Alyssa Grimm Concept Map Information Page 1

Alyssa Grimm
Spring 2016

Reason for Needing Health Care: Acute cholecystitis

o Target assessment:
Objective assessment
Current medications
Nutritional status
Nausea
Pain
Subjective assessment
Abdomen
o Observation
o Auscultation
o Palpation
Nutritional status
Fluid & electrolyte balances

#1 Key Problem: Risk for electrolyte imbalance

o As evidenced by:
Vomiting/nausea
Electrolyte lab values on 3/19 @ 1200:
Na = 133 (currently normal)
K = 4.1 (currently normal)
Cl = 96 (currently normal)
Order for Zofran to prevent vomiting and loss of electrolytes

#2 Key Problem: Risk for deficient fluid volume

o As evidenced by:
Vomiting/nausea
Constipation
Order for IV fluids
Order for Zofran to prevent vomiting and loss of fluid
Lips are dried and cracked
Capillary refill is currently less than 3 seconds

#3 Key Problem: Constipation

o As evidence by:
Patient and family reported constipation.
3/16: Patient given prescription for Miralax and Culterelle.
X-ray performed on 3/17 showed bowel filled with stool.
3/17: patient received enema.
History of constipation and large bowel movements for at least 3 years
4/10: abdominal pain began
Baseline is one bowel movement per week.
Bowel sounds present during auscultation
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Environmental change caused by hospital stay

Emotional stress related to hospital stay and medical diagnosis
Patient reports a decrease in appetite.
Patient reports that she has not been eating as much and has only been
eating soft foods for the past 3 months due to the pain from getting braces.

#4 Key Problem: Risk for infection

o As evidenced by:
Medical diagnosis of acute cholecystitis
CRP (c-reactive protein) lab values:
3/19 @1200: CRP = 10.2 (elevated)
3/22 @ 1400: CRP = 4.4 (elevated)
Order for antibiotic, ampicillin-sulbactam
WBC lab value on 3/19 @ 1200 = 14.7

#5 Key Problem: Risk for situational low self-esteem

o As evidence by:
Patient reports that she is missing her friends
Patient is admitted to hospital during her Spring Break from school.
Patient looks upset.

#6 Key Problem: Nausea

o As evidence by:
Patient and family reports nausea.
Patient has been vomiting.
Order for Zofran to prevent nausea
On the night of 3/17, patient vomited nine times.
Pure green bile emesis

#7 Key Problem: Acute pain

o As evidenced by:
Related to medical diagnosis of acute cholecystitis
Tenderness upon palpation at McBurneys point
Order for morphine IV PRN for pain
3/20 @ 1300: Patient reported a pain rating of 4 (on 0-10 scale) in RLQ of
abdomen, unable to describe quality, duration since 3/16 (1 week so far)
Respirations are elevated @ 20 bpm
3/22 @ 1600: Patient reports pain is dull, aching, and cramping
3/18 during admission: Father reported patient was doubling over and
crying because of her pain.

#8 Key Problem: Nutrition imbalance: lower than requirements

o As evidenced by:
BMI = 16.00 kg/m3
Patient and family reports no weight gain since August 2015.
Patient has been on an NPO or clear liquid diet during 3/19 & 3/20.
Alyssa Grimm Concept Map Information Page 3

Patient reports a decrease in appetite.

Patient reports that she has not been eating as much and has only been
eating soft foods for the past 3 months due to the pain from getting braces.
Mother requested a consult with a dietitian.
Hematocrit lab values:
3/19: 4.70 (normal)
3/22: 3.74 (low)
Growth percentiles:
Height = 157.5 cm = 50-75% percentile
Weight = 39.7 kg = 25% percentile

#1 Key Problem: Risk for electrolyte imbalance

o General goal: Patient will maintain electrolyte lab values within the normal range.
o Predicted behavioral outcome objective: The patient will be willing to participate
in all of the following nursing interventions on the day of care.
o Evaluation of outcomes objective: Patient responses are as expected. Patient
participated in all nursing interventions performed that involved her directly. No
signs of electrolyte imbalance were present during day of care.

