Nursing Diagnoses: Definitions, risk factors and characteristics

Recreation, deficit:

State in which an individual experiences a diminution of the stimulus, interest or participation in recreational activities.

Related Factors:
- Long-term hospitalization.
- Long-term treatments.
- Lack of suitable environments.

Features:
- Boredom.
- I want to do something.
- The usual hobbies it can not do in the Hospital.

Defensive Coping:

State in which an individual experiences a false positive self-evaluation based on a self-protective pattern of defense against perceived threats underlying the positive self-esteem.

Related Factors:
- Earrings of development.

Features:
- Denial of problems, weaknesses, etc …
- Rationalization of failures.
- Defensive Stance to criticism.
- Greatness.
- Attitude of superiority, hostile laughter.

Ineffective family coping:

Support, comfort, assistance or encouragement insufficient, ineffective or compromised, usually by a person sustaining fundamental (family caregiver), the patient may need it to control or dominate adaptive tasks related to your health challenge.

Related factors:
- Information or inadequate understanding by the family caregiver.
- Concern transient family caregiver who is trying to control occasional conflicts.
- Transient familial disorganization and role changes.
- Little support for the family.
- Exhausting prolonged disease-bearing capacity of the family members.

Features:
- The patient expressed complaints of family caregivers.
- The caregiver describes with concern patient’s disease.
- The family caregiver support attempts to develop behaviors with less satisfactory results.
- The family caregiver is retracted or limited or temporarily communicates with the patient.

Ineffective individual coping:

Adaptive behavior disorder and inability to solve problems.

Related factors:
- Situational crises of maturation.
- Vulnerability of the person.
- Multiple life changes.
- Lack of vacation.
- Relaxation inadequate.
- Exercise scarce.
- Poor nutrition.
- Overload of work.
- Limits few realistic.
- Method of inadequate competition.

Features:
- Inability to meet basic human needs and solve problems.
- Destructive behavior toward himself.
- Changes in social participation.
- Inappropriate use of defense mechanisms.
- Handling verbal.
- Lack of appetite, sleep, etc …
- Excessive use of snuff, alcohol or drugs.
- Chronic fatigue, insomnia, etc …
- Hypertension, diabetes, ulcers, headaches, irritable bowel, muscle aches, etc …
- Anxiety.
- Low self-esteem and chronic depression.

Social isolation:

Loneliness experienced by an individual and perceived as imposed by others and as a negative state or threat.

Related factors:
- Interest immature.
- Changes in physical appearance.
- Changes in mental status.
- Social behavior is not accepted.
- Social values not accepted.
- Altered state of being.
- Inadequate personal resources.

Features:
- Lack of family support.
- Emotional sad or off.
- Withdrawal, no communication, no eye contact.
- Concern for one’s own thoughts.
- Verbal and behavioral hostility.
- Presence of a physical and / or psychological.
- Expresses feelings of loneliness or rejection.
- Present feelings of indifference.
- Lack of meaningful goals in life and inability to meet the expectations of others.

Alterations sensory / perceptual (visual, auditory, kinesthetic, gustatory, tactile, olfactory)

State in which an individual experiences a change in the amount or type of stimuli received, accompanied decrease towards exaggeration or disorder of the response to such stimuli.

Related factors:
- Environment therapeutically restricted (insulation, bed rest, traction, etc ….
- Environment socially restricted (age, chronic illness, agony, institutionalization, etc ….)
- Reception, transmission and / or altered sensory integration (trauma, neurological disease, impaired sense organs, inability to communicate, learn, lack of sleep, pain, etc ….)
- Altered endogenous chemical (electrolyte imbalance, increased BUN, hypoxia, etc …) or exogenous (stimulants or depressants system. CNS).
- Psychological stress.

Features:
- Disoriented in time, space or people.
- Change the capabilities to solve a problem.
- Change in the pattern.
- Anxiety.
- Irritability, hallucinations, fear, depression, anger, poor concentration, auditory and visual distortions, and motor in-coordination.

Anxiety:

Vague and unsettling feeling whose source is often nonspecific or unknown to the individual.

Related factors:
- Threat of death, the concept itself, for the state of health to socioeconomic status, role change, the environment, changing patterns of interaction.
- Situational or maturation crisis.
- Transmission and interpersonal contagion.
- Unmet Needs.

