Nurse's Pocket Guide

P
Pregnancy (prenatal period) 1st trimester OB/CH
risk for imbalanced Nutrition: less than body requirements: risk factors
may include changes in appetite, insufficient intake (nausea/vomiting,
inadequate financial resources and nutritional knowledge),
meeting increased metabolic demands (increased thyroid activity
associated with the growth of fetal and maternal tissues).*
[Discomfort]/acute Pain may be related to hormonal influences, physical
changes, possibly evidenced by verbal reports (nausea, breast
changes, leg cramps, hemorrhoids, nasal stuffiness), alteration in
muscle tone, restlessness, and autonomic responses (changes in vital
signs).
risk for fetal Injury: risk factors may include environmental/hereditary
factors and problems of maternal well-being that directly affect the
developing fetus (e.g., malnutrition, substance use).*
[maximally compensated] Cardiac Output may be related to increased
fluid volume/maximal cardiac effort and hormonal effects of progesterone
and relaxin (places the client at risk for hypertension and/or
circulatory failure), and changes in peripheral resistance (afterload),
possibly evidenced by variations in BP and pulse, syncopal episodes,
presence of pathological edema.
readiness for enhanced family Coping may be related to situational/
maturational crisis with anticipated changes in family structure/roles,
needs sufficiently met and adaptive tasks effectively addressed to
enable goals of self-actualization to surface, as evidenced by movement
toward health-promoting and enriching lifestyle, choosing
experiences that optimize pregnancy experience/wellness.
risk for Constipation: risk factors may include changes in dietary/fluid
intake, smooth muscle relaxation, decreased peristalsis, and effects of
medications (e.g., iron).*
Fatigue/Insomnia may be related to increased carbohydrate metabolism,
altered body chemistry, increased energy requirements to perform
ADLs, discomfort, anxiety, inactivity, possibly evidenced by reports of
overwhelming lack of energy/inability to maintain usual routines, difficulty
falling asleep/dissatisfaction with sleep, decreased quality of life.
risk for ineffective Role Performance: risk factors may include maturational
crisis, developmental level, history of maladaptive coping,
absence of support systems.*
deficient Knowledge [Learning Need] regarding normal physiological/psychological
changes and self-care needs may be related to lack
of information/recall and misinterpretation of normal physiological/psychological
changes and their impact on the client/family, possibly
evidenced by questions, statements of concern, misconceptions,
and inaccurate follow-through of instructions/development of preventable
complications.
Pregnancy (prenatal period) 2nd trimester OB/CH
(Also refer to Pregnancy 1st trimester)
risk for disturbed Body Image: risk factors may include perception of
biophysical changes, response of others.*
*A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at
prevention.
878 NURSE’S POCKET GUIDE