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This Concept Map, created with IHMC CmapTools, has information related to: Acute Care 4.02.08, Risk for injury related to altered physical mobility, low H & H levels interventions Apply venous compression stockings to lower exremities bilaterally. Remove 30 minutes per shift and assess before reapplying., Assessment G/U Foley catheter urine yellow,clear Output: *i did not write it down, 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. Patient extremities pale., 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 0/10 after reassessment, Assessment Neuro/muscular Alert and Oriented x3 Muscle Strength: 5 BUE, 4 BLE, able to flex foot In bed, PT in AM CPM machine 30 degrees BIL, Patient will verbalize decrease in pain to acceptable level below 2/10. interventions Reassess pain level atleast 3 times during shift and record PCA pump use: being mindful of number of doses and number of attempts, Assessment Vital Signs Vitals q2h 1500 Temp:37.1C Pulse: 80 Resp: 18 B/P: 109/65 O2: 99% RA Pain: 0/10, Warfarin Tab 2.5mg PO 4/2/08 only (2100) used for Prevent clotting, prevent DVT formation from knee arthroscopy and decreased mobility, Risk for injury related to altered physical mobility, low H & H levels interventions Patient will change positions every 2 hours to promote range of motion and decrease risk of DVT. Use CPM machine to enhance ROM bilaterally., Impaired Gas Exchange related to decreased hemoglobin & hematocrit, being immobile post surgery, as evidenced by abnormal labs, pale skin, fatigue interventions Elevate Head of Bed to help chest expansion. Encourage incentive spirometry to increase lung expansion and decrease occurance of atelectasis, Assessment Respiratory Lung sounds: Clear in all fields No use of accessory muscles Symmetrical chest expansion, Risk for injury related to altered physical mobility, low H & H levels interventions Assess patient lower extremities for warmth redness, tenderness/soreness, Impaired Gas Exchange related to decreased hemoglobin & hematocrit, being immobile post surgery, as evidenced by abnormal labs, pale skin, fatigue interventions Check Sa02 q shift. If decreased, notify nurse and monitor until return to acceptable level, Assess patient lung sounds for abnormal/diminished sounds Assess for cough or sputum outcome Patient had clear lung sounds in Left/Right ant/post lung fields No noticable SOB. No cough., Assessment Skin/drains Skin is warm, pale, no breakdown Hemovac R and L knee Serosanguinous fluid Dressing D & I, Assess patient for SOB, increased HR or BP outcome Patient did not appear to be SOB No complaints of dyspnea while at rest. Patient was fatigued. HR and BP within normal limits, Encourage use of PCA pump. Reminding the patient to push the button when she is in pain, and the pump will not overdose her. outcome Patient resting, reported pain as 0/10, Patient is 59 year old Caucasian female Post Op Day #1 for Bilateral knee arthroscopy admitted on 4/1/08. Nursing Diagnoses Nursing Diagnosis: Pain, Check Sa02 q shift. If decreased, notify nurse and monitor until return to acceptable level outcome Patient SaO2 at 98% and maintained throughout shift, 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 2 units blood 1300 and 2000