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This Concept Map, created with IHMC CmapTools, has information related to: Acute Care Practice CMAP, Assessment for Gastrointestinal Abdomen soft, still awaiting BM post surgery, Bowel sounds present x 4 quadarants with flatus, No nausea or vomiting, Amitriptyline tab 10 mg PO HS intervention for Pain, Risk for injury related to immobility, altered CBC levels affecting 02 supply to the body and blood clotting factors interventions Check PT/INR levels to check for therapeutic level because patient is on coumadin, Assessment for Neurological Pupils: R/L 3/3 PERLA LOC 5 Alert and Oriented x3 Musculoskeletal: Muscle strength: + 5 plantar/dorsi strength CPM machine for Left knee at bedside Activity: Out of bed with assist PT Walk with walker as tolerated, Risk for infection related to surgery and foley catheter placement Interventions Monitor vital signs q4h noting changes in temp, Provide assistance for patient to move out of bed, sit in chair or change positions atleast atleast q2 hour or according to protocol Elevate legs when lying down to increase venous return and decrease risk of edema outcome Patient has legs elevated when lying in bed. Patient was able to reposition herself in bed with assistance to prevent skin breakdown, Patient is a 77 year old female admitted to the facility 1/28/08. She is currently 2 days post op for Left Total Knee Arthroscopy. Post op Nursing Diagnoses, Risk for infection related to surgery and foley catheter placement Interventions Administer prophylactic Ciprofloxacin as ordered checking 5 rights of meds, Past Medical History of Retinal repair OD Cataract surgery and RTKA 2004 Spinal Stenosis PUD, DOE, Remote Asthma , Arthritis, Hypercholesterolemia, D and C x 2 Arthroscopy of Right Knee Allergies: Iodine (dye), U/A 1/30/08 Sp.Gravity 1.007 pH 6.5 protein: neg glucose: neg Blood: large (+3) Ketones: 15 Bilirubin: neg Leukocytes: small (1+) ???? Why was this done on 1-30? What is signifiacnnce of +3 blood?, Labs are U/A 1/30/08 Sp.Gravity 1.007 pH 6.5 protein: neg glucose: neg Blood: large (+3) Ketones: 15 Bilirubin: neg Leukocytes: small (1+), Encourage patient to follow PT/exercise routine to increase circulation outcome Patient performing weight bearing and ROM exercises with assistance, Medication for shift is Amitriptyline tab 10 mg PO HS, Medication for shift is Warfarin Tab 2.5mg PO at bedtime tonight, Monitor vital signs q4h noting changes in temp outcome Temperature decreased to 36.5 taken 1400 on 1/30 Vital signs within normal limits, Patient is a 77 year old female admitted to the facility 1/28/08. She is currently 2 days post op for Left Total Knee Arthroscopy. Post op Medications, Assess patient lower extremities for warmth redness, tenderness/soreness outcome Patient has no signs of DVT formation, Integumentary assessment withing normal limits: no warmth, redness or tenderness, Encourage adequate fluid intake to maintain good skin turgor and nutrtional status outcome Patient tolerating clear/full liquid diet as ordered, Assessment for Respiratory Within normal limits: clear lung sounds, respirations regular with symmetrical chest expansion, no secretions or cough, Provide protection and support with pillows/pads to increase circulation and relieve pressure from tissue outcome Patient supported lower extremities and back with pillows in bed, repositioning often