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Please follow the instructions provided in the document, and refer to the example given at the bottom for guidance. Utilize the nursing diagnosis page to assist in answering the provided questions.
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NAANDA APPROVED NURSING DIAGNOSES
PHYSICAL PROBLEMS
BOWEL
• Bowel incontinence
• Constipation
• Colonic constipation
• Perceived constipation
• Constipation, Perceived
• Constipation, Risk for
• Constipation, Chronic Functional
• Constipation, Risk for Chronic Functional
• Contamination
• Contamination, Risk for
• Diarrhea
• Gastrointestinal Motility, Dysfunctional
• Gastrointestinal Motility
• Risk for Dysfunctional Gastrointestinal
• Perfusion, Risk for Ineffective
CIRCULATION
• Tissue Perfusion, Ineffective Peripheral
• Tissue Perfusion, Risk for Ineffective Peripheral
• Tissue Perfusion, Risk for Decreased Cardiac
• Tissue Perfusion, Risk for Ineffective Cerebral
• Bleeding, Risk for
• Cardiac Output, Decreased
• Cardiac Output, Risk for Decreased
• Cardiovascular Function, Risk for Impaired
• Shock, Risk for
• Surgical Recovery, Delayed
• Surgical Recovery, Risk for Delayed
• Vascular Trauma, Risk for
FLUID/HYDRATION
• Fluid volume deficit
• High risk for fluid volume deficit
• Fluid volume excess
• Fluid Volume, Risk for Deficient
• Fluid Volume, Risk for Imbalanced
• Fluid Balance, Readiness for Enhanced
• Electrolyte Imbalance, Risk for
ENDOCRINE
• Blood Glucose Level, Risk for Unstable
INFANT FEEDING/BREASTFEEDING PROBLEMS
• Effective breast-feeding
• Ineffective breast-feeding
• Interrupted breast-feeding
• Ineffective infant feeding pattern
•
•
•
•
•
•
•
Insufficient Breast Milk
Readiness for enhanced Breastfeeding,
Liver Function, Risk for Impaired
Jaundice, Neonatal
Jaundice, Risk for Neonatal
Sudden Infant Death Syndrome, Risk for
Suffocation, Risk for
MOBILITY ACTIVITY
• Activity Intolerance
• High risk for activitiy intolerance
• Diversional activity deficit
• High risk for disuse syndrome
• Transfer Ability, Impaired
• Activity Intolerance
• Activity Intolerance, Risk for
• Activity Planning, Ineffective
• Activity Planning, Risk for Ineffective
• Decreased Intracranial Adaptive Capacity
• Lifestyle, Sedentary
• Mobility, Impaired Bed
• Mobility, Impaired Physical
• Mobility, Impaired Wheelchair
• Sitting, Impaired
• Standing, Impaired
• Walking, Impaired
• Wandering
NEUROLOGIC DYSFUNCTION
• Autonomic Dysreflexia
• Autonomic Dysreflexia, Risk for
• Memory, Impaired
• Peripheral Neurovascular Dysfunction, Risk for
NUTRITION/EATING
• Nutrition, Imbalanced: Less than Body
Requirements
• Nutrition, Readiness for Enhanced
• Obesity
• Risk for Overweight
• Overweight
• Nausea
• Swallowing, Impaired
PAIN
•
•
•
•
•
Pain, Acute
Pain, Chronic
Pain Syndrome, Chronic
Pain, Chronic Malignant
Pain, Chronic Nonmalignant
•
PHYSICAL SAFETY/PROTECTION
• Altered protection
• Dysreflexia
• High risk for infection
• High risk for injury
• High risk for poisoning
• High risk for trauma
• Trauma, Risk for
• Sensory/perceptual alterations
• Unilateral neglect
• Infection, Risk for
• Injury, Risk for Corneal
• Falls, Risk for
• Injury, Risk for Perioperative-Positioning
• Injury, Risk for Thermal
• Injury, Risk for Urinary Tract
• Self-Mutilation
• Self-Mutilation, Risk for
• Suicide, Risk for
RESPIRATORY/BREATHING
• Airway Clearance, Ineffective
• Allergy Response, Risk for
• Risk for Aspiration,
• High risk for suffocation
• Inability to sustain spontaneous ventilation
• Dysfunctional ventilatory weaning response
• Ineffective airway clearance
• Ineffective breathing pattern
• Spontaneous Ventilation, Impaired
• Ventilatory Weaning Response, Dysfunctional
REST/SLEEP
• Fatigue
• Sleep, Readiness for Enhanced
