHAVIOR RELATED TO SELF ESTEEM
MOOD AND BEHAVIOR; Low self esteem...- MOOD AND BEHAVIOR RELATED TO ALTERED SLEEP PATTERNS
MOOD & BEHABIOR:
Sleep Pattern Disorder related to intermittent awakening
...- MOOD AND BEHAVIOR RELATED TO BORDERLINE
MOOD AND BEHAVIOR: Borderline personality
related to mood swings, angry outbursts and attempts to
cause tension between staff, poor impulse control,....- MOOD AND BEHAVIOR RELATED TO DEPRESSION
MOOD & BEHAVIOR:
Patient is exhibiting signs and symptoms of depression on
a daily basis. These include lethargy, anxiety, sad mood,
easily angered, unable to enjoy usual activities, social
i...- MOOD AND BEHAVIOR RELATED TO POWERLESSNESS
MOOD & BEHAVIOR ; Feelings of powerlessness over life
circumstances...- MOOD STATE ADJUSTMENT TO NURSING HOME
MOOD STATE
Adjustment problems.Resident is unhappy over placement in
nursing home. Makes negative statements, persistent anger
with self and others, repetitive health complaints,
reduced soc...- MOOD STATE GRIEF
MOOD
Grieving due to death of (spouse, parent, friend ect.)
Has had episodes of crying and sadness daily.
...- MRSA INFECTION CONTROL
Patient is at risk for infection from MRSA from colonized
site (usually the nose or skin )to site with breaks in
skin such as surgical wounds, bed sores, tubes such as
urinary cathethers, burns....- MUCOSITIS
Patient has developed mucositis from chemo/radiation
therapy. Patient at risk for altered comfort due to
pain,infection and risk for hemorrhage. Patient could
experience difficulty with eating,...- MUSCULAR DYSTROPHY CARE PLAN
DX OF MUSCULAR DYSTROPHY...- MYOCARDIAL INFARCTION
Patient has been diagnosed with unstable MI. Patient is
at risk for complications of infarct extension or
reoccurence, diminished cardiac output, heart failure,
pain, life threatening arrhythmi...- MYOCARDIAL INFARCTION - Decreased cardiac output
Patient has inadequate blood pumped by the heart to meet
metabolic demands of the body related to reduced
myocardial perfusion.
...- NANDA- ACTIVITY INTOLERANCE
Patient is at risk for activity intolerance due to:
Deconditioned status
Presence of circulatory problems
Presence of respiratory problems
History of previous intolerance...- NAUSEA AND VOMITING FROM CHEMO AND OR RADIATION
Patient is experiencing nausea and vomiting from
chemotherapy/radiation...- NECROTIZING FASCITIS
Patient has developed necrotizing fascitis due to:
Defining characteristics: trauma or skin opening, pain,
swelling, flu like symptoms, dehydration, symptoms worsen,
may have rash or blisters ...- NEUTROPENIA
Patient has a risk for infection related to neutropenia
secondary to treatment
Assessment: Because of the lack of neutrophils to produce
the usual inflammatory response to infection such...- NEW COLOSTOMY
Patient had a diagnosis of ______________.
Patient has just had surgery for a colostomy. Patient is
at risk for:
Impaired skin integrity
Impaired comfort level
Post op complications such as inf...- NEWBORN ASSESSMENT
The first 24 hours of life following birth is
the most critical period for the infant.
Careful assessment is vital to identify any
problem areas;
Infant is at risk for altered respiratory,
circul...- NON COMPLIANCE - MEDICATION
Patient is non compliant with medication regimen due to:
Choose from list of reasons, delete incorrect ones.
Misinformation or confusion about medication
Lack of information regarding current state...- NONCOMPLIANCE WITH TREATMENT REGIEMEN
Patient (and family members) are noncompliant related to
patients value system.
...- NUTRITION DIMINISHED APPETITE
NUTRITIONAL STATUS
Potential for poor nutrition due to:
Diminished appetite leaves 25% or more of food uneaten at
most meals.
...- NUTRITION DECREASE APPETITE WITH SPECIAL DIET
NUTRITIONAL STATUS
Potential for poor nutrition due to:
Diminished appetite leaves 25% or more of food uneaten at
most meals. Resident is also on a therapeutic diet.
...- NUTRITION DECREASED APPETITTE NEEDS SUPERVISION
NUTRITIONAL STATUS
Potential for inadequate nutrition due to:
Diminished appetite leaves 25% or more of food uneaten at
most meals.
Resident is on a therapeutic diet.
Resident is on a mechanic...- NUTRITION FOR WEIGHT REDUCTION
NUTRITIONAL STATUS
Resident is overweight and desires to be put on a weight
reduction program
.
...- NUTRITION WITH NONCOMPLIANCE
NUTRITIONAL STATUS
Potential for poor nutrition due to:
Diminished appetite leaves 25% or more of food uneaten at
most meals. Is on a therapeutic diet and is noncompliance
with diet. Gets sn...- NUTRITION H X OF MALNUTRITION
NUTRITIONAL STATUS
Poor nutrition less than body requirements. Diminished
appetite leaves 25% or more of food uneaten at most meals.
Resident has a hx of malnutrition.
...- NUTRITION LESS THAN BODY REQUIREMENTS FOR CHILD
Child has exhibited a change in eating patterns resulting
in nutrition less than body requirements.
Contributing factors to change of eating patterns are:
(List reasons, such as chemotherapy, de...- NUTRITION WITH MECHANICAL DIET
NUTRITIONAL STATUS
Potential for poor nutrition due to: Patient is on a
mechanically altered diet. Has difficulty chewing food.
