Nurse's Pocket Guide

focus, alteration in muscle tone, paresthesias, paralysis, guarding
behaviors, changes in vital signs (acute), autonomic responses, and
restlessness.
CH
imbalanced Nutrition: less than body requirements may be related to
altered ability to ingest, digest, and/or absorb nutrients (nausea/vomiting,
hyperactive gag reflex, intestinal disturbances); increased metabolic
activity/nutritional needs (fever, infection); possibly evidenced
by weight loss, decreased subcutaneous fat/muscle mass, lack of interest
in food/aversion to eating, altered taste sensation, abdominal
cramping, hyperactive bowel sounds, diarrhea, sore and inflamed
buccal cavity.
Fatigue may be related to decreased metabolic energy production,
increased energy requirements (hypermetabolic state), overwhelming
psychological/emotional demands, altered body chemistry (side
effects of medication, chemotherapy), possibly evidenced by
unremitting/overwhelming lack of energy, inability to maintain usual
routines, decreased performance, impaired ability to concentrate,
lethargy/restlessness, and disinterest in surroundings.
ineffective Protection may be related to chronic disease affecting
immune and neurological systems, inadequate nutrition, drug therapies,
possibly evidenced by deficient immunity, impaired healing,
neurosensory alterations, maladaptive stress response, fatigue,
anorexia, disorientation.
PSY
Social Isolation may be related to changes in physical appearance/mental
status, state of wellness, perceptions of unacceptable social or sexual
behavior/values, physical isolation, phobic fear of others (transmission
of disease), possibly evidenced by expressed feelings of
aloneness/rejection, absence of supportive SO(s), and withdrawal
from usual activities.
disturbed Thought Processes/chronic Confusion may be related to
physiological changes (hypoxemia, central nervous system—CNS—
infection by HIV, brain malignancies, and/or disseminated systemic
opportunistic infection), altered drug metabolism/excretion, accumulation
of toxic elements (renal failure, severe electrolyte imbalance,
hepatic insufficiency), possibly evidenced by clinical evidence of
organic impairment, altered attention span, distractibility, memory
deficit, disorientation, cognitive dissonance, delusional thinking,
impaired ability to make decisions/problem solve, inability to follow
complex commands/mental tasks, loss of impulse control, and altered
personality.
AIDS dementia CH
(Also refer to Dementia, presenile/senile)
impaired Environmental Interpretation Syndrome may be related to
dementia, depression, possibly evidenced by consistent disorientation,
inability to follow simple directions/instructions, loss of social
functioning from memory decline.
ineffective Protection may be related to chronic disease affecting immune
and neurological systems, inadequate nutrition, drug therapies,
HEALTH CONDITIONS AND CLIENT CONCERNS 789
A