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RELATED FACTORS High urethral pressure caused by weak [/absent] detrusor; Inhibition of reflex arc; Strong sphincter; Blockage [e.g., BPH, perineal swelling]; [Habituation of reflex arc]; [Use of medications with side effect of retention (e.g., atropine, belladonna, psychotropics, antihistamines, opiates)]; [Infections]; [Neurologic diseases/trauma] DEFINING CHARACTERISTICS Subjective Sensation of bladder fullness; Dribbling; Dysuria Objective Bladder distention; Small, frequent voiding or absence of urine output; Residual urine [150 ml or more]; Overflow incontinence; [Reduced stream] VENTILATION, IMPAIRED SPONTANEOUS Diagnostic Division: Respiration Definition: Decreased energy reserves results in an individual’s inability to maintain breathing adequate to support life RELATED FACTORS Metabolic factors; [hypermetabolic state (e.g., infection), nutritional deficits/depletion of energy stores]; Respiratory muscle fatigue; [Airway size/resistance; problems with secretion management] DEFINING CHARACTERISTICS Subjective Dyspnea; Apprehension 2786 Appendix N7 Nursing Diagnoses Objective Increased metabolic rate; Increased heart rate; Increased restlessness; Decreased cooperation; Increased use of accessory muscles; Decreased tidal volume; Decreased PO ; Decreased SaO ; Increased PCO 2 VENTILATORY WEANING RESPONSE, DYSFUNCTIONAL (DVWR) Diagnostic Division: Respiration Definition: Inability to adjust to lowered levels of mechanical ventilator support, that interrupts and prolongs the weaning process RELATED FACTORS Physical Ineffective airway clearance; Sleep pattern disturbance; Inadequate nutrition; Uncontrolled pain or discomfort; [Muscle weakness/fatigue, inability to control respiratory muscles; immobility] Psychological Knowledge deficit of the weaning process, patient role; Patient-perceived inefficacy about the ability to wean; Decreased motivation; Decreased self-esteem; Anxiety (moderate, severe); fear; insufficient trust in the nurse; Hopelessness; Powerlessness; [Unprepared for weaning attempt] Situational Uncontrolled episodic energy demands or problems; Inappropriate pacing of diminished ventilator support; Inadequate social support; Adverse environment (noisy, active environment, negative events in the room, low nurse-patient ratio, extended nurse absence from bedside, unfamiliar nursing staff); History of ventilator dependence Ͼ1 week; History of multiple unsuccessful weaning attempts DEFINING CHARACTERISTICS Responds to lowered levels of mechanical ventilator support with: Mild DVWR Subjective Expressed feelings of increased need for oxygen, breathing discomfort, fatigue, warmth; Queries about possible machine malfunction Objective Restlessness; Slight increased respiratory rate from baseline; Increased concentration on breathing Moderate DVWR Subjective Apprehension Objective Slight increase from baseline blood pressure 20 mm Hg; Slight increase from baseline heart rate 20 beats/min; Baseline increase in respiratory rate breaths/min; Hypervigilance to activities; Inability to respond to coaching/cooperate; Diaphoresis; Eye widening, “wide-eyed look”; Decreased air entry on auscultation; Color changes: pale, slight cyanosis; Slight respiratory accessory muscle use Severe DVWR Objective Agitation; Deterioration in arterial blood gases from current baseline; Increase from baseline blood pressure 20 mm Hg; Increase from baseline heart rate 20 beats/min; Respiratory rate increases significantly from baseline; Profuse diaphoresis; Full respiratory accessory muscle use; Shallow, gasping breaths; Paradoxical abdominal breathing; Discoordinated breathing with the ventilator; Decreased level of consciousness; Adventitious breath sounds, audible airway secretions; Cyanosis VIOLENCE, [ACTUAL]/RISK FOR OTHER-DIRECTED Diagnostic Division: Safety Definition: Behaviors in which an individual demonstrates that he/she can be physically, emotionally, and/or sexually harmful to others Appendix N7– Nursing Diagnoses in Alphabetical Order 2787 RISK FACTORS History of violence: against others (e.g., hitting, kicking, scratching, biting or spitting, throwing objects at someone; attempted rape, rape, sexual molestation, urinating/ defecating on a person); Threats (e.g, verbal threats against property/person, social threats, cursing, threatening notes/letters or gestures, sexual threats); Antisocial behavior (e.g., stealing, insistent borrowing, insistent demands for privileges, insistent interruption of meetings; refusal to eat or take medication, ignoring instructions); Indirect (e.g., tearing off clothes, urinating/defecating on floor, stamping feet, temper tantrum; running in corridors, yelling, writing on walls, ripping objects off walls, throwing objects, breaking a window, slamming doors; sexual advances) OTHER FACTORS Neurological impairment (e.g., positive ECG, CT, or MRI; head trauma; positive