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Nursing Diagnosis Activity Intolerance

Related factors
Bedrest complete exhaustion imbalance between oxygen supply and demand immobility Lifestyle

Activity Intolerance; Risk for Activity Planning, ineffective Autonomic Dysreflexia

Autonomic Dysreflexia, risk for

Head Injury Subarachnoid Hemorrhage Guillain-Barre Syndrome Medication side effects

y y y y y y y y y y y y y y y y y y y y y y y y y y y y y y Threat or perceived threat to physical and emotional integrity Changes in role function Intrusive diagnostic and surgical tests and procedures Changes in environment and routines Threat or perceived threat to self-concept Threat to (or change in) socioeconomic status Situational and maturational crises Interpersonal conflicts 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 exudates in alveoli Physiological Neuromuscular dysfunction hyperplasia of bronchial walls; chronic obstructive pulmonary disease; infection; asthma; allergic airways Impaired gag reflex Poor Dentition Alteration In Consciousness Impaired Airway Defense Mechanisms Poor oral hygiene


Anxiety, death

Airway Clearance, ineffective

Aspiration, risk for

Allergy Response, latex

y No immune mechanism response

Allergy Response, risk for latex

Inability of parents to meet personal needs Anxiety associated with the parent role Substance abuse Premature infant; ill infant/child who is unable to effectively initiate parental contact due to altered behavioral organization y Separation; physical barriers y Lack of privacy y y y y

Attachment, risk for impaired

Bleeding, risk for

y y y y y Inadequate comprehension Low self-efficacy; Multiple stressors; Inadequate social support Low socioeconomic status Negative attitudes toward health care

Behavior, risk-prone health

Body Image, disturbed

y y y y y y y y y y

Psychosocial biophysical cognitive/perceptual cultural spiritual, or developmental changes illness trauma or injury surgery illness treatment

Bowel Incontinence

Breastfeeding, effective

y Change in stool consistency (diarrhea, constipation, fecal impaction) y abnormal motility (metabolic disorders, inflammatory bowel disease, infectious disease, drug induced motility disorders, food intolerance) y defects in rectal vault function (low rectal compliance from ischemia, fibrosis, radiation, infectious proctitis, Hirschprung's disease, local or infiltrating neoplasm, severe rectocele) y sphincter dysfunction (obstetric or traumatic induced incompetence, fistula or abscess, prolapse, third degree hemorrhoids, pseudodyssynergia of the pelvic muscles) y neurological disorders impacting gastrointestinal motility, rectal vault function and sphincter function (cerebro vascular accident, spinal injury, traumatic brain injury, central nervous system tumor, advanced stage dementia, encephalopathy, profound mental retardation, multiple sclerosis, myelodysplasia and related neural tube defects, gastroparesis of diabetes mellitus, heavy metal poisoning, chronic alcoholism, infectious or autoimmune neurological disorders, myasthenia gravis) y Normal breast structure y Normal infant oral structure y Gestational age >34* weeks y Infant eagerness to breastfeed y s/s MER y Adequate infant output (for day of PP age) y Maternal knowledge/confidence/support y Verbalization of satisfaction BF process y y y y y y y y y y y Infant anomaly infant receiving supplemental feedings with artificial nipple interruption in breastfeeding knowledge deficit maternal ambivalence maternal anxiety maternal breast anomaly nonsupportive family; nonsupportive partner poor infant reflex prematurity; previous breast surgery previous history of breastfeeding failure

Breastfeeding, ineffective

Breastfeeding, interrupted

Breathing Pattern, ineffective

y Maternal-infant separation RT illness of either, prematurity/immaturity, etc. y Short-term contraindications to breastfeeding y Need to wean abruptly y Maternal employment y Inflammatory process: viral or bacterial y Hypoxia y Neuromuscular impairment y Pain y Musculoskeletal impairment y Tracheobronchial obstruction y Perception or cognitive impairment y Anxiety y Decreased energy and fatigue y Decreased lung expansion y y y y y y Extremes of weight or age Dehydration Illness and/or trauma, especially affecting temperature regulation center Drugs Environment: exposure to hot or cold temperatures Inappropriate clothing

Body Temperature, risk for imbalanced

y Inactivity or vigorous activity y y y y y y Increased or decreased ventricular filling (preload) Alteration in afterload Impaired contractility Alteration in heart rate, rhythm, and conduction Decreased oxygenation Cardiac muscle disease

Cardiac Output, decreased

Conflict, decisional (specify) Coping, defensive

y y y y y Change in or loss of body part Diagnosis of serious illness Recent change in health status Unsatisfactory support system Inadequate psychological resources (poor self-esteem, lack of motivation) Personal vulnerability Inadequate coping method Situational crises Maturational crises Inadequate fiber intake Immobility/inadequate physical activity Inadequate fluid intake Pain on defecation Change in routine (diet intake) Abuse of laxatives Delaying defecation when urge is present Use of prescribed constipating medications (narcotic analgesic, iron, antacid and anticholinergic)

Coping, ineffective
y y y y y y y y y y y y


Constipation, perceived

y Altered thought process y Family health beliefs y Knowledge deficit about normal processes A. diminished defecation reflex associated with: 1. suppression of urge to defecate because of lack of privacy and reluctance to use bedpan 2. decreased gravity filling of lower rectum resulting from horizontal positioning; weakened abdominal muscles associated with generalized loss of muscle tone resulting from prolonged immobility; decreased gastrointestinal motility associated with decreased activity and the increased sympathetic nervous system activity that occurs with anxiety.

