Nurse's Pocket Guide

A
Amputation MS
risk for ineffective peripheral Tissue Perfusion: risk factors may include
reduced arterial/venous blood flow, tissue edema, hematoma formation,
hypovolemia.*
acute Pain may be related to tissue and nerve trauma, psychological
impact of loss of body part, possibly evidenced by reports of incisional/phantom
pain, guarding/protective behavior, narrowed/selffocus,
and autonomic responses.
impaired physical Mobility may be related to loss of limb (primarily
lower extremity), altered sense of balance, pain/discomfort, possibly
evidenced by reluctance to attempt movement; impaired coordination;
decreased muscle strength, control, and mass.
disturbed Body Image may be related to loss of a body part, possibly evidenced
by verbalization of feelings of powerlessness, grief, preoccupation
with loss, and unwillingness to look at/touch stump.
Amyotrophic lateral sclerosis (ALS) MS
impaired physical Mobility may be related to muscle wasting/weakness,
possibly evidenced by impaired coordination, limited range of
motion, and impaired purposeful movement.
ineffective Breathing Pattern/impaired spontaneous Ventilation may
be related to neuromuscular impairment, decreased energy, fatigue,
tracheobronchial obstruction, possibly evidenced by shortness of
breath, fremitus, respiratory depth changes, and reduced vital
capacity.
impaired Swallowing may be related to muscle wasting and fatigue, possibly
evidenced by recurrent coughing/choking and signs of aspiration.
PSY
Powerlessness [specify level] may be related to chronic/debilitating
nature of illness, lack of control over outcome, possibly evidenced by
expressions of frustration about inability to care for self and depression
over physical deterioration.
Grieving may be related to perceived potential loss of self/physiopsychosocial
well-being, possibly evidenced by sorrow, choked feelings,
expression of distress, changes in eating habits, sleeping patterns, and
altered communication patterns/libido.
CH
impaired verbal Communication may be related to physical barrier
(neuromuscular impairment), possibly evidenced by impaired articulation,
inability to speak in sentences, and use of nonverbal cues
(changes in facial expression).
risk for Caregiver Role Strain: risk factors may include illness severity of
care receiver, complexity and amount of home-care needs, duration
of caregiving required, caregiver is spouse, family/caregiver isolation,
lack of respite/recreation for caregiver.*
*A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at
prevention.
792 NURSE’S POCKET GUIDE