Patient Problems and Nursing Diagnoses

Vocabulary flashcards defining various nursing diagnoses, patient problems, and risks from the clinical reference guide.

Activity Intolerance (risk)

Insufficient physiologic or psychological energy to endure or complete required or desired daily activities.

Acute Confusion

Abrupt onset of a cluster of global, transient changes & disturbances in attention, cognition, psychomotor activity, level of consciousness, or the sleep/wake cycle.

Acute Pain

Unpleasant sensory & emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months.

Anxiety

Vague uneasy feeling or discomfort or dread accompanied by an autonomic response.

Autonomic Dysreflexia (Risk)

State in which a person with a spinal cord injury, when faced with a casual stimulus, experiences a disinhibition of the sympathetic nervous system that endangers your life.

Bathing self-care deficit

State in which the individual manifests an inability to carry out or complete bathing and hygiene activities by himself.

Bowel Incontinence

Change in normal bowel habits characterized by the involuntary passage of stool.

Caregiver Role Strain (risk)

Difficulty in performing family caregiver role.

Chronic Confusion

An irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli, decreased capacity for intellectual thought processes and manifested by disturbances of memory, orientation, and behavior.

Chronic Low Self Esteem

State in which the individual experiences a prolonged negative self-evaluation or negative feelings towards herself or her abilities. Negative evaluation and/or feelings about one's own capabilities, lasting at least three months.

Chronic Pain

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. A duration of greater than 6 months.

Constipation (risk)

Decrease in normal frequency of defecation accompanied by the difficult or incomplete passage of stool and/or passage of excessively hard, dry stool.

Decreased Cardiac Output (risk)

Inadequate blood pumped by the heart to meet the metabolic demands of the body.

Deficient Fluid Volume (risk)

Decreased intravascular, interstitial and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium.

Defensive Coping

Repeated projection of falsely positive self-evaluation based on a self-protective pattern that defends against underlying perceived threated to positive self-regard.

Deficient Knowledge

Absence of deficiency of cognitive information related to a specific topic.

Delayed Surgical Recovery

Extension of the number of postoperative days required to initiate and perform activities that maintain life, health, and well-being.

Diarrhea

Passage of loose, unformed stools.

Disturbed Body Image

Confusion and/or dissatisfaction in mental picture of one's physical self.

Disturbed sensory perception

Hallucinations, depersonalization or derealization

Disturbed Sleep Pattern

Time-limited interruptions of sleep amount and quality due to external factors.

Disturbed Thought Process

Denial of problem, limited insight into illness

Dressing Self-Care Deficit

State in which the individual has an inability to perform or complete the activities of dressing and grooming themselves.

Dysfunctional Family Processes

Psychosocial, spiritual, and physiological functions of the family unit are chronically disorganized, which lead to conflict, denial of problems, resistance to change, ineffective problem solving and a series of self-perpetuating crises.

Dysfunctional Gastrointestinal Motility (risk)

Increased, decreased, ineffective, or lack of peristaltic activity within the gastrointestinal system.

Excess Fluid Volume

Increased isotonic fluid retention.

Fatigue

An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at the usual level.

Fear

Response to perceived threat that is consciously recognized as a danger.

Feeding Self-Care Deficit

State in which the individual has an inability to perform or complete the activities of feeding themselves.

Grieving

A normal complex process that includes emotional, physical, spiritual, social, and intellectual responses and behaviors by which individuals, families, and communities incorporate an actual, anticipated, or perceived loss into their daily lives.

Hopelessness

Subjective state in which an individual sees limited or no alternatives or personal choices available and is unable to mobilize energy on own behalf.

Hyperthermia

Core body temperature above the normal diurnal range due to failure of thermoregulation.

Hypothermia

Core body temperature below the normal diurnal range due to failure of thermoregulation.

Imbalanced Nutrition: Less than Body Requirements

Intake of nutrients insufficient to meet metabolic needs.

Impaired Gas Exchange

Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

Impaired Oral Mucous Membrane (risk)

Injury to the lips, soft tissue, buccal cavity, and/or oropharynx.

Impaired Physical Mobility

Limitation in independent, purposeful physical movement of the body or of one or more extremities.

Impaired Skin Integrity (risk)

Altered epidermis and/or dermis.

Impaired Social Interaction

Insufficient or excessive quantity or ineffective quality of social exchanges.

Impaired Spontaneous Ventilation

Decreased energy reserves resulting in an inability to maintain independent breathing that is adequate to support life.

Impaired Swallowing

Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function.

Impaired Urinary Elimination

Dysfunction in urine elimination.

Impaired Verbal Communication

Decreased, delayed, or absent ability to receive, process, transmit, and/or use a system of symbols.

Ineffective Airway Clearance

Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.

Ineffective Activity Planning (risk)

Inability to prepare for a set of actions fixed in time and under certain conditions.