Features:
- Self or negative feelings about himself.
- Earrings of development.
- Verbalization of negative feelings about himself.
- Expressions of shame or guilt.
- Difficulty making decisions.

Suffocation, risk for:

Heightened risk of accidental asphyxiation, ie, lack of sufficient air for inhalation.

Risk Factors:
- Reduction of smell or motor skills.
- Lack of safety education, safety precautions, etc …
- Cognitive or emotional difficulties.
- Illness or disease process.
- Vehicle heating in the garage.
- Children playing in the tub or a pool unattended.
- Gas leaks in the house.
- Clothes too tight in the neck.
- Eating large bites of food.

Aspiration risk:

State in which an individual experiences risk of entry of gastric secretions, oropharyngeal secretions, food or liquid in the airways exogenous, due to the absence of dysfunction of the protective mechanisms.

Risk factors:
- Reduced level of consciousness.
- Decreased reflexes of cough and nausea.
- Presence of tracheostomy, tracheostomy balloon inflated excessively, etc …
- Gastrointestinal probes.
- Food administered by nasogastric tube.
- Increase in intragastric pressure, increased gastric residual content, etc …
- Decreased gastrointestinal motility.
- Delayed gastric emptying.
- Impaired swallowing.
- Surgery or trauma to the face, mouth or neck.

Self-esteem disorder:

Negative feelings about oneself or one’s capabilities can be expressed directly or indirectly.

Features:
- Verbalization of a negative evaluation of himself.
- Expressions of shame or guilt.
- Evaluation of himself as incapable of dealing with the events.
- Rationalization of negative feedback.
- Duda to try new things.
- Denial of obvious problems for others.
- Streamlining the failures.
- Hypersensitivity to criticism.

Self-mutilation, high risk:

State in which an individual experiences a high risk of doing an act on himself to hurt (not kill) that produce tissue damage and stress relief.

Related factors:
- Individuals with personality disorder or psychotic state.
- Children emotionally abused.
- Individuals with a history of self harm.
- Inability to cope in a healthy way to emotional stress.
- Feelings of depression, rejection, guilt.
- Lack of family.
- Dysfunctional family.
- Hallucinations.

Verbal communication, impaired:

State in which an individual experiences a decrease or absence of the ability to use or understand language.

Related factors:
- Reduction of cerebral circulation.
- Physical barrier as brain tumor, tracheostomy, intubation.
- Anatomical defect, cleft palate
- Psychosis or lack of stimulation.
- Cultural difference.
- Related to the development or age.

Features:
- Inability to speak, negative speech, stuttering, stuttering, etc …
- Dyspnea.
- Disorientation.
- Inability to find the words to say them or identify objects, etc ….
- Flight of ideas.
- Verbalization incessant.
- Difficulty in phonation.
- Inability to speak in sentences structured.

Knowledge deficit (specify):

State in which lack specific information.

Related factors:
- Lack of exposure.
- Lack of memory.
- Misinterpretation of information.
- Cognitive Limitations.
- Lack of interest in learning.
- Request by the patient not be informed.

Features:
- Verbalization of the problem.
- Follow the instruction inaccurate.
- Inadequate performance of the test.
- Exhibition of misconception.
- Request for information.

Self-care deficit of: Food

State in which a person has an inability to perform or complete upset feeding activities.

Features:
- Inability to take food from plate to mouth.

Self-care deficit: bathing:

State in which a person has an inability to perform or complete upset bathing and hygiene activities.

Features:
- Inability to wash the body or its parts.
- Inability to obtain or access the water source.
- Inability to regulate temperature or water flow.

Self-care deficit: evacuation:

State in which a deranged person has a disability to perform or complete basic activities of elimination.

Related factors:
- Disorder of transferability.
- Disorder of the state of mobility.
- Activity Intolerance.
- Pain, discomfort.
- Perceptual or cognitive disorder, muscle, musculoskeletal, etc ….
- Depression, severe anxiety.

Features:
- Inability to toilet or potty.
- Inability to get on and off the toilet or wedge.
- Inability to manipulate the items needed to go to the bathroom.
- Inability to genito-anal hygiene properly.
- Inability to flush the toilet or empty the potty.

Self-care deficit: dressing / arrangement:

State in which a person has an inability to perform or complete disordered dress and grooming activities alone.

