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Abusive verbal attacks on staff and others.
Adjustment: lifestyle change resulting from admission.
Anxiety related to [ SPECIFY ]
At risk for Dehydration due to decreased fluid consumption R/T poor PO intake. Hx. CHF - receives d...
At risk for developing a pressure ulcer due to ____.
At risk of permanent blindness due to [ SPECIFY ]
Behavior problem related to Dx. SDAT, End Stage Renal Disease as evidenced by agitation, yelling a...
Blindness due to [ SPECIFY ]
Body image disturbance (actual or potential) due to colostomy/urinary ileostomy.
Bowel incontinence related to [ SPECIFY ]
Cellulitis of lower extremity
CHF (Congestive Heart Failure), Fluid Volume Excess
CHF/Congestive Heart Failure: (Potential for) Decreased cardiac output
CHF/Congestive Heart Failure: Potential for fluid volume overload.
CHF/Congestive Heart Failure: Episodes of dyspnea
CHF/Congestive Heart Failure: Potential for decreased endurance due to decreased cardiac output
Chronic constipation related to [ SPECIFY ]
Chronic diarrhea related to [ SPECIFY ]
Cognitive loss/dementia related to Alzheimers dementia, aeb: impaired decision making, short and/or ...
Colostomy D/T Hx. Intestinal Obstruction
Communication problems related to hearing deficit.
Complains about food and leaves [ ]% of food uneaten.
Complains of frequent hunger.
Complains of mouth pain.
Confined to a chair with safety belt or positioning pillow that prevents rising related to [ SPECIFY...
Conflict between patient/resident and family is present.
Death/dying issues, other psychosocial issues related to terminal prognosis, nursing home placement.
Decline in mood state as evidenced by ____.
Decrease in activity level related to [ SPECIFY ]
Decreased endurance related to [ SPECIFY ]
Delirium or acute confusional episode related to [specify] as evidenced by [specify]
Delirium related to sensory impairment.
Demonstrates verbal expressions of distress as evidenced by [ SPECIFY ]
Dependent on staff for activities, cognitive stimulation, social interaction due to [specify]
Diabetic Control
Diabetic Control
Diagnosis of adult failure to thrive. Patient is exhibiting weight loss, anorexia, poor nutritional ...
Difficulty in making decisions.
Difficulty in making self understood; ability is limited to making concrete requests.
Difficulty maintaining adequately open airways due to: [ SPECIFY ]
Difficulty swallowing related to [ SPECIFY ]
Difficulty with food retained in his/her mouth causing ____ problem.
Disoriented to time, place, person and circumstance as related to relocation of room in facility.
Disruption in usual sleep pattern due to _________
Disturbing to others: Physically disruptive by [ DESCRIBE BEHAVIOR ].
Disturbing to others: Verbally noisy / Verbally abusive.
Easily distracted.
Eats less than ____% of meals.
Education needs related to reproduction and sexuality.
Education needs related to breastfeeding. Potential for complications related to breastfeeding.
Emotional unwillingness to participate in activity program due to
Endangering to others; will [ DESCRIBE BEHAVIOR ].
Endangering to self; will [ DESCRIBE BEHAVIOR ].
Episodes of Inappropriate Sexual Behavior
Episodes of incoherent speech.
Episodes of Sexuaaly Innapropriate behavior
Establishes own goals as evidenced by ____
Excessive confusion as evidenced by [ SPECIFY ]
Experiences pain frequently related to [ SPECIFY ].
Experiencing ____ side effects from psychotropic drug use.
Experiencing mouth pain related to [ ], or all natural teeth lost or broken, or loose ...
Expresses hopelessness related to [ SPECIFY ]
Expresses powerlessness related to [ SPECIFY ]
Failing vision, glucoma, cataracts. Potential for injury.
Fear of [ SPECIFY ] related to [ SPECIFY ]
Feeding tube necessary for nutritional needs due to comatose status.
Fluid overload or potential fluid volume overload related to [SPECIFY] as evidenced by [SPECIFY]
Fluid volume deficit related to [ SPECIFY ]
Fluid volume excess related to [ SPECIFY ]
Frequent falls due to impaired balance and unsteady gait.
Frequent periods of agitated and restless behavior as evidenced by ____.
Grieving over entering nursing home.
Has a feeding tube which could lead to a fluid volume deficit related to inadequate fluid intake.
Has a stage [ ] pressure ulcer related to [emaciation / cognitive impairment].
Has experienced a decline in behavioral status related to ____ as evidenced by ____.
Has experienced a decline in cognitive status as evidenced by ____.
Has experienced a decline in behavioral status related to ____ as evidenced by ____.
Has experienced improvement in behavioral status as evidenced by ____.
Has fallen [ ] times in the last [ SPECIFY ]
Has frequent combative behavior.
Has frequent dietary complaints
Has potential for drug toxicity due to psychotropic drug use.
High risk for falls related to [SPECIFY]
High risk for falls related to use of psychoactive drugs, antidepressants, antipsychotics, anxiety/...
High risk for pressure ulcer due to ____.