...- NUTRITIONAL NEEDS WITH DECUBITUS ULCER
NUTRITIONAL STATUS
Potential for inadequate nutrition due to:
Diminished appetite leaves 25% or more of food uneaten at
most meals.
Has special nutritional needs due to decubitus ulcers.
...- NUTRITON NONSPECIFIC
NUTRITIONAL STATUS
Potential for altered nutrition due to:
...- OB-GYN POSITIVE MSAFP FOR DOWNES SYNDROME
Resident is experiencing anxiety due to positive results
of MSAFP for Downes Syndrome...- OB-GYN POSTPARTUM CARE-NORMAL VAGINAL DELIVERY
Patient has just delivered a normal healthy infant. At
risk for complications of vagainal delivery such as
pain, abnormal blood loss, infection, urinary retention
and constipation....- OB-GYN GESTATIONAL DIABETES
Patient has a diagnosis of gestational diabetes mellitus.
Patient is at risk for hypertension, preeclampsia, UTIs,
and diabetes in the future....- OB-GYN HYPERBILIRUBINEMIA IN NEWBORN INFANT
Infant has been diagnosed with hyperbilirubinemia. Infant
is at risk for complications of infection, decreased
cardiac output, poor nutritional status, altered level of
consciousness and impai...- OBESITY - NUTRITION MORE THAN BODY REQUIREMENTS
Patient is morbidly obese due to excessive intake of food.
Obesity increases risk for cardiovascular disease,
pulmonary problems, diabetes and decreased physical
activity. Patient is at risk for...- OLGIVIES SYNDROME
Patient has been diagnosed with Olgivies syndrome.
At risk for compllications of ischemic injury, perforation
of cecum and peritonitis....- ORTHOPEDICS - AC JOINTSEPERATION
Patient has suffered AC joint seperation due to trauma and
had an open reduction. At risk for infection, inadequate
maintenance of immobilization, skin impairment decreased
mobility and pain...- ORTHOPEDICS - HANGING ARM CAST
Patient has a hanging arm cast due to fx of humerus.
At risk for pain and discomfort due to trauma and
immobility, impaired mobility, impaired skin integrity,
altered nutrition, ineffective copin...- ORTHOPEDICS - KNEE ARTHROSCOPY
Patient has sustained a sports injury of the knee and
requires arthroscopic surgery. At risk for complicatins
of infection, embolus and pain....- ORTHOPEDICS - LONG LEG CAST
Patient has long leg cast for closed reduction of (put in
name of fx).
Patient is at risk for pain and discomfort due to trauma
and immobility.
At risk for impaired physicial immobility, impaire...- ORTHOPEDICS - ROTATOR CUFF REPAIR
Patient had surgical repair of a torn rotator cuff.
Patient is at risk for pain and discomfort, impaired
mobility, reduced functional use of shoulder-elbow join
and infection....- ORTHOPEDICS - SHOULDER ARTHROPLASTY
Patient has just had a should arthroplasty due to injury.
Patient is at risk for uncontrolled pain, impaired
mobility, infection, neurovascular damage and loosening or
failure of the prosthesis....- ORTHOPEDICS - SPRAIN OF ANKLE
Patient has sustained a sprain of the ankle due to
trauma. Is at risk for pain , edema, impaired mobility
and muscle spasms...- ORTHOPEDICS- SLAP REPAIR
Patient had slap repair due to injury. Patient is at risk
for pain and discomfort, impaired mobility, self care
deficit and neurological injury...- ORTHOPEDICS- TOTAL KNEE REPLACEMENT
Patient had a total knee replacment due to dx of
(osteoarthritis, trauma, infection). Patient is at risk
for complications of hemorrhage, infection,
thrombophlebitis, pneumonia, fat embolus, a...- OSTEOMYELITIS
Patient has a diagnosis of osteomyelitis in (name of site).
Patient is at risk for altered comfort level due to pain,
edema, fever, transmission of infection, impaired mobility
and ability to do ...- OSTEOPOROSIS
Patient has a diagnosis of Osteoporosis. Is a high risk
for fractures....- PACEMAKER
Patient has a pacemaker due to arrhythmias.
Patient is at risk for complications from malfunction of
the pacmaker. May experience dizzieness, syncope, dyspnea
or chest pain....- PAIN MANAGEMENT ACUTE PAIN NON VERBAL RESIDENT
PAIN MANAGEMENT
Resident has acute pain due to
...- PAIN MANAGEMENT ACUTE PAIN VERBAL RESIDENT
PAIN MANAGEMENT
Resident has acute pain due to
...- PAIN MANAGEMENT CHRONIC PAIN NON VERBAL RESIDENT
PAIN MANAGEMENT
Resident has chronic pain due to
...- PAIN MANAGEMENT CHRONIC PAIN VERBAL RESIDENT
PAIN MANAGEMENT
Resident has chronic pain due to
...- PALLATIVE CARE FOR END STAGE RENAL DISEASE
Patient has a diagnosis of end stage renal disease and has
elected to discontinue dialysis.
Patient is at risk for : fluid volume overload, impaired
skin integrity, anticipatory grieving related ...- PALLATIVE CARE FOR TERMINAL LUNG CANCER
Patient has a diagnosis of terminial lung cancer. Patient
has anorexia, weight loss, diminished energy level and
chronic pain. Patient is at risk for spiritual distress,
grief from terminal di...- PALLIATIVE CARE
PALLIATIVE CARE
Anorexia and weight loss due to terminal condition. Has
dx of
...- PANCREATITIS - FLUID VOLUME DEFICIT
Patient has a diagnosis of acute pancreatitis. Patient
is at risk for fluid volume deficit due to vomiting,
nausea, restricted oral intake or NPO, and gastric suction
tube.
