Nurse's Pocket Guide

impaired physical Mobility may be related to neuromuscular/skeletal
impairment, pain/discomfort, restrictive therapies (bedrest, extremity
immobilization), and psychological immobility, possibly evidenced
by inability to purposefully move within the physical environment,
imposed restrictions, reluctance to attempt movement,
limited range of motion, and decreased muscle strength/control.
risk for impaired Gas Exchange: risk factors may include altered blood
flow, blood/fat emboli, alveolar/capillary membrane changes (interstitial/pulmonary
edema, congestion).*
deficient Knowledge [Learning Need] regarding healing process, therapy
requirements, potential complications, and self-care needs may be
related to lack of exposure, misinterpretation of information, possibly
evidenced by statements of concern, questions, and misconceptions.
Frostbite MS/CH
impaired Tissue Integrity may be related to altered circulation and thermal
injury, possibly evidenced by damaged/destroyed tissue.
acute Pain may be related to diminished circulation with tissue
ischemia/necrosis and edema formation, possibly evidenced by verbal
reports, guarding/distraction behaviors, narrowed focus, and autonomic
responses (changes in vital signs).
risk for Infection: risk factors may include traumatized tissue/tissue
destruction, altered circulation, and compromised immune response in
affected area.*
Gallstones CH
(Refer to Cholelithiasis)
Gangrene, dry MS
ineffective peripheral Tissue Perfusion may be related to interruption in
arterial flow, possibly evidenced by cool skin temperature, change in
color (black), atrophy of affected part, and presence of pain.
acute Pain may be related to tissue hypoxia and necrotic process, possibly
evidenced by verbal reports, guarding/distraction behaviors, narrowed
focus, and autonomic responses (changes in vital signs).
Gas, lung irritant MS/CH
ineffective Airway Clearance may be related to irritation/inflammation
of airway, possibly evidenced by marked cough, abnormal breath
sounds (wheezes), dyspnea, and tachypnea.
risk for impaired Gas Exchange: risk factors may include irritation/inflammation
of alveolar membrane (dependent on type of agent and length
of exposure).*
Anxiety [specify level] may be related to change in health status and
threat of death, possibly evidenced by verbalizations, increased tension,
apprehension, and sympathetic stimulation.
Gastritis, acute MS
acute Pain may be related to irritation/inflammation of gastric mucosa,
possibly evidenced by verbal reports, guarding/distraction behaviors,
and autonomic responses (changes in vital signs).
*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 837
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