Nursing Diagnoses with Defining Characteristics

1 Nursing Diagnoseswith DefiningCharacteristics77 CNursing DiagnosisDefining CharacteristicsRelated FactorsAppendixRefer to Chapter 3 Diagnosis, p. 93 Activity intolerance(actual)Breathing pattern,ineffective (actual)Airway clearance,ineffective (actual)Excessive fatigue with activity Weakness with ambulation Inability to access surroundingenvironment by walkingindependently withoutcaregiver s help and assistivewalking of excessiveweaknessIncreased/decreasedresp iratory rate and rhythm(dyspnea)Increased heart rateFlaring of anterior naresVoiced difficulty breathing orshortness of lung sounds:rales, crackles, wheezes,rhonchi RespiratoryCardiac Immune systemMusculosketalNeurological problemsEndocrine problemsAnemiaGeneral anesthesiaDecreased oxygenation dueto allergic reaction and upperrespiratory tract infectionObstructive lung parenelync:pneumonia, COPD,continues78 Appendix CNursing DiagnosisDefining CharacteristicsRelated FactorsAnxiety, high (actual)Body image disturbed(actual)

2 Ineffective coughCyanosesDyspneaOrthopneaTenacious mucusInattentionFailure to concentrateIllogical thought process/reasoningForgetfulnessAnorexiaPe rsistant eating bingeeatingRestlessnessFidgetingRapid eye movementsMemory lossFailure to learnInability to concentrateCrying spellsFrequency of urinationPrecipitancy of urinationInability to recall pastincidentsDenial of change in bodystructureOvercompensation for loss orchange in body structureRegression to earlier stage ofdevelopmentDependence of peers,significant others, or caregiverVerbal discussion of perception of behavior demonstrating rejection of selfSoliciting support from othersfor incompetencePoor self-imagingInactivitySomnolencecancer, tuberculosis,emphysema, trauma(pneumothorax)Prolonged illnessEconomic disasterUnfamiliar environment suchas hospitalizationRole changeDisaster physical such asenvironmental and/or familiarUnresolved stressInherited psychologicalstatesSpiritual emptinessChange of statusChange of localityPostpartum stressorsKnowledge deficit related tospecific problem-solving skillsConflict related to values andethical issuesDrug related: prescribed obesityLoss of body partUnacceptance among peersNegative reinforcement fromsignificant othersUnrealistic expectation from selfUnrealistic expectation from othersRepeated failureGluttonyAnorexia nervosaChronic illnessLack of supportDepressionLack of motivationOvermedication (prescrip-tion, over the counter, and/orillegal)continuesAppendixC79 Nursing DiagnosisDefining CharacteristicsRelated FactorsBody temperatureimbalance.

3 Hyperthermia(actual)Body temperatureimbalance; hypothermiaBowel incontinence(actual)Beginning stage Rapid heartbeat Increased respirations Ashen or cyanotic appearance of the skin Skin cool or cold to touch Shivering spell Generalized spread ofgoosebumps over body Complaints of generalizedcoldness over body Temperature generallynormal Skin dry to touchAppearance and stage offever Shivering abates Elevated temperature Complaints of thirst Signs of dehydration drymuscus membranes,decreased urinary output Complaints of sensitivity tolight Anorexia Generalized weakness Muscle aches Restlessness, sleeplessness,confusion/disorientation Rapid heart rate andincreased respirations Herpes simplexTemperature below normal Pulse and respirationsdecrease Skin pale, cold and clammy Decreased blood pressure Diminished urination Shivering spell Drowsiness and confusionInability to control the passageof stoolPassing of small amounts ofstool constantlyAge Temperature changesmore labile in elderly adultsand young childrenStrenuous exerciseHormonal changes particular-ly in womenEnvironmental conditions vary (hot weather)Infectious agentsExposure to cold environment Improper clothing andshelter Abuse of sedatives Inadequate thermoregulationof the hypothalamicthermostatLack of sphincter controlInability to access bathroom Immobilitycontinues80 Appendix CNursing DiagnosisDefining CharacteristicsRelated FactorsCommunication, impairedverbal (actual)Infection (actual)

4 Presence of stool on clothingStool liquid in natureMinimal urge or no feeling orurge to defecateIrritation of perineurial areaUrgencyAphasiaRefusal to speakMuttering/stutteringLack of comprehension of thephases of communication(sender- message-receiver)Poor formulation of words andsentencesInability to speak the expectedlanguageDyspneaTachypneaAltered self-conceptKnowledge deficitFindings at the site of theinfection: Redness Swelling Pain HeatImpaired functioning of theaffected limb or part (wheninfection is severe)Elevated temperature withelevated pulse and respirationsGeneralized weakness andmalaise (cachectic): Loss of appetite Complaints of thirst Nausea and vomiting Palpable lymph nodesLaboratory profile: IncreasedWBC Increased erythrocyte Increased sedimentationrateLower motor neurondamageIntestinal obstructionDiet relatedIntestinal abnormalitiesLoss of muscle toneDiseases, colon and/or rectalSelf-imposed behaviorDiminished blood flow to thebrain (due to tumors orcerebrovascular accidentsand/or coma)Congenital anomalyDevelopmental stageImposed surgical interven-tions such as tracheostomyCultural barriersEnvironmental changeLow messages (uninformed)Loss of first defense againstorganism (broken skin)Inadequate nutritionalpattern: Impaired elimination Impaired digestion Impaired inflammatoryresponse Trauma (acute) Chronic diseasescontinuesAppendixC81 Nursing DiagnosisDefining CharacteristicsRelated FactorsDisuse syndrome, risk forDefinition.

