Nurse's Pocket Guide

taste sensation, lack of interest in food, debilitated state, decreased
subcutaneous fat/muscle mass, signs of mineral/electrolyte deficiency
including abnormal laboratory findings.
Delivery, precipitous/out of hospital OB
(Also refer to Labor, precipitous; Labor stages I–II)
risk for deficient Fluid Volume: risk factors may include presence of
nausea/vomiting, lack of intake, excessive vascular loss.*
risk for Infection: risk factors may include broken/traumatized tissue,
increased environmental exposure, rupture of amniotic membranes.*
risk for fetal Injury: risk factors may include rapid descent/pressure
changes, compromised circulation, environmental exposure.*
Delusional disorder PSY
risk for self-/other-directed Violence: risk factors may include perceived
threats of danger, increased feelings of anxiety, acting out in an irrational
manner.*
[severe] Anxiety may be related to inability to trust, possibly evidenced by
rigid delusional system, frightened of other people and own hostility.
Powerlessness may be related to lifestyle of helplessness, feelings of
inadequacy, interpersonal interaction, possibly evidenced by verbal
expressions of no control/influence over situation(s), use of paranoid
delusions, aggressive behavior to compensate for lack of control.
disturbed Thought Processes may be related to psychological conflicts,
increasing anxiety/fear, possibly evidenced by interference with ability
to think clearly/logically, fragmentation and autistic thinking,
delusions, beliefs and behaviors of suspicion/violence.
impaired Social Interaction may be related to mistrust of others/delusional
thinking, lack of knowledge/skills to enhance mutuality, possibly
evidenced by discomfort in social situations, difficulty in establishing
relationships with others, expression of feelings of rejection,
no sense of belonging.
Dementia, presenile/senile CH/PSY
(Also refer to Alzheimer’s disease)
impaired Memory may be related to neurological disturbances, possibly
evidenced by observed experiences of forgetting, inability to determine
if a behavior was performed, inability to perform previously
learned skills, inability to recall factual information or recent/past
events.
Fear may be related to decreases in functional abilities, public disclosure
of disabilities, further mental/physical deterioration, possibly evidenced
by social isolation, apprehension, irritability, defensiveness,
suspiciousness, aggressive behavior.
Self-Care Deficit [specify] may be related to cognitive decline, physical
limitations, frustration over loss of independence, depression, possibly
evidenced by impaired ability to perform ADLs.
risk for Trauma: risk factors may include changes in muscle coordination/balance,
impaired judgment, seizure 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 823
D