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Abusive verbal attacks on staff and others.
Adjustment: lifestyle change resulting from admission.
Anxiety related to [specify]
At risk for complications related to diagnosis of cirrhosis.
At risk for developing a pressure ulcer due to [specify].
At risk of permanent blindness due to [SPECIFY]
Behavior problem related to [SPECIFY] as evidenced by: [SPECIFY]
Behavior problem: resisting feeding, refusing to eat.
Blindness due to [SPECIFY]
Body image disturbance (actual or potential) due to colostomy/urostomy/ileostomy.
Bowel or bladder incontinence related to [SPECIFY]
CHF/Congestive Heart Failure: (Potential for) Decreased cardiac output
CHF/Congestive Heart Failure: Episodes of dyspnea
CHF/Congestive Heart Failure: Potential for decreased endurance due to decreased cardiac output
CHF/Congestive Heart Failure: Potential for fluid volume overload.
Chronic constipation related to [specify]
Chronic diarrhea related to [SPECIFY]
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.
Client has tracheostomy. At risk for complications including respiratory distress, increased secretions, wt loss, infection.
Client is a new admission with discharge potential. Stay projected to be of short duration, and client plans d/c to: __ Home __ Assisted Living
Client is s/p spinal cord injury and is at risk for autonomic dysreflexia related to exaggerated and unopposed response to noxious stimuli.
Client needs socialization with peers of same age group to meet psychosocial needs r/t being in a geriatric environment.
Client was a long-term smoker prior to admission, with potential for mood disturbance, nicotine withdrawal symptoms related to smoking cessation.
Client with antibiotic resistant infection, with risk for complications.
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.
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.
Cognitive loss/dementia related to Alzheimers dementia, aeb: impaired decision making, short and/or long term memory loss, neurological symptoms.
Communication problem: aphasia, with potential for behavior problem, impaired communication, psychosocial problems.
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 client and family is present.
Congestive Heart Failure (CHF), Fluid Volume Excess
Death/dying issues, other psychosocial issues related to terminal prognosis, nursing home placement.
Decline in mood state as evidenced by [specify]
Decrease in activity participation related to [specify]
Decreased endurance related to [specify]
Dehydration due to decreased fluid consumption.
Delirium or acute confusional episode related to [SPECIFY] as evidenced by [SPECIFY]
Delirium or acute confusional episode related to: [specify] as evidenced by [specify]
Demonstrates verbal expressions of distress as evidenced by [specify]
Dependent on staff for activities, cognitive stimulation, social interaction due to [SPECIFY]
Dependent on tube feeding for nutrition and hydration, and is at risk for aspiration, other complications related to tube feeding.
Diarrhea related to [SPECIFY] Antibiotic therapy [__] Chemotherapy [__] Diagnosis as evidenced by [SPECIFY]
Difficulty in making decisions.
Difficulty in making self understood; ability is limited to making concrete requests.
Difficulty maintaining adequate airway clearance related to [specify] as evidenced by [specify].
Difficulty maintaining adequately open airways due to: [specify]
Difficulty swallowing related to [specify]
Difficulty with food retained in his/her mouth causing [specify] problem.
Discomfort, potential for complications related to itching/burning eyes, blepharitis, dry eyes, conjunctivitis. (Specify problem)
Disoriented to time, place, person and circumstance as related to relocation of room in facility.
Disruption in usual sleep pattern due to [SPECIFY]
Disturbing to others: Physically disruptive by [specify]].
Disturbing to others: Verbally noisy / Verbally abusive.
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
Easily distracted.
Eats less than [specify]% of meals.
Emotional unwillingness to participate in activity program due to
Endangering to self; will [specify].
Episodes of incoherent speech.
Establishes own goals as evidenced by [specify]
Excessive confusion as evidenced by [specify]
Experiences pain frequently related to [specify].
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]
Frequent falls due to impaired balance and unsteady gait.
Grieving over entering nursing home.
Has a feeding tube which could lead to a fluid volume deficit related to inadequate fluid intake.
Has experienced a decline in behavioral status related to [specify] as evidenced by [specify].
Has experienced a decline in cognitive status as evidenced by [specify].
Has fallen [ ] times in the last [SPECIFY]
Has frequent dietary complaints
High risk for aspiration, complications due to dysphagia related to: [SPECIFY]
High risk for elopement related to [SPECIFY]
High risk for falls related to [SPECIFY]
High risk for pressure ulcer due to [specify].
History of sensory deprivation, exhibits socially inappropriate behavior as evidenced by exposure and masturbation in public.
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