Other related risks ...- PANCREATITIS - PAIN
Patient has a diagnosis of acute pancreatitis and is at
risk for altered comfort level due to pain (may be related
to abdominal distension, ileus, abcess formation,
peritoneal irritation, edema...- PAPILLOMA VIRUS
Patient is at risk for cancer due to a history of human
papilloma virus....- PARKINSONS DISEASE
Patient has a diagnosis of Parkinsons disease. Pt is at
risk for aspiration of food, decreased mobility, bladder
and bowel dysfunction, skin breakdown, depression and
general debilitation...- PAROTITIS
Patient has parotitis
Has altered level of comfort from pain,
absence of saliva...- PAROTITIS
...- PELVIC FRACTURE
Patient has sustained a pelvic fracture resulting from a
fall....- PERIPHERAL VASCULAR DISEASE
Patient has a diagnosis of peripheral vascular disease.
At risk for impaired skin integrity, stasis ulcers, pain,
and an extreme possibility of gangrene....- PERIVENTRICULAR LEUKOMALACIA
Patient has a diagnosis of Periventricular Leukomalacia.
Patient is at high risk for abnormal development. There
is no specific treatment for this condition....- PHYCHOSOCIAL ALTERATIONS
Patient is at risk for phychosocial changes in the elderly.
These include anxiety,ineffective coping,decisional
conflict, fear, grieving, hopelessness, powerlessness,
social isolation, disturbanc...- PICC LINE CARE
Pt has a PICC inserted for future use
Pt is at risk for for complications of
infection, phlebitis or catheter malfunction...- PNEUMONIA
Patient has a diagnosis of Pneumonia.
At risk for complications such as pleural effusion, septic
shock, pericarditis, bacteremia, meningitis, delirium,
atelectasis and delayed resolution....- POSTPARTUM TEACHING
Postpartum patient has a knowledge deficit regarding care
of self and infant....- POTENTIAL FOR FALLS
FALLS
Potential for injury from falls due to:
...- POTENTIAL FOR SIDE EFFECTS FROM PARKINSONS DISEASE DRUGS
Patient has a diagnosis of Parkinsons disease and is
taking Mirapex. Patient has sustained several falls....- POTENTIAL FOR COMPLICATIONS FROM DIALYSIS
DIALYSIS DEPENDENT
Resident has ESRD, is dialysis dependent and is at risk
for complications of dialysis.
...- POTENTIAL FOR DEHYDRATION DEPENDENT FOR HYDRATION
DEHYDRATION
Potential for dehydration due to:
Dependent on staff for hydration needs.Has cognitive and
communication deficits.
...- POTENTIAL FOR DEHYDRATION RECENT UTI
DEHYDRATION
Potential for dehydration due to:
Recent infection had UTI
...- POTENTIAL FOR DEHYDRATION TAKES DIURETIC UTI
DEHYDRATION
Potential for dehydration due to:
Recent infection had UTI
Dependent on staff for hydration needs.
Has cognitive and communication deficits.
Potential for fluid imbalance.
Take...- POTENTIAL FOR FALLS DUE TO MULTIPLE FACTORS
Patient is at risk for falls due to history of
falls, history of Parkinsons disease, severe
osteoarthritis of both knees and shoulder,
resident takes a daily diuretic, Parksinsons
drug and a psych...- POTENTIAL FOR FLUID IMBALANCE DAILY DIURETIC
DEHYDRATION
Potential for fluid imbalance.
Resident takes a daily diuretic.
...- POTENTIAL FOR INJURY FROM FALLS
FALLS
Potential for injury from falls due to:
...- POTENTIAL FOR INJURY FROM FALLS VERSION B
FALLS
Potential for injury from falls due to:
...- POTENTIAL FOR SKIN BREAKDOWN
PRESSURE ULCERS
Potential for skin breakdown. Resident is incontinent of
bladder and bowels, dependent for bed mobility and all
other mobility.
...- PRADER WILLI SYNDROME- SKIN PICKING
Patient is at risk for complications of skin
picking such as infection, chronic non-healing
lesions, lesions requiring a skin graft, nose
bleeding, rectal bleeding, social and hygienic
problems du...- PREGNANCY MORNING SICKNESS
At risk for altered nutrition less than body requirements
due to morning sickness, nausea and vomiting....- PREGNANCY - TOBACCO USE
Patient is a smoker and is pregnant. At risk for
potential harm to self as well as fetus....- PREGNANCY INDUCED HYPERTENSION
High risk of injury for ante partum patient with a
diagnosis of pregnancy induced hypertension.
Complications may include disseminated intravascular
coagulation or HELLP syndrome,prematurity, i...- PREGNANCY RISK FOR ALTERED NUTRITION
Patient is pregnant and at risk for altered nutrition less
than body requirements...- PREGNANCY WEIGHT GAIN
Patient is obese and is pregnant.
At risk for excessive weight gain....- PRESSURE ULCERS
PRESSURE ULCERS
Resident has decubitus ulcers as follows:
...- PROSTATE CANCER
Patient has a diagnosis of prostate cancer. Patient is at
risk for urinary retention, urinary stasis, infection and
altered comfort....- PROSTATE CANCER
Urinary Retention
Urinary Stasis
Risk for Infection
Anxiety
Altered Comfort...- PROSTECTOMY -LASER
Patient has a dx of BPH. Has just undergone laser
prostatectomy
Patient is at risk for complications of infection and
excessive bleeding...- PSORIASIS
Patient has a diagnosis of psoriasis. At risk for skin
infections, emotional distress due to appearance from the
lesions, physican discomfort from pain and itching and
interrupted sleep patter...- PSYCHOTROPHIC DRUG USE ANTIANXIETY AGENT
Potential for adverse effects from daily or PRN use of an
antianxiety agent. Resident
takes...- PSYCHOTROPHIC DRUG USE ANTIDEPRESSANT
Potential for adverse effects from daily use of an
antidepressant. Resident has a Dx of
Depression and takes...- PSYCHOTROPHIC DRUG USE ANTIPSYCHOTIC
Potential for adverse effects from daily use of
antipsychotic medication, takes
Resident has a Dx of...- PSYCHOTROPHIC DRUG USE FOR ZYPREXA
Potential for adverse effects from daily use of Zyprexa
for thinking problems and
agitation....- PULMONARY EDEMA
Patient has a diagnosis of pulmonary edema.