Nursing Interventions Rationals

Monitor vital signs at least three times a
day, or more frequently as needed. Notify
provider of significant deviation from
baseline.
Review laboratory data as ordered and
report deviations to provider.
Complete pain assessment. Assess and
document the onset, intensity, character,
location, duration, aggravating factors,
and relieving factors. Notify the provider
for an increase in pain or discomfort or if
comfort measures are not effective.
Monitor the patients respiratory status
and muscle strength.
Monitor cardiac rate and rhythm. Report
changes to provider.
Administer IV fluids as ordered.
Electrolyte imbalance can lead to clinical
manifestations such as respiratory failure,
arrhythmias, edema, muscle weakness,
and altered mental status.
Laboratory studies may include serum
electrolytes: potassium, chloride, sodium,
bicarbonate, magnesium, phosphate,
calcium; serum pH; comprehensive
metabolic panel; and blood gases.
Symptoms of electrolyte imbalance and
dehydration can include muscle cramps,
paresthesias, abdominal cramps, skin
manifestations, cardiac arrhythmias, and
tetany.
Phosphorus is an essential element in cell
structure, metabolism, and maintenance of
acid-base processes. Consequences of
hypophosphatemia include cardiac and
respiratory failure.
Magnesium imbalances can cause cardiac
arrhythmias. Low serum magnesium is
associated with hypokalemia and ECG
changes.
Administration of fluids should be done in
order to impact the plasma electrolytes and
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pH in a predictable fashion to prevent

adverse consequences.
Administer additional electrolyte A deficiency in an electrolyte requires it to
replacement as ordered. be replaced. This can be done through
food (if that would be sufficient enough)
or replacement therapy.
Teach the patient and family the signs and Focusing on the signs and symptoms of
symptoms of an electrolyte imbalance. electrolyte imbalances can result in the
patient receiving care at earliest signs of
imbalance. This can prevent further
complications.
#2 Key Problem: Risk for deficient fluid volume
o General goal: Patient will not present any signs or symptoms of dehydration.
o Predicted behavioral outcome objective: The patient will not present with any
additional signs or symptoms of dehydration during the day of care.
o Evaluation of outcomes objective: Patient responses are as expected. Patient
participated in all nursing interventions performed that involved her directly. No
additional signs of dehydration were present during day of care.

Nursing Interventions Rationals

Watch for early signs of hypovolemia,
including thirst, restlessness, headaches, and
inability to concentrate. Thirst is often the
first sign of dehydration.
Monitor pulse, respiration, and blood pressure
of stable client every 4 hours.
Assess: skin turgor, mucous membranes,
capillary refill.
Weight client daily and watch for sudden
decreases, especially in the presence of
decreasing urine output or active fluid loss.
Monitor total fluid intake and output.
Note the color of urine and specific gravity.
Administer antiemetics as ordered and
appropriate.
A study of healthy volunteers who
experienced a fluid restriction of up to 37
hours reported symptoms of headache,
decreased alertness, and inability to
concentrate.
Vital sign changes seen with fluid volume
deficit include tachycardia, tachypnea,
decreased pulse pressure first, then
hypotension, decreased pulse volume, and
increased or decreased body temperature.
Recognize signs and symptoms of fluid
imbalance.
Body weight change of 3% of body weight is
defined as dehydration.
A urine output of less than 0.5mL/kg/hour is
insufficient for normal renal function and
indicates hypovolemia.
Normal urine is straw-colored or amber.
Dark-colored urine with increasing specific
gravity reflects increased urine concentration
and fluid deficit. Increasing specific gravity of
urine also reflects fluid deficit.
The goal is to stop the loss that results from
vomiting.
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Hydrate the patient with ordered IV fluids if Isotonic IV fluids such as 0.9% normal saline
prescribed. or lactated Ringers allow replacement of
intravascular volume.

#3 Key Problem: Constipation

o General Goal: Patient will report a decrease in constipation and will be able to
have a bowel movement.
o Predicted behavioral outcome objective: The patient will report a decrease in
constipation and have at least one bowel movement during the day of care.
o Evaluation of outcomes objective: Patient participated in all nursing interventions
performed that involved her directly. Patient did not report an increase or decrease
in constipation or have bowel movement during day of care.