• Sleep Deprivation
• Sleep Pattern, Disturbed
• Insomnia
SELF-CARE
• Bathing/Hygiene self-care deficit
• Feeding self-care deficit
• Toileting self-care deficit
• Self-Care, Readiness for Enhanced
• Self-Care Deficit, Bathing
• Self-Care Deficit, Dressing
• Self-Care Deficit, Feeding
• Self-Care Deficit, Toileting
• Self-Concept, Readiness for Enhanced
Self-Neglect
SEX/SEXUALITY
• Altered sexuality patterns
• Sexual dysfunction
• Sexuality Pattern, Ineffective
SKIN/MUCOUS MEMBRANE
• Impaired Oral Mucous Membrane
• Risk for Impaired Oral Mucous Membrane
• High Risk for impaired tissue integrity
• Impaired tissue integrity
• Dry Eye, Risk for
• Skin Integrity, Impaired
• Skin Integrity, Risk for Impaired
• Latex Allergy Response
• Latex Allergy Response, Risk for
• Pressure Ulcer, Risk for
TEMPERATURE
• Body Temperature, Risk for Imbalanced
• High risk for altered body temperature
• Hyperthermia
• Hypothermia
• Hypothermia, Risk for
• Hypothermia, Risk for Perioperative
• Reaction to Iodinated Contrast Media, Risk for
• Protection, Ineffective
• Thermoregulation, Ineffective
URINARY/VOIDING
• Altered urinary elimination
• Reflex incontinence
• Total incontinence
• Urinary retention
• Elimination, Readiness for Enhanced Urinary
• Incontinence, Functional Urinary
• Incontinence, Overflow Urinary
• Incontinence, Reflex Urinary
• Incontinence, Risk for Urge Urinary
• Incontinence, Stress Urinary
• Incontinence, Urge Urinary
• Renal Perfusion, Risk for Ineffective
PSYCHOSOCIAL
COMMUNICATION, THINKING, KNOWLEDGE
• Altered thought processes
• Knowledge/skills deficit
• Knowledge, Deficient
• Knowledge, Readiness for Enhanced
•
•
•
•
•
•
Impaired verbal communication
Comfort, Readiness for Enhanced
Communication, Readiness for Enhanced
Confusion, Acute
Confusion, Chronic
Confusion, Risk for Acute
COPING/ADJUSMENT
• Anxiety
• Defensive coping
• Ineffective individual coping
• Coping, Compromised Family
• Coping, Defensive
• Coping, Disabled Family
• Coping, Ineffective Community
• Coping, Readiness for Enhanced
• Coping, Readiness for Enhanced Community
• Coping, Readiness for Enhanced Family
• Diversional Activity, Deficient
• Decisional conflict
• Fear
• Grieving
• Anticipatory grieving
• Dysfunctional grieving
• Grieving, Complicated
• Grieving, Risk for Complicated
• Hope, Readiness for Enhanced
• Hopelessness
• Human Dignity, Risk for Compromised
• Impaired adjustment
• Ineffective denial
• Power, Readiness for Enhanced
• Powerlessness
• Powerlessness, Risk for
• Stress Overload
• Relocation stress syndrome
• Relocation Stress Syndrome, Risk for
• Spiritual distress
• Social Interaction, Impaired
• Social Isolation
• Sorrow, Chronic
• Spiritual Distress
• Spiritual Distress, Risk for
• Spiritual Well-Being, Readiness for Enhanced
• Religiosity, Impaired
• Religiosity, Readiness for Enhanced
• Religiosity, Risk for Impaired
• Death Anxiety
• Decision-Making, Readiness for Enhanced
• Decisional Conflict
• Denial, Ineffective
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•
•
•
Emancipated Decision Making, Impaired
Emancipated Decision Making, Readiness for
Enhanced Emancipated Decision Making. Risk
for Impaired
Emotional Control, Labile
Impulse Control, Ineffective
FAMILY & GROWTH/DEVELOPMENT
• Attachment, Risk for Impaired
• Altered family processes
• Family Processes, Dysfunctional
• Family Processes, Interrupted
• Family Processes, Readiness for Enhanced
• Altered growth and development
• Development, Risk for Delayed
• Growth, Risk for Disproportionate
• Altered parenting
• High risk for altered parenting
• Caregiver role strain
• High risk for caregiver role straing
• Family coping: potential for growth
• Ineffective family coping: compromised
• Role Conflict, Parental