History of sensory deprivation, exhibits socially inappropriate behavior as evidenced by exposure an...
Hospice Care
Hypotension, potential for complications.
Impaired airway clearance, related to : [ SPECIFY ]
Impaired expressive or receptive communication related to [SPECIFY] as evidenced by [SPECIFY]
Impaired skin integrity due to surgical wound.
Impaired skin integrity related to incontinence and immobility.
Impaired verbal communication due to [ SPECIFY ]
In danger of aspiration related to feeding tube.
Inability to communicate due to ____.
Inability to maintain appearance at a satisfactory level due to [impaired mobility/decreased strengt...
Inability to maintain appearance at a satisfactory level due to [bedfast/decreased strength/limb co...
Inability to perform own oral hygiene independently related to [ SPECIFY ]
Inadequate fluid intake related to a decreased sensorium or swallowing difficulties or impaired verb...
Incontinence of bladder due to [ SPECIFY ]
Incontinent of bowel due to cognitive impairment.
Increased need for good nutrition due to pressure ulcer.
Indifferent to social interactions, therefore spends less than [ 1/3 ] of time involved in activity ...
Infection related to [ SPECIFY ]
Infection related to chronic/acute UTI.
Inflamed gums.
Is taking [ MEDICATION ].
Lack of contact with family/friends due to family/friends living in another state or country.
Limited physical mobility secondary to [specify]
Little or no activity involvement
Loss of hearing due to [ SPECIFY ]
Loss of short-term or long-term memory related to [ diagnosis ].
Lost [ ]% of body weight in last [ ] days related to [ SPECIFY ]
Mental function varies during the course of the day as evidenced by ____.
Misunderstands communication.
Mobility impaired related to: [ SPECIFY ]
Multiple falls over last ____.
Must maintain nutritional status via tube feeding related to [inability to swallow/refusal to eat/lo...
Need to monitor blood pressure [ FREQUENCY ].
Need to monitor blood sugars R/T D.M.; FSBS checks Q [FREQUENCY ].
Need to monitor pulse [ daily ].
Need to monitor respiratory function [ FREQUENCY ].
Need to monitor temperature [ FREQUENCY ].
Need to monitor vital signs [ monthly].
Need to monitor weight [ FREQUENCY ].
Needs assistance with ADLs: requires staff intervention or assistance to remain clean, neat and fre...
Needs assistance with Bathing/Hygiene related to [ SPECIFY ]
Needs assistance with dressing / grooming related to [ SPECIFY ]
Needs assistance with dressing as evidenced by impaired ability to fasten clothing
Needs pain monitoring and management related to dx [SPECIFY]
No memory recall ability due to ____.
Non-compliant with therapeutic diet.
Noncompliance related to [ SPECIFY ]
Noncompliant with therapeutic diet.
Not interested or willing to participate in scheduled activities.
Not participating to fullest capability in some activities of daily living such as [ EXAMPLE ].
Open conflict with and repeated criticism of staff.
Over Ideal Body Weight range of [ ]lbs.-[ ]lbs. Current weight is [ ]lbs.
Pain related to [ SPECIFY ]
Patient has had a uti in last 30 days.
Patient has tracheostomy. At risk for icomplications including respiratory distress, increased secr...
patient refuses labs, fingersticks, and wound care
Periods of lethargy as evidenced by ____.
Periods of restlessness.
PICC line
Poor food and fluid intake due to ____.
Poor food and fluid intake due to ____.
Poor nutritional intake resulting in loss of ____ pounds during last ____ days.
Poor oral hygiene due to tooth loss and dental caries.
Post trauma response related to falls.
Potential for adjustment reaction related to new admission to nursing home/long term care facility.
Potential for alteration in cardiac output related to [specify diagnosis]
Potential for bladder/bowel elimination complications related to ostomy
Potential for complications related to dx of Renal Failure/End Stage Renal Disease requiring dialysi...
Potential for complications related to hypertension, including altered cardiac output, ineffective t...
Potential for complications, recurrence of GI bleeding.
Potential for complications related to Diabetic Ketoacidosis (DKA).
Potential for complications, s/sx related to dx of hypothyroidism
Potential for complications related to surgical wound. Type/location: ___________________________...
Potential for dehydration due to recent diarrhea. Hx. Diverticulosis
Potential for dehydration due to recent weight loss.
Potential for dehydration and poor fluid intake due to ____.
Potential for discomfort, injury related to dx of Meniere�s disease.
Potential for drug-related movement disorder or gait disturbance related to taking [MEDICATION] and ...
Potential for drug-related cognitive/behavioral impairment related to taking [MEDICATION] and deliri...
Potential for drug-related discomfort such as constipation, fecal impaction or urinary retention rel...
Potential for falling related to environmental hazards.
Potential for falls due to side effects of medication [ SPECIFY MEDICATION ]
Potential for falls due to wandering.
Potential for falls due to poor balance.
Potential for falls due to unsteady gait.
Potential for falls due to confusion and episodes of agitation.
Potential for falls related to underlying health problem(s) such as [cardiovascular/neuromuscular] ...