Patient is at risk for respiratory failure.
Patient has a knowledge deficit regarding the disease.
Patient is exhibiting signs and symptoms of fluid volu...- PULMONARY POLYMYOSITIS
Patient has a diagnosis of pulmonary polymyositis. Is at risk for respiratory infections, aspiration pneumonia, and hypoventiliation. ...- PYELONEPHRITIS
Patient has a diagnosis of Pyelonephritis related to:
bacterial infection of the bladder spread to ureters and
kidneys.
urinary obstruction trauma
metabolic disorders
renal disease
pregnancy
...- PYELONEPHRITIS IN INFANTS AND CHILDREN
Impaired Urinary Elimination
Impaired Comfort
Risk for Deficient Fluid Volume...- RADIATION THERAPY- SKIN IMPAIRMENT
Patient is receiving radiation therapy for cancer and is
at risk for impaired skin integrity.
Impairmen could result in erythema, dry desquamation or
wet desquamation...- RENAL FAILURE ACUTE
Patient has a diagnosis of acute renal failure. Is at
risk for infection, fluid volumn disturbance, decreased
physical activity/function and altered nutrition....- REPAIR OF RECTOCELE OR ENTEROCELE
• Anxiety due to fear of surgery
• Acute Pain
• Risk of infection
...- RESTLESS LEG SYNDROME
Patient has been diagnosed with restless leg snydrome.
Patient is at risk for sleep disturbance, fatigue and
exhaustion....- RESTORATIVE AMBULATION
Resident has declined with functional ambulation due to
(put in; diagnosis, condition)
Resident has potential for increased function in
ambulation and will be put in restorative ambulation
prog...- RESTRAINTS POTENTIAL ALTERED COMFORT LEVEL
RESTRAINTS
Potential for alteration in comfort during times
restrained.
...- RHABDOMYOLYSIS
Patient has been diagnosed with rhabdomyolysis due to (put
cause: trauma, crush syndrome, infection, drug abuse,
malignant hyperthermia, seizures, strenerous exercise,
head injury, prolonged co...- RISK FOR OTHER DIRECTED VIOLENCE
Patient demonstrates the risk to physically, emotionally
or sexually harm others....- RISK FOR ACTIVITY INTOLERANCE
At risk for experiencing insufficient physiological or
psychological energy to endure or complete required or
desired daily activities....- RISK FOR ALTERED NUTRITION DUE TO WIRED JAW
Patient has wired jaw due to facial trauma and fractures.
Patient is at risk for altered nutrition, less than body
requirements....- RISK FOR INEFFECTIVE AIRWAY CLEARANCE
Infant is at risk for ineffective airway clearance related
to cesarean delivery....- RISK FOR INFECTION
Post opertative patient is at risk for infection due to
(Choose most appropriate and delete the rest.)
Invasive procedures
Insufficient knowledge to avoid exposure to pathogens.
Trauma
Tissue des...- RISK FOR INJURY FROM VIOLENCE
Patient has been the recent victim of brutal physicial
assault. Patient is at risk for injury/trauma due to
violence in the future due to life style, environment and
substance abuse. ...- RISK FOR POST TRAUMA SYNDROME
Patient is at risk for post traumatic syndrome related to
a physicial assault. Patient may exhibit exaggerated
startle reflex, flashbacks, nightmares panic attacks,
general anxiety, societal wi...- RISK FOR SELF DIRECTED HARM
Individual demonstrates behavior hat he/she will
physically, emotional or sexually harm self...- SACRAL FLAP CLOSURE
Patient has a sacral flap closure due to non healing
decubitus ulcer.
At risk for complications of infection, wound seperation
or wound dihiscense, pulmonary complications, pain and
immobilit...- SCABIES
Patient is at risk for altered level of comfort due to
itching from scabies and is at risk for infection due to
scratching....- SCHIZOPHRENIA WITH DELUSIONS OR HALLUCINATIONS
Resident is unable to distinguish reality from
hallucinations and /or delusions
...- SEIZURE ACTIVITY
SEIZURE DISORDER
Potential for injury due to seizure disorder.
...- SELF ADMINISTRATION OF MEDICATIONS
Resident has requested to execute his right to
self administer medication(s)...- SEPSIS
Sysemic inflammatory response syndrome resulting from...- SEXUAL DISINHIBITION
Patient exhibits unwelcome inappropriate sexual behaviors
towards another male patient....- SEXUAL DISINHIBITION-INAPPROPRIATE TOUCHING
Patient exhibits unwelcome inappropriate sexual behaviors
towards another patient.
...- SEXUALLY TRANSMITTED DISEASES
Patient is sexually active and has expressed a knowledge
deficit regarding transmission, risks, symptoms and
treatments of sexually transmitted diseases...- SICK SINUS SYNDROME
Patient has a diagnosis of sick sinus syndrome. (abnormal
heart rate, could have bradycardia or tachycardia)
Patient is at risk for heart failure, falls from fainting
and inadequate cardiac outpu...- SICKLE CELL ANEMIA
SICKLE CELL ANEMIA
Potential for complications of Sickle cell anemia....- SIDE RAILS
Patient no longer is cognizant of the boundaries of the
bed and must have side rails for protection from falls or
injury....- SINUSITIS
Inflammatory Reaction Resulting from
...- SKIN TEARS
Potential for skin tears due to aging, fragile skin...- SLEEP ANPNEA WITH CPAP
• Ineffective Breathing pattern is due to the airway closes, breathing stops and the
sleeper awakens to open the airway.
