Nurse's Pocket Guide

D
risk for disturbed Sensory Perception (specify): risk factors may include
endogenous chemical alteration (glucose/insulin and/or electrolyte
imbalance).*
compromised family Coping may be related to inadequate or incorrect
information or understanding by primary person(s), other situational/
developmental crises or situations the significant person(s) may be
facing, lifelong condition requiring behavioral changes impacting
family, possibly evidenced by family expressions of confusion about
what to do, verbalizations that they are having difficulty coping with
situation, family does not meet physical/emotional needs of its members;
SO(s) preoccupied with personal reaction (e.g., guilt, fear), display
protective behavior disproportionate (too little/too much) to
client’s abilities or need for autonomy.
Diabetic ketoacidosis CH/MS
deficient Fluid Volume [specify] may be related to hyperosmolar urinary
losses, gastric losses and inadequate intake, possibly evidenced
by increased urinary output/dilute urine; reports of weakness, thirst,
sudden weight loss, hypotension, tachycardia, delayed capillary refill,
dry mucous membranes, poor skin turgor.
unstable blood Glucose may be related to medication management, lack
of diabetes management, indequate blood glucose moitoring, presence
of infection, possibly evidenced by elevated serum glucose level, presence
of ketones in urine, nausea, weight loss, blurred vision, irritability.
imbalanced Nutrition: less than body requirements that may be related
to inadequate utilization of nutrients (insulin deficiency), decreased
oral intake, hypermetabolic state, possibly evidenced by recent weight
loss, reports of weakness, lack of interest in food, gastric fullness/
abdominal pain,
Fatigue may be related to decreased metabolic energy production,
altered body chemistry (insufficient insulin), increased energy
demands (hypermetabolic state/infection), possibly evidenced by
overwhelming lack of energy, inability to maintain usual routines,
decreased performance, impaired ability to concentrate, listlessness.
risk for Infection: risk factors may include high glucose levels, decreased
leukocyte function, stasis of body fluids, invasive procedures, alteration
in circulation/perfusion.*
Dialysis, general CH
(Also refer to Dialysis, peritoneal; Hemodialysis)
imbalanced Nutrition: less than body requirements may be related to
inadequate ingestion of nutrients (dietary restrictions, anorexia, nausea/vomiting,
stomatitis), loss of peptides and amino acids (building
blocks for proteins) during procedure, possibly evidenced by
reported inadequate intake, aversion to eating, altered taste sensation,
poor muscle tone/weakness, sore/inflamed buccal cavity, pale conjunctiva/mucous
membranes.
Grieving may be related to actual or perceived loss, chronic and/or fatal
illness, and thwarted grieving response to a loss, possibly evidenced
*A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at
prevention.
826 NURSE’S POCKET GUIDE