Exchanges
1. Excess nutrient:
Nutritional higher metabolic needs
2.Nutritional Deficiency:
Nutritional intake below metabolic needs.
3.Risk of nutritional excess:
Nutrient intake likely to be higher metabolic needs.
4.Risk of infection:
High risk of contamination by pathogens.
5.Risk of impaired body temperature:
Risk of inability to maintain body temperature within normal limits.
6. Hypothermia:
Reduction in body temperature below the normal limits.
7. Hyperthermia:
Elevation of body temperature above the normal limits.
8. Ineffective Thermoregulation:
Fluctuations in body temperature between hypothermia and hyperthermia.
9. Dysreflexia:
Non-inhibition of influx of the sympathetic nervous system faces a noxious stimuli that threaten the life of a person with a spinal cord up to D7 or above.
10. Constipation:
Change in normal bowel habits characterized by a decrease in stool frequency and the emission of hard, dry stools.
11. Pseudo-constipation:
Self-diagnosis of constipation and use of laxatives, enemas or suppositories to ensure daily bowel.
12. Colic Constipation:
Emission of hard, dry stools due to a slower passage of food residues.
13. Diarrhea:
Change in bowel habits characterized by the frequent loose stools, liquid and unformed.
14. Fecal incontinence:
Change in bowel habits characterized by fecal accidents.
15. Altered urinary elimination:
Disturbance in urinary excretion.
16. Urinary Stress Incontinence:
Urine flow of less than 50 mL that occurs when abdominal pressure increases.
17. Urinary incontinence reflex:
Involuntary flow of urine occurring at somewhat predictable intervals when the bladder reaches a specified volume.
18. Urinary incontinence by reducing the time warning:
Involuntary flow of urine shortly after a strong urge to urinate is felt.
19. Functional Incontinence:
Involuntary and unpredictable flow of urine.
20. Urinary Incontinence complete (true):
Continuous and unpredictable flow of urine.
21. Urinary retention (acute or chronic)
Incomplete bladder evacuation. Strong pressure on the urethra prevents the bladder from emptying
completely inhibits urination or until the increase in abdominal pressure cause involuntary urine flow.
22. Decreased tissue perfusion:
(Specify) (cardio-pulmonary, cerebral, gastrointestinal, peripheral, renal)
23. Decrease in nutrition and cellular oxygenation secondary to decreased blood flow in capillaries.
The blood supply to tissues and cardiac output are normally directly connected. However, tissue perfusion may be insufficient without decreased cardiac output.
24. Excess fluid volume:
Increase water retention accompanied by edema.
25. Fluid Volume Deficit:
Vascular dehydration, cellular or intracellular secondary to dysfunction of regulatory mechanisms which caused an excessive demand organic or decrease the capacity of replacement.
26. Risk of deficit fluid volume:
Vascular risk of dehydration, intracellular or cell loss may result from active or dysfunction of regulatory mechanisms which would cause excessive demand or a drop in replacement capacity.
27. Decreased cardiac output:
Amount of blood pumped from the heart insufficient for tissue perfusion.
Note: In case of increase in basal metabolic rate, cardiac output may be normal without adequately meet the needs of the tissues. Cardiac output and blood flow to tissues are normally directly connected: the decrease in cardiac output results in impaired tissue perfusion. However, tissue perfusion may be insufficient without decreased cardiac output.
29. Disruption of gas exchange:
Decreased exchange of oxygen and / or carbon dioxide between the alveoli and vasculature.
This reaction can occur only following a medical problem but may also result from an ineffective airway clearance and / or ineffective breathing pattern.
30. Ineffective airway clearance:
Inability to clear the airways obstructions that impede the free passage of air.
31. Mode of breathing ineffective:
Way to inspire and / or expire does not allow fill or empty the lungs properly.
32. Inability to sustain spontaneous breathing:
Depletion of energy reserves making the person unable to maintain respiration sufficient to ensure their basic needs.
33. Intolerance cessation of assisted ventilation:
Inability to adapt to a decrease in mechanical ventilation and which interrupts extends the withdrawal process.
34. Risk of accident:
Situation in which a person may be injured because the conditions under which it is beyond the capacity of adaptation and defense.
35. Risk of choking:
Increased danger of accidental suffocation (lack of air).
36. Risk of poisoning:
High risk of accidentally come into contact with harmful substances in sufficient quantities to cause poisoning (adverse effects of a prescription medication or a drug).
37. Risk of trauma:
High risk of accidental injury to tissue (wound, burn, fracture …)
38. Risk of aspiration [suction]:
Risk of inhaling gastric secretions and / or oropharyngeal, solids or liquids into the trachea and bronchi (because of a malfunction or absence of normal protective mechanisms).
39. Risk of immobility syndrome:
Risk of deterioration of organ function due to inactivity musculoskeletal prescribed or inevitable.
Note: According to NANDA complications due to immobility including pressure ulcers, constipation, stasis of pulmonary secretions, thrombosis, urinary tract infection, urinary retention, loss of strength or endurance, postural hypotension, decreased the amplitude of joint movements, disorientation, impaired body image and feelings of helplessness.
40. Alteration of protective mechanisms:
Decreased ability to protect themselves from internal and external threats such as illness or accidents.
41. Damage to tissue integrity:
Mucosal lesion in the cornea, the integument or subcutaneous tissues.
42. Violation of the integrity of the oral mucosa:
Out of the tissue layers of the oral cavity.
43. Violation of the integrity of the skin:
Skin lesion; break in the integument, the largest multifunctional organ of the body.
44. Risk of injury to the skin:
Risk of skin lesion.
45. Decreased intracranial adaptive capacity
46. Disruption of the energy field