• Disturbed Sleep Pattern from brief arousals that disrupt continuous sleep...- SMOKING CESSATION
Resident is dependent on Tobacco products...- SPIRITUAL DISTRESS
At risk for spiritual distress due to cognitive mpairment,
fear, grief,institutionalization, social isolation,disease,
depression, change is relationships, quality of life,
unresolved conflict, i...- STASIS ULCERS POTENTIAL FOR COMPLICATIONS
STASIS ULCER
Resident has statsis ulcers on
Has dx of Diabetes Mellitus and hx of skin impairments.
...- STERILE CATHERIZATION CARE PLAN
Patient has a dx of (here put the specific diagnosis ie
neurogenic bladder ect) and must be catherized q ___
hours. Patient is at risk for infection...- STICKY BLOOD OR HUGHES SYNDROME
Patient has been diagnosed with Hughes syndrome also
known as sticky blood or antiphospholipid syndrome.
Patient is at risk for complications of Hughes syndrome
which includes both venous and a...- SUBSTANCE ABUSE - RISK FOR RELAPSE
Client has hx of substance abuse and is in treatment
program. Client is at risk for non compliance and relapse....- SUBSTANCE ABUSE -ALTERED HEALTH
Patient is at risk for altered health maintanence due to
lack of knowledge regarding useof illicit drugs and/or
alcohol on health, nature and progression of addiction,
effects of addiction on bo...- SUBSTANCE ABUSE- INEFFECTIVE DENIAL
Ineffective denial.
Patient refuses to acknowledge dependence on drugs and/or
alcohol and is unable to admit impact of dependence on
life pattern and health....- SUPRAPUBIC CATHETER
Patient has a suprapubic catheter. Is at risk for
infection....- SYNCOPE
Patient has a history of syncope.
Patient is at risk for injury from fall...- TETRALOGY OF FALLOT
Patient has a diagnosis of Tetralogy of Fallot.
Patient is at risk for failure to thrive, gain weight,
become dyspnic on exertion and at risk for
tetralogy "spells" (hypoxia)....- THROMBOCYTOPENIA
Patient has thrombocytopenia and is at risk for fatigue,
activity intolerance, compromised skin integrity related
to interventions, trauma, injury, infection and hemorrhage...- THRUSH (CANDIDIASIS)
Patient has a diagnosis of thrush. Patient is at risk for
insufficient nutrition, spread to the GI tract, lungs,
skin or other areas....- TOTAL HIP ARTHROPLASTY
Patient had a total hip arthroplasty due to end stage
osteoarthritis.
Patient is at risk for complications such as wound
infection, hip dislocation, shock, neurovascular
impairment, urinary ret...- TOTAL HIP ARTHROPLASTY - NANDA
Patient has just had a total hip arthroplasty.
Patient is at risk for:
Pain and alter comfort level from surgery and immobility
Impaired physicial mobility
Anxiety related to knowledge deficit of ...- TPN (TOTAL PARENTERAL NUTRITION)
Patient is receiving TPN due to (put in diagnosis here)
via a central line.
Patient is at risk for weight loss due to altered
nutrition, electrolyte imbalance, fluid volume imbalance
glucose in...- TRACHEOSTOMY CARE POTENTIAL FOR COMPLICATIONS
TRACHEOSTOMY
Resident has tracheostomy. At risk for infection,
ineffective airway clearance impaired
gas exchange
...- TRANSIENT ISCHEMIC ATTACKS
Patient has been diagnosed with transient
ischemic attacks.
Patient is at risk for confusion, impaired
memory, impaired environmental interpretation
syndrome, impaired sensory perception and
inef...- UPPER RESPIRATORY INFECTION
Patient has an upper respiratory infection. At risk for
complications such as sinusitis, pneumonia, bacteremia.
...- URINARY INCONTINENCE
URINARY INCONTINENCE
Altered in patterns of urinary incontinence. Resident has
declined to the point of being
totally incontinent.
...- URINARY INCONTINENCE AND PRESSURE ULCERS
URINARY INCONTINENCE AND PRESSURE ULCERS
Potential for impaired skin integrity due to incontinence
and limited mobility.
...- URINARY INCONTINENCE AND PRESSURE ULCERS I
URINARY INCONTINENCE AND PRESSURE ULCERS
Potential for impaired skin integrity due to incontinence
and limited mobility.
...- URINARY INCONTINENCE VERSION TWO
URINARY INCONTINENCE
Altered in patterns of urinary incontinence. Resident has
declined to the point of being totally incontinent.
...- URINARY INCONTINENCY - RETRAINING Version 2
Patient is incontinent of urine due to (put in diagnosis
or cause if known)
Patient is at risk for skin impairment or psychological
problems due to incontinence....- URINARY RETENTION
Patient has urinary retention due to (put diagnosis here).
Patient requires intermittant catherizations scheduled
every ___ hours.
Patient is at risk for urinary tract infections....- URINARY TRACT INFECTION
Patient has a diagnosis of urinary tract infection. At
risk for recurrent UTIs, urosepsis or renal damage....- UROSEPSIS
• Acute Pain and Discomfort
• Impaired urinary elimination
• Sexual dysfunction
...- VERTIGO
Patient has been experiencing episodes of vertigo. Is at
risk for injury due to fall from vertigo....- VICTIM OF INAPPROPRIATE TOUCHING
Patient is victim of unwelcome inappropriate sexual behaviors from another patient
Patient experiences post-trauma response....- VISION BLINDNESS
VISION
Resident is legally blind
...- VISION IMPAIRED DUE TO CATARACTS
VISION
Resident has highly impaired vision due to cataracts.
