Nurse's Pocket Guide

Sprain of ankle or foot CH
acute Pain may be related to trauma to/swelling in joint, possibly
evidenced by verbal reports, guarding/distraction behaviors, selffocusing,
and autonomic responses (changes in vital signs).
impaired Walking may be related to musculoskeletal injury, pain, and
therapeutic restrictions, possibly evidenced by reluctance to attempt
movement, inability to move about environment easily.
Stapedectomy MS
risk for Trauma: risk factors may include increased middle-ear pressure
with displacement of prosthesis and balancing difficulties/dizziness.*
risk for Infection: risk factors may include surgically traumatized tissue,
invasive procedures, and environmental exposure to upper respiratory
infections.*
acute Pain may be related to surgical trauma, edema formation, and
presence of packing, possibly evidenced by verbal reports, guarding/distraction
behaviors, and self-focus.
STD CH
(refer to Sexually transmitted disease)
Substance dependence/abuse PSY/CH
rehabilitation
(following acute detoxification)
ineffective Denial/Coping may be related to personal vulnerability, difficulty
handling new situations, learned response patterns, cultural
factors, personal/family value systems, possibly evidenced by lack of
acceptance that drug use is causing the present situation, use of
manipulation to avoid responsibility for self, altered social patterns/participation,
impaired adaptive behavior and problem-solving
skills, employment difficulties, financial affairs in disarray, and
decreased ability to handle stress of recent events.
Powerlessness may be related to substance addiction with/without periods
of abstinence, episodic compulsive indulgence, attempts at recovery,
and lifestyle of helplessness, possibly evidenced by ineffective
recovery attempts, statements of inability to stop behavior/requests
for help, continuous/constant thinking about drug and/or obtaining
drug, alteration in personal/occupational and social life.
imbalanced Nutrition: less than body requirements may be related to
insufficient dietary intake to meet metabolic needs for psychological/
physiological/economic reasons, possibly evidenced by weight less
than normal for height/body build, decreased subcutaneous fat/
muscle mass, reported altered taste sensation, lack of interest in food,
poor muscle tone, sore/inflamed buccal cavity, laboratory evidence of
protein/vitamin deficiencies.
Sexual Dysfunction may be related to altered body function (neurological
damage and debilitating effects of drug use), changes in appearance,
possibly evidenced by progressive interference with sexual functioning,
a significant degree of testicular atrophy, gynecomastia,
*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 895
S