Nurse's Pocket Guide

equired voice rest, possibly evidenced by inability to speak, change in
vocal characteristics, and impaired articulation.
risk for Aspiration: risk factors may include impaired swallowing,
facial/neck surgery, presence of tracheostomy/feeding tube.*
Laryngitis CH/PED
(Refer to Croup)
Latex allergy CH
latex Allergy Response may be related to no immune mechanism
response, possibly evidenced by contact dermatitis—erythema, blisters,
delayed hypersensitivity—eczema, irritation, hypersensitivity—
generalized edema, wheezing/bronchospasm, hypotension, cardiac
arrest.
Anxiety [specify level]/Fear may be related to threat of death, possibly
evidenced by expressed concerns, hypervigilance, restlessness, focus
on self.
risk for risk-prone health Behavior: risk factors may include health status
requiring change in occupation.*
Lead poisoning, acute PED/CH
(Also refer to Lead poisoning, chronic)
Contamination may be related to flaking/peeling paint (young children),
improperly lead-glazed ceramic pottery, unprotected contact
with lead (e.g., battery manufacture/recycling, bronzing, soldering/
welding), imported herbal products/medicinals, possibly evidenced
by abdominal cramping, headache, irritability, decreased attentiveness,
constipation, tremors.
risk for Trauma: risk factors may include loss of coordination, altered
level of consciousness, clonic or tonic muscle activity, neurological
damage.*
risk for deficient Fluid Volume: risk factors may include excessive vomiting,
diarrhea, or decreased intake.*
deficient Knowledge [Learning Need] regarding sources of lead and prevention
of poisoning may be related to lack of information/misinterpretation,
possibly evidenced by statements of concern, questions,
and misconceptions.
Lead poisoning, chronic CH
(Also refer to Lead poisoning, acute)
Contamination may be related to flaking/peeling paint (young children),
improperly lead-glazed ceramic pottery, unprotected contact
with lead (e.g., battery manufacture/recycling, bronzing,
soldering/welding), imported herbal products/medicinals, possibly
evidenced by chronic abdominal pain, headache, personality changes,
cognitive deficits, seizures, neuropathy.
imbalanced Nutrition: less than body requirements may be related to
decreased intake (chemically induced changes in the GI tract), possibly
evidenced by anorexia, abdominal discomfort, reported metallic
taste, and weight loss.
*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 855
L