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ACTIVITY INTOLERANCE [SPECIFY LEVEL]

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Inadequate mental or physical energy to accomplish daily activities. Risk factors include debilitating physical conditions such as anemia, obesity, musculoskeletal disorders, neurological deficits (such as those following stroke), severe heart disease, chronic pulmonary disease, metabolic disorders, and prolonged sedentary lifestyle.

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activity intolerance, risk for

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At risk of experiencing insufficient physiologic or psychologic energy to endure or complete required or desired daily activities.

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airway clearance, ineffective

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The inability to clear secretions or obstructions from the upper respiratory tract, and thus, to maintain an open, effective airway.

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allergy response, latex

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An allergic response to natural latex rubber products.

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allergy response, risk for latex

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At risk for allergic response to natural latex rubber products.

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ANXIETY [MILD, MODERATE, SEVERE, PANIC]

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An uneasy feeling of discomfort or dread accompanied by an autonomic response; the source is often nonspecific or unknown to the individual; a feeling of apprehension caused by anticipation of danger. It is a potential signal that warns of impending danger and enables the individual to take measures to deal with threat. Recurrence of such reactions that disrupt life when danger does not exist constitute anxiety disorders. These include generalized anxiety disorder, panic disorder, social anxiety disorder or phobia, posttraumatic stress disorder, obsessive-compulsive disorder and procedural anxiety

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ANXIETY, DEATH

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Vague uneasy feeling of discomfort or dread generated by perceptions of a real or imagined threat to one's existence.

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aspiration, risk for

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The state in which an individual is at risk for entry of gastric secretions, oropharyngeal secretions, or exogenous food or fluids into tracheobronchial passages due to dysfunction or absence of normal protective mechanisms. Pathological respiratory aspiration is prevented by placing the unconscious patient (or any other patient without a gag reflex) on his or her left side with the head turned laterally. A head-low position protects the airway, prevents silent regurgitation, and promotes evacuation of mucus or vomitus, e.g., by suctioning the nasopharynx as necessary.

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attachment, risk for impaired parent/infant/child

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Disruption of the interactive process between parent/significant other and infant that fosters the development of a protective and nurturing reciprocal relationship.

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autonomic dysreflexia

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The state in which a person with a spinal cord injury at T7 or above experiences a life-threatening uninhibited sympathetic response of the nervous system to a noxious stimulus.

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autonomic dysreflexia, risk for

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A lifelong threatening uninhibited response of the sympathetic nervous system for an individual with a spinal cord injury or lesion at T8 or above who has recovered from spinal shock.

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BEHAVIOR, RISK-PRONE HEALTH

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Inability to modify lifestyle/behaviors in a manner consistent with a change in health status.

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body image, disturbed

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Disruption in the way one perceives one's body image (e.g., after an injury or illness) or an incongruity between one's actual appearance and the way one perceives it (e.g., in anorexia nervosa).

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body temperature, risk for imbalanced

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At risk for failure to maintain body temperature within normal range.

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bowel incontinence

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

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breastfeeding, effective

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The state in which the mother-infant exhibit appropriate proficiency and satisfaction with breastfeeding. Expected outcomes, including maternal nipple trauma and soreness related to breastfeeding, are minimized. Infant weight gain proceeds within expected parameters.

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breastfeeding, ineffective

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The state in which a mother, infant, or child experiences dissatisfaction or difficulty with breastfeeding process.

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breastfeeding, interrupted

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A break in the continuity of the breastfeeding process as a result of inability or inadvisability to put a baby to breast for feeding.

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breathing pattern, ineffective

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

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CARDIAC OUTPUT, DECREASED

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Inadequate blood pumped by the heart to meet the metabolic demands of the body. In a hypermetabolic state, although cardiac output may be within normal range, it may still be inadequate to meet the needs of the body's tissues. Cardiac output and tissue perfusion are interrelated, although there are differences. When cardiac output is decreased, tissue perfusion problems will develop; however, tissue perfusion problems can exist without decreased cardiac output.

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caregiver role strain

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A caregiver's felt or exhibited difficulty in performing the family caregiver role.

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caregiver role strain, risk for

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The vulnerability of the caregiver for difficulties felt in performing the role of family caregiver.