...- VISION IMPAIRED DUE TO CATARACTS
VISION
Resident has highly impaired vision due to cataracts.
...- VISION IMPAIRED DUE TO DIABETIC RETINOPATHY
VISION
Resident has highly impaired vision due to diabetic
retinopathy
...- VISION IMPAIRED DUE TO GLAUCOMA
VISION
Resident has highly impaired vision due to glaucoma.
...- VISION IMPAIRED DUE TO HEMIANOPIA
VISION
Resident has highly impaired vision due to hemianopia (can
only see half of visual
field.)
...- VISION IMPAIRED DUE TO MACULAR DEGENERATION
VISION
Resident has highly impaired vision due to macular
degeneration
...- VISUAL DECLINE
Patient has a dx of(put in appropriate diagnosis) and is
experiencing a visual decline.
Patient is at risk for injury and self care deficit....- WANDERING BEHAVIOR
WANDERING BEHAVIOR
Resident exhibits behavior of wandering with no rational
purpose and is at risk for elopement.
...- WOUND CARE FOR GROIN ABSCESS
Patient is diabetic and morbidly obese and has developed
an abscess on his groin. Patient has had and I & D and
has a closed drain system. At risk for complications of
further spread of infect...- WOUND VAC CARE PLAN
Resident has a stage 4 decubitus ulcer (Put dementions) on
(name site). Will need wound vac as other modalities have
failed...
...- SEPTIC SPONTANEOUS ABORTION
Patient had a spontaneous abortin complicated by infectin.
Patient is at risk for complications of PID, Peritonitis,
Hemorrhage and Septic shock. ...- -FAILURE TO THRIVE
Patient is experiencing progressive functional(add
cognitive if appropriate) deterioration due to diagnosis
of _______________________.
ASSESSMENT: Presence of anorexia, inadequate food intake,...- ALTERED NUTRTION LESS THAN BODY REQUIREMENTS
Patient has altered nutrition less than body requirements
due to a diagnosis of( put in diagnosis)
ASSESSMENT: Height, weight, serum albumin level, total
protein level, food allergies and tol...- ALTERED TISSUE PERFUSION
Patient has altered tissue perfusion due to:
Example:
Blood loss from surgery, hypovolemia....- ALZHEIMERS-IMPAIRED COMMUNICATION
Patient has impaired communication skills due to a dx of
Alzheimers. Patient has both receptive and expressive
communication deficits. He/She has difficulty
understanding what is being said as ...- ALZHEIMERS-IMPAIRED THOUGHT PROCESSES
Patient has an impaired level of cognitive function, both
long and short term memory deficits,impaired decision
making skills, problem solving skills, impaired ability to
comprehend what is bei...- ALZHEIMERS-RISK FOR INJURY
Patient has a dx of Alzheimers and is at risk for injury
from falls due to lack of awareness of environmental
hazzards. Patient is forgetful and has impaired safety
judgment....- ALZHEIMERS-SELF CARE DEFICIT
Patient has a diagnosis of Alzheimers dementia. Patient
has a self care deficit due to impaired cognitive
function. (Add physical also if relevant)...- CABG-Decreased cardiac output
Pt has coronary artery disease and is
scheduled for a CABG.
Patient is at risk for decreased cardiac
output due to hypothermia, recovery from
general anesthesia and complications such as
arrhythm...- CHRONIC LOW SELF ESTEEM
Patient has longstanding negative self evaluation/feelings
about self or self capabilities. Patient has severe
depression....- CONGESTIVE HEART FAILURE-ACTIVITY INTOLERANCE
Patient has an activity intolerance due to
CHF. patient is experiencing shortness of
breath and extreme fatigue from simple activity
Assessment: Pulse, respirations, B/P, dyspnea
at rest and wi...- CONGESTIVE HEART FAILURE-EXCESS FLUID VOLUME
Patient has excess fluid volume due to
congestive heart failure.
Assessment: Abdominal girth, heart sounds,
pulse, B/P, lung sounds, respirations, skin
color, temperature, turgor, intake and ou...- CRANIOTOMY-CRANIECTOMY-POST OP-tissue perfusion
Patient is at risk for ineffective tissue
perfusion related to edema or bleeding ...- CRANIOTOMY-CRANIOECTOMY-ALTERED COGNITION
Risk for altered thought processes due to
neurological changes secondary to edema or
surgical excision of part of brain or tumor...- CRANIOTOMY-CRANIOECTOMY-INFECTION
At risk for post op infection related to
presence of incision, drains, invasive
monitoring devices and environmental pathogens...- CRANIOTOMY-CRANIOECTOMY-SELF CARE DEFICIT
Patient has a self care deficit due to altered
level of consciousness, weakness, post op status...- CVA-IMPAIRED MOBILITY
Patient has had a recent CVA with (left or right)
hemiparesis.
Patient has a self care deficit and is at risk for
contractures and impaired skin integrity....- CVA-IMPAIRED THOUGHT PROCESS
Patient has had a CVA and has cognitive deficits.
Patient has impaired judgment, reasoning abilitly, long
and short term memory and comprehension....- CVA-IMPAIRED VERBAL COMMUNICATION
Patient has recently had CVA.
