Nurse's Pocket Guide

abnormal breath sounds, ineffective cough, cyanosis, and altered respiratory
rate/depth.
risk for Infection: risk factors may include stasis of respiratory secretions
and development of atelectasis.*
imbalanced Nutrition: less than body requirements may be related to
impaired digestive process and absorption of nutrients, possibly evidenced
by failure to gain weight, muscle wasting, and retarded physical
growth.
deficient Knowledge [Learning Need] regarding pathophysiology of
condition, medical management, and available community resources
may be related to insufficient information/misconceptions, possibly
evidenced by statements of concern and questions, inaccurate followthrough
of instructions, development of preventable complications.
compromised family Coping may be related to chronic nature of disease
and disability, inadequate/incorrect information or understanding by
a primary person, possibly evidenced by significant person attempting
assistive or supportive behaviors with less than satisfactory
results, protective behavior disproportionate to client’s abilities, or
need for autonomy.
Cystitis CH
acute Pain may be related to inflammation and bladder spasms, possibly
evidenced by verbal reports, distraction behaviors, and narrowed
focus.
impaired Urinary Elimination may be related to inflammation/irritation
of bladder, possibly evidenced by frequency, nocturia, and
dysuria.
deficient Knowledge [Learning Need] regarding condition, treatment, and
prevention of recurrence may be related to inadequate information/
misconceptions, possibly evidenced by statements of concern and
questions, recurrent infections.
Cytomegalic inclusion disease CH
(Refer to Cytomegalovirus infection)
Cytomegalovirus (CMV) infection CH
risk for disturbed visual Sensory Perception: risk factors may include
inflammation of the retina.*
risk for fetal Infection: risk factors may include transplacental exposure,
contact with blood/body fluids.*
Deep Vein Thrombosis (DVT) CH/MS
(Refer to Thrombophlebitis)
Degenerative joint disease CH
(Refer to Arthritis, rheumatoid)
Dehiscence (abdominal) MS
impaired Skin Integrity may be related to altered circulation, altered
nutritional state (obesity/malnutrition), and physical stress on incision,
*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 821
D