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comfort, readiness for enhanced

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

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communication, IMPAIRED VERBAL

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The state in which a person experiences a decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols or anything that conveys meaning.

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COMMUNICATION, READINESS FOR ENHANCED

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A pattern of exchanging information and ideas with others that is sufficient for meeting one's needs and life's goals and can be strengthened.

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CONFLICT, DECISIONAL (SPECIFY)

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Uncertainty about course of action to be taken when choice among competing actions involves risk, loss, or challenge to values and beliefs.

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CONFLICT, PARENTAL ROLE

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Parent experience of role confusion and conflict in response to crisis. Separation from child due to chronic illness [/disability]; Intimidation with invasive modalities (e.g., intubation)/restrictive modalities (e.g., isolation); Specialized care centers; Home care of a child with special needs [e.g., apnea monitoring, hyperalimentation]; Change in marital status; [Conflicts of the role of the single parent]; Interruptions of family life due to home care regimen (e.g., treatments, caregivers, lack of respite)

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CONFUSION, ACUTE

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Abrupt onset of reversible disturbances of consciousness, attention, cognition, and perception that develop over a short period of time

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CONFUSION, CHRONIC

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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.

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CONFUSION, RISK FOR ACUTE

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At risk for reversible disturbances of consciousness, attention, cognition, and perception that develop over a short period of time.

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CONSTIPATION

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

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CONSTIPATION, PERCEIVED

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Self-diagnosis of constipation and abuse of laxatives, enemas, and suppositories to ensure a daily bowel movement.

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CONSTIPATION, RISK FOR

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At risk for a decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool.

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CONTAMINATION

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Exposure to environmental contaminants in doses sufficient to cause adverse health effects.

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CONTAMINATION, RISK FOR

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Accentuated risk of exposure to environmental contaminants in doses sufficient to cause adverse health effects.

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COPING, COMPROMISED FAMILY

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Usually supportive primary person (family member or close friend [significant other]) provides insufficient, ineffective, or compromised support, comfort, assistance, or encouragement that may be needed by the client to manage or master adaptive tasks related to his/her health challenge.

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COPING, DEFENSIVE

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

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COPING, DISABLED FAMILY

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The behavior of a significant person (family member or other primary person) that disables his or her own capacities and the client's capacity to effectively address tasks essential to either person's adaptation to the health challenge.

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COPING, INEFFECTIVE

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

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COPING, INEFFECTIVE COMMUNITY

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A pattern of community activities for adaption and problem solving that is unsatisfactory for meeting the demands or needs of the community. [Community is defined as "a group of people with a common identity or perspective, occupying space during a given period of time, and functioning through a social system to meet its needs within a larger social environment."]

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COPING, READINESS FOR ENHANCED

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

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COPING, READINESS FOR ENHANCED COMMUNITY

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Pattern of community activities for adaptation and problem solving that is satisfactory for meeting the demands or needs of the community but can be improved for management of current and future problems/stressors.

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COPING, READINESS FOR ENHANCED FAMILY

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Effective managing of adaptive tasks by family member involved with the client's health challenge, who now exhibits desire and readiness for enhanced health and growth in regard to self and in relation to the client.

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DEATH SYNDROME, RISK FOR SUDDEN INFANT

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Presence of risk factors for sudden death of an infant under 1 year of age [Sudden Infant Death Syndrome (SIDS) is the sudden death of an infant under 1 year of age, which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history. SIDS is a subset of Sudden Unexpected Death in Infancy (SUDI) that is the sudden and unexpected death of an infant due to natural or unnatural causes.].

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DIGNITY, RISK FOR COMPROMISED HUMAN

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At risk for perceived loss of respect and honor.

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DECISION MAKING, READINESS FOR ENHANCED

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A pattern of choosing courses of action that is sufficient for meeting short- and long-term health-related goals and can be strengthened.

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DENIAL, INEFFECTIVE

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Conscious or unconscious attempt to disavow the knowledge or meaning of an event to reduce anxiety/fear to the detriment of health.

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DENTITION, IMPAIRED

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Disruption in tooth development/eruption patterns or structural integrity of individual teeth.

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DEVELOPMENT, RISK FOR DELAYED

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At risk for delay of 25% or more in one or more of the areas of social or self-regulatory behavior, or cognitive, language, gross or fine motor skills.

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DIARRHEA

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Passage of loose, unformed stools.

