Nurse's Pocket Guide

M
Mononucleosis, infectious CH
Fatigue may be related to decreased energy production, states of discomfort,
and increased energy requirements (inflammatory process),
possibly evidenced by reports of overwhelming lack of energy, inability
to maintain usual routines, lethargy, and malaise.
acute Pain[/Discomfort] may be related to inflammation of lymphoid
and organ tissues, irritation of oropharyngeal mucous membranes,
and effects of circulating toxins, possibly evidenced by verbal reports,
distraction behaviors, and self-focusing.
Hyperthermia may be related to inflammatory process, possibly evidenced
by increased body temperature, warm/flushed skin, and
tachycardia.
deficient Knowledge [Learning Need] regarding disease transmission,
self-care needs, medical therapy, and potential complications may be
related to lack of information/misinterpretation, possibly evidenced
by statements of concern, misconceptions, and inaccurate followthrough
of instructions.
Mood disorders PSY
(Refer to Depressive disorders)
Mountain sickness, acute (AMS) CH/MS
acute Pain may be related to reduced O2 tension, possibly evidenced by
reports of headache.
Fatigue may be related to stress, increased physical exertion, sleep deprivation,
possibly evidenced by overwhelming lack of energy, inability
to restore energy even after sleep, compromised concentration,
decreased performance.
risk for deficient Fluid Volume: risk factors may include increased water
loss (e.g., overbreathing dry air), exertion, altered fluid intake (nausea).*
Multiple personality PSY
(Refer to Dissociative disorders)
Multiple sclerosis CH
Fatigue may be related to decreased energy production/increased energy
requirements to perform activities, psychological/emotional demands,
pain/discomfort, medication side effects, possibly evidenced by verbalization
of overwhelming lack of energy, inability to maintain usual
routine, decreased performance, impaired ability to concentrate,
increase in physical complaints.
disturbed visual, kinesthetic, tactile Sensory Perception may be related
to delayed/interrupted neuronal transmission, possibly evidenced by
impaired vision, diplopia, disturbance of vibratory or position sense,
paresthesias, numbness, and blunting of sensation.
impaired physical Mobility may be related to neuromuscular impairment;
discomfort/pain; sensoriperceptual impairments;, decreased
muscle strength, control and/or mass; deconditioning, as evidenced
by limited ability to perform motor skills; limited range of motion;
gait changes/postural instability.
*A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at
prevention.
862 NURSE’S POCKET GUIDE