Nurse's Pocket Guide

acute Pain may be related to ischemia of myocardial tissue, possibly evidenced
by verbal reports, guarding/distraction behaviors (restlessness),
facial mask of pain, self-focusing, and autonomic responses
(diaphoresis, changes in vital signs).
Anxiety [specify level]/Fear may be related to threat of death, threat of
change of health status/role functioning and lifestyle, interpersonal
transmission/contagion, possibly evidenced by increased tension,
fearful attitude, apprehension, expressed concerns/uncertainty, restlessness,
sympathetic stimulation, and somatic complaints.
risk for decreased Cardiac Output: risk factors may include changes in
rate and electrical conduction, reduced preload/increased SVR, and
altered muscle contractility/depressant effects of some medications,
infarcted/dyskinetic muscle, structural defects.*
CH
risk for sedentary Lifestyle: risk factors may include lack of resources,
lack of training or knowledge of specific exercise needs, safety concerns/fear
of injury.*
Myocarditis MS
(Also refer to Myocardial infarction)
Activity Intolerance may be related to imbalance in O2 supply and
demand (myocardial inflammation/damage), cardiac depressant
effects of certain drugs, and enforced bedrest, possibly evidenced by
reports of fatigue, exertional dyspnea, tachycardia/palpitations in
response to activity, ECG changes/dysrhythmias, and generalized
weakness.
risk for decreased Cardiac Output: risk factors may include degeneration
of cardiac muscle.*
deficient Knowledge [Learning Need] regarding pathophysiology of condition/outcomes,
treatment, and self-care needs/lifestyle changes may
be related to lack of information/misinterpretation, possibly evidenced
by statements of concern, misconceptions, inaccurate follow-through
of instructions, and development of preventable complications.
Myringotomy PED/MS
(Refer to Mastoidectomy)
Myxedema CH
(Also refer to Hypothyroidism)
disturbed Body Image may be related to change in structure/function
(loss of hair/thickening of skin, masklike facial expression, enlarged
tongue, menstrual and reproductive disturbances), possibly evidenced
by negative feelings about body, feelings of helplessness, and
change in social involvement.
imbalanced Nutrition: more than body requirements may be related to
decreased metabolic rate and activity level, possibly evidenced by
weight gain greater than ideal for height and frame.
risk for decreased Cardiac Output: risk factors may include altered electrical
conduction and myocardial contractility.*
*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 865
M