Nurse's Pocket Guide

of others, destructive behaviors, increased dependency, refusal to follow
rules.
complicated Grieving may be related to real or perceived loss of any
concept of value to individual, bereavement overload/cumulative
grief, thwarted grieving response, feelings of guilt generated by
ambivalent relationship with the lost concept/person, possibly evidenced
by difficulty in expressing/denial of loss, excessive/inappropriately
expressed anger, labile affect, developmental regression,
changes in concentration/pursuit of tasks.
Hopelessness may be related to lifestyle of helplessness (repeated failures,
dependency), incomplete grief work of losses in life, lost belief in
transcendent values/God possibly evidenced by verbal cues/despondent
content, apathy/passivity, decreased response to stimuli, lack of
initiative, nonparticipation in care or decision making.
Adoption/loss of child custody PSY
risk for complicated Grieving: risk factors may include actual loss of child,
expectations for future of child/self, thwarted grieving response to loss.*
risk for Powerlessness: risk factors may include perceived lack of
options, no input into decision process, no control over outcome.*
Adrenal crisis, acute MS
(Also refer to Addison’s disease; Shock)
deficient Fluid Volume [hypotonic] may be related to failure of regulatory
mechanism (damage to/suppression of adrenal gland), inability
to concentrate urine, possibly evidenced by decreased venous filling/pulse
volume and pressure, hypotension, dry mucous membranes,
changes in mentation, decreased serum sodium.
acute Pain may be related to effects of disease process/metabolic imbalances,
decreased tissue perfusion, possibly evidenced by reports of
severe pain in abdomen, lower back, or legs.
impaired physical Mobility may be related to neuromuscular impairment,
decreased muscle strength/control, possibly evidenced by generalized
weakness, inability to perform desired activities/movements.
risk for Hyperthermia: risk factors may include presence of illness/
infectious process, dehydration.*
risk for ineffective Protection: risk factors may include hormone deficiency,
drug therapy, nutritional/metabolic deficiencies.*
Adrenalectomy MS
ineffective Tissue Perfusion (specify) may be related to hypovolemia and
vascular pooling (vasodilation), possibly evidenced by diminished
pulse, pallor/cyanosis, hypotension, and changes in mentation.
risk for Infection: risk factors may include inadequate primary defenses
(incision, traumatized tissues), suppressed inflammatory response,
invasive procedures.*
deficient Knowledge [Learning Need] regarding condition, prognosis,
self-care and treatment needs may be related to unfamiliarity with
long-term therapy requirements, possibly evidenced by request for
information and statement of concern/misconceptions.
*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 787
A