Has the following impairments:
Add your own or delete what does not apply.
word finding difficulty
slurred speech
dysarthria
aphasis receptive
aphasia expressive
...- DIABETES - KNOWLEDGE DEFICIT
Knowledge deficit relating to difficulty understanding the
disease process of Diabetes and its effect on general
health and self care....- DIABETES MELLITUS-NONCOMPLIANCE
Patient is an insulin dependent diabetic and is resistive
in adhering to her diet.
Patient is non compliant with treatment regimen...- DISTURBED SENSORY PERCEPTION -VISUAL
Patient has a diagnosis of _________________ (Put in
appropriate dx such as Macular Degeneration.
Patient has disturbed sensory perception....- DISTURBED SENSORY PERCEPTION -VISUAL
Patient has a diagnosis of _________________ (Put in
appropriate dx such as Macular Degeneration.
Patient has disturbed sensory perception....- DISTURBED SLEEP PATTERN
Patient has time limited disruption of sleep
amount and quality.
ASSESSMENT: Past and current sleep patterns,
sleeping environment, quality of sleep,
identify factors that may interfere with
r...- EXCESSIVE FLUID VOLUME-ESRD
Patient has a diagnosis of end stage renal
disease.
Patient has fluid and electrolyte imbalance.
Assessment: Cardiovascular: heart sounds,
rate, rhythm, blood pressure, EKG changes
indicati...- FLUID VOLUME DEFICIT
Patient has fluid volume deficit Post op due to:
NPO status
intraoperative blood loss
(May add other causes or delete these and add causes of
choice)...- FLUID VOLUME EXCESS
Patient has fluid volume excess due to diagnosis of CHF....- HEMOTHORAX -IMPAIRED GAS EXCHANGE
Patient has a hemothorax. At risk for
impaired gas exchange related to a deficit in
oxygenation
Assessment: History of recent trauma,
Neurological status: including level of
consciousness, ori...- HEMOTHORAX-ANXIETY
Patient has a hemothorax and is at risk for anxiety due to
situational crisis
Assessment:
Neurological: LOC, mentation, orientation, judgment,
insight
Support systems: Family, friends, cl...- HEMOTHORAX-INEFFECTIVE TISSUE PERFUSION
Patient has been diagnosed with a hemothorax and is at
risk for ineffective tissue perfusion related to decreased
cellular exchange,hypovolemia or hypotension
Assessment:
Cardiovascular: He...- HEPATITIS- ALCOHOLIC
Patient has a history of heavy alcohol use and
has developed alcoholic hepatitis. At risk
for altered nutrition less than body
requirements, activity intolerance related to
fatigue and altered le...- HYPERTENSION
Patient has diagnosis of hypertension.
At risk for decreased cardiac output....- HYPERTENSION-ALTERED HEALTH MAINTENCE
Patient has a dx of hypertension.
At risk for altered health maintence due to lack of
knowledge of disease process, complications and management
of hypertension. ...- HYPERTHYROIDISM - ALTERED NUTRITION
Altered nutrition less than body requirements due to hyper
metabolism, inadequate diet and weight loss....- HYPERTHYROIDISM - RISK FOR OCULAR INJURY
Patient has a diagnosis of hyperthyroidism and is at risk
for injury related to ocular problems. Patient is at risk
for corneal ulceration secondary to inability to close
eyelids (exophthalmos)...- HYPERTHYROIDISM- ACTIVITY INTOLERANCE
Patient has a diagnosis of hyperthyroidism and is
experiencing weakness, fatigue, irritability, SOB on
exertion, increased heart rate on exertion secondary to
increased metabolic rate....- HYPERTHYROIDISM-RISK FOR INJURY- TREMORS
Patient has a diagnosis of hyperthyroidism and is at risk
for injury due to tremors incoordination, decreased
ability to attend, concentrate and fatigue....- IDIOPATHIC THROMBOCYTOPENIA PURPURA
Patient has been diagnosed with Idiopathic
thrombocytopenia purpura.
Patient is at risk for altered tissue perfusion related to
blood loss manifested by epistaxis, bleeding from gums,
hematuria...- IMPAIRED ADJUSTMENT TO AMPUTATION
Patient has recently had amputation of __________ (put in
limb)
due to_________________________ (put in reason such as
trauma, diabetes mellitus)
Patient is exhibiting impaired adjustment to the...- IMPAIRED COMMUNICATION-EXPRESSIVE
Patient has impaired communication due to a diagnosis of
Parkinsons. Patient has dysarthria, tremor, slurred
speech, decreased tongue mobility, difficulty with moving
facial muscles. ...- IMPAIRED PHYSICAL MOBILITY
Patient has impaired physical mobility related to
diagnosis of Parkinsons disease. Patient has exhibited
regidity, tremors, shuffling gait, cogwheeling....- IMPAIRED SOCIAL INTERACTION
Patient has impaired social interaction related to
feelings of worthlessness. Patient has displayed
discomfort in group therapy sessions....- INEFFECTIVE BREAST FEEDING
Ineffective breastfeeding. Dissatisfaction or difficulty
a mother or infant experiences with the breastfeeding
process. Characterized by maternal anxiety, non sustained
suckling at the breast,...- INEFFECTIVE COPING SKILLS
Patient has displayed ineffective coping by exhibiting
inability to form valid appraisal of the stressors,
inadequate choices of practiced responses and/or inability
to use available resources. ...- INTESTINAL OBSTRUCTION-FLUID DEFICIT
Patient has been diagnosed with an intestinal obstruction.
Patient is at risk for fluid volume deficit related to
vomiting and decrease in intestinal fluid reabsorption
Assessment: Onset, odo...- INTESTINAL OBSTRUCTION-PAIN
Patient has been diagnosed with an intestinal obstruction
Patient at risk for altered comfort level due to pain from
abdominal distension and increased peristalsis
ASSESSMENT; Detailed ...- LYMPHEDEMA OF LOWER EXTREMITY
Alteration in Tissue Perfusion...- MULTIPLE SCLEROSIS-IMPAIRED MOBILITY
Patient has a diagnosis of multiple sclerosis.
