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NUR 105 Clinical Concept Map (Clinical Worksheet page 1)
NUR 105 Clinical Area - Student use ACTUAL data findings from clinical. Assess the patient. Develop two physiological and one psychosocial nursing diagnosis include all 3 parts of nursing diagnosis.
Actual Nursing Diagnosis/Problem: constipation r/t decreased peristalsis r/t low fiber intake 2nd small bowel obstruction with perforation
Supporting Data:
Pt Complaints of straining when having BM
Pt complains of abdominal bloating
Pt complains Abdominal pain
Patient complains of sudden Loss of appetite
Patient emphasize on being afraid to have bowel movements due to pain and straining every time
Large, dry stools that are difficult to pass
Bright red blood on surface of stool
Abdominal examination reveal distension and tenderness
Patient states having less than or about 3 BM per week
Reason for seeking medical attention-
Chief complaint: abdominal pain,SOB
Medical Diagnosis/Surgical Procedure: SBO with Perforation, Diverticulitis
Co-morbidities/focused assessment:
HTN
HLD
Hysterectomy
Culture: Jamaican
and Religion: Christian
Lab Results with Normal Range
WBC: 11.6 (Normal: 4.5-11)
Hemoglobin: 11.3 (Normal 12-16)
Hematocrit: 34.6 (Normal 36-47)
Platelets: 337
Na+: 140 (Normal 135-145)
K+: 3.8
Cr: 0.60 (Normal 0.6-1.2)
Glucose: 83
Actual Nursing Diagnosis/Problem: Impaired gas exchange related to abdominal distension related to pressure on the diaphragm secondary to small bowel obstruction with perforation
Supporting Data: 72 year old
Admitted on 9/13 for SBO with perf
X -Ray of abdomen done on 9/13 at outside source
Respiratory Rate: Increased rate may indicate compensatory response to hypoxia.
Oxygen Saturation: 90%
Respiration: 22
Auscultation: wheezing, crackles
labored breathing.
Abdominal Examination
Patient complains of abdominal pain
Distension: abdomen appear to be distended and have areas of tenderness to touch
Bowel Sounds: diminished sounds indicating possible ileus or obstruction.
Patient complains of feeling bloated/puffy
ABG (Arterial Blood Gas):
Pulmonary Function Tests:
Actual Nursing Diagnosis/Problem: anxiety related to prolonged hospital stay
Supporting Data
Patient states wanting to get out the hospital
Patient states she is tired of laying in bed all day
Patient states feeling overwhelm due to hospital staff constantly come in and out of room
Patient complains of not getting sufficient rest due to staff coming in for labs and other early morning tests
Patient emphasize on her freedom/independence outside the hospital and being able to prepare her own meals
I don’t know how this fits
NUR 105 Clinical Concept Map (Clinical Worksheet page 2)
Utilize the nursing diagnoses on page 1 that you developed. Identify appropriate nursing interventions. This is your basis of your homework.
Actual Nursing Diagnosis/Problem: Impaired gas exchange related to abdominal distension related to pressure on the diaphragm secondary to small bowel obstruction with perforation
Goal: my patient will maintain an SpO2 level of 92% or higher while at rest, and a respiratory rate of 12-20 demonstrating effective gas exchange while in my care
All Nursing Interventions:1. Administer oxygen therapy as ordered.
2. Elevate the head of the bed to a 30–45-degree angle
3. Teach and encourage the patient to perform deep breathing and coughing exercises
4. Promote Activity as Tolerated
5. Consult with a dietitian to assess nutritional needs and modify diet as necessary.
6. Administer Medications as Ordered
7. Educate Patient and Family
8. Administer IV Fluids and Electrolytes
9. Insert Nasogastric (NG) Tube
10. Collaborate with the surgical team and prepare the patient for potential surgery.
11. Regularly check complete blood count (CBC), electrolytes, WBC and possibly cultures if infection is suspected
12. Assess respiratory rate, depth, and oxygen saturation frequently
13. Provide Pain Management
14. Monitor Vital Signs Closely
15. Perform frequent abdominal assessments, checking for distention, tenderness, and signs of peritonitis (e.g.,rebound tenderness).
Actual Nursing Diagnosis/Problem: constipation r/t decreased peristalsis r/t low fiber intake 2nd small bowel obstruction with perforation
Goal: Patient will report soft, formed stool during bowel movements while in my care
All Nursing Intervention: 1. Perform manual disimpaction
2. Administer laxatives or stool softeners as prescribed
3. Advise patients to take the recommended dose of dietary fiber of at least 20 to 30 g daily. Encourage intake of prune juice
4. Promote increased fluid intake
5. Avoid caffeine and alcohol
6. Encourage daily exercise and physical activities
7. Institute a toilet schedule or bowel training as appropriate.
8. Encourage the patient to have an elimination diary
9. Apply a gentle abdominal massage
10. Educate on Fiber Intake
11. Advise taking probiotics
12. Administer enema (phosphate enema, saline, tap water, and soap sud enema) if indicated
13. provide comfort measures
14.
Pathophysiology of Primary Medical/Surgical Diagnosis
(Write on a separate page)
Actual Nursing Diagnosis/Problem: anxiety related to prolonged hospital stay
Goal: My patient will be free of prolonged hospital stay anxiety while in my care
All Nursing Intervention:1. Assess Anxiety Levels
2. Offer clear explanations about procedures, treatments, and what to expect during the hospital stay to reduce uncertainty
3. Encourage Expression of Feelings
4. Teach Relaxation Techniques
5. Create a Calm Environment
6. Establish a daily schedule for activities, meals, and care to provide structure and predictability.
7. Involve Family and Friends
8.Provide activities such as books, puzzles, or music to divert attention away from anxiety-provoking thoughts.
9. Encourage Physical Activity
10. Provide Cultural and Spiritual Support
11. Teach mindfulness techniques to help the patient stay present and reduce overwhelming thoughts about the future
12. Use Therapeutic Communication
13. Involve the patient in discharge planning to give them a sense of control and preparedness for their transition back home.
14. Build a trusting relationship by actively listening and showing empathy to help the patient feel understood and supported.
NUR 105 Clinical Concept Map
Utilize the information on page 1 and 2 to fill in information below. Explain why/how the nursing intervention helps patient achieve the goal (Scientific rational) with citation. Insert and document patient’s actual response to the intervention and evaluate and summarize patient’s outcome.
| Actual Nursing Diagnosis/Problem: Nursing Diagnosis/Problem: Impaired gas exchange related to abdominal distension related to pressure on the diaphragm secondary to small bowel obstruction with perforation | |
| Predicted Patient Behavioral Outcome (Goal): : my patient will maintain an SpO2 level of 92% or higher while at rest, and a respiratory rate of 12-20 demonstrating effective gas exchange while in my care | |
| Nursing Interventions: Administer oxygen therapy as ordered. Scientific Rationale: Supplemental oxygen can improve oxygenation levels, compensating for impaired gas exchange due to abdominal distension and diaphragm pressure. An oxygen saturation of <90% (normal: 95% to 100%) or a partial pressure of oxygen of <80 (normal: 80 to 100) indicates significant oxygenation problems. | Actual patient response/evaluation: |
| Overall Evaluation of Goal attainment and care effectiveness: | |
| Describe the relationship between the nursing diagnosis/problem in this plan and the other two nursing diagnosis/problem you identified on the Clinical Worksheet | |
References
Include two peer review evidence-based article to support your plan. Submit article(s) with Concept Map.
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Fall 2023/Spring 2024
