Nurse's Pocket Guide

alance, presence of multiple diseases/organ involvement), and use of
multiple prescribed/OTC drugs.*
disturbed Thought Processes may be related to physiological changes of
aging (loss of cells and brain atrophy, decreased blood supply),
altered sensory input, pain, effects of medications, and psychological
conflicts (disrupted life pattern), possibly evidenced by slower reaction
times, memory loss, altered attention span, disorientation,
inability to follow, altered sleep patterns, and personality changes.
Insomnia may be related to internal factors (illness, psychological stress,
inactivity) and external factors (environmental changes, facility routines),
possibly evidenced by reports of difficulty in falling asleep/not
feeling rested, interrupted sleep/awakening earlier than desired, change
in behavior/performance, increasing irritability, and listlessness.
risk for ineffective Sexuality Pattern: risk factors may include biopsychosocial
alteration of sexuality, interference in psychological/physical
well-being, self-image, and lack of privacy/SO(s).*
risk for Relocation Stress Syndrome: risk factors may include multiple
losses, feeling of powerlessness, lack of/inappropriate use of support
system, changes in psychosocial/physical health status.*
risk for impaired Religiosity: risk factors may include ineffective support/coping,
lack of social interaction, depression. *
Lupus erythematosus, systemic (SLE) CH
Fatigue may be related to inadequate energy production/increased
energy requirements (chronic inflammation), overwhelming psychological
or emotional demands, states of discomfort, and altered body
chemistry (including effects of drug therapy), possibly evidenced by
reports of unremitting and overwhelming lack of energy/inability to
maintain usual routines, decreased performance, lethargy, and
decreased libido.
acute Pain may be related to widespread inflammatory process affecting
connective tissues, blood vessels, serosal surfaces and mucous membranes,
possibly evidenced by verbal reports, guarding/distraction behaviors,
self-focusing, and autonomic responses (changes in vital signs).
impaired Skin/Tissue Integrity may be related to chronic inflammation,
edema formation, and altered circulation, possibly evidenced by presence
of skin rash/lesions, ulcerations of mucous membranes, and
photosensitivity.
disturbed Body Image may be related to presence of chronic condition
with rash, lesions, ulcers, purpura, mottled erythema of hands, alopecia,
loss of strength, and altered body function, possibly evidenced by
hiding body parts, negative feelings about body, feelings of helplessness,
and change in social involvement.
Lyme disease CH/MS
acute/chronic Pain[/Discomfort] may be related to systemic effects of
toxins, presence of rash, urticaria, and joint swelling/inflammation,
possibly evidenced by verbal reports, guarding behaviors, autonomic
responses, and narrowed focus.
*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 857
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