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Nursing Care Plan Guide - Revised 5-04

Nursing Care Plan Guide - Revised 5-04

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Published by hanje

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Published by: hanje on Aug 21, 2009
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05/11/2014

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NURSING DIAGNOSIS: NANDA 2003
AIR 
RESPIRATION
Airway clearance, ineffectiveAspiration, risk forBreathing pattern, ineffectiveGas exchange, impairedSpontaneous ventilation: inability to sustainVentilatory weaning response, dysfunctionalVentilation, impaired spontaneous
WATER 
CIRCULATION
Adaptive capacity intra-cranial, decreasedCardiac output, decreasedDysreflexiaTissue perfusion, ineffective (specify):cerebral, cardio-pulmonary, renal, gastro-intestinal peripheral)
FLUID
Fluid volume deficitFluid volume deficit, risk forFluid volume excessFluid volume imbalance, risk forFluid volume, readiness for enhancedOral mucous membranes, impaired
 
Swallowing, impaired
FOOD 
FOOD/FLUID
Breastfeeding, effectiveBreastfeeding, ineffectiveBreastfeeding, interruptedDentition, impaired
 
Infant feeding pattern, ineffectiveNauseaNutrition,
 
imbalanced:
 
less than bodyrequirementsNutrition, imbalanced
:
more than bodyrequirementsNutrition, readiness for enhancedNutrition, imbalanced:
 
risk for more
 
than body requirements
ELIMINATION 
 
ELIMINATION
ConstipationConstipation, risk forConstipation, perceivedDiarrheaIncontinence, bowelIncontinence, functional (urinary)Incontinence, reflex (urinary)Incontinence, stress (urinary)Incontinence, total (urinary)Incontinence, urge (urinary)Incontinence, urge (urinary) risk forUrinary elimination,
 
impairedUrinary elimination, readiness forenhancedUrinary retention
ACTIVITY/REST 
ACTIVITY/REST
 Activity intoleranceActivity intolerance, risk forDisuse syndrome, risk forDiversional activity, deficientFatigueSleep deprivationSleep, readiness for enhancedSleep pattern, disturbedTransfer ability, impairedWalking, impaired
HYGIENE
 Self-care deficit (specify): feeding, bathing/ hygiene, dressing/grooming, toileting
COMFORT
 Pain, (acute)Pain, chronicInjury, risk forPerioperative positioning injury, risk forPhysical mobility, impairedSocial isolation
SOLITUDE–SOCIAL ISOLATION 
 
EGO INTEGRITY
 Adjustment, impairedAnxiety, deathAnxiety (specify level)Body image disturbedConflict, decisional (specify)Coping, ineffectiveConflict, parental roleCoping, ineffective communityCoping, community, readiness for enhancedCoping, compromised familyCoping, disabled familyCoping, family, readiness for enhanced
 
Coping, defensiveCoping, readiness for enhancedDenial, ineffectiveEnergy field, disturbedFearGrieving, anticipatoryGrieving, dysfunctionalHopelessnessPersonal identity disturbedPost trauma responsePowerlessnessPowerlessness, risk forRape-trauma syndromeRape-trauma syndrome: compound reactionRape-trauma syndrome: silent reactionRelocation stress syndromeRelocation stress syndrome, risk forSelf-concept, readiness for enhanced
 
Self-esteem, chronic lowSelf-esteem, situational lowSelf-esteem, situational low, risk forSorrow, chronicSpiritual distressSpiritual distress, risk for
SOCIAL INTERACTION
 Caregiver role strainCaregiver role strain, risk forCommunication impaired, verbalCommunication, readiness for enhancedCommunity coping, enhanced, potential forCommunity coping, ineffectiveEnvironmental interpretation syndrome, ImpairedFailure to thrive, adultFamily coping, ineffective: compromisedFamily coping, ineffective: disablingFamily coping, potential for growthFamily process, dysfunctional: alcoholismFamily processes, interruptedFamily processes, readiness for enhancedLoneliness, risk forParent/infant/child attachment impaired, risk forParental role conflictParenting, Impaired
 
Parenting, impaired
,
risk forParenting, readiness for enhancedRole performance, Ineffective
 
Role strain, caregiverRole stain, caregiver, risk forSocial interaction, impairedSocial isolation(OVER)

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