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This Concept Map, created with IHMC CmapTools, has information related to: Acute Care 3.26.08, Reassess pain level atleast 3 times during shift and record PCA pump use: being mindful of number of doses and number of attempts outcome Checked pain level through out shift. Patient pain decreased to a 3/10 after reassessment, Administer antiinfectives/ antibiotics per order double checking correct dose, route, time, etc outcome Medication given. Patient tolerated well., Assessment G/U Foley d/c at 1400 Up to bathroom, urine clear, yellow Output: 700ml/shift, Assessment Neuro/muscular Alert and Oriented x3 Muscle Strength: 5 BUE, 4 BLE, Up out of bed with 1 assist and walker, Disturbed body image related to newly placed ostomy, tumor removal, as evidenced by not looking at ostomy pouch and drain, patient did not want to empty pouch for herself. interventions Encourage patient to start handling ostomy but allow her time to watch without having to do it herself - time to adjust., Assessment Vital Signs Vitals at 1400 Temp:37.6 C Pulse: 80 Resp: 18 B/P: 123/70 O2: 98%/ RA Pain: 2/10, Maintain sterile technique for IV and other therapies outcome Cleaned hands before working with IVs and maintained sterile working field when necessary., Encourage patient to lay in a comfortable position. Support patient as she stands up out of bed to decrease pain with movement. interventions Reassess pain level atleast 3 times during shift and record PCA pump use: being mindful of number of doses and number of attempts, Pain related to abdominal surgery, as evidenced by patient statement of 7/10 pain when she attempts to move. Expected Outcome Patient will verbalize decrease in pain to acceptable level below 3/10., Assessment Respiratory Lung sounds: Clear ant/post Symmetrical chest rise No use of accessory muscles, Risk for Infection related to surgery, new ileosomy Interventions Maintain sterile technique for IV and other therapies, Encourage patient to lay in a comfortable position. Support patient as she stands up out of bed to decrease pain with movement. interventions Encourage use of PCA pump. Reminding the patient to push the button when she is in pain, and the pump will not, Patient will verbalize decrease in pain to acceptable level below 3/10. interventions Reassess pain level atleast 3 times during shift and record PCA pump use: being mindful of number of doses and number of attempts, Risk for Infection related to surgery, new ileosomy Interventions Administer antiinfectives/ antibiotics per order double checking correct dose, route, time, etc, Risk for Infection related to surgery, new ileosomy Interventions Assess for signs and symptoms of infection: increase temp, increased WBC, change in B/P or HR, decreased tissue perfusion, Listen to patient's comments and response to situation. outcome Patient stated that she did not know how she could do this. She does not like "holes in the body"., Encourage patient to start handling ostomy but allow her time to watch without having to do it herself - time to adjust. outcome Patient did not watch while skin care nurse changed her pouch. Patient said she would attempt to empty her ostomy on her own later., Assessment Cardiac Apical Pulse regular Radial pulse +2 Bil Femoral pulse +2 Bil Dorsalis Pedis +2 Bil Post Tibia +2 Bil Cap refill brisk Warm temperature no numbness or tingling No edema, Patient is 60 year old Caucasian Female POD 6 of L anterior resection admitted on 3/18/08 for Malignant Neoplasm in Rectum. Nursing Diagnoses Nursing Diagnonsis: Risk for infection, Teach patient how to empty ostomy pouch correctly. Encourage her to try on her own. outcome Patient did not empty ostomy pouch while I was present. Should be able to empty by the end of shift.