Ineffective Breathing Pattern

Inspiration and/or expiration that does not provide adequate ventilation.

Ineffective Coping

Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.

Ineffective Health Maintenance

Inability to identify, manage, and/or seek out help to maintain health.

Ineffective Health Management

Pattern of regulating and integrating into daily living a therapeutic regimen for the treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals.

Ineffective Tissue Perfusion (specify tissue - peripheral, cardiac, cerebral) (risk)

Decrease in blood circulation that may compromise health.

Ineffective Role Performance

A pattern of behavior and self-expression that does not match the environmental context, norms, and expectations.

Ineffective Thermoregulation

Temperature fluctuation between hypothermia and hyperthermia.

Insomnia

A disruption in amount and quality of sleep that impairs functioning.

Interrupted Family Processes

Change in family relationships and/or functioning.

Latex Allergy Response (risk)

A hypersensitive reaction to natural latex rubber products.

Moral Distress

Response to the inability to carry out one's chosen ethical/moral decision/action.

Obesity

A condition in which an individual accumulates abnormal or excessive fat for age and gender that exceeds overweight.

Overweight (risk)

Vulnerable to abnormal or excessive fat accumulation for age and gender, which may compromise health.

Post-Trauma Syndrome (risk)

Sustained maladaptive response to a traumatic, overwhelming event.

Powerlessness

The lived experience of lack of control over a situation, including a perception that one's own actions do not significantly affect an outcome.

Readiness for Enhanced Comfort

A pattern of ease, relief and transcendence in physical, psychospiritual, environmental, and/or social dimensions, which can be strengthened.

Readiness for Enhanced Coping

A pattern of cognitive and behavioral efforts to manage demands that is sufficient for well-being, which can be strengthened.

Readiness for Enhanced Health Management

A pattern of regulating and integrating into daily living a therapeutic regimen for the treatment of illness and its sequelae, which can be strengthened.

Readiness for Enhanced Knowledge

A pattern of cognitive information related to a specific topic, or its acquisition, which can be strengthened.

Readiness for Enhanced Self- Care (specify what care - bathing, feeding, etc)

A pattern of performing activities for oneself that helps to meet health-related foals, which can be strengthened.

Risk for Aspiration

Vulnerable to entry of gastrointestinal secretions, oropharyngeal secretions, solids or fluids into the tracheobronchial passages, which may compromise health.

Risk for Bleeding

Vulnerable to a decrease in blood volume, which may compromise health.

Risk for Electrolyte Imbalance

Vulnerable to changes in serum electrolyte levels that may compromise health.

Risk for Falls

Vulnerable to increased susceptibility to falling, which may cause physical har, and compromise health.

Risk for Imbalanced Body Temperature

Vulnerable to failure to maintain body temperature within normal parameters, which may compromise health.

Risk for Imbalanced Fluid Volume

Vulnerable to a decrease, increase, or rapid shift from one to the other of intravascular, interstitial, and/or intracellular fluid, which may compromise health. This refers to body fluid loss, gain, or both.

Risk for Impaired Liver Function

Vulnerable to a decrease in liver function, which may compromise health.

Risk for Infection

Vulnerable to invasion and multiplication of pathogenic organisms, which may compromise health.

Risk for Injury

Vulnerable to physical damage due to environmental conditions interacting with the individual's adaptive and defensive resources, which may compromise health.

Risk for Loneliness

Vulnerable to experiencing discomfort associated with a desire or need for more contact with others, which may compromise health.

Risk for Peripheral Neurovascular Dysfunction

Vulnerable to disruption in the circulation, sensation, and motion of an extremity, which may compromise health.

Risk for suicide

Susceptible to self-inflicted, life-threatening injury. History of suicide attempts, high ACE scores, etc

Risk for Unstable Blood Glucose Level

Vulnerable to variation of blood glucose/sugar levels from the normal range, which may compromise health.

Risk for Other-Directed Violence

Susceptible to behaviors in which an individual demonstrates that he or she can be physically, emotionally, and/or sexually harmful to others. History of violence, SUB, detoxing, etc

Self-Care Deficit (risk)

Specify the deficit. The lack of ability to perform a task for self-care.

Self-Mutilation (risk)

Deliberate self-injurious behavior causing tissue damage with the intent of causing nonfatal injury to attain relief of tension. Hurting self to relive stress (cutting, burning, hair pulling, etc)

Sexual Dysfunction

A state in which an individual experiences a change in sexual function during the sexual response phases of desire, excitation, and/or orgasm, which is viewed as unsatisfying, unrewarding, or inadequate.

Situational Low Self-Esteem

Development of a negative perception of self-worth in response to a current situation.

Social Isolation (risk)

Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state.

Spiritual distress (risk)

A state of suffering related to the impaired ability to experience and integrate meaning in life through connections with self, others, the world, or a superior being. Express lack of control over personal situations or expresses anger at God