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This Concept Map, created with IHMC CmapTools, has information related to: Acute Care 4.09.08, Assessment Vital Signs Vitals at 1400 Temp:37.1 C Pulse: 89 Resp: 18 B/P: 127/76 O2: 95%/ RA Pain: 7/10 Abd pain, Docusate cap 100mg PO BID use Stool softener, decreases constipation, Hydromorphone 2mg IV q4h in 50 ml NS IVPB for Pain, Keep patient NPO, only ice chips to let bowels rest and decrease pain. interventions Administer Dilaudid 2mg IV in 50ml NS PRN q4h, Encourage patient to increase mobility as tolerated to increase peristalsis outcome Patient only got out of bed to use BR., Administer Dilaudid 2mg IV in 50ml NS PRN q4h outcome Administered medication at 1620 Patient tolerated med well., Patient is 50 year old African American Female admitted on 4/08/08 with Abodminal pain, Diverticulitis Nursing Diagnoses Nursing Diagnosis: Constipation, Patient is 50 year old African American Female admitted on 4/08/08 with Abodminal pain, Diverticulitis Patient History Allergies/Medical History, Patient will verbalize decrease in pain to acceptable level below 3/10. interventions Reassess pain level 30min-1h after medication administered, Reassess pain level 30min-1h after medication administered outcome Patient pain decreased to a 0/10. Patient sleeping, Assessment Skin Skin is warm, pink, no breakdown, Patient is 50 year old African American Female admitted on 4/08/08 with Abodminal pain, Diverticulitis Lab levels Labs, Patient is 50 year old African American Female admitted on 4/08/08 with Abodminal pain, Diverticulitis Nursing Diagnoses Nursing Diagnosis: Pain, Patient is 50 year old African American Female admitted on 4/08/08 with Abodminal pain, Diverticulitis interventions during shift Medications, Constipation related to altered structure, presence of inflammation as evidenced by decreased in stool and patient's report of pressure, wanting to have a BM but unable. interventions Assess patient abdomen for distention, abnormal bowel sounds, Constipation related to altered structure, presence of inflammation as evidenced by decreased in stool and patient's report of pressure, wanting to have a BM but unable. interventions Administer Docusate Sodium as ordered to soften stool., Assessment Neuro/muscular Alert and Oriented x3 Muscle Strength: 5 BUE, 5 BLE, Up out of bed to BR, Risk for Powerlessness related to chronic nature of diseease process and recurrent episodes. Interventions Encourage client to be active in own health care management and take responsibility for diet, actions, and preventitive measures., Constipation related to altered structure, presence of inflammation as evidenced by decreased in stool and patient's report of pressure, wanting to have a BM but unable. interventions Encourage patient to increase mobility as tolerated to increase peristalsis, Assessment Respiratory Clear lung sounds No sputum/cough No accessory muscle use symmetrical expansion