Nurse's Pocket Guide

situational low Self-Esteem may be related to functional impairment;
rejection of other(s).
Failure to thrive, infant/child PED
imbalanced Nutrition: less than body requirements may be related to
inability to ingest/digest/absorb nutrients (defects in organ function/metabolism,
genetic factors), physical deprivation/psychosocial
factors, possibly evidenced by lack of appropriate weight gain/weight
loss, poor muscle tone, pale conjunctiva, and laboratory tests reflecting
nutritional deficiency.
delayed Growth and Development may be related to inadequate caretaking
(physical/emotional neglect or abuse), indifference, inconsistent
responsiveness, multiple caretakers, environmental and stimulation
deficiencies, possibly evidenced by altered physical growth, flat
affect, listlessness, decreased response, delay or difficulty in performing
skills or self-control activities appropriate for age group.
risk for impaired Parenting: risk factors may include lack of knowledge,
inadequate bonding, unrealistic expectations for self/infant, and lack
of appropriate response of child to relationship.*
deficient Knowledge [Learning Need] regarding pathophysiology of
condition, nutritional needs, growth/development expectations, and
parenting skills may be related to lack of information/misinformation
or misinterpretation, possibly evidenced by verbalization of concerns,
questions, and misconceptions, or development of preventable
complications.
Fatigue syndrome, chronic CH
Fatigue may be related to disease state, inadequate sleep, possibly evidenced
by verbalization of unremitting/overwhelming lack of
energy, inability to maintain usual routines, listless, compromised
concentration.
chronic Pain may be related to chronic physical disability, possibly evidenced
by verbal reports of headache, sore throat, arthralgias,
abdominal pain, muscle aches, altered ability to continue previous
activities, changes in sleep pattern.
Self-Care Deficit [specify] may be related to tiredness, pain/discomfort,
possibly evidenced by reports of inability to perform desired ADLs.
risk for ineffective Role Performance: risk factors may include health
alterations, stress.*
Fetal alcohol syndrome PED
risk for Injury [CNS damage]: risk factors may include external chemical
factors (alcohol intake by mother), placental insufficiency, fetal
drug withdrawal in utero/postpartum and prematurity.*
disorganized Infant Behavior may be related to prematurity, environmental
overstimulation, lack of containment/boundaries, possibly
evidenced by change from baseline physiological measures, tremors,
startles, twitches, hyperextension of arms/legs, deficient self-regulatory
behaviors, deficient response to visual/auditory stimuli.
*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 835
F