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DISTRESS, MORAL

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

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DISUSE SYNDROME, RISK FOR

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At risk for deterioration of body systems as the result of prescribed or unavoidable musculoskeletal inactivity. NANDA identifies complications from immobility that can include pressure ulcer, constipation, stasis of pulmonary secretions, thrombosis, urinary tract infection/retention, decreased strength/endurance, orthostatic hypotension, decreased range of joint motion, disorientation, body image disturbance, and powerlessness.

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DIVERSIONAL ACTIVITY, DEFICIENT

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Decreased stimulation from (or interest or engagement in) recreational or leisure activities. Internal/external factors that may or may not be beyond the individual's control.

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ENERGY FIELD, DISTURBED

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Disruption of the flow of energy [aura] surrounding a person's being that results in a disharmony of the body, mind, and/or spirit.

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ENVIRONMENTAL INTERPRETATION SYNDROME, IMPAIRED

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Consistent lack of orientation to person, place, time, or circumstances over more than 3 to 6 months, necessitating a protective environment.

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FATIGUE

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

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FAILURE TO THRIVE, ADULT

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A progressive functional deterioration of a physical and cognitive nature; the individual's ability to live with multisystem diseases, cope with ensuing problems, and manage his/her care is remarkably diminished.

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FALLS, RISK FOR

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Increased susceptibility to falling that may cause physical harm.

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FAMILY PROCESSES, DYSFUNCTIONAL: ALCOHOLISM

answer

Psychosocial, spiritual, and physiological functions of the family unit are chronically disorganized, which leads to conflict, denial of problems, resistance to change, ineffective problem solving, and a series of self-perpetuating crises. Abuse of alcohol [/addictive substances]; Family history of alcoholism/resistance to treatment; Inadequate coping skills; Addictive personality; Lack of problem-solving skills; Biochemical influences; Genetic predisposition

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FAMILY PROCESSES, INTERRUPTED

answer

Situational transition/crises; Developmental transition/crises [e.g., loss or gain of a family member, adolescence, leaving home for college]; Shift in health status of a family member; Family roles shift; Power shift of family members; Modification in family finances/social status; Interaction with community

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FAMILY PROCESSES, READINESS FOR ENHANCED

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A pattern of family functioning that is sufficient to support the well-being of family members and can be strengthened.

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FEAR

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Response to perceived threat [real or imagined] that is consciously recognized as a danger.

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FLUID BALANCE, READINESS FOR ENHANCED

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A pattern of equilibrium between fluid volume and chemical composition of body fluids that is sufficient for meeting physical needs and can be strengthened.

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[FLUID VOLUME, DEFICIENT (HYPER/HYPOTONIC)]

answer

Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration with changes in sodium.

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FLUID VOLUME, DEFICIENT [ISOTONIC]

answer

Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium. This diagnosis has been structured to address isotonic dehydration (hypovolemia) when fluids and electrolytes are lost in even amounts and excluding states in which changes in sodium occur. For client needs related to dehydration associated with alterations in sodium, refer to [deficient Fluid Volume: hyper/hypotonic]

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FLUID VOLUME EXCESS

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Compromised regulatory mechanism [e.g., syndrome of inappropriate antidiuretic hormone (SIADH), or decreased plasma proteins as found in conditions such as malnutrition, draining fistulas, burns, organ failure]; Excess fluid intake; Excess sodium intake; [Drug therapies such as chlorpropamide, tolbutamide, vincristine, triptylines, carbamazepine]

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FLUID VOLUME, RISK FOR DEFICIENT

answer

At risk for experiencing vascular, cellular, or intracellular dehydration.

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FLUID VOLUME, RISK FOR IMBALANCED

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A risk of a decrease, an increase, or a rapid shift from one to the other of intravascular, interstitial, and/or intracellular fluid. This refers to body fluid loss, gain, or both.

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GAS EXCHANGE, IMPAIRED

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Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveoli-capillary membrane. [This may be an entity of its own but also may be an end result of other pathology with an interrelatedness between airway clearance and/or breathing pattern problems.]

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GLUCOSE, RISK FOR UNSTABLE BLOOD

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Risk for variation of blood glucose/sugar levels from the normal range.

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GRIEVING

answer

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.

