Nurse's Pocket Guide

secondary defenses (e.g., decreased hemoglobin, immunosuppression),
inadequate acquired immunity, environmental exposure, malnutrition,
rupture of amniotic membranes.*
deficient Knowledge regarding treatment/prevention, prognosis of condition
may be related to lack of exposure to information and/or
unfamiliarity with resources, misinterpretation possibly evidenced by
verbalization of problem, inaccurate follow-through of instructions,
development of preventable complications/continuation of infectious
process.
[Discomfort] may be related to body response to infective agent, properties
of infection (e.g., skin/tissue irritation, development of
lesions), possibly evidenced by verbal reports, restlessness, withdrawal
from social contacts.
Inflammatory bowel disease CH
(Refer to Colitis, ulcerative; Crohn’s disease)
Influenza CH
Pain[/Discomfort] may be related to inflammation and effects of circulating
toxins, possibly evidenced by verbal reports, distraction behaviors,
and narrowed focus.
risk for deficient Fluid Volume: risk factors may include excessive gastric
losses, hypermetabolic state, and altered intake.*
Hyperthermia may be related to effects of circulating toxins and dehydration,
possibly evidenced by increased body temperature,
warm/flushed skin, and tachycardia.
risk for ineffective Breathing: risk factors may include response to infectious
process, decreased energy/fatigue.*
Insulin shock MS/CH
(Refer to Hypoglycemia)
Intestinal obstruction MS
(Refer to Ileus)
Irritable bowel syndrome CH
acute Pain may be related to abnormally strong intestinal contractions,
increased sensitivity of intestine to distention, hypersensitivity to
hormones gastrin and cholecystokinin, skin/tissue irritation/perirectal
excoriation, possibly evidenced by verbal reports, guarding behavior,
expressive behavior (restlessness, moaning, irritability).
Constipation may be related to motor abnormalities of longitudinal
muscles/changes in frequency and amplitude of contractions, dietary
restrictions, stress, possibly evidenced by change in bowel
pattern/decreased frequency, sensation of incomplete evacuation,
abdominal pain/distention.
Diarrhea may be related to motor abnormalities of longitudinal muscles/
changes in frequency and amplitude of contractions, possibly evidenced
by precipitous passing of liquid stool on rising or immediately
after eating, rectal urgency/incontinence, bloating.
*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 851
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