Nurse's Pocket Guide

minimizes health status change, failure to take action, and evidence of
failure to improve.
Seizure disorder CH
deficient Knowledge [Learning Need] regarding condition and medication
control may be related to lack of information/misinterpretations,
scarce financial resources, possibly evidenced by questions,
statements of concern/misconceptions, incorrect use of anticonvulsant
medication, recurrent episodes/uncontrolled seizures.
chronic low Self-Esteem/disturbed personal Identity may be related to
perceived neurological functional change/weakness, perception of
being out of control, stigma associated with condition, possibly evidenced
by negative feelings about “brain”/self, change in social involvement,
feelings of helplessness, and preoccupation with perceived
change or loss.
impaired Social Interaction may be related to unpredictable nature of
condition and self-concept disturbance, possibly evidenced by
decreased self-assurance, verbalization of concern, discomfort in
social situations, inability to receive/communicate a satisfying sense
of belonging/caring, and withdrawal from social contacts/activities.
risk for Trauma/Suffocation: risk factors may include weakness, balancing
difficulties, cognitive limitations/altered consciousness, loss of
large or small-muscle coordination (during seizure).*
Sepsis, puerperal OB
(Also refer to Septicemia)
risk for Infection [spread/septic shock]: risk factors may include presence
of infection, broken skin, and/or traumatized tissues, rupture of
amniotic membranes, high vascularity of involved area, stasis of body
fluids, invasive procedures, and/or increased environmental exposure,
chronic disease (e.g., diabetes, anemia, malnutrition), altered
immune response, and untoward effect of medications (e.g., opportunistic/secondary
infection).*
Hyperthermia may be related to inflammatory process/hypermetabolic
state, possibly evidenced by increase in body temperature, warm/
flushed skin, and tachycardia.
risk for impaired parent/infant Attachment: risk factors may include
interruption in bonding process, physical illness, perceived threat to
own survival.*
risk for ineffective peripheral Tissue Perfusion: risk factors may include
interruption/reduction of blood flow (presence of infectious
thrombi).*
Septicemia MS
(Also refer to Sepsis, puerperal)
ineffective Tissue Perfusion (specify) may be related to changes in arterial/venous
blood flow (selective vasoconstriction, presence of
*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 891
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