Features:
- Ability to be altered or removed the necessary items.
- Ability to obtain or replace altered garments.
- Ability to fasten their dresses altered.
- Inability to maintain satisfactory aspect.

Swallowing disorder:

State in which an individual has a decreased ability to move voluntarily liquid and / or solids from the mouth to the stomach.

Related factors:
- Neuromuscular disorder such as reduced gag reflex, decreased strength of the muscles involved in chewing.
- Mechanical obstruction, such as edema, tracheostomy tube.
- Fatigue.
- Perception limited.
- Red and irritated oropharyngeal cavity.

Features:
- Evidence observed difficulty swallowing.
- Evidence of aspiration.

Sexual dysfunction

State in which an individual experiences a change in sexual function, which is considered inadequate.

Related factors:
- Role models ineffective or absent.
- Physical abuse.
-Abuse psychosocial.
- Vulnerability.
- Conflict of values.
- Poor information or knowledge.
- Lack of privacy.
- Impairment of body structure or function, such as pregnancy, drugs, surgery, radiation, disease processes.

Features:
- Verbalization of the problem.
- Changes in achieving perceived sex role.
- Actual or perceived limitation imposed by illness and / or therapy.
- Conflicts in the valuation.
- Changes in achieving sexual satisfaction.
- Inability to achieve the desired satisfaction.
- Need to confirm the desirable characteristics of person.
- Changes in the relationship.
- Rate of interest for himself and others.

Pain:

State in which the individual experiences and communicates the presence of severe discomfort or an uncomfortable feeling.

Related factors:
- Biological Agents.
- Chemical.
- Physical agents.
- Agents psychological.

Features:
- Verbal communication of pain descriptors.
- Behavior of defense protection.
- Facial mask of pain.
- Alteration of muscle tone.
- Answers autonomous, such as increased blood pressure, changes in pulse, respiratory rate increased or decreased.

Despair:

Subjective state in which an individual sees alternatives or personal choices available or limited or no and is unable to mobilize energy for itself.

Related factors:
- Restriction of the activity voluntary.
- Decreased or impaired physiological state.
- Stress of long evolution.
- Abandonment.
- Loss of belief in transcedentales values (God).

Features:
- Passivity, decreased verbalization.
- Assigned decreased.
- Signs that indicate verbal discouragement.
- Lack of initiative.
- Decreased response to stimuli.
- Decreased appetite.
- Lack of participation in their care.
- See a different side of the speaker.

Diarrhea:

State in which an individual experiences a change in normal bowel habits characterized by frequent loose stools emissions, liquid and without consistency.

Related factors:
- Stress and anxiety.
- Dietary intake.
- Drugs.
- Inflammation, irritation or intestinal malabsorption.
- Toxins.
- Pollutants.
- Radiation.

Features:
- Abdominal pain.
- Cramps.
- Increased frequency of bowel movements.
- Increased frequency of bowel sounds.
- Loose stools liquid.
- Urgency.
- Changes in color.

Urinary excretion, impaired:

State in which an individual experiences a disturbance in urination.

Related factors:
- Postsensorial motor disorder.
- Neuromuscular disorder.
- Mechanical trauma.

Features:
- Dysuria.
- Frequency.
- Difficulty starting urination.
- Incontinence.
- Nocturia.
- Retention.
- Urgency.

Early bereavement:

State in which an individual experiences grief occurs before the actual loss.

Related factors:
- Potential loss of someone perceived significant.
- Potential loss fisiopsicosocial perceived welfare.
- Potential loss of perceived personal possessions.

Features:
- Potential loss of significant object.
- An expression of suffering in the potential loss.
- Denial of potential loss.
- Guilt.

Mourning dysfunctional

State in which there is a real or perceived loss.

Related factors.
- Loss of a real or perceived object.
- Response frustrated duel against a loss.
- Absence of anticipatory grief.
- Chronic disease fatal.
- Loss of significant others, welfare fisiopsicosocial or personal possessions.

Features:
- Verbal expression of suffering for the loss.
- Denial of the loss.

Constipation:

State in which an individual experiences a change in normal bowel habits, characterized by decreased frequency of defecation and / or removal of hard, dry stools.

Related factors:
- Not drinking enough water and food.
- Physical activity decreased.
- Personal habits.
- Medication.
- Gastrointestinal obstructive lesions.
- Chronic use of laxatives.
- Pain with bowel movements.
- Lack of privacy.
- Pregnancy.
- Abdominal musculature weak.
- Emotional disorders.

