Urinary, retention
Self-care, deficit: use the potty / toilet
4. MOBILIZATION:
Disuse, high risk of syndrome
Physical mobility, disorder
Peripheral Neurovascular, high risk of dysfunction
Activity intolerance
Fatigue
Activity, high risk of intolerance
5. REST / SLEEP:
Sleep pattern disturbance
6. WEAR PROPER CLOTHING AND CHOOSE:
Self-care, deficit: dressing / grooming
7. TEMPERATURE:
Body temperature: high risk of impaired
Hypothermia
Hyperthermia
Ineffective Thermoregulation
8. HEALTH / SKIN
Tissue perfusion, altered (specify) renal
Cerebral, cardiopulmonary, gastrointestinal, peripheral.
Tissue, impaired integrity
Oral mucous membrane, altered
Skin, impaired
Cutaneous, high risk of deterioration of the integrity
Self-care, deficit: bathing / hygiene
9. SECURITY:
Infection, high risk of
Dysreflexia
Injury, high risk
Poisoning, high risk of
Trauma, high risk of
Protection, impaired
Family, alteration processes
Role of caregiver, overexertion in
The role of caregiver, high risk to overuse in the
Defensive coping
Denial ineffective
Ineffective family coping: disabling
Ineffective family coping: engaged
Therapeutic regimen, ineffective management of (individual)
Growth and development, altered
Transfer, stress syndrome
Pain
Chronic Pain
Bereavement dysfunctional
Early Mourning
Violence, high risk: self-injury, injury to other
Self-mutilation, high risk of
Post-traumatic response
Rape, traumatic syndrome of
Violation, trauma syndrome: compound reaction
Violation, trauma syndrome: silent reaction
Anxiety
Fear
10. COMMUNICATION:
Verbal, disorder
Social, impaired interaction
Social isolation
Sexual dysfunction
Sexuality, altered patterns of
COPING: ineffective
Sen-so-perceptual alterations (specify) visual
auditory, kin esthetic, gustatory, tactile, olfactory.
11- Religion / Beliefs:
Spiritual suffering
Treatment, tracking no (specify)
Decisions, conflict in the making (specify)
Hopelessness
Impotence
12 WORK / BE
Role, impaired performance
Parenteral, alteration
Parenteral, high risk of disruption
3. Elimination pattern:
Constipation
Constipation perceived
Colonic constipation.
Diarrhea.
Bowel incontinence.
Altered urinary excretion
Functional incontinence
Stress incontinence
Urge incontinence
Total incontinence
Reflex incontinence
Urinary retention
Altered endogenous chemical (electrolyte imbalance, increased BUN, hypoxia, etc ) or exogenous
(stimulants or depressants system. CNS).
Psychological stress.
Features:
Disoriented in time, space or people.
Change the capabilities to solve a problem.
Change in the pattern.
Anxiety.
Irritability, hallucinations, fear, depression, anger, poor concentration, auditory and visual distortions, and
motor in-coordination.
Anxiety:
Vague and unsettling feeling whose source is often nonspecific or unknown to the individual.
Related factors:
Threat of death, the concept itself, for the state of health to socioeconomic status, role change, the
environment, changing patterns of interaction.
Situational or maturation crisis.
Transmission and interpersonal contagion.
Unmet Needs.
Features:
Self or negative feelings about himself.
Earrings of development.
Verbalization of negative feelings about himself.
Expressions of shame or guilt.
Difficulty making decisions.
Aspiration risk:
State in which an individual experiences risk of entry of gastric secretions, oropharyngeal secretions, food or
liquid in the airways exogenous, due to the absence of dysfunction of the protective mechanisms.
Risk factors:
Reduced level of consciousness.
Decreased reflexes of cough and nausea.
Presence of tracheostomy, tracheostomy balloon inflated excessively, etc
Gastrointestinal probes.
Food administered by nasogastric tube.
Activity Intolerance.
Pain, discomfort.
Perceptual or cognitive disorder, muscle, musculoskeletal, etc .
Depression, severe anxiety.
Features:
Inability to toilet or potty.
Inability to get on and off the toilet or wedge.
Inability to manipulate the items needed to go to the bathroom.
Inability to genito-anal hygiene properly.
Inability to flush the toilet or empty the potty.
Self-care deficit: dressing / arrangement:
State in which a person has an inability to perform or complete disordered dress and grooming activities
alone.
Features:
Ability to be altered or removed the necessary items.
Ability to obtain or replace altered garments.
Ability to fasten their dresses altered.
Inability to maintain satisfactory aspect.