Nursing Interventions Rationals

Have the patient or family keep a 7-day diary
of bowel habits, including information such
as time of day; usual stimulus; consistency,
amount, and frequency of stool; difficulty
defecating; fluid consumption; and use of any
aids to defecation.
Palpate for abdominal distention, percuss for
dullness, and auscultate bowel sounds.
Encourage a fluid intake of 1.5 to 2 L/day,
unless contraindicated because of other health
concerns.
Teach client to respond promptly to the
defecation urge.
Provide privacy for defecation. If not
contraindicated, help the patient to the
bathroom and close the door.
Health care providers define constipation
mainly in terms of frequency, but those
affected are more concerned about hard stool
and discomfort and straining when attempting
to defecate. A diary of bowel habits is
valuable in treatment of constipation; the use
of a diary has proven to be more accurate than
client recall in determining the presence of
constipation.
In patients with constipation, the abdomen is
often distended and tender, and stool in the
colon produces a dull percussion sound.
Bowel sounds will be present.
When dehydrated, the body absorbs
additional water from stools, resulting in dry,
hard stools that are difficult to pass.
A study determined that the defecation urge
can be delayed and that delaying defecation
decreased bowel movement frequency, stool
weight, and transit time.
Bowel elimination is a private act in Western
cultures, and a lack of privacy can hinder the
Alyssa Grimm Concept Map Information Page 6

defecation urge, thus contributing to

Encourage the patient to resume walking and
activities of daily living as much as possible.
Encourage fiber intake ensuring that the fiber
is palatable to the individual and that fluid
intake is adequate. Add fiber gradually to
decrease bloating and flatus.
constipation.
Decreased mobility leads to constipation.
Even minimal activity increases peristalsis,
which is necessary to prevent constipation.
Larger stools move through the colon faster
than smaller stools, and dietary fiber make
stools bigger because it is undigested in the
upper intestinal tract.

#4 Key Problem: Risk for infection

o General goal: Patient will not present with any signs or symptoms of an infection.
o Predicted behavioral outcome objective: The patient will not present with any
additional signs or symptoms of infection during the day of care.
o Evaluation of outcomes objective: Patient participated in all nursing interventions
performed that involved her directly. Patient did not experience any changes
related to infection.

Nursing Interventions Rationals

Teach patient to observe and report signs of
infection such as redness, warmth, discharge,
increased body temperature, change in mental
status, shaking, chills, and hypotension.
Note and report laboratory values (ex: WBC
count and differential, serum protein, serum
albumin, and cultures).
Use appropriate hand hygiene (ex:
handwashing or use of alcohol-based hand
rubs).
Recommend responsible use of antibiotics;
use antibiotics sparingly.
Monitor patients vitamin D levels.
These are signs and symptoms of an
infection/sepsis. Early reporting can help
decrease further complications by treating the
infection.
While WBC count may be in the normal
range, an increased number of immature
bands may be present. An increased level of
WBCs is an indicator of infection.
Meticulous infection prevention precautions
are required to prevent health care-associated
infection, with particular attention to hand
hygiene and standard precautions.
Antibiotics are used to treat an infection. Use
and misuse of antibiotics results in several
problems, the most significant of which are
increases in resistance.
Vitamin D deficiency has been correlated
with increased rates of infection. The recent
discovery that vitamin D induces
antimicrobial peptide gene expression
explains, in part, the antibiotic effect of
vitamin D and has greatly renewed interest in
Alyssa Grimm Concept Map Information Page 7

the ability of vitamin D to improve immune

Encourage fluid intake.
Follow standard precautions and wear gloves
during any contact with blood, mucous
membranes, nonintact skin, or any body
substance except sweat. Standard precautions
apply to all patients.
function.
Fluid intake helps thin secretions and replace
fluid lost during fever, if present.
Hands of health care workers are the most
common cause of health care-associated
infections.

#5 Key Problem: Risk for situational low self-esteem

o General goal: Patient will seek help when necessary and acknowledge personal
strengths.
o Predicted behavioral outcome objective: The patient will state at least one
personal strength during the day of care.
o Evaluation of outcomes objective: Patient stated that she does well in school,
outcome objective fulfilled.

Nursing Interventions Rationals

Assess the patient for signs and symptoms of
depression and potential for suicide and/or
violence. If present, immediately notify the
appropriate personnel of symptoms.
Assess for unhealthy coping mechanisms and
make appropriate referrals.
Assist in the identification of problems and
situational factors that contribute to problems, resources strengthen the patients self-
offering options for resolution.
Have client list strengths.
Accept patients own pace in working through Recommended therapeutic communication
grief or crisis situations.
Teach the patient mindfulness techniques to
cope more effectively with strong emotional
responses.
Well-documented suicide risk assessments are
a core measure of quality of care.
A health risk assessment that helps to refer
patients to medical management programs
helped to increase overall wellness.
Recognize that the patients own personal
determination.
It has been identified that helping the patient
identify strengths empowers her in the
recovery process.
skills such as eye contact, use of therapeutic
touch, and active listening can be enhance by
an understanding of the grief process.
Mindfulness therapy may be helpful in
dealing with stress.
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Assess the patients support system (family, Family strength assessments help the nurse to
friends, and community) and involve them if incorporate family strengths into nursing care,
desired. especially in times of crisis.