Features:
- Frequency less than the usual pattern.
- Hard stool.
- Mass palpable.
- Straining to defecate.
- Decreased bowel sounds.
Feeling of fullness or abdominal or rectal pressure.
- Number of faeces less than usual.
- Nausea.

Decreased Cardiac Output:

State in which the amount of blood pumped by the heart declined enough to not adequately cover the needs of body tissues.

Related factors:
- Changes in preload, afterload or inotropic heart.
- Disturbance of rate, rhythm or conduction.

Features:
- Changes in hemodynamic structures.
- Arrhythmias.
- Fatigue.
- Cyanosis, oliguria, anuria, decreased peripheral pulses and skin moist.
- Rales.
- Dyspnea.

Hyperthermia:

State in which the body temperature of an individual is elevated above the normal range.

Related factors:
- Exposure to hot environment.
- Vigorous activity.
- Medication / anesthesia.
- Inappropriate dress.
- Illness or injury.
- Increased metabolic rate.
- Dehydration.
- Decreased ability to sweat.

Features:
Increased body temperature above the normal range.
- Red skin.
- Warm to the touch.
- Respiratory rate increased.
- Tachycardia.
- Seizures.

Hypothermia:

State in which an individual’s body temperature is reduced below its normal range but below 34.6 ° C.

Related factors:
- Exposure to cold environment.
- Illness or injury.
- Inability or reduced ability to shake.
- Malnutrition.
- Apparel inadequate.
- Consumption of alcohol.
- Medication vasodilator.
- Decreased metabolic rate.
- Inactivity.
- Old age.

Features:
- Chills.
- Skin cold.
- Pale.
- Slow capillary refill.
- Tachycardia.
- Cyanosis of the nail beds.
- Hypertension.
- Piloerection.

Body image disorder:

Altering the way a person perceives the image of his own body.

Related factors:
- Biophysical.
- Cognitive-perceptual.
- Psychosocial.
- Cultural.

Features:
- There must be one of the following two features for which there is a diagnosis.
A. – Verbal response to a real or perceived change in the structure and / or function.
2. – Non-verbal response to a real or perceived change in the structure and / or function.
- Loss of a body part.
- Do not look the body, not touching it, hide it.
- Trauma of a non-functioning.
- Changes in social participation.
- Negative feelings about the body.
- Feelings of helplessness or despair.
- Concern for the change or loss.
- Emphasis on the remaining forces, strengthening of procurement.
- Refusal to verify the actual change.
- Populations at risk:

- Loss of a body part.
- Dependence of a machine.
- Meaning of the body part or function respect to age, sex, level of development, or needs.
- Physical change by chemical agents.
- Trauma or mutilation.
- Pregnancy and / or maturational changes.

Stress incontinence:

State in which an individual experiences a loss of less than 50 ml urine. to an increase in abdominal pressure.

Related factors:
- Degenerative changes of the pelvic muscles.
- High intraabdominal pressure (obesity, pregnant uterus).
- Bladder valve incompetent.
- Excessive distension between voiding.
- Weakness of the pelvic muscles and structural supports.

Features:
- Drip reported or observed by increasing abdominal pressure.
- Urinary urgency.
- Frequency (more than two hours).

Urge incontinence:

State in which an individual experiences an involuntary loss of urine that occurs after a strong feeling of needing to urinate.

Related factors:
- Decreased bladder capacity (pelvic inflammatory disease, surgery, catheterization, etc ….)
- Irritation of the bladder stretch receptors that cause spasm (infection).
- Alcohol.
- Caffeine.
- Increase fluid intake.
- Increased urinary concentration.
- Excessive bladder distension.

Features:
-Urinary urgency.
- High frequency.
- Nocturia.
- Urination in small amounts.
- Inability to reach the bathroom.

Functional incontinence:

State in which an individual experiences an involuntary urination and unpredictable.

Related factors:
- Environment altered.
- Sensory deficits, cognitive or mobility.

Features:
- Need to urinate or bladder contractions of sufficient intensity to lead to a loss of urine before having a proper receptacle.

Bowel incontinence:

State in which an individual experiences a change in normal bowel habits, characterized by involuntary discharge of feces.

Related factors:
- Effect neuromuscular.
- Effect on skeletal muscle.
- Depression or severe anxiety.
- Disorder of perception or knowledge.