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GRIEVING, COMPLICATED

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A disorder that occurs after the death of a significant other [/object], in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment.

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GRIEVING, RISK FOR COMPLICATED

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At risk for a disorder that occurs after the death of a significant other, in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment.

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GROWTH, RISK FOR DISPROPORTIONATE

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At risk for growth above the 97th percentile or below the 3rd percentile for age, crossing two percentile channels; disproportionate growth.

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GROWTH AND DEVELOPMENT, DELAYED

answer

Inadequate caretaking; [Physical/emotional neglect or abuse]; Indifference; Inconsistent responsiveness; Multiple caretakers; Separation from significant others; Environmental/stimulation deficiences; Effects of physical disability [handicapping condition]; Prescribed dependence [insufficient expectations for self-care]; [Physical/emotional illness (chronic, traumatic), e.g., chronic inflammatory disease, pituitary tumors, impaired nutrition/metabolism, greater-than-normal energy requirements; prolonged/painful treatments; prolonged/repeated hospitalizations]; [Sexual abuse]; [Substance use/abuse]

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HEALTH MAINTENANCE, INEFFECTIVE

answer

Inability to identify, manage, and/or seek out help to maintain health. This diagnosis contains components of other nursing diagnoses. We recommend subsuming health maintenance interventions under the "basic" nursing diagnosis when a single causative factor is identified (e.g., deficient Knowledge; Communication, impaired verbal; Thought Processes, disturbed; Individual/Family Coping, ineffective; Growth and Development, delayed).

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HEALTH-SEEKING BEHAVIORS (SPECIFY)

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Active seeking (by a person in stable health) of ways to alter personal health habits and/or the environment in order to move toward higher level of health. Stable health is defined as achievement of age-appropriate illness-prevention measures; client reports good or excellent health, and signs and symptoms of disease, if present, are controlled.

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HOME MAINTENANCE, IMPAIRED

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Inability to independently maintain a safe, growth-promoting immediate environment.

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HOPE, READINESS FOR ENHANCED

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A pattern of expectations and desires that is sufficient for mobilizing energy on one's own behalf and can be strengthened.

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HOPELESSNESS

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

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HYPERTHERMIA

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Body temperature is elevated above normal range.

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HYPOTHERMIA

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Body temperature is below normal range.

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IDENTITY, DISTURBED PERSONAL

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Inability to distinguish between self and nonself. To be developed; [Organic brain syndrome]; [Poor ego differentiation, as in schizophrenia]; [Panic/dissociative states]; [Biochemical body change]

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IMMUNIZATION STATUS, READINESS FOR ENHANCED

answer

A pattern of conforming to local, national, and/or international standards of immunization to prevent infectious disease(s) that is sufficient to protect a person, family, or community and can be strengthened.

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INFANT BEHAVIOR, DISORGANIZED

answer

Disintegrated physiological and neurobehavioral responses to the environment.

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INFANT BEHAVIOR, READINESS FOR ENHANCED ORGANIZED

answer

A pattern of modulation of the physiologic and behavioral systems of functioning of an infant (i.e., autonomic, motor, state, organizational, self-regulatory, and attentional-interactional systems) that is satisfactory but that can be improved.

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INFANT BEHAVIOR, RISK FOR DISORGANIZED

answer

Risk for alteration in integration and modulation of the physiologic and behavioral systems of functioning (i.e., autonomic, motor, state, organizational, self-regulatory, and attentional-interactional systems).

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INFANT FEEDING PATTERN, INEFFECTIVE

answer

Impaired ability to suck or coordinate the suck-swallow response, resulting in inadequate oral nutrition for metabolic needs.

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INFECTION, RISK FOR

answer

At increased risk for being invaded by pathogenic organisms. Inadequate primary defenses (broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids, change in pH secretions, altered peristalsis); Inadequate secondary defenses (e.g., decreased hemoglobin, leukopenia, suppressed inflammatory response); Inadequate acquired immunity; Immunosuppression; Tissue destruction; Increased environmental exposure; Invasive procedures; Chronic disease; Malnutrition; Trauma; Pharmaceutical agents (e.g., immunosuppressants, [antibiotic therapy]); Rupture of amniotic membranes; Insufficient knowledge to avoid exposure to pathogens

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INJURY, RISK FOR

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At risk of injury as a result of environmental conditions interacting with the individual's adaptive and defensive resources. The potential for injury differs from individual to individual, and situation to situation. It is our belief that the environment is not safe, and there is no way to list everything that might present a danger to someone. Rather, we believe nurses have the responsibility to educate people throughout their life cycles to live safely in their environment.

