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This Concept Map, created with IHMC CmapTools, has information related to: 2-12-09, VS: 118/70, P 70, RR 18, Temp. 98.2; O2 sat 98 @RA; NPO;voids every hour;PERRLA; A&O X 3; moist, pink skin; cap. refillɛpulses- rad 4+bilat, Fem 2+ bilat, Dor. Ped. 3+ bilat, Tem 3+ bilat; reg RR, breathe sounds clear in all fields;distended abdomen;refused bath, changed linens, bowel sounds active X4 quad; old Emsam patch on left abdomen, hospital does not carry this med, has been without her bipolar and BP med. for 24 hours; Bed rest w/bath room privileges; Full code; Allergies to Haldol, PCN, Sulfa drugs, Lithium. Medications Morphine sulfate, bystolic, Emsam patch, Klonopin, Lamictal, Prevaid, Levaquin, Tramadol, 59yr old, WF Assessed developmental stage Ego Integrity vs despair AEB pt pride involving her work as a CNA home health nurse. She was telling me stories about some of her experiences in the past and about her pt that she visits now., 59yr old, WF Assessed pt VS: 118/70, P 70, RR 18, Temp. 98.2; O2 sat 98 @RA; NPO;voids every hour;PERRLA; A&O X 3; moist, pink skin; cap. refillɛpulses- rad 4+bilat, Fem 2+ bilat, Dor. Ped. 3+ bilat, Tem 3+ bilat; reg RR, breathe sounds clear in all fields;distended abdomen;refused bath, changed linens, bowel sounds active X4 quad; old Emsam patch on left abdomen, hospital does not carry this med, has been without her bipolar and BP med. for 24 hours; Bed rest w/bath room privileges; Full code; Allergies to Haldol, PCN, Sulfa drugs, Lithium., Bipolar, HTN, surgery to fix abdominal aortic aneurysm Anticipatory Guidance Tell her that if she needs to come to the hospital again to go ahead and bring her meds in cause the hospital does not have them., Patient will state understanding of the importance of getting rest and sufficient sleep before check out of hospital. To accomplish 1. Assess pt for pain at beginning of shift 2. Administer pain med. as prescribed. 3. Re-access pain level periodically throughout shift. 4. Make pt as comfortable as possible. 5. Educate pt on the important of rest and sleep to the body during times of stress., 59yr old, WF Nsg Dx #2 Risk for Falls r/t side effects of pain medication., Acute Pain r/t abdominal distention AEB facial expressions and pain 7/10. Goal #2 Patient will state understanding of the importance of getting rest and sufficient sleep before check out of hospital., Patient will report pain 4/10 before the end of my shift. Evaluation Goal not met. After administering morphine, pt stated pain 8/10 with headache. Re-access med management for pt., Patient will report pain 4/10 before the end of my shift. To accomplish 1. Assess pt for pain at beginning of shift 2. Administer pain med. as prescribed. 3. Re-access pain level periodically throughout shift. 4. Make pt as comfortable as possible. 5. Educate pt on the important of rest and sleep to the body during times of stress., 1. Ensure that bed is in low locked position and that side rails are up X 4. 2. Assist pt to restroom and help get her to the tests. 3. Stress to her the importance of using the call button when she needs to get out of bed so that I can help her. 4.Make sure that call light is in reach. 5. Ensure that there is nothing cluttering up the floor. After completion Goal met. Pt did not have any falls during my shift., Patient will not fall during shift. To accomplish 1. Ensure that bed is in low locked position and that side rails are up X 4. 2. Assist pt to restroom and help get her to the tests. 3. Stress to her the importance of using the call button when she needs to get out of bed so that I can help her. 4.Make sure that call light is in reach. 5. Ensure that there is nothing cluttering up the floor., Risk for Falls r/t side effects of pain medication. Goal #1 Patient will not fall during shift., Patient will state understanding of the importance of getting rest and sufficient sleep before check out of hospital. Evaluation Goal met. After speaking with pt, she verbalized an understanding that she needs to get more rest and sleep as she has not been sleeping well., 1. Assess pt for pain at beginning of shift 2. Administer pain med. as prescribed. 3. Re-access pain level periodically throughout shift. 4. Make pt as comfortable as possible. 5. Educate pt on the important of rest and sleep to the body during times of stress. After completion Goal met. After speaking with pt, she verbalized an understanding that she needs to get more rest and sleep as she has not been sleeping well., 59yr old, WF Diagnosed with Nausea, Vomiting & abdominal pain with bloating, 1. Assess pt for pain at beginning of shift 2. Administer pain med. as prescribed. 3. Re-access pain level periodically throughout shift. 4. Make pt as comfortable as possible. 5. Educate pt on the important of rest and sleep to the body during times of stress. After completion Goal not met. After administering morphine, pt stated pain 8/10 with headache. Re-access med management for pt., 1. Ensure that bed is in low locked position and that side rails are up X 4. 2. Assist pt to restroom and help get her to the tests. 3. Stress to her the importance of using the call button when she needs to get out of bed so that I can help her. 4.Make sure that call light is in reach. 5. Ensure that there is nothing cluttering up the floor. After completion Goal met. Pt always asked for either my assistance or her friend's when she needed to go to the bathroom., 59yr old, WF Nsg Dx #1 Acute Pain r/t abdominal distention AEB facial expressions and pain 7/10., 59yr old, WF Obtained History Bipolar, HTN, surgery to fix abdominal aortic aneurysm, Acute Pain r/t abdominal distention AEB facial expressions and pain 7/10. Goal #1 Patient will report pain 4/10 before the end of my shift.