#6 Key Problem: Nausea

o General goal: Patient will experience no nausea or vomiting.
o Predicted behavioral outcome objective: The patient will experience a decreased
level of nausea and no vomiting during the day of care.
o Evaluation of outcomes objective: Patient reported a decrease in nausea after
receiving ordered Zofran and did not experience any vomiting during the day of
care.

Nursing Interventions Rationals

Implement appropriate dietary measures such
as NPO status as appropriate; small, frequent
meals; and low-fat meals. It may be helpful to
avoid foods that are spicy, fatty, or highly
salty. Reverting to previous practices when ill
in the past and consuming comfort foods
may also be helpful at this time.
Recognize and implement interventions and
monitor complications associated with N&V.
This may include administration of IV fluids
and electrolytes.
Consider nonpharmacological interventions
such as acupressure, acupuncture, music
therapy, distraction, and slow, deliberate
movements.
Administer appropriate antiemetics, according
to emetic cause, by most effective route,
considering the side effects of the medication,
Expert opinion consensus recommends these
interventions, with no research data available.
Recognition of complications of N&V is
critical to prevent and manage complications
of dehydration and electrolyte imbalance.
Nonpharmacological interventions can
augment pharmacological interventions
because they predominantly affect the higher
cortical centers that trigger N&V.
Antiemetic medications are effective at
different receptor sites and treat different
causes of N&V. A combination of agents may
be more effective than single agents.
Alyssa Grimm Concept Map Information Page 9

with attention to and coverage for the

timeframes that the nausea is anticipated.
Assist the client and family with identifying
and avoiding irritants that exacerbate nausea
(ex: strong odors from food, plants, perfume,
and room deodorizers).
All medications except antiemetics should be
given after meals to minimize the risk of
nausea.
Document each episode of nausea and/or
vomiting separately, as well as effectiveness
of interventions. Consider an assessment tool
for consistency of evaluation.
Avoiding irritants that exacerbate nausea can
decrease the chances of the nausea occurring
or worsening.
Some medications cause pain or nausea if
given on an empty stomach.
A systematic approach can provide
consistency, accuracy, and measurement
needed to direct care. It is important to
recognize that nausea is a subjective
experience.

#7 Key Problem: Acute pain

o General goal: Patient will experience no pain.
o Predicted behavioral outcomes objective: The patient will rate pain no higher than
a 4 (0-10 scale) during the day of care.
o Evaluation of outcomes objective: Patient consistently rated pain a 4 or below
during the day of care with the help of interventions.

Nursing Interventions Rationals

Determine if the patient is experiencing
pain at the time. If pain is present, conduct
and document a comprehensive pain
assessment and implement or request
orders to implement pain management
interventions to achieve a satisfactory
level of comfort. Components of this
initial assessment include location,
quality, onset/duration, temporal profile,
intensity, aggravating and alleviating
factors, and effects of pain on function and
quality of life.
Assess pain intensity level in a client
routinely using a valid and reliable self-
report pain tool, such as the 0-10 numeric
pain rating scale. Ask the patient to
identify a comfort-function goal, a pain
level, on a self-report pain tool, that will
Determining location, temporal aspects,
pain intensity, characteristics, and the
impact of pain on function and quality of
life are critical to determine the
underlying cause of pain and
effectiveness of treatment. Self-report is
considered the single most reliable
indicator of pain presence and intensity.
The first step in pain assessment is to
determine if the client can provide a self-
report. Ask the client to rate pain intensity
or select descriptors of pain intensity
using a valid and reliable self-report pain
tool. The relationship between pain level
and functional goals should be a major
Alyssa Grimm Concept Map Information
allow the client to perform necessary or
desired activities easily.
Explain to the patient the pain
management approach, including
pharmacological and nonpharmacological
interventions, the assessment and
reassessment process, potential side
effects, and the importance of prompt
reporting of unrelieved pain.
Prevent pain by administering analgesia
before painful procedures whenever
possible.
Administer supplemental analgesic doses
as ordered to keep the patients pain level
at or below the comfort-function goal, or
desired outcome.
When the client is able to tolerate oral
intake, obtain a prescription to change
analgesics to the oral route of
administration.
In addition to administering analgesics,
support the patients use of
nonpharmacological methods to help
control pain, such as distraction, imagery,
relaxation, and application of heat and
cold.
Reinforce the importance of taking pain
medications to maintain the comfort-
function goal.
Perform all teaching when pain is
relatively well controlled.
Page 10
focus of the development of
individualized pain management plans.
One of the most important steps toward
improved control of pain is a better
patient understanding of the nature of
pain, its treatment, and the role the patient
needs to play in pain control.
IV opioids can effectively decrease the
severe pain associated with many
common procedures.
An order for PRN supplemental analgesic
doses between regular doses is essential
in providing comprehensive pain
management.
The oral route is preferred because it is
the most convenient and cost effective.
Cognitive-behavioral (mind-body)
strategies can restore the patients sense
of self-control, personal efficacy, and
active participation in his or her own care.
Teaching patients to stay on top of their
pain and prevent it from getting out of
control will improve the ability to
accomplish the goals of recovery.
Pain interferes with cognition.
Alyssa Grimm Concept Map Information Page 11