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INJURY, RISK FOR PERIOPERATIVE POSITIONING

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At risk for injury as a result of the environmental conditions found in the perioperative setting.

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INSOMNIA

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

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INTRACRANIAL ADAPTIVE CAPACITY, DECREASED

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Intracranial fluid dynamic mechanisms that normally compensate for increases in intracranial volumes are compromised, resulting in repeated disproportionate increases in intracranial pressure (ICP) in response to a variety of noxious and nonnoxious stimuli.

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KNOWLEDGE, DEFICIENT [LEARNING NEED] (SPECIFY)

answer

Absence or deficiency of cognitive information related to specific topic. [Lack of specific information necessary for patient/significant other(s) to make informed choices regarding condition/lifestyle changes.]

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KNOWLEDGE (SPECIFY), READINESS FOR ENHANCED

answer

The presence or acquisition of cognitive information related to a specific topic is sufficient for meeting health-related goals and can be strengthened.

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LIFESTYLE, SEDENTARY

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Reports a habit of life that is characterized by a low physical activity level.

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LIVER FUNCTION, RISK FOR IMPAIRED

answer

At risk for liver dysfunction. Viral infection (e.g., hepatitis A, hepatitis B, hepatitis C, Epstein-Barr); HIV co-infection; Hepatotoxic medications (e.g., acetaminophen, statins); Substance abuse (e.g., alcohol, cocaine)

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LONELINESS, RISK FOR

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At risk for experiencing discomfort associated with a desire or need for more contact with others.

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MEMORY, IMPAIRED

answer

Inability to remember or recall bits of information or behavioral skills [Impaired memory may be attributed to physiopathological or situational causes that are either temporary or permanent.]

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MOBILITY, IMPAIRED BED

answer

Limitation of independent movement from one bed position to another.

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MOBILITY, IMPAIRED PHYSICAL

answer

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

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MOBILITY, IMPAIRED WHEELCHAIR

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Limitation of independent operation of wheelchair within environment.

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NAUSEA

answer

A subjective, unpleasant, wavelike sensation in the back of the throat, epigastrium, or abdomen that may lead to the urge or need to vomit.

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NEGLECT, UNILATERAL

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Impairment in sensory and motor response, mental representation, and spatial attention to body and the corresponding environment characterized by inattention to one side and overattention to the opposite side. Left side neglect is more severe and persistent than right side neglect.

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NONCOMPLIANCE [ADHERENCE, INEFFECTIVE] (SPECIFY)

answer

Behavior of person and/or caregiver that fails to coincide with a health-promoting or therapeutic plan agreed upon by the person (and/or family, and/or community) and health care professional. In the presence of an agreed-on health-promoting or therapeutic plan, person's or caregiver's behavior is fully or partially adherent or nonadherent and may lead to clinically ineffective, partially ineffective outcomes.

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NUTRITION: LESS THAN BODY REQUIREMENTS, IMBALANCED

answer

Intake of nutrients insufficient to meet metabolic needs.

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NUTRITION: MORE THAN BODY REQUIREMENTS, IMBALANCED

answer

At risk for an intake of nutrients that exceeds metabolic needs.

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NUTRITION: READINESS FOR ENHANCED

answer

A pattern of nutrient intake that is sufficient for meeting metabolic needs and can be strengthened.

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ORAL MUCOUS MEMBRANE, IMPAIRED

answer

Disruptions of the lips and soft tissue of the oral cavity.

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NUTRITION: RISK FOR MORE THAN BODY REQUIREMENTS, IMBALANCED

answer

At risk for an intake of nutrients that exceed metabolic needs

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PAIN, ACUTE

answer

...Pain that typically is produced by sudden injury (e.g., fracture) or illness (e.g., acute infection) and is accompanied by physical signs such as increased heart rate, elevated blood pressure, pupillary dilation, sweating, or hyperventilation. Depending on the severity of the underlying stimulus, acute pain may be managed with acetaminophen or anti-inflammatory drugs, immobilization and elevation of the injured body part, or the topical application of heat or ice. Severe acute pain, such as that of broken ribs or of an ischemic part, may require narcotics, often with adjunctive agents like hydroxyzine for relief, or antiemetics. Acute pain should be managed aggressively.

