Nurse's Pocket Guide

D
risk for ineffective Breathing Pattern: risk factors may include increased
abdominal pressure with restricted diaphragmatic excursion, rapid
infusion of dialysate, pain/discomfort, inflammatory process (e.g.,
atelectasis/pneumonia).*
Diaper rash PED
(Refer to Candidiasis)
Diarrhea PED/CH
deficient Knowledge [Learning Need] regarding causative/contributing
factors and therapeutic needs may be related to lack of information/misconceptions,
possibly evidenced by statements of concern,
questions, and development of preventable complications.
risk for deficient Fluid Volume: risk factors may include excessive losses
through GI tract, altered intake.*
acute Pain may be related to abdominal cramping and irritation/excoriation
of skin, possibly evidenced by verbal reports, facial grimacing,
and autonomic responses.
impaired Skin Integrity may be related to effects of excretions on delicate
tissues, possibly evidenced by reports of discomfort and disruption
of skin surface/destruction of skin layers.
Digitalis toxicity MS/CH
decreased Cardiac Output may be related to altered myocardial contractility/electrical
conduction, properties of digitalis (long half-life
and narrow therapeutic range), concurrent medications, age/general
health status and electrolyte/acid-base balance, possibly evidenced by
changes in rate/rhythm/conduction (development/worsening of dysrhythmias),
changes in mentation, worsening of heart failure, elevated
serum drug levels.
risk for imbalanced Fluid Volume: risk factors may include excessive
losses from vomiting/diarrhea, decreased intake/nausea, decreased
plasma proteins, malnutrition, continued use of diuretics; excess
sodium/fluid retention.*
deficient Knowledge [Learning Need] regarding condition/therapy and
self-care needs may be related to information misinterpretation and
lack of recall, possibly evidenced by inaccurate follow-through of
instructions and development of preventable complications.
risk for disturbed Thought Processes: risk factors may include physiological
effects of toxicity/reduced cerebral perfusion.*
Dilation and curettage (D and C) OB/GYN
(Also refer to Abortion, elective or spontaneous termination)
deficient Knowledge [Learning Need] regarding surgical procedure, possible
postprocedural complications, and therapeutic needs may be related
to lack of exposure/unfamiliarity with information, possibly evidenced
by requests for information and statements of concern/misconceptions.
Dilation of cervix, premature OB
(Also refer to Labor, preterm)
*A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at
prevention.
828 NURSE’S POCKET GUIDE