CONCEPT MAP Nicole Reinke Reinke Week 4: 11/17-11/18 11/17-11/18 ▲ Weight pt daily and watch for sudden decreases, assess
▲ Assess pt’s level of anxiety before every procedure, use faces scale to help identify anxiety level, encourage pt to talk about things that cause anxiety, assess what could help the anxiety- distraction, etc, use therapeutic touch, and provide a protective and safe environment
trends in output for 3 days, observe for tachycardia, tachypnea, and decreased pulse pressure, provide oral hygiene to keep mucous membranes moist, provide lip moisturizer, moisturiz er, and place sign of day and location in area where pt can read to remember where she is.
● Client will maintain moist mucous membranes
● Client will verbalize and identify symptoms of anxiety.
and be orientated to person, place, and time as needed throughout the shift. Deficient fluid volume r/t inadequate
fluid volume intake aeb decreased urine output, dry mucous membranes, and decreased blood pressure.
bstruction of small bowel leads to proximal dilation of of testine due to accumulation accumulation of cell secretions. This timulates cell secretory activity resulting in more fluid ccumulation. It becomes strangulated when a loop loop of istended bowel twists.
Acute Pain r/t pressure from
distended abdomen aeb sharp pain in stomach area
History of malignancy (colon cancer)
Primary Dx: Small Bowel Obstruction
Pain, nausea, vomiting, diarrhea
Anxiety r/t change in health status
aeb agitation, scared, hand tremors, and fatigue.
R hip fracture, multiple mini CVAs, hypertension, hypertension, myocardial infarction, irritable bowel syndrome, syndrome, colon cancer, cancer, dementia, dementia, and depression
Imbalanced nutrition: less than body requirements requirements r/t inability inability to digest food aeb nausea and vomiting.
● Client will describe pain and point to the
● Client will consume adequate nourishment
face that describes pain every 2 hrs
during the day.
ssess pain using faces scale, ask pt if they want in management, reassess pain, provide comfort easures to distract from pain, orient patient
▲ Weight pt. daily and compare changes, continue IV fluids, monitor NG suction, monitor oral cavity and provide oral hygiene, work with care team to d determine when to allow feedings.
CONCEPT MAP Nicole Reinke Week 4: 11/17-11/18
Medical Diagnosis
Nursing Diagnosis
● Expected Outcome
Pathophysiology Signs and Symptoms
▲ Nursing Interventions
Etiology & Risk Factors
Secondary Diagnosis Patient Story: Female in her late 70s admitted for small bowel obstruction, recent fracture of right hip- with recent surgery, history of: multiple mini CVAs, hypertension, MI, irritable bowel syndrome, colon carcinoma, dementia, and depression. Married and lives with husband and two dogs. Has two kids. Was a housewife for 30+years.
Important Labs: WBC 15.45 H (3.8-12.0) Platelets 611 H (140-440) Neutrophils 93.2 H (93.5-79.5) Lymphocytes 4.1 L (13.0-43.0) CK-MB 4.1 (not significant) BUN/Creat 24.0 H (6.0-20.0)
Patient’s Medications: Nitroglycerin, ranitidine, hydromorphone, dextrose with potassium
References: Ackley, J. A.; Gail, B. L. (2006). Nursing Diagnosis Handbook: A guide to planning care. Missouri: Mosby, Inc. Huether, S. E.; McCance, K. L. (2004). Understanding Pathophysiology. Missouri: Mosby, Inc. Lewis (2007). Medical-Surgical Nursing: Assessment and management of clinical problems. Missouri: Mosby, Inc.
