Nurse's Pocket Guide

ineffective Breathing Pattern may be related to impingement of the
diaphragm by enlarging uterus, possibly evidenced by reports of
shortness of breath, dyspnea, and changes in respiratory depth.
risk for [decompensated] Cardiac Output: risk factors may include
increased circulatory demand, changes in preload (decreased venous
return) and afterload (increased peripheral vascular resistance), and
ventricular hypertrophy.*
risk for excess Fluid Volume: risk factors may include changes in regulatory
mechanisms, sodium/water retention.
ineffective Sexuality Pattern may be related to conflict regarding
changes in sexual desire and expectations, fear of physical injury to
woman/fetus, possibly evidenced by reported difficulties, limitations,
or changes in sexual behaviors/activities.
Pregnancy (prenatal period) 3rd trimester OB/CH
(Also refer to Pregnancy 1st and 2nd trimester)
deficient Knowledge [Learning Need] regarding preparation for
labor/delivery, infant care may be related to lack of exposure/experience,
misinterpretations of information, possibly evidenced by
request for information, statement of concerns/misconceptions.
impaired Urinary Elimination may be related to uterine enlargement,
increased abdominal pressure, fluctuation of renal blood flow, and
glomerular filtration rate (GFR), possibly evidenced by urinary frequency,
urgency, dependent edema.
risk for ineffective [individual/] family Coping: risk factors may include
situational/maturational crisis, personal vulnerability, unrealistic
perceptions, absent/insufficient support systems.*
risk for maternal Injury: risk factors may include presence of hypertension,
infection, substance use/abuse, altered immune system,
abnormal blood profile, tissue hypoxia, premature rupture of membranes.*
Pregnancy, adolescent OB/CH
(Also refer to Pregnancy, prenatal period)
interrupted Family Processes may be related to situational/developmental
transition (economic, change in roles/gain of a family member),
possibly evidenced by family expressing confusion about what to do,
unable to meet physical/emotional/spiritual needs of the members,
family inability to adapt to change or to deal with traumatic experience
constructively, does not demonstrate respect for individuality
and autonomy of its members, ineffective family decision-making
process, and inappropriate boundary maintenance.
Social Isolation may be related to alterations in physical appearance,
perceived unacceptable social behavior, restricted social sphere, stage
of adolescence, and interference with accomplishing developmental
tasks, possibly evidenced by expressions of feelings of aloneness/
rejection/difference from others, uncommunicative, withdrawn, no
eye contact, seeking to be alone, unacceptable behavior, and absence
of supportive SO(s).
*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 879
P