Nurse's Pocket Guide

D
possibly evidenced by poor/delayed wound healing and disruption of
skin surface/wound closure.
risk for Infection: risk factors may include inadequate primary
defenses (separation of incision, traumatized intestines, environmental
exposure).*
risk for impaired Tissue Integrity: risk factors may include exposure of
abdominal contents to external environment.*
Fear/[severe] Anxiety may be related to crises, perceived threat of death,
possibly evidenced by fearfulness, restless behaviors, and sympathetic
stimulation.
deficient Knowledge [Learning Need] regarding condition/prognosis
and treatment needs may be related to lack of information/recall and
misinterpretation of information, possibly evidenced by development
of preventable complication, requests for information, and
statement of concern.
Dehydration PED/CH
deficient Fluid Volume [specify] may be related to etiology as defined by
specific situation, possibly evidenced by dry mucous membranes,
poor skin turgor, decreased pulse volume/pressure, and thirst.
risk for impaired Oral Mucous Membrane: risk factors may include
dehydration and decreased salivation.*
deficient Knowledge [Learning Need] regarding fluid needs may be
related to lack of information/misinterpretation, possibly evidenced
by questions, statement of concern, and inadequate follow-through
of instructions/development of preventable complications.
Delirium tremens (acute alcohol MS/PSY
withdrawal)
Anxiety [severe/panic]/Fear may be related to cessation of alcohol
intake/physiological withdrawal, threat to self-concept, perceived
threat of death, possibly evidenced by increased tension, apprehension,
fear of unspecified consequences, identifies object of fear.
disturbed Sensory Perception (specify) may be related to exogenous
(alcohol consumption/sudden cessation)/endogenous (electrolyte
imbalance, elevated ammonia and blood urea nitrogen—BUN)
chemical alterations, sleep deprivation, and psychological stress, possibly
evidenced by disorientation, restlessness, irritability, exaggerated
emotional responses, bizarre thinking, and visual and auditory distortions/hallucinations.
risk for decreased Cardiac Output: risk factors may include direct effect
of alcohol on heart muscle, altered SVR, presence of dysrhythmias.*
risk for Trauma: risk factors may include alterations in balance, reduced
muscle coordination, cognitive impairment, and involuntary
clonic/tonic muscle activity.*
imbalanced Nutrition: less than body requirements may be related to
poor dietary intake, effects of alcohol on organs involved in digestion,
interference with absorption/metabolism of nutrients and amino
acids, possibly evidenced by reports of inadequate food intake, altered
*A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at
prevention.
822 NURSE’S POCKET GUIDE