Features:
Involuntary discharge of feces.

Reflex incontinence:

State in which an individual experiences an involuntary loss of urine occurring at somewhat predictable intervals when it reaches a specific bladder volume.

Related factors:
- Neurological disorder.

Features:
- Not perceive bladder filling.
- Do not feel the need to urinate or have a sensation of bladder fullness.
- Contraction / spasm of the bladder inhibition at regular intervals.

Total Incontinence:

State in which an individual experiences a continuous and unpredictable loss of urine.

Related factors:
- Neuropathy which prevents the transmission of the reflex bladder.
- Active neurological dysfunction urination at unpredictable times.
- Trauma or disease affecting the spinal nerves.
- Anatomical impairment.

Features:
- Constant flow of urine.
- Incontinence refractory to treatment.
- Nocturia.
- Lack of perineal sensation or perception of bladder filling.
- Lack of awareness of incontinence.

Infection, high risk:

State in which an individual has an increased risk of invasion by pathogenic microorganisms.

Related factors:
- Inadequate primary defenses (skin lesions, tissue trauma, decreased ciliary action, stasis of body fluids).
- Inadequate secondary defenses (decreased hemoglobin, leukopenia, immunosuppression).
- Acquired immunity inappropriate.
- Destruction of tissue and increased environmental exposure.
- Chronic illness.
- Invasive procedures.
- Pharmacological agents and trauma.
- Rupture of amniotic membranes.
- Insufficient knowledge to prevent exposure to pathogens.

Impaired Skin Integrity:

State in which the skin of an individual is altered unfavorably.

Related factors:
- Hyperthermia and hypothermia.
- Chemicals.
- Shear forces, pressure continues, clamping radiation., Etc. …
- Physical immobility.
- State of nutrition.
- Circulation altered.
- Sensitivity altered.
- Psychogenic.
- Edema.

Features:
- Interrupt the continuity of the skin.
- Destruction of skin layers.
- Invasion of body structures.

Altered gas exchange:

State in which an individual experiences an imbalance between oxygen uptake and carbon dioxide removal.

Related factors:
- Supply of oxygen altered.
- Changes in alveolar-capillary membrane.
- Blood flow altered.
- Impaired transport capacity of oxygen in the blood.

Features:
- Confusion.
- Drowsiness.
- Restlessness.
- Irritability.
- Inability to clear secretions.
- Hypercapnia.
- Hypoxia.

Activity intolerance:

State in which an individual has no physiological or psychological energy enough to resist or complete required or desired daily activities.

Related factors:
- Generalized weakness.
- Sedentary lifestyle.
- Imbalance between supply and demand for oxygen.
- Bed rest or immobility.

Features:
- Verbal report of fatigue or weakness.
- Response abnormal heart rate or blood pressure to the activity.
- Discomfort or exertional dyspnea.
- Changes reflect Electrographic arrhythmias or ischemia.

Injury, high risk:

State in which the individual is at risk for injury as a result of environmental conditions that interact with the adaptive and defensive resources of the individual.

Risk factors:
- Dysfunction sensory integration or effector.
- Tissue hypoxia.
- Malnutrition.
- Autoimmune.
- Abnormal blood profile.
- Lesion on the skin.
- Mobility impaired.
- Related development.
- Factors such as personal

Altered health maintenance:

Inability to identify, control, and / or seek help to maintain health.

Related factors:
- Lack of or alteration in the capacidadesd and communication.
- Lack of ability to make deliberate judgments.
- Perceptual or cognitive disorder.
- Loss of motor skills.
- Lack of material resources.
- No obttenci?n of development tasks.

Features:
- Lack of knowledge about basic health practices.
- Inability reported or observed to accept responsibility for proper sanitation practices.
- Interest expressed to improve the health behaviors.
- Lack of resources reported or observed.
- Disorder reported or observed personal support system.

Fear:

Feeling of fear related to an identifiable source, the person gives as valid.

Related factors:
- Origins natural or innate (sudden noise, loss of hardware, height, pain, etc …)
- Answer learned.
- A lack of knowledge or familiarity.
- Language Barrier.
- Sensory disorder.
- Or phobias phobic stimuli.
- Environmental stimuli.

