Nurse's Pocket Guide

D
risk for sedentary Lifestyle: risk factors may include lack of interest/
motivation, lack of resources, lack of training or knowledge of specific
exercise needs, safety concerns/fear of injury. *
risk for Caregiver Role Strain: risk factors may include illness severity of
care receiver, duration of caregiving required, care receiver exhibiting
deviant/bizarre behavior; family/caregiver isolation, lack of
respite/recreation, spouse is caregiver.*
risk for complicated Grieving: risk factors may include preloss psychological
symptoms, predisposition for anxiety and feelings of inadequacy,
frequency of major life events.*
Depressant abuse CH/PSY
(Also refer to Drug overdose, acute [depressants])
ineffective Denial may be related to weak underdeveloped ego, unmet selfneeds,
possibly evidenced by inability to admit impact of condition on
life, minimizes symptoms/problem, refuses healthcare attention.
ineffective Coping may be related to weak ego, possibly evidenced by
abuse of chemical agents, lack of goal-directed behavior, inadequate
problem solving, destructive behavior toward self.
imbalanced Nutrition: less than body requirements may be related to
use of substance in place of nutritional food, possibly evidenced by
loss of weight, pale conjunctiva and mucous membranes, electrolyte
imbalances, anemias.
risk for Injury: risk factors may include changes in sleep, decreased concentration,
loss of inhibitions.*
Depressive disorders, major PSY
depression, dysthymia
risk for self-directed Violence: risk factors may include depressed mood
and feeling of worthlessness and hopelessness.*
[moderate to severe] Anxiety/disturbed Thought Processes may be
related to psychological conflicts, unconscious conflict about essential
values/goals of life, unmet needs, threat to self-concept, sleep deprivation,
interpersonal transmission/contagion, possibly evidenced
by reports of nervousness or fearfulness, feelings of inadequacy;
agitation, angry/tearful outbursts, rambling/discoordinated speech,
restlessness, hand rubbing or wringing, tremulousness, poor memory/
concentration, decreased ability to grasp ideas, inability to follow/
impaired ability to make decisions, numerous/repetitious physical
complaints without organic cause, ideas of reference, hallucinations/
delusions.
Insomnia may be related to biochemical alterations (decreased serotonin),
unresolved fears and anxieties, and inactivity, possibly evidenced
by difficulty in falling/remaining asleep, early morning awakening/awakening
later than desired, reports of not feeling rested,
physical signs (e.g., dark circles under eyes, excessive yawning).
Social Isolation/impaired Social Interaction may be related to alterations
in mental status/thought processes (depressed mood), inadequate
*A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at
prevention.
824 NURSE’S POCKET GUIDE