Pain:
State in which the individual experiences and communicates the presence of severe discomfort or an
uncomfortable feeling.
Related factors:
Biological Agents.
Chemical.
Physical agents.
Agents psychological.
Features:
Verbal communication of pain descriptors.
Behavior of defense protection.
Facial mask of pain.
Alteration of muscle tone.
Answers autonomous, such as increased blood pressure, changes in pulse, respiratory rate increased or
decreased.
Diarrhea:
State in which an individual experiences a change in normal bowel habits characterized by frequent loose
stools emissions, liquid and without consistency.
Related factors:
Stress and anxiety.
Dietary intake.
Drugs.
Inflammation, irritation or intestinal malabsorption.
Toxins.
Pollutants.
Radiation.
Features:
Abdominal pain.
Cramps.
Increased frequency of bowel movements.
Increased frequency of bowel sounds.
Loose stools liquid.
Urgency.
Changes in color.
Urinary excretion, impaired:
State in which an individual experiences a disturbance in urination.
Related factors:
Postsensorial motor disorder.
Neuromuscular disorder.
Mechanical trauma.
Features:
Dysuria.
Frequency.
Difficulty starting urination.
Incontinence.
Nocturia.
Retention.
Urgency.
Constipation:
State in which an individual experiences a change in normal bowel habits, characterized by decreased
frequency of defecation and / or removal of hard, dry stools.
Related factors:
Not drinking enough water and food.
Physical activity decreased.
Personal habits.
Medication.
Gastrointestinal obstructive lesions.
Chronic use of laxatives.
Pain with bowel movements.
Lack of privacy.
Pregnancy.
Abdominal musculature weak.
Emotional disorders.
Features:
Frequency less than the usual pattern.
Hard stool.
Mass palpable.
Straining to defecate.
Decreased bowel sounds.
Feeling of fullness or abdominal or rectal pressure.
Number of faeces less than usual.
Nausea.
Decreased Cardiac Output:
State in which the amount of blood pumped by the heart declined enough to not adequately cover the needs of
body tissues.
Related factors:
Changes in preload, afterload or inotropic heart.
Disturbance of rate, rhythm or conduction.
Features:
Changes in hemodynamic structures.
Arrhythmias.
Fatigue.
Features:
Chills.
Skin cold.
Pale.
Slow capillary refill.
Tachycardia.
Cyanosis of the nail beds.
Hypertension.
Piloerection.
Body image disorder:
Altering the way a person perceives the image of his own body.
Related factors:
Biophysical.
Cognitive-perceptual.
Psychosocial.
Cultural.
Features:
There must be one of the following two features for which there is a diagnosis.
A. Verbal response to a real or perceived change in the structure and / or function.
2. Non-verbal response to a real or perceived change in the structure and / or function.
Loss of a body part.
Do not look the body, not touching it, hide it.
Trauma of a non-functioning.
Changes in social participation.
Negative feelings about the body.
Feelings of helplessness or despair.
Concern for the change or loss.
Emphasis on the remaining forces, strengthening of procurement.
Refusal to verify the actual change.
Populations at risk:
Loss of a body part.
Dependence of a machine.
Meaning of the body part or function respect to age, sex, level of development, or needs.
Physical change by chemical agents.
Trauma or mutilation.
Pregnancy and / or maturational changes.
Urge incontinence:
State in which an individual experiences an involuntary loss of urine that occurs after a strong feeling of
needing to urinate.
Related factors:
Decreased bladder capacity (pelvic inflammatory disease, surgery, catheterization, etc .)
Irritation of the bladder stretch receptors that cause spasm (infection).
Alcohol.
Caffeine.
Increase fluid intake.
Increased urinary concentration.
Excessive bladder distension.
Features:
-Urinary urgency.
High frequency.
Nocturia.
Urination in small amounts.
Inability to reach the bathroom.
Bowel incontinence:
State in which an individual experiences a change in normal bowel habits, characterized by involuntary
discharge of feces.
Related factors:
Effect neuromuscular.
Effect on skeletal muscle.
Depression or severe anxiety.
Disorder of perception or knowledge.
Features:
Involuntary discharge of feces.
Infection, high risk:
State in which an individual has an increased risk of invasion by pathogenic microorganisms.
Related factors:
Inadequate primary defenses (skin lesions, tissue trauma, decreased ciliary action, stasis of body fluids).
Inadequate secondary defenses (decreased hemoglobin, leukopenia, immunosuppression).
Acquired immunity inappropriate.
Destruction of tissue and increased environmental exposure.
Chronic illness.
Invasive procedures.
Pharmacological agents and trauma.
