Warning:
JavaScript is turned OFF. None of the links on this page will work until it is reactivated.
If you need help turning JavaScript On, click here.
This Concept Map, created with IHMC CmapTools, has information related to: 2-17-09, VS: temp 99.1, pulse 69, RR 20, BP 131/69, O2 94. Full code, NPO diet, IV Right thumb, D5 1/2NS w/20 KCL @ 150cc/hr, BN O2 @ 2L/min, NKA, GI consult, surgery consult, repeat chest X-ray, monitor liver function; BR w/ BNC, pupils 2- bilat, EOM +, Extremities 5 X4, calm, clear speech, alert, 15 coma scale; strong, regular heart sounds; warm, pink skin and nailbeds, cap. refill ɛ no edema; Pulses: rad R 4+, L UTA; Brach 2+ bilat, Fem 2+ bilat, Dor ped 2 + bilat, temp 2+ bilat; regular respirations, breath sounds clear X 5, mucus secreation +, soft abdomen, bowel sounds active X 4 quaduarants, voided 180 mls, IV site w/o edema or erythema, side rails up X2; cooperative, pain lever 1/10. Medications Levaquin, Pepcid, Flagyl, Dilaudid, Phenergan, Lovenox, 61 yr old, WF Assessed pt VS: temp 99.1, pulse 69, RR 20, BP 131/69, O2 94. Full code, NPO diet, IV Right thumb, D5 1/2NS w/20 KCL @ 150cc/hr, BN O2 @ 2L/min, NKA, GI consult, surgery consult, repeat chest X-ray, monitor liver function; BR w/ BNC, pupils 2- bilat, EOM +, Extremities 5 X4, calm, clear speech, alert, 15 coma scale; strong, regular heart sounds; warm, pink skin and nailbeds, cap. refill ɛ no edema; Pulses: rad R 4+, L UTA; Brach 2+ bilat, Fem 2+ bilat, Dor ped 2 + bilat, temp 2+ bilat; regular respirations, breath sounds clear X 5, mucus secreation +, soft abdomen, bowel sounds active X 4 quaduarants, voided 180 mls, IV site w/o edema or erythema, side rails up X2; cooperative, pain lever 1/10., 61 yr old, WF Assessed developmental stage Ego Integrity vs. Despair; Task met AEB happiness and missing her husband, her desire to get back to her life., No significant history to report. Anticipatory Guidance Encourage her to continue regular checkups with her doctor even though she has no history of significant illness and to continue to take her vitamins., Patient will display proper use of non- pharmacologic techniques of pain management to assist in reducing the restlessness that usually accompanies pain. To accomplish 1. Perform assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors to plan appropriate interventions. 2. Provide optimal pain relief as prescribed. 3. Evaluate the effectiveness of the pain - control used througth ongoing assessment of the pain. 4. Monitor VS including pain periodically. 5. Teach the use of nonpharmacolog techniques before, after, and during painful activities., 61 yr old, WF Nsg Dx #2 Impaired Urinary elimination frequency r/t UTI, NPO diet, and strict I's and O's., Patient will report 4/10 pain level by the end of my shift. Evaluation Goal met. Patient reported that pain was "much better" and reported pain scale 1/10., Acute pain r/t cholecystitis and pancreatitis AEB verbal reports, right upper quadrant pain, guarding, statsis of bile. Goal #2 Patient will display proper use of non- pharmacologic techniques of pain management to assist in reducing the restlessness that usually accompanies pain., Patient will report 4/10 pain level by the end of my shift. To accomplish 1. Perform assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors to plan appropriate interventions. 2. Provide optimal pain relief as prescribed. 3. Evaluate the effectiveness of the pain - control used througth ongoing assessment of the pain. 4. Monitor VS including pain periodically. 5. Teach the use of nonpharmacolog techniques before, after, and during painful activities., Patient will demonstrate diurnal frequency no more than every 2 hours during my shift. To accomplish 1. Assess bladder function including pain scale, duration, last time pt voided, and characteristics of her symptoms. 2. Encourage patient to use toilet as soon as she feels the need. 3. Help patient with her self-care and educate on the proper wiping techinque. 4. Assess pain level periodically. 5. Administer anti-infectives as prescribed. 6. Administer pain med. as prescibed., 1. Assess bladder function including pain scale, duration, last time pt voided, and characteristics of her symptoms. 2. Encourage patient to use toilet as soon as she feels the need. 3. Help patient with her self-care and educate on the proper wiping techinque. 4. Assess pain level periodically. 5. Administer anti-infectives as prescribed. 6. Administer pain med. as prescibed. After completion Goal met. Patient voids with ease periodically. Urine is dark orange, clear, and odorous., Patient will display proper use of non- pharmacologic techniques of pain management to assist in reducing the restlessness that usually accompanies pain. Evaluation Goal not met. It was not a needed therapy at this time. Do not continue., Impaired Urinary elimination frequency r/t UTI, NPO diet, and strict I's and O's. Goal #1 Patient will demonstrate diurnal frequency no more than every 2 hours during my shift., Patient wil state absense of pain or excessive urgency during bladder storage or during urination during my shift. Evaluate Goal met. Patient states that there is no more pain or burning with urination., 61 yr old, WF Diagnosed with Acute Biliary Pancreatitis, Acute cholecystitis w/cholelithiasis,evidence of cholestasis, right lower lobe pneumonia, UTI w/ hypokalemia, 1. Perform assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors to plan appropriate interventions. 2. Provide optimal pain relief as prescribed. 3. Evaluate the effectiveness of the pain - control used througth ongoing assessment of the pain. 4. Monitor VS including pain periodically. 5. Teach the use of nonpharmacolog techniques before, after, and during painful activities. After completion Goal not met. It was not a needed therapy at this time. Do not continue., 61 yr old, WF Nsg Dx #1 Acute pain r/t cholecystitis and pancreatitis AEB verbal reports, right upper quadrant pain, guarding, statsis of bile., 1. Assess bladder function including pain scale, duration, last time pt voided, and characteristics of her symptoms. 2. Encourage patient to use toilet as soon as she feels the need. 3. Help patient with her self-care and educate on the proper wiping techinque. 4. Assess pain level periodically. 5. Administer anti-infectives as prescribed. 6. Administer pain med. as prescibed. After completion Goal met. Patient states that there is no more pain or burning with urination., 1. Perform assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors to plan appropriate interventions. 2. Provide optimal pain relief as prescribed. 3. Evaluate the effectiveness of the pain - control used througth ongoing assessment of the pain. 4. Monitor VS including pain periodically. 5. Teach the use of nonpharmacolog techniques before, after, and during painful activities. After completion Goal met. Patient reported that pain was "much better" and reported pain scale 1/10., 61 yr old, WF Obtained History No significant history to report.