AW's Concept Map by Sarah Nickel

Gastric Perforation

sarah7nickel — 2022-02-16 22:56:11 UTC

Perforated viscous/stomach

Impaired Skin Integrity r/t immobility and frequently loose stools aeb discomfort and redness in perineal area

sarah7nickel — 2022-02-16 23:02:37 UTC

Risk for Imbalanced Nutrition: Less than Body Requirements

sarah7nickel — 2022-02-16 23:21:24 UTC

Acute Pain r/t Bowel Perforation aeb 5/10 generalized pain throughout the abdomen

sarah7nickel — 2022-02-16 23:51:01 UTC

Risk for Electrolyte Imbalance r/t partial gastrectomy aeb excess bowel incontinence

sarah7nickel — 2022-02-16 23:58:09 UTC

PRIORITY 1

sarah7nickel — 2022-02-17 00:46:23 UTC

PRIORITY 2

sarah7nickel — 2022-02-17 00:47:34 UTC

PRIORITY 3

sarah7nickel — 2022-02-17 00:48:26 UTC

PRIORITY 4

sarah7nickel — 2022-02-17 00:49:15 UTC

Intervention 4

sarah7nickel — 2022-02-17 00:53:19 UTC

Note location and quality (REEDA) of surgical incision (Rationale: shape of incision can influence degree of postoperative pain experienced.)

Intervention 1

sarah7nickel — 2022-02-17 04:14:08 UTC

Evaluate pain characteristics and intensity (1-10, PQRST) (Rationale: creates baseline to evaluate whether pain is becoming worse, staying the same, or getting better) (Unbound Medicine, 2022a)

References

sarah7nickel — 2022-02-17 04:15:17 UTC

https://nursing.unboundmedicine.com/nursingcentral/view/nurses-pocket-guide/2819083/all/acute_Pain?q=acute+pain

https://nursing.unboundmedicine.com/nursingcentral/view/nurses-pocket-guide/2819185/all/impaired_Skin_Integrity_and_risk_for_impaired_Skin_Integrity#4.0

https://nursing.unboundmedicine.com/nursingcentral/view/nurses-pocket-guide/2819200/all/imbalanced_Nutrition:_less_than_body_requirements#4.0

https://nursing.unboundmedicine.com/nursingcentral/view/nurses-pocket-guide/2819242/all/situational_low_Self_Esteem_and_risk_for_situational_low_Self_Esteem#3.0

Intervention 2

sarah7nickel — 2022-02-17 04:18:28 UTC

Ascertain pt's goal for pain (e.g., would they be satisfied with 1 pain) (Rationale: 0 pain might not be achievable for the pt but sufficient discomfort could be alleviated by bringing the pain down) (Unbound Medicine, 2022a)

Intervention 3

sarah7nickel — 2022-02-17 04:21:47 UTC

Convey empathy by acknowledge and validate pain (Rationale: reduces defensiveness, promotes trust, and enhances cooperation with regimen) (Unbound Medicine, 2022a)

Intervention 1

sarah7nickel — 2022-02-17 04:24:17 UTC

Thorough skin assessment (type of skin distribution and general skin health) (Rationale: creates baseline to ascertain whether breakdown is getting better or worse) (Unbound Medicine, 2022b)

Intervention 2

sarah7nickel — 2022-02-17 04:28:19 UTC

Determine pt's discomfort level (e.g., mild or deep pain and severe itching) (Rationale: clarifies interventions and priorities needed) (Unbound Medicine, 2022b)

Intervention 3

sarah7nickel — 2022-02-17 04:31:26 UTC

Maintain and encourage good skin hygiene (shower, thorough washing, apply lotion/skin protectant) (Rationale: reduces risk of dermal trauma and promotes pt comfort) (Unbound Medicine, 2022b)

Intervention 1

sarah7nickel — 2022-02-17 04:35:13 UTC

Assess mental status, note client/caregiver report of change or altered LOC (rationale: most common sign of sodium imbalance and can be associated with additional electrolyte imbalances) (Unbound Medicine, 2022c)

