CONCEPT MAP

Nicole Reinke Week 4: 11/17-11/18 Weight pt daily and watch for sudden decreases, assess
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, and place sign of day and location in area where pt can read to remember where she is.

Assess pts 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

Client will maintain moist mucous membranes

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.
History of malignancy (colon cancer)

Client will verbalize and identify symptoms of

anxiety.

Anxiety r/t change in health status aeb agitation, scared, hand tremors, and fatigue.

Obstruction of small bowel leads to proximal dilation of ntestine due to accumulation of cell secretions. This timulates cell secretory activity resulting in more fluid accumulation. It becomes strangulated when a loop of distended bowel twists.

Primary Dx: Small

Bowel Obstruction

R hip fracture, multiple mini CVAs, hypertension, myocardial infarction, irritable bowel syndrome, colon cancer, dementia, and depression

Acute Pain r/t pressure from distended abdomen aeb sharp pain in stomach area

Pain, nausea, vomiting, diarrhea

Imbalanced nutrition: less than body requirements r/t inability to digest food aeb nausea and vomiting.

Client will describe pain and point to the

face that describes pain every 2 hrs

Client will consume adequate nourishment

during the day.

Assess pain using faces scale, ask pt if they want ain management, reassess pain, provide comfort measures 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 determine when to allow feedings. d

CONCEPT MAP
Nicole Reinke Week 4: 11/17-11/18

Medical Diagnosis
Pathophysiology Signs and Symptoms

Nursing Diagnosis

Expected Outcome

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)

Patients 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.