Nurse's Pocket Guide

disturbed kinesthetic/tactile Sensory Perception: may be related to neurological
deficit with loss of sensory reception and transmission, psychological
stress, possibly evidenced by reported/measured change in
sensory acuity and loss of usual response to stimuli.
reflex Urinary Incontinence/impaired Urinary Elimination may be
related to loss of nerve conduction above the level of the reflex arc,
possibly evidenced by lack of awareness of bladder filling/fullness,
absence of urge to void, uninhibited bladder contraction, urinary
tract infections (UTIs), kidney stone formation.
disturbed Body Image/ineffective Role Performance may be related to
loss of body functions, change in physical ability to resume role, perceived
loss of self/identity, possibly evidenced by negative feelings
about body/self, feelings of helplessness/powerlessness, delay in taking
responsibility for self-care/participation in therapy, and change in
social involvement.
Sexual Dysfunction may be related to loss of sensation, altered function,
and vulnerability, possibly evidenced by seeking of confirmation of
desirability, verbalization of concern, alteration in relationship with
SO, and change in interest in self/others.
Parathyroidectomy MS
acute Pain may be related to presence of surgical incision and effects of
calcium imbalance (bone pain, tetany), possibly evidenced by verbal
reports, guarding/distraction behaviors, self-focus, and autonomic
responses (changes in vital signs).
risk for excess Fluid Volume: risk factors may include preoperative renal
involvement, stress-induced release of ADH, and changing calcium/electrolyte
levels.*
risk for ineffective Airway Clearance: risk factors may include edema
formation and laryngeal nerve damage.*
deficient Knowledge [Learning Need] regarding postoperative
care/complications and long-term needs may be related to lack of
information/recall, misinterpretation, possibly evidenced by statements
of concern, questions, and misconceptions.
Parkinson’s disease CH
impaired Walking may be related to neuromuscular impairment (muscle
weakness, tremors, bradykinesia) and musculoskeletal impairment
(joint rigidity), possibly evidenced by inability to move about
the environment as desired, increased occurrence of falls.
impaired Swallowing may be related to neuromuscular impairment/
muscle weakness, possibly evidenced by reported/observed difficulty
in swallowing, drooling, evidence of aspiration (choking,
coughing).
impaired verbal Communication may be related to muscle weakness
and incoordination, possibly evidenced by impaired articulation, difficulty
with phonation, and changes in rhythm and intonation.
risk for Stress Overload: risk factors may include inadequate resources,
chronic illness, physical demands.*
*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 871
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