Nurse's Pocket Guide

B
abuse of alcohol/other drugs, transient psychotic symptoms, and performance
of self-mutilating acts.
chronic low Self-Esteem/disturbed personal Identity may be related to
lack of positive feedback, unmet dependency needs, retarded ego
development/fixation at an earlier level of development, possibly evidenced
by difficulty identifying self or defining self-boundaries, feelings
of depersonalization, extreme mood changes, lack of tolerance of
rejection or of being alone, unhappiness with self, striking out at others,
performance of ritualistic self-damaging acts, and belief that
punishing self is necessary.
Social Isolation may be related to immature interests, unaccepted social
behavior, inadequate personal resources, and inability to engage in
satisfying personal relationships, possibly evidenced by alternating
clinging and distancing behaviors, difficulty meeting expectations of
others, experiencing feelings of difference from others, expressing
interests inappropriate to developmental age, and exhibiting behavior
unaccepted by dominant cultural group.
Botulism (food-borne) MS
deficient Fluid Volume [isotonic] may be related to active losses—
vomiting, diarrhea, decreased intake—nausea, dysphagia, possibly evidenced
by reports of thirst, dry skin/mucous membranes, decreased BP
and urine output, change in mental state, increased hematocrit (Hct).
impaired physical Mobility may be related to neuromuscular impairment,
possibly evidenced by limited ability to perform gross/fine
motor skills.
Anxiety [specify level]/Fear may be related to threat of death, interpersonal
transmission, possibly evidenced by expressed concerns, apprehension,
awareness of physiological symptoms, focus on self.
risk for impaired spontaneous Ventilation: risk factors may include neuromuscular
impairment, presence of infectious process.*
CH
Contamination may be related to lack of proper precautions in food
storage/preparation as evidenced by gastointestinal and neurological
effects of exposure to biological agent.*
Brain tumor MS
acute Pain may be related to pressure on brain tissues, possibly evidenced
by reports of headache, facial mask of pain, narrowed focus,
and autonomic responses (changes in vital signs).
disturbed Thought Processes may be related to altered circulation to
and/or destruction of brain tissue, possibly evidenced by memory
loss, personality changes, impaired ability to make decisions/conceptualize,
and inaccurate interpretation of environment.
disturbed Sensory Perception (specify) may be related to compression/displacement
of brain tissue, disruption of neuronal conduction,
possibly evidenced by changes in visual acuity, alterations in
sense of balance/gait disturbance, and paresthesia.
*A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at
prevention.
804 NURSE’S POCKET GUIDE