Nurse's Pocket Guide

A
Abdominal perineal resection MS
(Also refer to Surgery, general)
disturbed Body Image may be related to presence of surgical wounds,
possibly evidenced by verbalizations of feelings/perceptions, fear of
reaction by others, preoccupation with change.
risk for Constipation: risk factors may include decreased physical activity/gastric
motility, abdominal muscle weakness, insufficient fluid
intake, change in usual foods/eating pattern.*
risk for Sexual Dysfunction: risk factors may include altered body structure/function,
radical resection/treatment procedures, vulnerability/
psychological concern about response of significant other(s) [SO(s)],
and disruption of sexual response pattern (e.g., erection difficulty).*
Abortion, elective termination OB
risk for decisional Conflict: risk factors may include unclear personal
values/beliefs, lack of experience or interference with decision making,
information from divergent sources, deficient support system.*
deficient Knowledge [Learning Need] regarding reproduction, contraception,
self-care, Rh factor may be related to lack of exposure/recall
or misinterpretation of information, possibly evidenced by request for
information, statement of misconception, inaccurate follow-through
of instructions, development of preventable events/complications.
risk for Spiritual Distress/moral Distress: risk factors may include perception
of moral/ethical implications of therapeutic procedure, time
constraints for decision making.*
Anxiety [specify level] may be related to situational/maturational crises,
unmet needs, unconscious conflict about essential values/beliefs, possibly
evidenced by increased tension, apprehension, fear of unspecific
consequences, sympathetic stimulation, focus on self.
acute Pain/[Discomfort] may be related to aftereffects of procedure/drug
effect, possibly evidenced by verbal report, distraction behaviors,
changes in muscle tone, autonomic responses/changes in vital signs.
risk for maternal Injury: risk factors may include surgical procedure,
effects of anesthesia/medications.*
Abortion, spontaneous termination OB
deficient Fluid Volume [isotonic] may be related to excessive blood loss,
possibly evidenced by decreased pulse volume and pressure, delayed
capillary refill, or changes in sensorium.
risk for Spiritual Distress: risk factors may include need to adhere to personal
religious beliefs/practices, blame for loss directed at self or God.*
deficient Knowledge [Learning Need] regarding cause of abortion, selfcare,
contraception/future pregnancy may be related to lack of familiarity
with new self/healthcare needs, sources for support, possibly
evidenced by requests for information and statement of concern/
misconceptions, development of preventable complications.
Grieving related to perinatal loss, possibly evidenced by crying, expressions
of sorrow, or changes in eating habits/sleep patterns.
*A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at
prevention.
782 NURSE’S POCKET GUIDE