Nurse's Pocket Guide

(wasting), aversion to eating, reported altered taste sensation, sore
and inflamed buccal cavity, diarrhea and/or constipation.
impaired Oral Mucous Membrane may be related to side effects of therapeutic
agents/radiation, dehydration, and malnutrition, possibly
evidenced by ulcerations, leukoplakia, decreased salivation, and
reports of pain.
disturbed Body Image may be related to anatomical/structural changes,
loss of hair and weight, possibly evidenced by negative feelings about
body, preoccupation with change, feelings of helplessness/hopelessness,
and change in social environment.
ineffective Protection may be related to inadequate nutrition, drug therapy/radiation,
abnormal blood profile, disease state (cancer), possibly
evidenced by impaired healing, deficient immunity, anorexia, fatigue.
readiness for enhanced Hope may be related to expectations of therapeutic
interventions, results of diagnostic procedures as evidenced by
expressed desire to enhance belief in possibilities/sense of meaning to
life.
Cholecystectomy MS
acute Pain may be related to interruption in skin/tissue layers with
mechanical closure (sutures/staples) and invasive procedures (including
T-tube/nasogastric—NG—tube), possibly evidenced by verbal
reports, guarding/distraction behaviors, and autonomic responses
(changes in vital signs).
ineffective Breathing Pattern may be related to decreased lung expansion
(pain and muscle weakness), decreased energy/fatigue, ineffective
cough, possibly evidenced by fremitus, tachypnea, and decreased
respiratory depth/vital capacity.
risk for deficient Fluid Volume: risk factors may include vomiting/NG
aspiration, medically restricted intake, altered coagulation.*
Cholelithiasis CH
acute Pain may be related to inflammation and distortion of tissues,
ductal spasm, possibly evidenced by verbal reports, guarding/distraction
behaviors, and autonomic responses (changes in vital signs).
imbalanced Nutrition: less than body requirements may be related to
inability to ingest/absorb adequate nutrients (food intolerance/pain,
nausea/vomiting, anorexia), possibly evidenced by aversion to food/
decreased intake and weight loss.
deficient Knowledge [Learning Need] regarding pathophysiology, therapy
choices, and self-care needs may be related to lack of information,
misinterpretation, possibly evidenced by verbalization of concerns,
questions, and recurrence of condition.
Chronic obstructive lung disease CH/MS
impaired Gas Exchange may be related to altered O 2 delivery (obstruction
of airways by secretions/bronchospasm, air trapping) and alveoli
destruction, possibly evidenced by dyspnea, restlessness, confusion,
abnormal ABG values, and reduced tolerance for activity.
*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 813
C