Skin
What is prolonged pressure to a bony prominence.
Patient with edema, weight gain of 5 pounds overnight, and disoriented because of CHF.
What is Excess Fluid Volume
Patient with shortness of breath, cough, and wheezing because of COPD
What is Impaired Gas Exchange
New admit, unsure date of last BM, rounded and tender abdomen, hypoactive bowel tones
What is Risk for Constipation
Patient who no longer attends church, has not been grocery shopping in 2 weeks, and missed Bingo the last month and their friends are concerned.
What is Impaired Social Interaction
Patient is weak, frail, underweight, and don't move very much
What is Risk for Pressure Ulcer
patient has not been drinking fluids, seems dehydrated, and altered level of consciousness and taking Lasix.
What is Risk for Electrolyte Imbalance
Patient with fast, shallow respirations, scared look in her eyes, looking for albuterol inhaler.
What is Ineffective Breathing Pattern
Frail elderly living alone with spoiled food in the fridge, empty medication bottles, feeling sluggish, and no hot water or electricity due to unpaid utility bills and much unopened mail.
What is Ineffective Health Maintenance
85yo patient crying over her husband's recent passing, minimal PO intake, and not answering her phone.
What is Grieving
Patient has a Diabetic Foot Ulcer (dfu)
What is Impaired Skin Integrity
Patient with shortness of breath, difficulty walking down the hall with walker because of CHF and deconditioning.
What is Activity Intolerance
Patient s/p right sided CVA with aphasia needing their fluids thickened.
What is Risk for Aspiration
Patient has had 6 loose stools today, accidents along the way, stomach cramping, and feels weak and dizzy
What is Diarrhea
Bowel Incontinence
(possible c diff)
Patient with rapid heart rate, fearful of impending doom, rapid respirations, unsure of why she feels the way she does.
What is Anxiety
Patient has a deep, infected surgical wound with a Wound VAC on it.
What is Impaired Tissue Integrity
Patient on Coumadin with many areas of ecchymosis on arms with 2+ pedal edema and cool to touch BLE
What is Ineffective Peripheral Tissue Perfusion
Patient with deconditioning, PNA, has wet gurgly breath sounds and weak cough.
What is Ineffective Airway Clearance
Patient with BMI 14, hx of anorexia, dehydrated, needing protein supplements but not drinking them, does not think there is a problem.
What is Imbalanced Nutrition: less than body requirements.
Patient avoids certain activity due to possible negative outcome though highly unlikely. so much so that it impairs function.
What is Fear
Patient with Afib, on Coumadin, much bruising on upper extremities, inconsistent with INR Checks and subsequent Coumadin dosing. Also not open to interventions for assistance.
Patient with low blood pressure, weak thready irregular pulse, cool/clammy skin, c/o dizziness with Afib and CHF
Patient who is declining to get out of bed, has a weak cough with diminished breath sounds and difficulty taking a deep breath due to multiple rib fractures after a fall at home.
What is Risk for Infection
45yo patient s/p multiple surgeries, with fibromyalgia, on long term opioid pain medication, poor fluid intake, living a sedentary lifestyle with minimal fruit and vegetable intake and prefers a high carb diet.
What is Risk for Constipation
Patient exhibiting disruptive behaviors after loss of family member, not checking blood sugars and random medication administration.
What is Ineffective Coping