Nurse's Pocket Guide

D
fragmentation of the personality), increased tension, feelings of inadequacy,
and focus on self, projection of personal perceptions onto the
environment.
risk for self-/other-directed Violence: risk factors may include dissociative
state/conflicting personalities, depressed mood, panic states, and
suicidal/homicidal behaviors.*
disturbed Personal Identity may be related to psychological conflicts
(dissociative state), childhood trauma/abuse, threat to physical
integrity/self-concept, and underdeveloped ego, possibly evidenced
by alteration in perception or experience of the self, loss of one’s own
sense of reality/the external world, poorly differentiated ego boundaries,
confusion about sense of self, confusion regarding purpose or
direction in life, memory loss, presence of more than one personality
within the individual.
compromised family Coping may be related to multiple stressors repeated
over time, prolonged progression of disorder that exhausts the supportive
capacity of significant person(s), family disorganization and role
changes, high-risk family situation, possibly evidenced by family/SO(s)
describing inadequate understanding or knowledge that interferes with
assistive or supportive behaviors, relationship and marital conflict.
Diverticulitis CH
acute Pain may be related to inflammation of intestinal mucosa,
abdominal cramping, and presence of fever/chills, possibly evidenced
by verbal reports, guarding/distraction behaviors, autonomic
responses, and narrowed focus.
Diarrhea/Constipation may be related to altered structure/function and
presence of inflammation, possibly evidenced by signs and symptoms
dependent on specific problem (e.g., increase/decrease in frequency
of stools and change in consistency).
deficient Knowledge [Learning Need] regarding disease process, potential
complications, therapeutic and self-care needs may be related to
lack of information/misconceptions, possibly evidenced by statements
of concern, request for information, and development of preventable
complications.
risk for Powerlessness: risk factors may include chronic nature of disease
process and recurrent episodes despite cooperation with medical regimen.*
Down syndrome PED/CH
(Also refer to Mental retardation)
delayed Growth and Development may be related to effects of physical/mental
disability, possibly evidenced by altered physical growth,
delay/inability in performing skills and self-care/self-control activities
appropriate for age.
risk for Trauma: risk factors may include cognitive difficulties and poor
muscle tone/coordination, weakness.*
imbalanced Nutrition: less than body requirements may be related to
poor muscle tone and protruding tongue, possibly evidenced by weak
*A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at
prevention.
830 NURSE’S POCKET GUIDE