Nurse's Pocket Guide

and ineffective sucking/swallowing and observed lack of adequate
intake with weight loss/failure to gain.
interrupted Family Processes may be related to situational/maturational
crises requiring incorporation of new skills into family dynamics,
possibly evidenced by confusion about what to do, verbalized difficulty
coping with situation, unexamined family myths.
risk for complicated Grieving: risk factors may include loss of “the perfect
child,” chronic condition requiring long-term care, and unresolved
feelings.*
risk for impaired parent/infant/child Attachment: risk factors may
include ill infant/child who is unable to effectively initiate parental
contact due to altered behavioral organization, inability of parents to
meet personal needs.*
risk for Social Isolation: risk factors may include withdrawal from usual
social interactions and activities, assumption of total childcare, and
becoming overindulgent/overprotective.*
Drug overdose, acute (depressants) MS/PSY
(Also refer to Substance dependence/abuse rehabilitation)
ineffective Breathing Pattern/impaired Gas Exchange may be related to
neuromuscular impairment/CNS depression, decreased lung expansion,
possibly evidenced by changes in respirations, cyanosis, and
abnormal ABGs.
risk for Trauma/Suffocation/Poisoning: risk factors may include CNS
depression/agitation, hypersensitivity to the drug(s), psychological
stress.*
risk for self-/other-directed Violence: risk factors may include suicidal
behaviors, toxic reactions to drug(s).*
risk for Infection: risk factors may include drug injection techniques,
impurities in injected drugs, localized trauma; malnutrition, altered
immune state.*
Duchenne’s muscular dystrophy PED/CH
(Refer to Muscular dystrophy [Duchenne’s])
DVT CH/MS
(Refer to Thrombophlebitis)
Dysmenorrhea GYN
acute Pain may be related to exaggerated uterine contractibility, possibly
evidenced by verbal reports, guarding/distraction behaviors, narrowed
focus, and autonomic responses (changes in vital signs).
risk for Activity Intolerance: risk factors may include severity of pain
and presence of secondary symptoms (nausea, vomiting, syncope,
chills), depression.*
ineffective Coping may be related to chronic, recurrent nature of problem,
anticipatory anxiety, and inadequate coping methods, possibly
evidenced by muscular tension, headaches, general irritability,
chronic depression, and verbalization of inability to cope, report of
poor self-concept.
*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 831
D