Intervention 2

sarah7nickel — 2022-02-17 04:38:10 UTC

Monitor heart rate and rhythm by palpitation and auscultation (Rationale: bradycardia, tachycardia, and other dysrhythmias are associated with potassium, calcium, and magnesium imbalances) (Unbound Medicine, 2022c)

Intervention 3

sarah7nickel — 2022-02-17 04:42:01 UTC

Monitor and assess inputs and outputs (Rationale: many factors related to this, such as diuresis, can alter electrolytes) (Unbound Medicine, 2022c)

sarah7nickel — 2022-02-17 10:25:05 UTC

Swallow assessment completed. Candidate for TPN. Might receive PICC on Feb. 17th

Intervention 2

sarah7nickel — 2022-02-17 10:29:42 UTC

Thorough GI assessment, which includes bowel sounds (rationale: determines ability of digestive tract to handle the digestive process) (Unbound Medicine, 2022d)

sarah7nickel — 2022-02-17 10:31:15 UTC

Anemia

Intervention 1

sarah7nickel — 2022-02-17 10:33:14 UTC

Take weights at regular intervals (rationale: monitors effectiveness of dietary plan) (Unbound Medicine, 2022d)

sarah7nickel — 2022-02-22 02:03:21 UTC

PRN Dilaudid

Situational Low Self-Esteem r/t deteriorating physiological condition, social isolation, and decreased environmental control aeb pt's loss of independence

sarah7nickel — 2022-02-22 02:14:20 UTC

Intervention 1

sarah7nickel — 2022-02-22 02:18:13 UTC

Assess negative moods or self-talk (feelings of unimportance and/or saying negative things about one's self can contribute to low self-esteem) (Unbound Medicine, 2022e)

Intervention 2

sarah7nickel — 2022-02-22 02:20:39 UTC

Help pt identify strengths and aspects of self that can be valued. (Unbound Medicine, 2022e)

Intervention 3

sarah7nickel — 2022-02-22 02:24:53 UTC

Support independance in activities as much as possible (Rationale: empowers pt) (Unbound Medicinc, 2022e)

GOAL

sarah7nickel — 2022-02-22 02:27:25 UTC

Pt will complete 2 tasks independently on Feb. 17th and 18th
Evaluation
GOAL PARTIALLY MET - pt ate independently (fluid diet) as well as independently completed oral care on Feb. 18th

GOAL

sarah7nickel — 2022-02-22 02:29:29 UTC

Pt will display laboratory results within normal range for individual by February 18th, 2022

Evaluation
Goal partially met - Na+ was low on Feb. 18th, but chloride was WNL when it was low on Feb. 16th

GOAL

sarah7nickel — 2022-02-22 02:31:16 UTC

Pt will rate pain <5 by noon on Feb. 18th and 18th. This will be measured using the pain scale.

Evaluation
GOAL MET - pain medication was given in a timely manner each day and pt rated pain <5 by noon each day

GOAL

sarah7nickel — 2022-02-22 02:33:04 UTC

Pt will display timely healing of incisions and remain free from pressure sores until Feb. 19th

Evaluation
GOAL MET!
Pt remained free from skin breakdown in the perineal area, remained free from pressure sores, and pt's incision site demonstrated healthy healing according to REEDA evaluations

Intervention 3

sarah7nickel — 2022-02-22 02:36:30 UTC

Assist with or encourage pt to complete oral care after meals and at bedtime (rationale: empowers pt and also prevents the overgrowth of bacteria in oral cavity)

GOAL

sarah7nickel — 2022-02-22 02:39:08 UTC

Pt will display normalization of laboratory values and be free of signs of malnutrition until Feb. 18th.

Evaluation
GOAL PARTIALLY MET
On January 18th: Albumin WNL, low sodium, low Hgb suggesting iron deficiency