Nurse's Pocket Guide

are refuted or wishes denied, manic excitement, with possible indicators
of threatening body language/verbalizations, increased motor
activity, overt and aggressive acts, hostility.*
imbalanced Nutrition: less than body requirements may be related to
inadequate intake in relation to metabolic expenditures, possibly evidenced
by body weight 20% or more below ideal weight, observed
inadequate intake, inattention to mealtimes, and distraction from
task of eating, laboratory evidence of nutritional deficits/imbalances.
risk for Poisoning [lithium toxicity]: risk factors may include narrow
therapeutic range of drug, client’s ability (or lack of) to followthrough
with medication regimen and monitoring, and denial of
need for information/therapy.*
Insomnia may be related to psychological stress, lack of recognition of
fatigue/need to sleep, hyperactivity, possibly evidenced by denial of
need to sleep, interrupted nighttime sleep, one or more nights without
sleep, changes in behavior and performance, increasing irritability/restlessness,
and dark circles under eyes.
disturbed Sensory Perception (specify) [overload] may be related to
decrease in sensory threshold, endogenous chemical alteration, psychological
stress, sleep deprivation, possibly evidenced by increased
distractibility and agitation, anxiety, disorientation, poor concentration,
auditory/visual hallucination, bizarre thinking, and motor incoordination.
interrupted Family Processes may be related to situational crises (illness,
economics, change in roles), euphoric mood and grandiose ideas/
actions of client, manipulative behavior and limit testing, client’s
refusal to accept responsibility for own actions, possibly evidenced by
statements of difficulty coping with situation, lack of adaptation to
change, or not dealing constructively with illness, ineffective family
decision-making process, failure to send and to receive clear messages,
and inappropriate boundary maintenance.
Bone cancer MS/CH
(Also refer to Myeloma, multiple; Amputation)
acute Pain may be related to bone destruction, pressure on nerves, possibly
evidenced by verbal or coded report, protective behavior, autonomic
responses.
risk for Trauma: risk factors may include increased bone fragility, general
weakness, balancing difficulties.*
Borderline personality disorder PSY
risk for self-/other-directed Violence/Self-Mutilation: risk factors may
include use of projection as a major defense mechanism, pervasive
problems with negative transference, feelings of guilt/need to
“punish” self, distorted sense of self, inability to cope with increased
psychological/physiological tension in a healthy manner.*
Anxiety [severe to panic] may be related to unconscious conflicts (experience
of extreme stress), perceived threat to self-concept, unmet
needs, possibly evidenced by easy frustration and feelings of hurt,
*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 803
B