Nurse's Pocket Guide

F
risk for impaired Parenting: risk factors may include mental and/or
physical illness, inability of mother to assume the overwhelming
task of unselfish giving and nurturing, presence of stressors (financial/legal
problems), lack of available or ineffective role model, interruption
of bonding process, lack of appropriate response of child to
relationship.*
PSY
ineffective [maternal] Coping may be related to personal vulnerability,
low self-esteem, inadequate coping skills, and multiple stressors
(repeated over period of time), possibly evidenced by inability to
meet basic needs/fulfill role expectations/problem solve, and excessive
use of drug(s).
dysfunctional Family Processes: alcoholism may be related to lack
of/insufficient support from others, mother’s drug problem and
treatment status, together with poor coping skills, lack of family stability/overinvolvement
of parents with children and multigenerational
addictive behaviors, possibly evidenced by abandonment,
rejection, neglectful relationships with family members, and decisions
and actions by family that are detrimental.
Fetal demise OB
Grieving may be related to death of fetus/infant (wanted or unwanted),
possibly evidenced by verbal expressions of distress, anger, loss, crying,
alteration in eating habits or sleep pattern.
situational low Self-Esteem may be related to perceived “failure” at a life
event, possibly evidenced by negative self-appraisal in response to life
event in a person with a previous positive self-evaluation, verbalization
of negative feelings about the self (helplessness, uselessness), difficulty
making decisions.
risk for Spiritual Distress: risk factors may include loss of loved one, low
self-esteem, poor relationships, challenged belief and value system
(birth is supposed to be the beginning of life, not of death) and
intense suffering.*
Fractures MS/CH
(Also refer to Casts; Traction)
risk for Trauma [additional injury]: risk factors may include loss of
skeletal integrity/movement of skeletal fragments, use of traction
apparatus, and so on.*
acute Pain may be related to muscle spasms, movement of bone fragments,
tissue trauma/edema, traction/immobility device, stress, and
anxiety, possibly evidenced by verbal reports, distraction behaviors,
self-focusing/narrowed focus, facial mask of pain, guarding/protective
behavior, alteration in muscle tone, and autonomic responses
(changes in vital signs).
risk for Peripheral Neurovascular Dysfunction: risk factors may include
reduction/interruption of blood flow (direct vascular injury, tissue
trauma, excessive edema, thrombus formation, hypovolemia).*
*A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at
prevention.
836 NURSE’S POCKET GUIDE