Features:
- Increased tension, apprehension, fear, fright, terror, panic, fear, etc …
- Increased alertness.
- Focus on strong.
- Eyes open.
- Hostile behavior.
- Sympathetic stimulation.

Physical mobility, disorder:

State in which the individual experiences of the capacity limitation of motion f?sicoindependiente.

Related factors:
- Activity Intolerance.
- Pain and discomfort.
- Perceptual or cognitive disorder.
- Neuromuscular disorder.
- Musculoskeletal disorder.
- Depression, severe anxiety.

Features:
- Inability to move purposefully within a physical environment.
- Reluctant to try the move.
- Limited range of motion.
- Decreased strength, control and / or muscle mass.
- Restrictions imposed by the movement.
- Coordination Disorder.

Altered oral mucosa:

State in which an individual experiences changes in the tissue layers of the oral cavity.

Related factors:
- Pathological conditions.
- Dehydration.
- Chemical or mechanical trauma.
- Diet absolute.
- Oral Hygiene ineffective.
- Oral breathing.
- Malnutrition.
- Infection.
- Salivation decreased or absent.
- Medication.

Features:
- Coated tongue.
- Stomatitis.
- Injury or mouth sores.
- Salivation decreased.
- Hyperemia.
- Oral plate.
- Scaling.
- Vesicles.
- Gingivitis.
- Caries.
- Halitosis.

Inefficient negation:

A conscious or unconscious attempt to deny conocimientoo the meaning of a certain event to reduce fear / anxiety about the health damage.

Features:
- Delay in seeking or refusal to receive medical attention.
- No perceived personal relevance of los’s?ntomas or danger.
- Use home remedies.
- Does not support the fear of death or disability.
- Minimize the symptoms.
- Moves the source of symptoms to other organs.
- Inappropriate affect.

Altered nutrition: less than body requirements

State in which a individuoexperimenta nutrient intake insufficient to meet metabolic needs.

Related factors:
Inability to digest or eat, or to absorb nutientes due to biological, psychological or economic.

Features:
- Weight loss by drinking enough.
- Intake below the Recommended Daily Allowances.
- Communication or evidence of lack of food.
- Abdominal pain, with or without pathological conditions.
- Oral cavity sore or inflamed.
- Weakness of the muscles needed for swallowing.

Altered nutrition: more than body requirements:

State in which an individual experiences a higher nutrient intake to metabolic needs.

Related factors:
Excessive intake relative to metabolic needs.

Features:
- Weight 10 – 20% above the ideal for height and build.
- Level of sedentary activity.
- Patterns of dysfunctional food.
- Eating while doing other activities.
- Concentra aimento the amount of a meal.

Forgot unilateral:

State in which an individual does not receive or pay attention to one side of your body.

Related factors:
- Effects of perceptual skills disorders (hemianopia).
- Unilateral blindness.
- Neurological disease or trauma.

Features:
- Lack of attention to stimuli on the affected side.
- Self care inadequate.
- Positions and / or security precautions to the affected side.
- Do not look toward the affected side.
- Leave food on the plate on the affected side.

Thought processes altered from:

State in which an individual experiences a disruption in cognitive operations and activities.

Related factors:
- Physiological changes.
- Psychological conflicts.
- Loss of memory.
- Impaired judgment.
- Lack of sleep.

Features:
- Cognitive Dissonance.
- Ease of distraction.
- Deficit or memory problems.
- Obsessions.
- Decrease of the capacity of attention.
- Inability to follow orders.
- Egocentricity.
- Hypervigilance / hypovigilance.
- Diminished ability to perceive ideas and make decisions.
- Hallucinations.
- Ideas of reference.
- Inappropriate affect.
- Altered sleep patterns.
- Conspiracy.

Altered tissue perfusion:

State in which an individual experiences decrease of the nutrition and oxygenation at the cellular level, due to a deficit of capillary blood supply.

Related factors:
- Interruption of blood flow.
- Interruption of blood flow.
- Problems of trade.
- Fluid overload.
- Hypovolemia.

Features:
- Cold extremities.
- Pale.
- Arterial pulsations diminished.
-Quality Skin: bright.

Breathing ineffective:

State in which the inspiration and / or expiration of the individual does not allow adequate ventilzci?n.

Related factors:
- Neuromuscular disorder.
- Pain.
- Musculoskeletal disorder or perceived.
- Anxiety.
- Fatigue.
- Inflammatory process.
- Decreased lung expansion.

