Adjustment: lifestyle change resulting from admission.
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Client at risk for activity intolerance due to asthma-related respiratory limitations.
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Client at risk for adverse drug reactions due to long-term polypharmacy.
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Client at risk for poor medication adherence with anticoagulants.
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Client demonstrates communication barriers due to Autistic Disorder.
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Client exhibits difficulty with social interaction due to Autistic Disorder.
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Client exhibits emotional distress and social isolation due to trigeminal neuralgia pain.
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Client exhibits impaired concentration and decision-making due to anxiety.
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Client exhibits physical symptoms of anxiety, including muscle tension and fatigue.
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Client experiences chronic back pain due to unspecified dorsalgia, limiting daily activities.
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Client experiences chronic low back pain impacting daily activities and mobility.
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Client experiences excessive worry and restlessness due to unspecified anxiety disorder.
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Client experiences hyperactivity interfering with daily routines due to ADHD, combined type.
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Client experiences intrusive thoughts and flashbacks related to traumatic events.
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Client experiences sensory processing challenges due to Autistic Disorder.
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Client experiences severe facial pain due to trigeminal neuralgia, impacting daily activities.
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Client has excessive caloric intake contributing to obesity, unspecified.
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Client has inadequate physical activity levels exacerbating obesity, unspecified.
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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 reports low energy and fatigue impacting daily functioning due to depression.
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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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Decrease in activity participation related 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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Difficulty in making self understood; ability is limited to making concrete requests.
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Discomfort, potential for complications related to itching/burning eyes, blepharitis, dry eyes, conjunctivitis. [specify] issue.)
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Emotional unwillingness to participate in activity program due to
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Expresses powerlessness related to [specify]
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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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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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Inadequate fluid intake related to [specify]
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Infection related to chronic/acute UTI.
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Mental function varies during the course of the day as evidenced by [specify].
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Mobility impaired related to: [specify]
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Must maintain nutritional status via tube feeding related to [inability to swallow/refusal to eat/low cal intake].
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Needs assistance with ADLs: requires staff intervention or assistance to remain clean, neat and free of body odors due to:
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Needs assistance with Bathing/Hygiene related to [specify]
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Non-compliant with therapeutic diet.
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Noncompliance related to [specify]
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Noncompliant with therapeutic diet.
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Not participating to fullest capability in some activities of daily living such as [specify].
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Potential for adjustment reaction related to new admission to nursing home/long term care facility.
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Potential for alteration in cardiac output related to [specify]
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Potential for complications, discomfort related to sleep apnea.
Contributing factors:
[__] Obesity
[__] Hypertension
[__] Nasopharyngeal narrowing
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Potential for complications, ineffective airway clearance, discomfort related to diagnosis of tuberculosis.
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Potential for drug-related movement disorder or gait disturbance related to taking [MEDICATION] and [(Parkinsons/poor balance/tardive dyskinesia/loss of limb movement/motor agitation/swallowing problem/vertigo/accidents)].
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Potential for infection, complications related to dx of urinary retention.
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Potential for recurrence of Urinary Tract Infection/chronic UTI.
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Potential for seizure activity, injury related to seizure disorder.
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Potential to develop a urinary tract infection related to frequent catheter insertion and/or client pulling on catheter.
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Requires [#] siderails when in bed related to [specify]
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RESPIRATORY: Impaired breathing pattern, shortness of breath on exertion related to: [specify]
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Sleep cycle disturbances as evidenced by [specify].
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Strong identification with past roles, sad feelings over loss of roles, and perceives facility daily routine different from prior pattern in the community as evidenced by [specify].
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Teeth missing and does not have/use dentures.
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Verbal communication impaired related to [specify]
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Wanders in hallways and into others room uninvited.
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Wears external catheter due to [specify].
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