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PAIN, CHRONIC

answer

...1. Long-lasting discomfort, with episodic exacerbations, that may be felt in the back, one or more joints, the pelvis, or other parts of the body. 2. Pain that lasts more than 3-6 months. 3. Pain that lasts more than a month longer than the usual or expected course of an illness. 4. Pain that returns periodically every few weeks or months for many years. Chronic pain is often described by sufferers as being debilitating, intolerable, disabling, or alienating and may occur without an easily identifiable cause. Studies have shown a high correlation between chronic pain and depression or dysphoria, but it is unclear whether the psychological aspects of chronic pain precede or develop as a result of a person's subjective suffering. Chronic pain is the leading cause of disability in the U.S.

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PARENTING, IMPAIRED

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...Inability of the primary caretaker to create an environment that promotes the optimum growth and development of the child.

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PARENTING, READINESS FOR ENHANCED

answer

...A pattern of providing an environment for children or other dependent persons that is sufficient to nurture growth and development and can be strengthened.

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PARENTING, RISK FOR IMPAIRED

answer

...Risk for inability of the primary caretaker to create, maintain, or regain an environment that promotes the optimum growth and development of the child.

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PERIPHERAL NEUROVASCULAR DYSFUNCTION, RISK FOR

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...A state for which an individual is at risk of experiencing a disruption in circulation, sensation, or motion of an extremity.

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POISONING, RISK FOR

answer

...Accentuated risk of accidental exposure to, or ingestion of, drugs or dangerous products in doses sufficient to cause poisoning.

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POST-TRAUMA SYNDROME [SPECIFY STAGE]

answer

...Sustained maladaptive response to a traumatic, overwhelming event.

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POST-TRAUMA SYNDROME, RISK FOR

answer

...A risk for sustained maladaptive response to a traumatic, overwhelming event.

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POWER, READINESS FOR ENHANCED

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...A pattern of participating knowingly in change that is sufficient for well being and can be strengthened.

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POWERLESSNESS [SPECIFY LEVEL]

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...Perception that one's own action will not significantly affect an outcome; a perceived lack of control over a current situation or immediate happening.

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POWERLESSNESS, RISK FOR

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...At risk for perceived lack of control over a situation and/or one's ability to significantly affect an outcome.

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PROTECTION, INEFFECTIVE

answer

...The state in which an individual experiences a decrease in the ability to guard the self from internal or external threats such as illness or injury

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RAPE-TRAUMA SYNDROME

answer

...Sustained maladaptive response to a forced, violent sexual penetration against the victim's will and consent.

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RAPE-TRAUMA SYNDROME: COMPOUND REACTION

answer

...A nursing diagnosis accepted at the NANDA 13th Conference (1998); forced violent sexual penetration against the victim's will and consent. The trauma syndrome that develops from this attack or attempted attack includes an acute phase of disorganization of the victim's lifestyle and a long-term process of reorganization of lifestyle.

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RAPE-TRAUMA SYNDROME: SILENT REACTION

answer

...A nursing diagnosis accepted at the NANDA 13th Conference (1998); forced violent sexual penetration against the victim's will and consent. The trauma syndrome that develops from this attack or attempted attack includes an acute phase of disorganization of the victim's lifestyle and a long-term process of reorganization of lifestyle.

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RELIGIOSITY, IMPAIRED

answer

...Impaired ability to exercise reliance on beliefs and/or participate in rituals of a particular faith tradition.

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RELIGIOSITY, READINESS FOR ENHANCED

answer

...Ability to increase reliance on religious beliefs and/or participate in rituals of a particular faith tradition.

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RELIGIOSITY, RISK FOR IMPAIRED

answer

...At risk for an impaired ability to exercise reliance on religious beliefs and/or participate in rituals of a particular faith tradition.

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RELOCATION STRESS SYNDROME

answer

......Physiologic and/or psychological disturbances as a result of transfer from one environment to another.

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RELOCATION STRESS SYNDROME, RISK FOR

answer

...At risk for physiological and/or psychosocial disturbance following transfer from one environment to another.

