Health Promotion Nursing Diagnosis

A limitation in independent, purposeful physical movement of the body or of one or more extremities Defining Characteristics: Postural instability during performance of routine activities of daily living (ADLs);  limited ability to perform gross motor skills;  limited ability to perform fine motor skills;  uncoordinated or jerky movements;  limited range of motion;  difficulty turning;  decreased reaction time;  movement-induced shortness of breath;  gait changes (e.g., decreased walking speed, difficulty initiating gait, small steps, shuffles feet, exaggerated lateral postural sway);  engages in substitutions for movement (e.g., increased attention to other's activity, controlling behavior, focus on preillness/predisability);  slowed movement;  movement-induced tremor Related Factors: Medications;  prescribed movement restrictions;  discomfort;  lack of knowledge regarding value of physical activity;  body ma...

Altered epidermis and/or dermis Defining Characteristics: Invasion of body structures;  destruction of skin layers (dermis);  disruption of skin surface (epidermis) Related Factors: External Hyperthermia;  hypothermia;  chemical substance (e.g., incontinence);  mechanical factors (e.g., friction, shearing forces, pressure, restraint);  physical immobilization;  humidity;  extremes in age;  moisture;  radiation;  medications Internal Altered metabolic state;  altered nutritional state (e.g., obesity, emaciation);  altered circulation;  altered sensation;  altered pigmentation;  skeletal prominence;  developmental factors;  immunological deficit;  alterations in skin turgor (change in elasticity);  altered fluid status NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Tissue Integrity: Skin and Mucous Membranes Wound Healing: Primary Intention Wound Healing: Secondary Inte...

Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function Defining Characteristics: Oral phase impairment Lack of tongue action to form bolus;  weak suck resulting in inefficient nippling;  incomplete lip closure;  food pushed out of mouth;  slow bolus formation;  food falls from mouth;  premature entry of bolus;  nasal reflux;  inability to clear oral cavity; long meals with little consumption;  coughing, choking, or gagging before a swallow;  abnormality in oral phase of swallow study;  piecemeal deglutition;  lack of chewing;  pooling in lateral sulci;  sialorrhea or drooling Pharyngeal phase impairment Altered head positions;  inadequate laryngeal elevation;  food refusal;  unexplained fevers;  delayed swallow;  recurrent pulmonary infections;  gurgly voice quality;  nasal reflux;  choking, coughing, o...

Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues Defining Characteristics: Damaged or destroyed tissue (e.g., cornea, mucous membrane, integumentary, or subcutaneous) Related Factors: Mechanical (e.g., pressure, shear, friction);  radiation (including therapeutic radiation);  nutritional deficit or excess;  thermal (temperature extremes);  knowledge deficit; irritants, chemical (including body excretions, secretions, medications);  impaired physical mobility;  altered circulation;  fluid deficit or excess NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Tissue Integrity: Skin and Mucous Membranes Wound Healing: Primary Intention Wound Healing: Secondary Intention Client Outcomes Reports any altered sensation or pain at site of tissue impairment Demonstrates understanding of plan to heal tissue and prevent injury Describes measures to protect and heal the tissue, including wound care Wound decreases in size a...

Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway Defining Characteristics: Dyspnea;  diminished breath sounds;  orthopnea;  adventitious breath sounds (crackles, wheezes);  cough, ineffective or absent;  sputum production;  cyanosis;  difficulty vocalizing;  wide-eyed;  changes in respiratory rate and rhythm;  restlessness Related Factors: Environmental Smoking;  smoke inhalation;  second-hand smoke Obstructed Airway Airway spasm;  retained secretions;  excessive mucus;  presence of artificial airway;  foreign body in airway;  secretions in bronchi;  exudate in alveoli Physiological Neuromuscular dysfunction;  hyperplasia of bronchial walls;  chronic obstructive pulmonary disease;  infection;  asthma;  allergic airways NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Respiratory Status: Ventilation Respir...

Dissatisfaction or difficulty a mother, infant, or child experiences with the breastfeeding process Defining Characteristics: Unsatisfactory breastfeeding process;  nonsustained suckling at the breast;  resisting latching on;  unresponsive to comfort measures;  persistence of sore nipples beyond first week of breastfeeding;  observable signs of inadequate infant intake; insufficient emptying of each breast per feeding;  infant inability to latch on to maternal breast correctly;  infant arching and crying at the breast; infant exhibiting fussiness and crying within the first hour after breastfeeding;  actual or perceived inadequate milk supply;  no observable signs of oxytocin release;  insufficient opportunity for suckling at the breast Related Factors: Nonsupportive partner/family;  previous breast surgery;  infant receiving supplemental feedings with artificial nipple;  prematurity;  previous history of breastfeedin...

An allergic response to natural latex rubber products Defining Characteristics: Type I reactions: Immediate reactions (<1hour) to latex proteins (can be life threatening);  contact urticaria progressing to generalized symptoms;  edema of the lips, tongue, uvula, and/or throat;  shortness of breath;  tightness in chest;  wheezing;  bronchospasm leading to respiratory arrest;  hypotension;  syncope;  cardiac arrest May also include: orofacial characteristics:  edema of sclera or eyelids, erythema and/or itching of the eyes, tearing of the eyes, nasal congestion, itching and /or erythema, rhinorrhea, facial erythema, facial twitching;  gastrointestinal characteristics: abdominal pain, nausea;  generalized characteristics: flushing, general discomfort, generalized edema, increasing complaint of total body warmth, restlessness Type IV reactions: delayed onset: eczema;  irritation;  reaction to additives causes di...

Inability to form a valid appraisal of stressors, inadequate choices of practiced responses, and/or inability to use available resources Defining Characteristics: Lack of goal-directed behavior/resolution of problem, including inability to attend, difficulty with organized information, sleep disturbance, abuse of chemical agents;  decreased use of social support;  use of forms of coping that impede adaptive behavior;  poor concentration;  fatigue;  inadequate problem solving;  verbalized inability to cope or ask for help; inability to meet basic needs;  destructive behavior toward self or others;  inability to meet role expectations;  high illness rate;  change in usual communication patterns; risk taking Related Factors: Gender differences in coping strategies;  inadequate level of confidence in ability to cope;  uncertainty;  inadequate social support created by characteristics of relationships;  inadequate level...