Rupture of amniotic membranes.
Insufficient knowledge to prevent exposure to pathogens.
Impaired Skin Integrity:
State in which the skin of an individual is altered unfavorably.
Related factors:
Hyperthermia and hypothermia.
Chemicals.
Shear forces, pressure continues, clamping radiation., Etc.
Physical immobility.
State of nutrition.
Circulation altered.
Sensitivity altered.
Psychogenic.
Edema.
Features:
Interrupt the continuity of the skin.
Destruction of skin layers.
Invasion of body structures.
Altered gas exchange:
State in which an individual experiences an imbalance between oxygen uptake and carbon dioxide removal.
Related factors:
Supply of oxygen altered.
Changes in alveolar-capillary membrane.
Blood flow altered.
Impaired transport capacity of oxygen in the blood.
Features:
Confusion.
Drowsiness.
Restlessness.
Irritability.
Inability to clear secretions.
Hypercapnia.
Hypoxia.
Activity intolerance:
State in which an individual has no physiological or psychological energy enough to resist or complete
required or desired daily activities.
Related factors:
Generalized weakness.
Sedentary lifestyle.
Imbalance between supply and demand for oxygen.
Bed rest or immobility.
Features:
Verbal report of fatigue or weakness.
Response abnormal heart rate or blood pressure to the activity.
Discomfort or exertional dyspnea.
Changes reflect Electrographic arrhythmias or ischemia.
Injury, high risk:
State in which the individual is at risk for injury as a result of environmental conditions that interact with the
adaptive and defensive resources of the individual.
Risk factors:
Dysfunction sensory integration or effector.
Tissue hypoxia.
Malnutrition.
Autoimmune.
Abnormal blood profile.
Lesion on the skin.
Mobility impaired.
Related development.
Factors such as personal
Urinary Retention:
State in which an individual presents an incomplete emptying of the bladder.
Related factors:
High urethral pressure caused by weak detrusor.
Inhibition of the reflex arc.
Strong sphincter.
Lock.
Features:
Bladder distention.
Frequent urination and small.
Sensation of bladder fullness.
Drip.
Residual urine.
Dysuria.
Overflow.
Sleep pattern disturbance:
Disruption of sleep time causes discomfort or interferes with desired lifestyle.
Related factors:
Sensory disturbances.
Psychological stress.
External factors.
Social changes.
Features:
Complaints of difficulty sleeping.
Desvelo earlier or later than desired.
Sleep disruption.
Changes in behavior and performance.
Irritability.
Disorientation.
Tremors.
Frequent yawning.
Changes in posture.
Ineffective thermoregulation:
State in which an individuals body temperature fluctuates between hypothermia and hyperthermia.
Related factors:
Trauma or disease.
Prematurity.
Old age.
Ambient temperature fluctuating.
Features:
Fluctuations in body temperature below or above the normal range.
Trauma, high risk:
Heightened risk of accidental tissue injury (wounds, burns, fractures, etc )
Risk factors:
Weakness.
Poor eyesight.
Lack of coordination.
Lack of safety precautions.
Lack of knowledge.
Beds high.
Use of stairs.
Poor lighting of stoves.
Driving in a dangerous manner.
Etc.
By air, cleaning ineffective:
State in which an individual is unable to remove the obstructions ecreciones respiratory tract to maintain
airway patency.
Related factors:
Reduction of energy.
Fatigue.
Infection.
Obstruction.
Discharge.
Trauma.
Disorder perceptual / cognitive.
Features:
Abnormal breathing sounds.
Tachypnea.
Cough effective, with or without expectoration.
Cyanosis.
Dyspnea.
Fever.
Fluid volume, deficit:
State in which an individual experiences vascular dehydration, cellular or intracellular, associated with a
failure of compensatory mechanisms.
Related factors:
Failure of compensatory mechanisms.
Features:
Possible weight gain.
Hypotension.
Lelnado venos decreased.
Decreased volume and pulse.
Body temperature auemntada.
Skin and mucous membranes dry.
Hemoconcentration.
Weakness.
Edema.
Sed.
Liquid volume, excess:
State in which an individual experiences vascular dehydration, cellular or intracellular, associated with a
failure of compensatory mechanisms.
Related factors:
Failure of regulatory mechanisms.
Excessive fluid intake.
Excessive sodium intake.
Features:
Edema.
Diarrhea.
Anasarca.
Weight gain.
Intake greater than the stool.
Third heart sound.
Congestion.
Changing breathing pattern.
Changes in pulmonary artery pressure.
Oliguria.
Restlessness, anxiety.