Block.3.Concept.Map.1.docx - CONCEPT MAP – MS – Block 3 “ Client(incl age gender ethnicity 54 year old male Caucasian(transgender Diagnosis(brief

Block.3.Concept.Map.1.docx - CONCEPT MAP – MS – Block 3...

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CONCEPT MAP – MS – Block 3 “? Goal #1: Patient will have a tolerable pain level score of <5 by end of shift Priority Nursing Diagnosis #1 Acute pain r/t recent lumbar surgery AEB pain level of 9/10 Assess pain, respiratory and bowel function. Caution with opioids; Constipation, Headache, drowsiness Assess pain, respiratory, and bowel function Caution with opioids; constipation, drowsiness, dizziness, sedation O 2 , RR, BP, P, LOC, bowel function, depression and anxiety levels, pain level (intensity, site, duration, onset), Patient education opioids, fall risk; S/e: HA, constipation, sedation, dizziness, drowsiness Priority Nursing Interventions with rationale (5) 1. Encourage pt to eat and drink fluids 2. Encourage walking as tolerated to help recovery process 3. Administer antiemetics and pain medication as ordered PRN and before meals 4. Kj 5. Educate importance of nutrition and hydration and how it effects wound healing and helps with pain Goal #2: Adequate nutrition and hydration ask Priority Nursing Diagnosis #2
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  • Fall '19
  • acute pain

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