neurological findings; seizure disorders, [temporal lobe epilepsy]); Cognitive impairment (e.g., learning disabilities, attention deficit disorder, decreased intellectual functioning); [organic brain syndrome]; History of childhood abuse/witnessing family violence, [negative role modeling]; cruelty to animals; firesetting; Prenatal and perinatal complications/abnormalities; History of drug/alcohol abuse; pathological intoxication, [toxic reaction to medication]; Psychotic symptomatology (e.g, auditory, visual, command hallucinations; paranoid delusions; loose, rambling, or illogical thought processes); [panic states; rate reactions; catatonic/manic excitement]; Motor vehicle offenses (e.g., frequent traffic violations, use of motor vehicle to release anger); Suicidal behavior, impulsivity; availability and/or possession of weapon(s); Body language: rigid posture, clenching of fists and jaw, hyperactivity, pacing, breathlessness, threatening stances; [Hormonal imbalance (e.g., premenstrual syndrome, postpartal depression/psychosis)]; [Expressed intent/desire to harm others directly or indirectly]; [Almost continuous thoughts of violence] VIOLENCE, [ACTUAL]/RISK FOR SELF-DIRECTED Diagnostic Division: Safety Definition: Behaviors in which an individual demonstrates that he/she can be physically, emotionally, and/or sexually harmful to self RISK FACTORS Age 15– 19, over 45; Marital status (single, widowed, divorced) ; Employment (unemployed, recent job loss/failure); occupation (executive, administrator, owner of business, professional, semiskilled worker); Conflictual interpersonal relationships; Family background (chaotic or conflictual, history of suicide); Sexual orientation: bisexual (active), homosexual (inactive); Physical health (hypochondriac, chronic or terminal illness); Mental health (severe depression, psychosis, severe personality disorder, alcoholism or drug abuse); Emotional status (hopelessness, despair [lifting of depressed mood]; increased anxiety, panic, anger, hostility); history of multiple suicide attempts; suicidal ideation (frequent, intense, prolonged); suicide plan (clear and specific; lethality: method and availability of destructive means); Personal resources (poor achievement, poor insight, affect unavailable and poorly controlled); Social resources (poor rapport, socially isolated, unresponsive family); Verbal clues (e.g., talking about death, “better off without me,” asking questions about lethal dosages of drugs; Behavioral clues (e.g., writing forlorn love notes, directing angry messages at a significant other who has rejected the person, giving away personal items, taking out a large life insurance policy); Persons who engage in autoerotic sexual acts [e.g., asphyxiation] WALKING, IMPAIRED Diagnostic Division: Safety Definition: Limitation of independent movement within the environment on foot RELATED FACTORS To be developed; [Condition affecting muscles/joints impairing ability to walk] DEFINING CHARACTERISTICS Impaired ability to walk required distances, walk on an incline/decline, or walk on uneven surfaces, to navigate curbs, climb stairs 2788 Appendix N7 Nursing Diagnoses WANDERING [Specify sporadic or continual] Diagnostic Division: Safety Definition: Meandering, aimless or repetitive locomotion that exposes the individual to harm; frequently incongruent with boundaries, limits, or obstacles RELATED FACTORS Cognitive impairment, specifically memory and recall deficits, disorientation, poor visuoconstructive (or visuospatial) ability, language (primarily expressive) defects; Cortical atrophy; Premorbid behavior (e.g., outgoing, sociable personality; premorbid dementia); Separation from familiar people and places; Emotional state, especially frustration, anxiety, boredom, or depression (agitation); Physiological state or need (e.g., hunger/thirst, pain, urination, constipation); Over/understimulating social or physical environment; Sedation; Time of day DEFINING CHARACTERISTICS Objective Frequent or continuous movement from place to place, often revisiting the same destinations; Persistent locomotion in search of “missing” or unattainable people or places; Scanning, seeking, or searching behaviors; Haphazard locomotion; Fretful locomotion or pacing; Long periods of locomotion without an apparent destination; Locomotion into unauthorized or private spaces; Trespassing; Locomotion resulting in unintended leaving of a premise; Inability to locate significant landmarks in a familiar setting; Getting lost; Locomotion that cannot be easily dissuaded or redirected; Following behind or shadowing a caregiver’s locomotion; Hyperactivity; Periods of locomotion interspersed with periods of nonlocomotion (e.g., sitting, standing, sleeping) Notes F A Davis offers Taber’s in print, on CD, online, and for your PDA Which version of Taber’s is right for you? 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