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Tags/Categories: [17]
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Abusive verbal attacks on staff and others.
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Adjustment: lifestyle change resulting from admission.
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Anxiety related to [specify]
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At risk for complications related to diagnosis of cirrhosis.
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At risk for developing a pressure ulcer due to [specify].
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At risk of permanent blindness due to [SPECIFY]
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Behavior problem related to [SPECIFY] as evidenced by: [SPECIFY]
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Behavior problem: resisting feeding, refusing to eat.
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Blindness due to [SPECIFY]
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Body image disturbance (actual or potential) due to colostomy/urostomy/ileostomy.
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Bowel or bladder incontinence related to [SPECIFY]
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CHF/Congestive Heart Failure: (Potential for) Decreased cardiac output
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CHF/Congestive Heart Failure: Episodes of dyspnea
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CHF/Congestive Heart Failure: Potential for decreased endurance due to decreased cardiac output
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CHF/Congestive Heart Failure: Potential for fluid volume overload.
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Chronic constipation related to [specify]
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Chronic diarrhea related to [SPECIFY]
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Client has a history of substance abuse: __Alcohol __Narcotics __Other drug use and has potential for complications such as recurrence of substance abuse, postacute withdrawal symptoms, mood and/or behavioral disturbances.
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Client has tracheostomy. At risk for complications including respiratory distress, increased secretions, wt loss, infection.
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Client is a new admission with discharge potential. Stay projected to be of short duration, and client plans d/c to: __ Home __ Assisted Living
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Client is s/p spinal cord injury and is at risk for autonomic dysreflexia related to exaggerated and unopposed response to noxious stimuli.
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Client needs socialization with peers of same age group to meet psychosocial needs r/t being in a geriatric environment.
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Client was a long-term smoker prior to admission, with potential for mood disturbance, nicotine withdrawal symptoms related to smoking cessation.
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Client with antibiotic resistant infection, with risk for complications.
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Cognitive function mildly impaired; short-term memory loss, with independent or modified independent decision making and psychosocial strengths; establishes own goals and makes own decisions.
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Cognitive loss/dementia or alteration in thought processes related to [SPECIFY] as evidenced by: impaired decision making, short and/or long term memory loss, and/or neurological symptoms.
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Cognitive loss/dementia related to Alzheimers dementia, aeb: impaired decision making, short and/or long term memory loss, neurological symptoms.
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Communication problem: aphasia, with potential for behavior problem, impaired communication, psychosocial problems.
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Communication problems related to hearing deficit.
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Complains about food and leaves [ ]% of food uneaten.
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Complains of frequent hunger.
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Complains of mouth pain.
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Confined to a chair with safety belt or positioning pillow that prevents rising related to [specify]
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Conflict between client and family is present.
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Congestive Heart Failure (CHF), Fluid Volume Excess
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Death/dying issues, other psychosocial issues related to terminal prognosis, nursing home placement.
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Decline in mood state as evidenced by [specify]
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Decrease in activity participation related to [specify]
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Decreased endurance related to [specify]
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Dehydration due to decreased fluid consumption.
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Delirium or acute confusional episode related to [SPECIFY] as evidenced by [SPECIFY]
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Delirium or acute confusional episode related to: [specify] as evidenced by [specify]
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Demonstrates verbal expressions of distress as evidenced by [specify]
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Dependent on staff for activities, cognitive stimulation, social interaction due to [SPECIFY]
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Dependent on tube feeding for nutrition and hydration, and is at risk for aspiration, other complications related to tube feeding.
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Diarrhea related to [SPECIFY] Antibiotic therapy [__] Chemotherapy [__] Diagnosis as evidenced by [SPECIFY]
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Difficulty in making decisions.
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Difficulty in making self understood; ability is limited to making concrete requests.
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Difficulty maintaining adequate airway clearance related to [specify] as evidenced by [specify].
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Difficulty maintaining adequately open airways due to: [specify]
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Difficulty swallowing related to [specify]
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Difficulty with food retained in his/her mouth causing [specify] problem.
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Discomfort, potential for complications related to itching/burning eyes, blepharitis, dry eyes, conjunctivitis. (Specify problem)
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Disoriented to time, place, person and circumstance as related to relocation of room in facility.
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Disruption in usual sleep pattern due to [SPECIFY]
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Disturbing to others: Physically disruptive by [specify]].
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Disturbing to others: Verbally noisy / Verbally abusive.
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Dx of gastritis, with potential for discomfort, fluid volume deficit and/or other complications r/t [SPECIFY] as evidenced by: __ Abdominal pain __ Bloating __ Abdominal distention __ Lack of appetite __ Burping __ Constipation __ Diarrhea __ Indigestion __ N/V (with/without hematemesis __ Blood in stools
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Easily distracted.
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Eats less than [specify]% of meals.
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Emotional unwillingness to participate in activity program due to
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Endangering to self; will [specify].
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Episodes of incoherent speech.
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Establishes own goals as evidenced by [specify]
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Excessive confusion as evidenced by [specify]
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Experiences pain frequently related to [specify].
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Expresses hopelessness related to [specify]
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Expresses powerlessness related to [specify]
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Failing vision, glucoma, cataracts. Potential for injury.
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Fear of [specify] related to [specify]
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Feeding tube necessary for nutritional needs due to comatose status.
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Fluid overload or potential fluid volume overload related to [SPECIFY] as evidenced by [SPECIFY]
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Fluid volume deficit related to [specify]
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Frequent falls due to impaired balance and unsteady gait.
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Grieving over entering nursing home.
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Has a feeding tube which could lead to a fluid volume deficit related to inadequate fluid intake.
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Has experienced a decline in behavioral status related to [specify] as evidenced by [specify].
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Has experienced a decline in cognitive status as evidenced by [specify].
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Has fallen [ ] times in the last [SPECIFY]
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Has frequent dietary complaints
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High risk for aspiration, complications due to dysphagia related to: [SPECIFY]
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High risk for elopement related to [SPECIFY]
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High risk for falls related to [SPECIFY]
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High risk for pressure ulcer due to [specify].
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History of sensory deprivation, exhibits socially inappropriate behavior as evidenced by exposure and masturbation in public.
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