Potential for impaired skin integrity related to ____
Potential for incontinent episodes secondary to [immobility / communication / disease process / de...
Potential for injury / automatic and peripheral neuropathies related to diabetes as evidenced by dec...
Potential for injury due to psychotropic drug use.
Potential for injury from hypoglycemia related to diabetes. as evidenced by: weakness, drowsiness, ...
Potential for oral/dental problems due to [ SPECIFY ]
Potential for pacemaker malfunction/failure or altered cardiac output r/t implanted pacemaker
Potential for pain, complications related to dx of Angina Pectoris
Potential for safety hazard, injury related to smoking.
Potential for seizure activity, injury related to seizure disorder.
Potential for skin breakdown related to [wt. loss/previous ulcers/impaired tactile sensory percepti...
Potential for violence towards self and other as evidenced by periods of scratching and hitting at s...
Potential for/Alteration in fluid maintenance due to IV therapy related to ( ).
Potential or actual dehydration related to [SPECIFY] as evidenced by [SPECIFY]
Potential to develop a urinary tract infection related to frequent catheter insertion and/or residen...
Problem of ____ that requires ____.
Rarely understands commands or communication.
Receiving nutrition via iv.
Recent fall resulting in fracture of ____ hip.
Refuses to eat related to [ dentures not fitting ].
Refuses to wear glasses.
Regularly complains of hunger related to dislike of therapeutic diet.
Religious/spiritual beliefs require fasting and medications/meals are refused during these times.
Removes clothing in public areas.
Requires [#] siderails when in bed related to [ SPECIFY ]
Requires assistance with ADL's, but demonstrates capability to be more independent in some ADL's.
Requires foley catheter d/t hx. urinary retention.
Requires HTR chair with tray D/T poor safety awareness, unsteady gait and Hx. multiple falls at home...
Requires mechanically altered and/or syringe fed diet due to ____.
Requires special diet of [ SPECIFY ]
Requires W/C with reverse lap belt for safety D/T poor safety awareness, unsteady gait, Hx. Falls, S...
Requires wheelchair with reverse lap belt to poor safety awareness, poor balance, unsteady gait. H...
Requires wrist restraint(s) related to [ SPECIFY ]
Resident c/o difficulty sleeping. Receives Hypnotic.
Resists care as evidenced by ____.
RESPIRATORY: Impaired breathing pattern, shortness of breath on exertion related to: [ SPECIFY ]
Risk for bleeding, injury associated with daily use of antiplatelet medications. (Aspirin, Plavix, T...
Risk for dehydration related to daily diuretic use.
Sad or anxious mood that can/cannot be altered.
Septicemia: High risk for complications related to septicemia
Short term and long term memory loss due to ____.
Shows signs and symptoms of depression.
Shows signs of bitterness due to ____.
Sleep cycle disturbances as evidenced by ____.
Social interaction difficulties related to [ SPECIFY ]
Social isolation related to [ SPECIFY ]
Social isolation, refuses to [ SPECIFY ]
Socially inappropriate/disruptive behavior as evidenced by ____.
Spiritual distress related to [ SPECIFY ]
Staff/patient believe that he/she is capable of increased independance as evidenced by ____.
Stage [ ] pressure sore(s) in the location of [ SPECIFY ]
State of tearfulness persists coupled with statements of dejection from immediate family members.
Strong identification with past roles, sad feelings over loss of roles, and perceives facility daily...
Swallowing impaired related to [ SPECIFY ]
Teeth missing and does not have/use dentures.
Toileting deficit related to [ SPECIFY ]
Total care for all ADL task related to [ SPECIFY ]
Tube feedings necessary due to inability to swallow nutrients without choking or aspirating.
Ulceration of skin ____ due to impaired circulation.
Unable to feed self due to ____.
Unable to make needs known.
Unable to perform ADL's due to contractures of extremeties.
Unable to perform ADL's due to hearing problems, reducing communication ability.
Unable to perform ADL's due to impaired thought process.
Unable to perform basic hygiene needs due to confusion.
Unable to propel own wheelchair.
Unable to sense the need to void related to impaired mobility or loss of sphincter control.
Unable to transfer to ____.
Unable to turn or move self in bed.
Unable to understand or express self due to ____.
Unable to walk due to ____.
Under Ideal Body Weight range of [ ]lbs.-[ ]lbs. Current weight is [ ]lbs.
Unhappy with roommate and is rude to roommate as a result.
Unhappy with roommate.
Urinary catheter is needed due to ____.
Verbal communication impaired related to [ SPECIFY ]
Vision impairment due to ____.
Visual deficit secondary to [ SPECIFY ]
Visual impairment due to degenerative changes.
Voids small amounts frequently related to the inability to completely empty the bladder.
Wanders about facility aimlessly and often wanders into other rooms.
Wanders in hallways and into other's room uninvited.
Wears external catheter due to ____.
Withdrawn from activities of interest and has reduced social interaction as evidenced by ____.
Withdrawn from activities of interest and has reduced social interaction as evidenced by ____.

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