Nurse's Pocket Guide

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Anxiety [specify level] may be related to change in health status and
threat of death, possibly evidenced by apprehension, expressed concerns,
and focus on self.
acute Pain may be related to generalized inflammatory process and
effects of embolic phenomena, possibly evidenced by verbal reports,
narrowed focus, distraction behaviors, and autonomic responses
(changes in vital signs).
risk for Activity Intolerance: risk factors may include imbalance
between O 2 supply and demand, debilitating condition.*
risk for ineffective Tissue Perfusion (specify): risk factors may include
embolic interruption of arterial flow (embolization of thrombi/
valvular vegetations).*
Endometriosis GYN
acute/chronic Pain may be related to pressure of concealed bleeding/
formation of adhesions, possibly evidenced by verbal reports (pain
between/with menstruation), guarding/distraction behaviors, and
narrowed focus.
Sexual Dysfunction may be related to pain secondary to presence of
adhesions, possibly evidenced by verbalization of problem, and altered
relationship with partner.
deficient Knowledge [Learning Need] regarding pathophysiology of
condition and therapy needs may be related to lack of information/misinterpretations,
possibly evidenced by statements of concern
and misconceptions.
Enteritis MS/CH
(Refer to Colitis, ulcerative; Crohn’s disease)
Epididymitis MS
acute Pain may be related to inflammation, edema formation, and tension
on the spermatic cord, possibly evidenced by verbal reports,
guarding/distraction behaviors (restlessness), and autonomic responses
(changes in vital signs).
risk for Infection, [spread]: risk factors may include presence of inflammation/infectious
process, insufficient knowledge to avoid spread of
infection.*
deficient Knowledge [Learning Need] regarding pathophysiology, outcome,
and self-care needs may be related to lack of information/
misinterpretations, possibly evidenced by statements of concern, misconceptions,
and questions.
Epilepsy CH
(Refer to Seizure disorder)
Erectile dysfunction CH
Sexual Dysfunction may be related to altered body function possibly
evidenced by reports of disruption of sexual response pattern, inability
to achieve desired satisfaction.
*A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at
prevention.
834 NURSE’S POCKET GUIDE