Nurse's Pocket Guide

eadings, jugular vein distention, cold/clammy skin, diminished
peripheral pulses, and decreased urinary output.
risk for impaired Gas Exchange: risk factors may include ventilation
perfusion imbalance, alveolar-capillary membrane changes.*
Shock, hypovolemic/hemorrhagic MS
(Also refer to Shock)
deficient Fluid Volume [isotonic] may be related to excessive vascular
loss, inadequate intake/replacement, possibly evidenced by hypotension,
tachycardia, decreased pulse volume and pressure, change in
mentation, and decreased/concentrated urine.
Shock, septic MS
(Refer to Septicemia)
Sick sinus syndrome MS
(Also refer to Dysrhythmia, cardiac)
decreased Cardiac Output may be related to alterations in rate, rhythm,
and electrical conduction, possibly evidenced by ECG evidence of
dysrhythmias, reports of palpitations/weakness, changes in mentation/consciousness,
and syncope.
risk for Trauma: risk factors may include changes in cerebral perfusion
with altered consciousness/loss of balance.*
SLE CH
(Refer to Lupus erythematosus, systemic)
Smallpox MS
risk of Infection [spread]: risk factors may include contagious nature of
organism, inadequate acquired immunity, presence of chronic disease,
immunosuppression.*
deficient Fluid Volume may be related to hypermetabolic state,
decreased intake (pharyngeal lesions, nausea), increased losses (vomiting),
fluid shifts from vascular bed, possibly evidenced by reports of
thirst, decreased BP, venous filling and urinary output; dry mucous
membranes, decreased skin turgor, change in mental state, elevated
Hct.
impaired Tissue Integrity may be related to immunological deficit, possibly
evidenced by disruption of skin surface, cornea, mucous membranes.
Anxiety [specify level]/Fear may be related to threat of death, interpersonal
transmission/contagion, separation from support system, possibly
evidenced by expressed concerns, apprehension, restlessness,
focus on self.
CH
interrupted Family Processes may be related to temporary family disorganization,
situational crisis, change in health status of family member,
possibly evidenced by changes in satisfaction with family, stressreduction
behaviors, mutual support; expression of isolation from
community resources.
*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 893
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