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ROLE PERFORMANCE, INEFFECTIVE

answer

...A change in patterns of behavior and self-expression that do not match the environmental context, norms, and expectations.

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SELF-CARE DEFICIT, [SPECIFY LEVEL] FEEDING, BATHING/HYGIENE, DRESSING/GROOMING, TOILETING

answer

...Impaired ability to perform or complete feeding, bathing/hygiene, dressing and grooming, or toileting activities for oneself [on a temporary, permanent, or progressing basis] (Specify level of independence using a standardized functional scale). Self-care also may be expanded to include the practices used by the client to promote health, the individual responsibility for self, a way of thinking. Refer to Nursing Diagnoses impaired Home Maintenance, ineffective Health Maintenance

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SELF-ESTEEM, CHRONIC LOW

answer

...Long-standing negative feelings about self or capabilities.

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SELF-ESTEEM, SITUATIONAL LOW

answer

...Episodic feelings about self or capabilities that develop in response to a loss or change.

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SELF-ESTEEM, SITUATIONAL LOW, RISK FOR

answer

...At risk for developing a negative perception of self-worth in response to a current situation. (specify situation)

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SELF-MUTILATION

answer

...A state in which an individual is at high risk to perform a deliberate act upon the self with the intent to injure, not kill, which produces immediate tissue damage to the body.

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SELF-MUTILATION, RISK FOR

answer

...A state in which an individual is at high risk to perform a deliberate act upon the self with the intent to injure, not kill, which produces immediate tissue damage to the body.

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SENSORY/PERCEPTION, DISTURBED (SPECIFY: VISUAL, AUDITORY, KINESTHETIC, GUSTATORY, TACTILE, OLFACTORY)

answer

...Change in the quantity or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli.

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SEXUAL DYSFUNCTION

answer

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

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SEXUALITY PATTERNS, INEFFECTIVE

answer

...Expressions of concern regarding one's own sexuality.

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SKIN INTEGRITY, IMPAIRED

answer

...A state in which an individual has altered epidermis and/or dermis.

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SKIN INTEGRITY, RISK FOR IMPAIRED

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...A state in which an individual's skin is at risk of being adversely altered.

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SLEEP, READINESS FOR ENHANCED

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...SLEEP, READINESS FOR ENHANCED

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SLEEP DEPRIVATION

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...Prolonged periods of time without sleep (sustained natural, periodic suspension of relative consciousness).

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SOCIAL INTERACTION, IMPAIRED

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...The state in which an individual participates in an insufficient or excessive quantity or ineffective quality of social exchange.

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SOCIAL ISOLATION

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

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SORROW, CHRONIC

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...A cyclical, recurring, and potentially progressive pattern of pervasive sadness that is experienced by a parent or caregiver, or individual with chronic illness or disability in response to continual loss, throughout the trajectory of an illness or disability.

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SPIRITUAL DISTRESS, RISK FOR

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...At risk for an altered sense of integration with life and the universe in which dimensions that transcend and empower the self may be disrupted.

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SPIRITUAL WELL-BEING, READINESS FOR ENHANCED

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...Ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, or a power greater than oneself.

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STRESS OVERLOAD

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...Excessive amounts and types of demands that require action.

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SUFFOCATION, RISK FOR

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...Accentuated risk of accidental suffocation (inadequate air available for inhalation).

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SUICIDE, RISK FOR

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...Risk for self-inflicted, life-threatening injury.

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SURGICAL RECOVERY, DELAYED

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

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SWALLOWING, IMPAIRED

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

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THERAPEUTIC REGIMEN MANAGEMENT: EFFECTIVE

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...A pattern of regulating and integrating into daily living a program for treatment of illness and its sequelae that is satisfactory for meeting specific health goals.

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THERAPEUTIC REGIMEN MANAGEMENT: INEFFECTIVE

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...A pattern of regulating and integrating into daily living a program for treatment of illness and the sequelae of illness that is unsatisfactory for meeting specific health goals.

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THERAPEUTIC REGIMEN MANAGEMENT, INEFFECTIVE COMMUNITY

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...A pattern of regulating and integrating into community processes programs for treatment of illness and the sequelae of illness that is unsatisfactory for meeting health-related goals.