5 At risk for lackof function of all bodysystemsFluid volume, risk fordeficient (actual)Constipation (actual) Identification of causativeorganism in culture ofexudate from the affectedareaUrine Bacteria cultured in urine Cloudy urine Blood or pus in urine(Risk Factors)Acute or chronic painSemiconscious or unconsciousstate Immobility Paralysis: multiple fracturesDehydration Decreased urinary output Increased specific gravity Increased hematocrit Marked weight loss overshort period of time Dry mucous membraneinsipidus (initial stage) Coated or dry crackingtongue Excessive thirst Decreased blood pressure Decreased pulse volume Decreased pulseInfrequent or absence ofbowel movementComplaints of abdominal painExcessive flatusDecrease in size and volumeof stoolPasty stoolPalpable abdominal massGeneral malaiseHeadacheChange in color of stool(darker to black)Difficulty passing stoolPain with the passage of stoolPassage of small watery stool(Similar to Risk Factors)PainImmobilityUnconsciousness orsemiconsciousnessImmobility.

6 Multiple fracturesDraining woundPersistent vomiting and/ordiarrheaLimited fluid intakeHemorrhageExcessive administration ofmedication such as diureticsExcessive urination as inpolydypsia in diabetesmellitus and diabetesBrunsUlcerative colitisAIDSI mmobilityDecreased fluid intakeDietary imbalance (lack of fiber)Overuse of laxativesLoss of muscle tone due todisease processes and/orphysiological changes andneurological damageLack of exercise (causingdecreased muscle tone)ObesityInaccessibility to bathroomfacilitycontinues82 Appendix CNursing DiagnosisDefining CharacteristicsRelated FactorsFluid volume, excess(actual)Home maintenance,impaired (actual)Infection, risk forPresence of hard stool inlower and or upper rectum ondigital examinationHypoactive bowel soundsNausea and/or vomitingLack of desire to eatIncreased respiratory rateEdema excessive (anasarca)Output less than intakeRapid weight gainPulmonary overloadChanges in heart soundsDecreased hemoglobinDecreased hematocritOrthopneaMental confusionRales and crackles onauscultation of lungsElectrolyte imbalanceAgitationBlood pressure fluctuationsAlteration in kidney functionDirty and unkempt environment.

7 Utensils,supplies, and equipmentscattered and out of placeEvidence of weariness,tiredness, and anxiety amongfamily membersAbnormal environmentaltemperatureInfestation by termites,vermin, and or insectsOdorous smell in environmentPediculosisLack of skin integrity at site ofbacterial invasionWeak immune systemKnowledge deficit regardinghygienic measuresLack of knowledge of thespread of microorganismsLack of response to the urgeto defecateDecreased motility ofgastrointestinal tract due toagingEmotional factorsVarious pharmaceuticalproducts with side effects ofconstipationAlteration in cardiacregulatory systemRenal dysfunction Liver disorders Carcinoma Overhydration (intra-venous) High salt intakeUnavailable assistanceInability to properly care forself due to mental or physicaldisabilityAbsent or diminishedresourcesOvercrowdingChronic illness such ascerebrovascular accidents,Alzehimer s osteoporosis, andarthritisThe risk factors are also therelated factorsOthers are chronic diseasessuch as diabetes,AIDS, and tuberculosisPharmaceuticals such assteroidal medicationscontinuesAppendixC83 Nursing DiagnosisDefining CharacteristicsRelated FactorsFluid volume, excess(actual)Trauma to tissueUnsanitary environmentLack of knowledge aboutwound careNutritional deficiencyProlonged illnessesAltered blood profile (lowWBC, HBC, andHCT)Increased respiratory rateEdema excessive (anasarca)Output less than intakeIncreased specific gravity(urine)

8 Rapid weight gainPulmonary overloadChanges in heart soundsDecreased hemoglobinOrthophneaMental confusionRales and crackles onauscultation of lungsElectrolyte imbalanceAgitationBlood pressure fluctuationsAlteration in kidney functionAlteration in cardiacregulatory systemRenal dysfunctionLiver disordersCarcinomaOverhydration (intravenous)High salt intake Reference:Cox, , Hinz, M., Lubno, M., Scott-Tilley, D., Newfield, S., Slater, M.,Sridaromont, K. (2002). Clinical applications of Nursing diagnosis. Philadelphia: Davis.