• Role Performance, Ineffective
• Role Strain, Caregiver
• Role Strain, Risk for Caregiver
• Parenting, Impaired
• Parenting, Readiness for Enhanced
• Parenting, Risk for Impaired
• Dentition, Impaired
• Frail Elderly Syndrome
• Frail Elderly Syndrome, Risk for
• Resilience, Impaired
• Resilience, Readiness for Enhanced
• Resilience, Risk for Impaired
HEALTH MANAGEMENT
• Altered health maintenance
• Health-seeking behavior
• Impaired home maintenance management
• Ineffective management of therapeutic
regimen
• Noncompliance
• Health, Deficient Community
• Health Behavior, Risk-Prone
• Health Maintenance, Ineffective
• Health Management, Ineffective
• Health Management, Readiness for Enhanced
• Health Management, Ineffective Family
• Home Maintenance, Impaired
INFANT BEHAVIOR
• Behavior, Disorganized Infant Behavior
• Readiness for Enhanced Organized Infant
Behavior,
• Risk for Disorganized Infant
• Mood Regulation, Impaired
• Loneliness, Risk for
• Moral Distress
ROLE/RELATIONSHIP
• Altered role performance
• Impaired social interaction
• Social Isolation
• Relationship, Ineffective
• Relationship, Risk for Ineffective
• Relationship, Readiness for Enhanced
SELF-ESTEEM
• Body image disturbance
• Self-esteem disturbance
• Chronic low self-esteem
• Situational low self-esteem
• Personal Identity, Disturbed
• Personal Identity, Risk for Disturbed
• Self-Esteem, Chronic Low
• Self-Esteem, Risk for Chronic Low
• Self-Esteem, Situational Low
• Self-Esteem, Risk for Situational Low
VIOLENCE
• High risk for self-mutilation
• Self-Directed Violence, Risk For
• Other-Directed Violence, Risk for
• Post-trauma responses
• Rape-trauma syndrome
• Rape-trauma syntdrome: compound reaction
• Post-Trauma Syndrome
• Post-Trauma Syndrome, Risk for
MATERNITY
Childbearing Process, Ineffective
• Childbearing Process, Readiness for Enhanced
• Childbearing Process, Risk for Ineffective
• Comfort, Impaired
• Maternal/Fetal Dyad, Risk for Disturbed
• Pain, Labor
Student :
Date:
Initials
Room:
Patient Data Form Pediatrics
Current Diagnosis / Surgery / Priorities:
AM Report
Adm. Date:
VS / pain assessment (rate 0 – 10)
Frequency:
Time
T
P
R
BP
AGE:
M / F
Weight:
Pain
ALLERGIES:
Teach/psychosocial/
cultural, D/C needs:
Fluids / Nutrition:
Activity
/Restraints /
Isolation :
Diet / Feeding method
Activity
Calming/Pain needs:
GT feeds:
RN
Development needs:
Safety precaut.
CNA
Labs / Diagnostics
MD
IV solution /rate:
Additional notes:
Respiratory
Time O2 L/min
Teaching Needs:
IV site/type:
O2 Sat
Rx
24 hour fluid calc.
INTAKE & OUTPUT
IN – Mntnce.
1X
1.5 X
___ mL/day
___ mL/day
___ mL/hr
___ mL/hr
Treatments / Tests
Parent
present?
Notes:
Y/N
Isolation:
❑ Mask
❑ Gloves
❑ Gown
Cultural/Spiritual:
Wounds/Drains:
Discharge:
I&O During Shift
Intake Output Net
__mL
___mL
+/- mL
Physical Assessment (Head-to-toe)
Off Shift Report:
Gen.:
Skin:
HEENT:
Pulses: (radial / femoral / pedal)
Cardiac:
Resp.:
Abd.:
Neuro:
Extremities (orthopedic: neurovascular assessment):
Wounds (location / drainage / dressing/tubes/drains):
G&D:(eg) Erikson, Piaget, physical, gross/fine motor, language, socialization, cognition, etc):
Safety check: Perform when enter room + check and document when you leave
❑ O2 Sat monitor: Alarms set + Site rotation
LOW sat _______ HIGH sat _______
❑ Apnea monitor: Alarms set LOW RR _______ HIGH RR _________ Apnea time _______________
❑ Cardiac monitor: Alarms set
LOW Heart rate _______ HIGH Heart rate ________ RATE matches apical________
(Update May 2021)
❑ IV fluid / rate – matches order
❑ Infusion device set
❑ IV tubing – dates checked
❑ Oxygen ordered level ______
❑ Suction working
❑ Suction supplies @ bedside
❑ Bag & mask – appropriate size
❑ Face shield
❑ No choking hazards (
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