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THERAPEUTIC REGIMEN MANAGEMENT, INEFFECTIVE FAMILY

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...A pattern of regulating and integrating into family processes a program for treatment of illness and the sequelae of illness that is unsatisfactory for meeting specific health needs.

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THERAPEUTIC REGIMEN MANAGEMENT: READINESS FOR ENHANCED

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...A pattern of regulating and integrating into daily living programs for treatment of illness and its sequelae that are sufficient for meeting health-related goals and can be strengthened.

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THERMOREGULATION, INEFFECTIVE

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...The state in which the individual's temperature fluctuates between hypothermia and hyperthermia.

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THOUGHT PROCESSES, DISTURBED

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...A state in which an individual experiences a disruption in cognitive operations and activities.

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TISSUE INTEGRITY, IMPAIRED

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...A state in which an individual experiences damage to mucous membrane or corneal, integumentary, or subcutaneous tissue.

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TISSUE PERFUSION, INEFFECTIVE (SPECIFY TYPE): RENAL, CEREBRAL, CARDIOPULMONARY, GASTROINTESTINAL, PERIPHERAL

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The state in which an individual experiences a decrease in nutrition and oxygenation at the cellular level due to a deficit in capillary blood supply.

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TRANSFER ABILITY, IMPAIRED

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...Limitation of independent movement between two nearby surfaces.

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TRAUMA, RISK FOR

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...Accentuated risk of accidental tissue injury (e.g., wound, burn, fracture).

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URINARY ELIMINATION, IMPAIRED

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...Dysfunction in urine elimination.

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URINARY ELIMINATION, READINESS FOR ENHANCED

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...A pattern of urinary functions that is sufficient for meeting eliminatory needs and can be strengthened.

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URINARY INCONTINENCE, FUNCTIONAL

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...Inability of usually continent person to reach toilet in time to avoid unintentional loss of urine.

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URINARY INCONTINENCE, OVERFLOW

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...Involuntary loss of urine associated with overdistention of the bladder.

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URINARY INCONTINENCE, REFLEX

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...Involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached.

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URINARY INCONTINENCE, RISK FOR URGE

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...At risk for an involuntary loss of urine associated with a sudden, strong sensation or urinary urgency.

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URINARY INCONTINENCE, STRESS

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...Sudden leakage of urine with activities that increase intra-abdominal pressure.

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URINARY INCONTINENCE, TOTAL

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...Continuous and unpredictable loss of urine.

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URINARY INCONTINENCE, URGE

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...Involuntary passage of urine occurring soon after a strong sense of urgency to void.

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URINARY RETENTION [ACUTE/CHRONIC]

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...Incomplete emptying of the bladder.

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VENTILATION, IMPAIRED SPONTANEOUS

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...Decreased energy reserves results in an individual's inability to maintain breathing adequate to support life.

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VENTILATORY WEANING RESPONSE, DYSFUNCTIONAL (DVWR)

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Inability to adjust to lowered levels of mechanical ventilator support, which interrupts and prolongs the weaning process.

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VIOLENCE, [ACTUAL]/RISK FOR OTHER-DIRECTED

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... At risk for behaviors in which an individual demonstrates that he/she can be physically, emotionally, and/or sexually harmful to others.

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VIOLENCE, [ACTUAL]/RISK FOR SELF-DIRECTED

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...Behaviors in which an individual demonstrates that he/she can be physically, emotionally, and/or sexually harmful to self.

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WALKING, IMPAIRED

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...Limitation of independent movement within the environment on foot.

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WANDERING [SPECIFY SPORADIC OR CONTINUAL]

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...Locomotion (with dementia or brain injury) characterized by its frequency and persistence: course appears to be meandering, aimless, or repetitive; frequently incongruent with boundaries, limits, or obstacles; impaired navigational ability.

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SELF-CARE, READINESS FOR ENHANCED

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...A pattern of performing activities for oneself that helps to meet health-related goals and can be strengthened.

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SELF-CONCEPT, READINESS FOR ENHANCED

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...A pattern of perceptions or ideas about the self that is sufficient for well-being and can be strengthened.

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INFECTION, RISK FOR SPREAD

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...The state in which an individual is at risk for transferring an opportunistic or pathogenic agent to others

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Functional Urinary Incontinence

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State in which a usually continent client experiences incontinence because of a difculty or inability to reach the toilet in time

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