Nurse's Pocket Guide

A
possibly evidenced by deficient immunity, impaired healing, neurosensory
alterations, maladaptive stress response, fatigue, anorexia,
disorientation.
Alcohol abuse/withdrawal CH/MS/PSY
(Refer to Drug overdose, acute [depressants]; Delirium tremens; Substance
dependency/abuse rehabilitation)
Alcohol intoxication, acute MS
(Also refer to Delirium tremens)
acute Confusion may be related to substance abuse, hypoxemia, possibly
evidenced by hallucinations, exaggerated emotional response,
fluctuation in cognition/level of consciousness, increased agitation.
risk for ineffective Breathing Pattern: risk factors may include neuromuscular
impairment/CNS depression.*
risk for Aspiration: risk factors may include reduced level of consciousness,
depressed cough/gag reflexes, delayed gastric emptying.*
Aldosteronism, primary MS
deficient Fluid Volume [isotonic] may be related to increased urinary
losses, possibly evidenced by dry mucous membranes, poor skin turgor,
dilute urine, excessive thirst, weight loss.
impaired physical Mobility may be related to neuromuscular impairment,
weakness, and pain, possibly evidenced by impaired coordination,
decreased muscle strength, paralysis, and positive Chvostek’s
and Trousseau’s signs.
risk for decreased Cardiac Output: risk factors may include hypovolemia
and altered electrical conduction/dysrhythmias.*
Alkalosis, respiratory MS
(Also refer to underlying cause/condition)
impaired Gas Exchange may be related to ventilation-perfusion imbalance
(decreased O2 carrying capacity of blood, altered O2 supply, alveolar-capillary
membrane changes), possibly evidenced by dyspnea,
tachypnea, changes in mentation, tachycardia, hypoxia, hypocapnia.
Allergies, seasonal CH
(Refer to Hay fever)
Alopecia CH
disturbed Body Image may be related to effects of illness/therapy or
aging process, change in appearance, possibly evidenced by verbalization
of feelings/concerns, fear of rejection/reaction of others,
focus on past appearance, preoccupation with change, feelings of
helplessness.
ALS CH
(Refer to Amyotrophic lateral sclerosis)
Alzheimer’s disease CH
(Also refer to Dementia, presenile/senile)
*A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at
prevention.
790 NURSE’S POCKET GUIDE