Features:
- Dyspnea, respiratory distress, tachypnea, cyanosis, nasal flaring, cough, changes in depth of breathing, etc …
- Increased anteroposterior diameter.
- Use of accessory muscles.
- Chest expansion altered.

Urinary Retention:

State in which an individual presents an incomplete emptying of the bladder.

Related factors:
- High urethral pressure caused by weak detrusor.
- Inhibition of the reflex arc.
- Strong sphincter.
- Lock.

Features:
- Bladder distention.
- Frequent urination and small.
- Sensation of bladder fullness.
- Drip.
- Residual urine.
- Dysuria.
- Overflow.

Altered sexuality:

State in which an individual is concerned about their sexuality.

Related factors:
- A lack of awareness of alternative responses.
- Lack of privacy.
- Role models ineffective or absent.
- Conflicts about sexual orientation.
- Fear of pregnancy.

Features:
- Difficulties, limitations, or changes in behavior or reported sexual activity.

Sleep pattern disturbance:

Disruption of sleep time causes discomfort or interferes with desired lifestyle.

Related factors:
- Sensory disturbances.
- Psychological stress.
- External factors.
- Social changes.

Features:
- Complaints of difficulty sleeping.
- Desvelo earlier or later than desired.
- Sleep disruption.
- Changes in behavior and performance.
- Irritability.
- Disorientation.
- Tremors.
- Frequent yawning.
- Changes in posture.

Spiritual suffering:

Disruption in the life principle that pervades the whole being of a person and that integrates and transcends biological and psychosocial nature.

Related factors:
- The separation of religious and cultural ties.
- Challenge the beliefs and value system.

Features:
- Expresses concern about the meaning of life.
- Anger at God.
- Speaks the inner conflict about beliefs.
- Search for spiritual help.
- Considers the disease as a punishment.
- Self-incrimination.

Ineffective thermoregulation:

State in which an individual’s body temperature fluctuates between hypothermia and hyperthermia.

Related factors:
- Trauma or disease.
- Prematurity.
- Old age.
- Ambient temperature fluctuating.

Features:
- Fluctuations in body temperature below or above the normal range.

Trauma, high risk:

Heightened risk of accidental tissue injury (wounds, burns, fractures, etc …)

Risk factors:
- Weakness.
- Poor eyesight.
- Lack of coordination.
- Lack of safety precautions.
- Lack of knowledge.
- Beds high.
- Use of stairs.
- Poor lighting of stoves.
- Driving in a dangerous manner.
- Etc. …

By air, cleaning ineffective:

State in which an individual is unable to remove the obstructions ecreciones respiratory tract to maintain airway patency.

Related factors:
- Reduction of energy.
- Fatigue.
- Infection.
- Obstruction.
- Discharge.
- Trauma.
- Disorder perceptual / cognitive.

Features:
- Abnormal breathing sounds.
- Tachypnea.
- Cough effective, with or without expectoration.
- Cyanosis.
- Dyspnea.
- Fever.

Violence, risk for: directed toward himself or toward other:

State in which a individual experimental behaviors that can be physically dangerous to himself or others.

Risk factors.
- Antisocial character.
- Battered women.
- Child abuse.
- Manic excitement.
- Reactions of anger.
- Suicidal behavior.
- Temporal lobe epilepsy.
- Toxic reactions to medication.

Fluid volume, deficit:

State in which an individual experiences vascular dehydration, cellular or intracellular, associated with a failure of compensatory mechanisms.

Related factors:
- Failure of compensatory mechanisms.

Features:
- Possible weight gain.
- Hypotension.
- Lelnado venos decreased.
- Decreased volume and pulse.
- Body temperature auemntada.
- Skin and mucous membranes dry.
- Hemoconcentration.
- Weakness.
- Edema.
- Sed.

Liquid volume, excess:

State in which an individual experiences vascular dehydration, cellular or intracellular, associated with a failure of compensatory mechanisms.

Related factors:
- Failure of regulatory mechanisms.
- Excessive fluid intake.
- Excessive sodium intake.

Features:
- Edema.
- Diarrhea.
- Anasarca.
- Weight gain.
- Intake greater than the stool.
- Third heart sound.
- Congestion.
- Changing breathing pattern.
- Changes in pulmonary artery pressure.
- Oliguria.
- Restlessness, anxiety.