#8 Key Problem: Nutritional imbalance: lower than requirements

o General goal: Patient will describe appetite as good, eat balanced and
proportional meals, and experience no unintended weight loss.
o Predicted behavioral outcomes objective: The patient will order and eat at least
50% of a meal during the day of care.
o Evaluation of outcomes objective: Patient ordered and ate 25% of dinner during
the day of care. Needs further reinforcement.

Nursing Interventions Rationals

Use a nutritional screening tool to determine Research has shown that from 23% to 50% of
the possibility of malnutrition. Watch for all clients are malnourished on admission, and
recent weight loss over 10 lb., 10% under the presence of malnutrition increases the
healthy weight, not eating for more than 3 length of hospital stay.
days, normal eating for greater than 5 days,
and body mass index (BMI) of less than 20,
or other reasons why the client may be
malnourished, and refer to a dietitian for a
complete nutritional assessment.
Recognize that clients with acute disease or An increased intake of calories is desired to
injury-related malnutrition, wounds, recent aid in the healing process and maintain
surgery, trauma, and a fever are using more nutritional status.
calories and need increased calories to
maintain their nutritional status.
Note laboratory test results as available: A serum albumin level of less than 3.5 is
serum albumin, prealbumin, serum total considered an indicator of risk of poor
protein, serum ferritin, transferrin, nutritional status.
hemoglobin, hematocrit, and electrolytes.
Alyssa Grimm Concept Map Information Page 12

Monitor food intake; record percentages of Use of a food diary is helpful for both the
served food that is eaten. Keep a 3-day food patient and the nurse, to examine usual foods
diary to determine actual intake; consult with eaten, patterns of eating, and presence of
dietitian for actual calorie count if needed. deficiencies in the diet.
For the patient who is malnourished and can Fortified foods, such as those with increased
eat, offer small quantities of energy-dense and protein, were acceptable to patients if they
protein-enriched food, served in an appetizing tasted the same as regular foods.
fashion, at frequent intervals.
Avoid interruptions during mealtimes; meals Some hospitals have started a protected
should be eaten in a calm and peaceful meal-time effort to ensure that patients are
environment. Interruptions have a negative not disturbed during mealtime.
effect on clients nutrition.
Provide companionship at mealtime to Mealtime usually is a time for social
encourage nutritional intake. interaction; often patients will eat more food
if other people are present at mealtimes.
Administer antiemetics and pain medications The presence of nausea or pain decreases the
as ordered and needed before meals. appetite.
If client is nauseated, remove cover of food The sudden, concentrated food odors that
tray before bringing it into the clients room. come when the cover is removed in front of
the patient can trigger nausea.
Refer to a physician and dietitian a child who Good nutrition is extremely important for
is underweight for any reason. children to ensure sufficient growth and
development of all body systems.
Weigh and measure the length (height) of the Age-related growth charts are available for
child and use a growth chart to help determine use.
growth pattern, which reflects nutrition.
Work with the child and parent to develop an The goal with a child is sometimes to
appropriate weight gain plan. maintain existing weight as the body grows
taller. In the presence of a nutritional
imbalance, lower than requirements, the goal
is to continue to gain weight as the body
grows taller.