Nurse's Pocket Guide

evidenced by frequency, dysuria, urgency, incontinence, or
retention.
Constipation may be related to decreased muscle tone associated with
diastasis recti, prenatal effects of progesterone, dehydration, excess
analgesia or anesthesia, pain (hemorrhoids, episiotomy, or perineal
tenderness), prelabor diarrhea and lack of intake, possibly evidenced
by frequency less than usual pattern, hard-formed stool, straining at
stool, decreased bowel sounds, and abdominal distention.
Insomnia may be related to pain/discomfort, intense exhilaration/
excitement, anxiety, exhausting process of labor/delivery, and
needs/demands of family members, possibly evidenced by verbal
reports of difficulty in falling or staying asleep/dissatisfaction with
sleep, lack of energy, nonrestorative sleep.
Post-traumatic stress disorder PSY
Post-Trauma Syndrome related to having experienced a traumatic life
event, possibly evidenced by reexperiencing the event, somatic reactions,
psychic/emotional numbness, altered lifestyle, impaired sleep,
self-destructive behaviors, difficulty with interpersonal relationships,
development of phobia, poor impulse control/irritability, and explosiveness.
risk for other-directed Violence: risk factors may include startle reaction,
an intrusive memory causing a sudden acting out of a feeling as
if the event were occurring, use of alcohol/other drugs to ward off
painful effects and produce psychic numbing, breaking through the
rage that has been walled off, response to intense anxiety or panic
state, and loss of control.*
ineffective Coping may be related to personal vulnerability, inadequate
support systems, unrealistic perceptions, unmet expectations, overwhelming
threat to self, and multiple stressors repeated over a period
of time, possibly evidenced by verbalization of inability to cope or
difficulty asking for help, muscular tension/headaches, chronic
worry, and emotional tension.
complicated Grieving may be related to actual/perceived object loss
(loss of self as seen before the traumatic incident occurred, as well
as other losses incurred in/after the incident), loss of physiopsychosocial
well-being, thwarted grieving response to a loss, and
lack of resolution of previous grieving responses, possibly evidenced
by verbal expression of distress at loss, anger, sadness, labile
affect; alterations in eating habits, sleep/dream patterns, libido;
reliving of past experiences, expression of guilt, and alterations in
concentration.
interrupted Family Processes may be related to situational crisis, failure
to master developmental transitions, possibly evidenced by expressions
of confusion about what to do and that family is having difficulty
coping, family system not meeting physical/emotional/spiritual
needs of its members, not adapting to change or dealing with
traumatic experience constructively, and ineffective family decisionmaking
process.
*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 877
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