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This Concept Map, created with IHMC CmapTools, has information related to: Acute Care 2.13.08, Patient is 53 year old African-American Female admitted on 2/11/08 for Total Left Hip Arthroscopy, currently post op Day #2 Nursing Diagnoses Risk for injury, Reassess pain level 30min-1h after medication administered outcome Patient pain decreased to a 2/10 both times after reassessment, Assessment G/U Foley catheter D/C at 1400 urine clear and yellow Output: 600ml/shift, Administer Docusate per order to soften stool outcome Patient had no complaints of constipation. Stated that she had flatus., Patient will have BM before discharge and no complaints of constipation Interventions Administer Docusate per order to soften stool, Assessment Neuro/muscular Alert and Oriented x3 Muscle Strength: 5 BUE, 5 RLE, 4LLE Up out of bed with walker, Assessment Vital Signs Vitals at 1400 Temp:37.7 C Pulse: 90 Resp: 18 B/P: 154/75 O2: 95%/ RA Pain: 7/10 L Hip, Blood glucose at 1445: 172 intervention Insulin Glargine 50 units SC 5 min AC at 1700, Encourage patient to increase mobility as tolerated to increase peristalsis outcome Patient was able to walk around room 3x during shift and participated in physical therapy per shift., Reposition patient q2h, with abduction block pillow in between legs when laying down to promote comfort and prevent pressure interventions Reassess pain level 30min-1h after medication administered, Patient will have BM before discharge and no complaints of constipation Interventions Encourage patient to increase mobility as tolerated to increase peristalsis, Low levels of: RBC, HGB, HCT related to blood loss in surgery, Assessment Respiratory Lung sounds clear NC 1.5 LPM O2 Symmetrical chest rise unlabored breathing incentive spirometer at bedside, Pain related to left hip arthroscopy as evidenced by patient complaining of 9/10 pain and uncomfortable positioning. Expected Outcome Patient will verbalize decrease in pain to acceptable level below 4/10., Assess patient lower extremities for warmth redness, tenderness/soreness outcome Patient has no signs of DVT formation, Integumentary assessment within normal limits: no warmth, redness or tenderness, Reposition patient q2h, with abduction block pillow in between legs when laying down to promote comfort and prevent pressure interventions Administered 10mg oxycodone /650 mg acetaminophen at 1350 and 1750, Risk for injury related to altered mobility, altered CBC levels interventions Assess patient lower extremities for warmth redness, tenderness/soreness, Patient will verbalize decrease in pain to acceptable level below 4/10. interventions Reassess pain level 30min-1h after medication administered, Blood glucose at 1445: 172 intervention Insulin Sliding Scale, Assess patient for SOB, increased HR or BP outcome Patient shows no signs of SOB or abnormal cardiovascular activity