Patient has impaired physical mobility related
to neuromuscular disease process
At risk for complications of immobility such
as skin breakdown and co...- MYOCARDIAL INFARCTION-ALTERED PERFUSION
Patient has altered tissue perfusion of the
heart to meet metabolic demands of the body
related to reduced myocardial damage.
ASSESSMENT:
Vital signs,arhythmias, dyspnea, abnormal
respiratory r...- MYOCARDIAL INFARCTION-PAIN
Acute chest pain due to Myocardial infarction
Assessment: Character of chest pain which can
be described as steady substernal, crushing,
vice like, crushing. Assess severity, varies,
may be rel...- NAUSEA
Patient has nausea related to (put in cause)
ASSESSMENT: Take patient history of past illness, chronic
diseases, medications, any causative factors, food
allergies, hx of recently ingest...- NON COMPLIANCE WITH TREATMENT
Non compliance to treatment regimen for hypertension.
Patients behavior may lead to clinically ineffective or
partially ineffective outcomes.
Defining characterists:
Development of complication...- OVARIAN CANCER-PAIN MANAGEMENT
Altered level of comfort due to diagnosis of ovarian
cancer.
At risk for pain
ASSESSMENT for Ovarian Cancer:
Early manifestations: abdominal discomfort, indigestion,
flatulence, anorexia, ...- POST PARTUM DIET
Knowledge deficit related to postpartum diet
Assessment: Psychosocial status, cognitive
ability including decision making skills,
learning ability, memory skills and motivation
to learn informa...- PROSTECTOMY - LASER -INFECTION RISK
Patient has just undergone a laser prostectomy for BPH.
Patient is at risk for infection related to external
factors....- PROSTECTOMY - RISK FOR BLEEDING
Patient has a dx of BPH and has just undergone a laser
prostectomy.
At risk for excessive bleeding from surgical procedure...- PYELONEPHRITIS -FLUID VOLUME DEFICIT RISK
Patient has dx of Pyelonephritis.
Patient is at risk for fluid volume deficit related to
fever, nausea and vomiting...- PYELONEPHRITIS- PEDIATRIC -FLUID VOLUME LOSS RISK
Pediatric patient has dx of Pyelonephritis. Patient is at
risk for fluid volume deficit due to high fever, nausea &
vomiting. ...- PYELONEPHRITIS-IMPAIRED COMFORT
Pediatric patient has diagnosis of Pyelonephritis.
At risk for impaired comfort level due to pain and dysuria...- RETROPERITONEAL ABSCESS
Nursing Diagnosis:
Post opertative patient is at risk for infection due to
(Choose most appropriate and delete the rest.)
Invasive procedures
Insufficient knowledge to avoid exposure to pathogens....- Risk for impaired skin integrity due to falls
Patient has impaired skin integrity due to a fall, has
severe bruising on buttocks, hips and elbows as well as a
small abrasion on ankle. Mobility is impaired due to
generalized weakness and res...- RISK FOR INEFFECTIVE FEEDING OF INFANT
Risk for ineffective feeding of infant due to mothers
knowledge deficit
Maternal Assessment: Mothers nutritional status, age and
maturity level, sleep and rest patterns, condition of
breasts...- RISK FOR INFECTION POST OP
Post opertative patient is at risk for infection due to
(Choose most appropriate and delete the rest.)
Invasive procedures
Insufficient knowledge to avoid exposure to pathogens.
Trauma
Tissue de...- RISK FOR INJURY - DIZZIENESS
Patient has been experiencing dizzieness from
hypertension, is non compliant with diet and is at risk
for injury from a fall.
...- RISK OF POSTPARTUM HEMORRHAGE
Risk for Fluid volume deficit related to post partum
hemorrhage....- SPINAL CORD INJURIES - IMPAIRED MOBILITY
Patient has sustained a spinal cord injury due to (trauma,
auto accident, gunshot wound ect.)
Physical mobility is limited as patient is quadraplegic or
paraplegic
Patient is at risk for compl...- SPINAL CORD INJURY - IMPAIRED MOBILITY
Patient has sustained a spinal cord injury due to (put in
reason ie,,trauma, auto accident , gunshot wound ect.)
Patient is at risk for complications of pneumonia, venous
stasis and thrombus form...- SPINAL CORD INJURY- CONSTIPATION
Patient has a spinal cord injury due to (reason)
At risk for constipation due to paralysis...- SPINAL CORD INJURY-IMPAIRED ELIMINATION
Patient has sustained a spinal cord injury due to (put in
reason)
Patient is at risk for impaired urinary elimination issues
due to sensory or neuromuscular impairment such as urinary
retention...- SPINAL CORD INJURY-INEFFECTIVE COPING
Patient has a spinal cord injury due to (put in reason)
Patient is having ineffective coping due to paralysis...- SPONTANEOUS ABORTION - SEPTIC
Patient had a spontaneous abortion complicated by
infection.
Patient is at risk for complications of PID, Peritonitis,
Hemorrhage, Septic shock....- SUICIDE RISK
At risk for self inflicted, life threatening injury due to
severe depression, dx of major depressive disorder,
anxiety disorder, mixed personality disorder He has
suicidal thoughts, severe depre...- TOTAL KNEE REPLACEMENT
Patient underwent a total knee replacement due
to dx of (put in reason, osteoarthritis,
trauma, infection)
Patient is at risk for delayed recovery from
surgery due to complications such as
hemorr...
Total Care Plans 494
Care Plan List