Nurse's Pocket Guide

Anxiety [specify level] may be related to threat of death of self/fetus,
interpersonal contagion, physiological response (release of catecholamines),
possibly evidenced by fearful/scared affect, sympathetic
stimulation, stated fear of unspecified consequences, and expressed
concerns.
Vaginismus GYN/CH
acute Pain may be related to muscle spasm and hyperesthesia of the
nerve supply to vaginal mucous membrane, possibly evidenced by
verbal reports, distraction behaviors, and self-focus.
Sexual Dysfunction may be related to physical and/or psychological
alteration in function (severe spasms of vaginal muscles), possibly
evidenced by verbalization of problem, inability to achieve desired
satisfaction, and alteration in relationship with SO.
Vaginitis GYN/CH
impaired Tissue Integrity may be related to irritation/inflammation and
mechanical trauma (scratching) of sensitive tissues, possibly evidenced
by damaged/destroyed tissue, presence of lesions.
acute Pain may be related to localized inflammation and tissue trauma,
possibly evidenced by verbal reports, distraction behaviors, and selffocus.
deficient Knowledge [Learning Need] regarding hygienic/therapy needs
and sexual behaviors/transmission of organisms may be related to
lack of information/misinterpretation, possibly evidenced by statements
of concern, questions, and misconceptions.
Varices, esophageal MS
(Also refer to Ulcer, peptic [acute])
deficient Fluid Volume [isotonic] may be related to excessive vascular
loss, reduced intake, and gastric losses (vomiting), possibly evidenced
by hypotension, tachycardia, decreased venous filling, and
decreased/concentrated urine.
Anxiety [specify level]/Fear may be related to change in health status
and threat of death, possibly evidenced by increased tension/
apprehension, sympathetic stimulation, restlessness, focus on self,
and expressed concerns.
Varicose veins CH
chronic Pain may be related to venous insufficiency and stasis, possibly
evidenced by verbal reports.
disturbed Body Image may be related to change in structure (presence
of enlarged, discolored tortuous superficial leg veins), possibly
evidenced by hiding affected parts and negative feelings about
body.
risk for impaired Skin/Tissue Integrity: risk factors may include altered
circulation/venous stasis and edema formation.*
Venereal disease CH
(Refer to Sexually transmitted disease—STD)
*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 905
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