Constipation, risk for

B. C.

Confusion, acute

Confusion, risk for acute

Confusion, chronic

y y y y y y y y y y y y y y y y

60 years of age Dementia alcohol abuse abuse; delirium uncontrolled pain multiple morbidities and medications Alzheimers disease (dementia of the Alzheimers type) Multiinfarct dementia Cerebrovascular accident (CVA) Acquired immune deficiency disease Chronic hepatic encephalopathy Chronic drug intoxication Chronic subdural hematoma Parkinsons disease Huntingtons chorea Creutzfeldt-Jakob disease

Comfort, impaired Comfort, readiness for enhanced Contamination Contamination, risk for

y y y y y

Sternotomy (mediastinal incision) or donor site (leg or arm incision) Myocardial ischemia (acute MI, angina) Tissue inflammation, edema formation Intraoperative nerve trauma

Caregiver Role Strain

Caregiver Role Strain, risk for

y Caregiver expresses difficulty in performing patient care y Caregiver verbalizes anger with responsibility of patient care y Caregiver worries that own health will suffer because of caregiving y Caregiver states that formal and informal support systems are inadequate y Caregiver regrets that caregiving responsibility does not allow time for other activities y Caregiver expresses problems in coping with patients behavior y Caregiver expresses negative feeling about patient or relationship y Caregiver neglects patient care y Caregiver abuses patient y Brain injury that adversely affects the transmission, reception or interpretation of language or other forms of communication y Structural problem (e.g., cleft palate, laryngectomy, tracheostomy, intubation, or wired jaws) y Cultural difference (e.g., speaks different language) y Dyspnea y Fatigue y Sensory challenge involving hearing or vision y Change in marital status y home care of a child with special needs y interruptions of family life due to home care regimen (e.g., treatments, caregivers, lack of respite) y intimidation with invasive modalities (e.g., intubation) y intimidation with restrictive modalities (e.g., isolation) y separation from child due to chronic illness y specialized care center y Change in or loss of body part y Diagnosis of serious illness y Recent change in health status y Unsatisfactory support system y Inadequate psychological resources (poor self-esteem, lack of motivation) y Personal vulnerability y Inadequate coping method y Situational crises y Maturational crises y y y y y y y y y y y y y y y y y Coexisting situations affecting the significant person developmental crises the significant person may be facing exhaustion of supportive capacity of significant people inadequate information by a primary person inadequate understanding of information by a primary person incorrect information by a primary person lack of reciprocal support little support provided by client, in turn, for primary person prolonged disease that exhausts supportive capacity of significant people situational crises the significant person may be facing temporary family disorganization temporary family role changes temporary preoccupation by a significant person Situational crisis temporary family disorganization and role changes Highly ambivalent family relationship Prolonged disease and disability progression that exhausts the supportive capacity of SO

Communication, impaired verbal

Communication, readiness for enhanced

Conflict, parental role

Coping, ineffective community

Coping, readiness for enhanced community

Coping, compromised family

Coping, disabled family

y y y y y

Client providing little support in turn for SO SO with chronically unexpressed feelings of guilt Anxiety Hostility despair Unconciousness Neuromuscular Impairment Musculoskeletal condition Immobility Traction/casts/splints Monotonous environment Long-term hospitalization Lack of motivation with signs of depression Skeletal-muscular impairments Overwhelming stress Threat of unpleasant reality Fear of deaths Fear of separation Fear of loss of autonomy Anxiety Lack of competency in using effective coping mechanisms Lack of control of life situation Lack of emotional support from others Multiple negative factors Dietary alteration Stress/anxiety Inflammation/irritation of the bowel drug side effects spoiled food tube feeding allergy

Coping, readiness for enhanced family

y y y y y y y y y y y y y y y y y y y

Disuse Syndrome, risk for

Diversional Activity, deficient Decision Making, readiness for enhanced

Denial, ineffective

Dignity, risk for compromised human Distress, moral Diarrhea

y y y y y y y

Dentition, impaired Death Syndrome, risk for sudden infant

y Ineffective oral hygeine

y y y y y y

Inadequate prenatal care Placental abnormalities Low weight gain during pregnancy Their first pregnancy at younger than 20 years of age Anemia History of sexually transmitted diseases or urinary tract infections

Development, risk for delayed

y Slowing or blocking of energy flows secondary to: maturational factors: age-related developmental crisis or difficulties y pathophysiologic factors: illness, injury, pregnancy; situational factors: anxiety, fear, grieving, pain; treatment-related factors: chemotherapy, immobility, labor and delivery, perioperative experience y Dementia (Alzheimer's disease) y multiinfarct dementia

Energy Field, disturbed Electrolyte Imbalance, risk for Environmental Interpretation Syndrome, impaired Fatigue Fear Failure to Thrive, adult Feeding Pattern, ineffective infant

y y y y y y y

Depression Apathy Fatigue Prematurity Neurological impairment/delay Oral hypersensitivity Prolonged NPO

Anatomic abnormality Hypertonic dehydration: uncontrolled diabetes mellitus/insipidus, HHNC, increased intake of hypertonic fluids/IV therapy, inability to respond to thirst reflex/inadequate free water supplementation (high-osmolarity enteral feeding formulas), renal insufficiency/failure]; [Hypotonic dehydration: chronic illness/malnutrition, excessive use of hypotonic IV solutions

Fluid Balance, readiness for enhanced [Fluid Volume, deficient hyper/hypotonic]

y y y y y y y y y