Nursing Diagnosis Risk for latex allergy response

Risk for Impaired Liver Function

Risk for Impaired Skin Integrity

Risk for Unstable Blood Glucose

Bowel Incontinence

Constipation

Diarrhea

Functional Urinary Incontinence

Impaired Urinary Elimination

Overflow urinary incontinence

Perceived Constipation

Readiness for enhanced urinary elimination

Reflex Urinary Incontinence

Risk for Constipation

Risk for urge urinary incontinence

Defining Characteristics Risk Factors: > History of reactions to latex > Allergies to bananas, avocados, tropical fruits, kiwi, chestnuts, poinsettia plants > history of allergies or asthma > Professions with daily exposure to latex > Multiple surgical procedures, especially from infancy Risk Factors: > Viral Infection ( Hepatitis A, B, C, Epstein - Barr) > HIV co-infection > Hepatotoxic medications (Acetaminophen, Statins) > Substance Abuse (Alcohol, coccaine) Risk Factors: External: > Chemical Substance; radiation > Hypothermia; Hyperthermia > Physical immobilization > Excretions; Secretions; humidity; moisture > Mechanical Factors (Shearing forces, pressure, restraint) > Extremes of Age Internal: > Medications > Imbalanced nutrition state (obesity, emaciation) > impaired metablic state (flud status) > skeletal prominence > changes in skin turgor (presence of edema) > impaired circulation. Sensation > changes in pigmentation > developmental factors > psychogemetic factors

YES

NO

> immunologic factors Risk Factors: > lack of acceptance of diagnosis > deficient knowledge of diabetes management > lack of diabetes management/ adherance to diabetes management > dietary intake; weight gain/ weight loss; rapid growth periods; pregnancy Physical health status/ activity level Stress; mental health status Developmental level

Subjective: - recognizes rectal fullness, but reports inability to expel formed stool. - Urgency, inability to delay defecation Self-report of inability to feel rectal fullness

Objectives: - Constant dribbling of soft stool Fecal staining of clothing/ bedding Fecal odor Red perianal skin Inability to recognize/ inattention to urge to defecate Hyperactive bowel sounds At least three loose liquid stools per day

Subjective:

- Change in bowel pattern; unable to pass stool; decreased frequency, decreased volume of stool - Increased abdominal pressure; feeling of rectal fullness/ pressure

- Abdominal pain; pain with defecation; nausea; vomiting; headache; indigestion; generalized fatigue Objective: Hard, formed stool Straining with defecation Hypoactive, hyperactive bowel sounds; borborygmi

- Distended abdomen; abdominal tenderness with/without palpable muscle resistance; palpable rectal Percussed abdominal dullness

Subjective: Abdominal pain Urgency, cramping Objective: Hyperactive bowel sounds At least three loose liquid stools per day Reports involuntary leakage of small volumes of urine Nocturia Objective: Bladder distention High post-void residual volume

- Observed involuntary leakage of small amounts of urine Subjective: Senses need to void (voiding in large amounts)

Objective:

- Loss of urine before reaching toilet; amount of time required to reach toilet exceeds length of time between sensing urge and uncontrolled voiding Subjective Frequency, urgency Hesitancy Dysuria Nocturia (enuresis) Objective: Incontinence Retention Subjective: Reports involuntary leakage of small volumes of urine

Nocturia Objective: Bladder distention High post-void residual volume

- Observed involuntary leakage of small amounts of urine

Subjective: Expectation of a daily bowel movement Expected passage of stool at the same time every day Overuse of laxatives/ enemas/ suppositories

Subjective: Expresses willingness to enhance urinary elimination Positions self for emptying of bladder Objective: Urine is straw colored/ odorless

- Amount of output/ specific gravity is within normal limits Fluid intake is adequate for daily needs

Subjective: No sensation of bladder fullness/ urge to void/ voiding

- Sensation of urgency without voluntary inhibition of bladder contraction - Sensations associated with full bladder(sweating, restlessness, abdominal discomfort) Objective: Predictable pattern of voiding Inability to voluntary inhibit/initiate voiding

- Complete emptying (brain) lesion above sacral micturition center Risk Factors: FUNCTIONAL:

- Irregular defecation habits; inadequate toileting (timeliness, positioning for defecation, privacy)

- Insufficient physical activity; abdominal muscle weakness Recent environmental changes Habitual denial/ ignoring urge to defecate PSYCHOLOGICAL: Emotional stress, depression, mental confusion PHYSIOLOGICAL

- Change in usual foods/ eating patterns; insufficient fiber/fluid intake, dehydration; poor eating habits - Inadequate dentition or oral hygiene - Decreased motility of gastrointestinal tract - PHARMACOLOGICAL - Phenothiazides, NSAIDS, sedatives, aluminumcontaining antacids, laxative overuse, bismuth salts, iron salts, anticholinergics, anti-depressants, calcium carbonate, diuretics, sympathomimetics, opiates - MECHANICAL - Hemorrhoids;pregnancy;obesity - Rectal abcess/ulcer; rectal anal stricture/fissures; rectal prolapse; rectocele - Prostate enlargement; post-surgical obstruction - Neurological impairment; hirschsprungs disease; tumor - Electrolyte imbalance - Risk factors: - Effects of medications/caffeine/ alcohol - Detrusor hyperreflexia(fr. Cystitis, urethritis, tumors, renal calculi, CNS disorders above pontine micturition center) - Impaired bladder contractility; involuntary sphincter relaxation - Ineffective toileting habits - Small bladder capacity