Nurse's Pocket Guide

H
lifestyle, possibly evidenced by reported/observed weakness, fatigue,
changes in vital signs, presence of dysrhythmias, dyspnea, pallor, and
diaphoresis.
deficient Knowledge [Learning Need] regarding cardiac function/disease
process, therapy and self-care needs may be related to lack of
information/misinterpretation, possibly evidenced by questions,
statements of concern/misconceptions; development of preventable
complications or exacerbations of condition.
Heatstroke MS
Hyperthermia may be related to prolonged exposure to hot environment/vigorous
activity with failure of regulating mechanism of
the body, possibly evidenced by high body temperature (greater
than 105F/40.6C), flushed/hot skin, tachycardia, and seizure
activity.
decreased Cardiac Output may be related to functional stress of hypermetabolic
state, altered circulating volume/venous return, and direct
myocardial damage secondary to hyperthermia, possibly evidenced
by decreased peripheral pulses, dysrhythmias/tachycardia, and
changes in mentation.
Hemodialysis MS/CH
(Also refer to Dialysis, general)
risk for Injury, [loss of vascular access]: risk factors may include clotting/thrombosis,
infection, disconnection/hemorrhage.*
risk for deficient Fluid Volume: risk factors may include excessive fluid
losses/shifts via ultrafiltration, hemorrhage (altered coagulation/disconnection
of shunt), and fluid restrictions.*
risk for excess Fluid Volume: risk factors may include excessive fluid
intake, rapid IV, blood/plasma expanders/saline given to support BP
during procedure.*
ineffective Protection may be related to chronic disease state, drug therapy,
abnormal blood profile, inadequate nutrition, possibly evidenced
by altered clotting, impaired healing, deficient immunity, fatigue,
anorexia.
Hemophilia PED
risk for deficient Fluid Volume [isotonic]: risk factors may include
impaired coagulation/hemorrhagic losses.*
risk for acute/chronic Pain: risk factors may include nerve compression
from hematomas, nerve damage, or hemorrhage into joint space.*
risk for impaired physical Mobility: risk factors may include joint hemorrhage,
swelling, degenerative changes, and muscle atrophy.*
ineffective Protection may be related to abnormal blood profile, possibly
evidenced by altered clotting.
compromised family Coping may be related to prolonged nature of
condition that exhausts the supportive capacity of significant person(s),
possibly evidenced by protective behaviors disproportionate
to client’s abilities/need for autonomy.
*A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at
prevention.
842 NURSE’S POCKET GUIDE