Nurse's Pocket Guide

isk for ineffective Sexuality Pattern: risk factors may include increasing
fear of pregnancy and/or repeat loss, impaired relationship with
SO(s), self-doubt regarding own femininity.*
Abruptio placentae OB
deficient Fluid Volume [isotonic] may be related to excessive blood loss,
possibly evidenced by hypotension, increased heart rate, decreased pulse
volume and pressure, delayed capillary refill, or changes in sensorium.
Fear related to threat of death (perceived or actual) to fetus/self, possibly
evidenced by verbalization of specific concerns, increased tension,
sympathetic stimulation.
acute Pain may be related to collection of blood between uterine wall and
placenta, uterine contractions, possibly evidenced by verbal reports,
abdominal guarding, muscle tension, or alterations in vital signs.
impaired fetal Gas Exchange may be related to altered uteroplacental O2 transfer, possibly evidenced by alterations in fetal heart rate and
movement.
Abscess, brain (acute) MS
acute Pain may be related to inflammation, edema of tissues, possibly evidenced
by reports of headache, restlessness, irritability, and moaning.
risk for Hyperthermia: risk factors may include inflammatory
process/hypermetabolic state and dehydration.*
acute Confusion may be related to physiological changes (e.g., cerebral
edema/altered perfusion, fever), possibly evidenced by fluctuation in
cognition/level of consciousness, increased agitation/restlessness, hallucinations.
risk for Suffocation/Trauma: risk factors may include development of
clonic/tonic muscle activity and changes in consciousness (seizure
activity).*
Abscess, skin/tissue CH/MS
impaired Skin/Tissue Integrity may be related to immunological
deficit/infection, possibly evidenced by disruption of skin, destruction
of skin layers/tissues, invasion of body structures.
risk for Infection [spread]: risk factors may include broken skin/traumatized
tissues, chronic disease, malnutrition, insufficient knowledge.*
Abuse CM
(Also refer to Battered child syndrome)
risk for Trauma: risk factors may include vulnerable client, recipient of
verbal threats, history of physical abuse.*
Powerlessness may be related to abusive relationship, lifestyle of helplessness
as evidenced by verbal expressions of having no control,
reluctance to express true feelings, apathy, passivity.
chronic low Self-Esteem may be related to continual negative evaluation
of self/capabilities, personal vulnerability, willingness to tolerate possible
life-threatening domestic violence as evidenced by self-negative
verbalization, evaluates self as unable to deal with events, rationalizes
away/rejects positive feedback.
*A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at
prevention.
HEALTH CONDITIONS AND CLIENT CONCERNS 783
A