Associate Degree Nursing Program Concept MapStep 4 & 5 Problem #1: Chronic Pain General Goal: Pt will verbalize

and demonstrate (non-verbal cues) relief and/or control of pain or discomfort Predicted Behavioral Outcome Objective(s): Pt will demonstrate comfort and willingness that will identify specific pain level that will allow her to perform ADLs, and pain will stay below the specific lever for remainder of cancer progression. Nursing Strategies Patient Responses 1. Assess the conditions associated with long-term Pt has - Stage l L heel pressure ulcer; Stage III R Heel pain Pressure Ulcer, Sacrococcygeal Stage l Pressure Ulcer, Bilateral knee arthroplasty, Symptoms of splenomegaly, Noeplastic Malignant Ovarian Cancer, Osteoarthritis 2. Evaluate current and past analgesic, opioid or other Pt is allergic to Codiene, PCN, Morphine, Percocet drug use 5/325; alleged reaction is unknown. Pt is prescribed Tylenol for pain and fever; when offered Tylenol for pain control pt declined for fear that it would react with her Coumadin treatment. 3. Evaluate pain behaviors Pt appears to be in severe pain, she is reluctant to her prescribed care. She exhibits facial grimacing, her body is tense and rigid, she winces to the touch and is guarded when attempts were made to assess her abdomen and lower extremities. 4. Assist client in minimizing effects of pain on PT/OT/ST and OT is ordered on a daily basis there is no interpersonal relationships and daily activities prescribed pain management other than Tylenol. Pt is resistant to therapy she cries out in pain and is guarded. In transfer from bed to wheelchair via Hoyer lift pt states, "I don't want that it hurts." PT was scheduled during breakfast. Pt was force to top eating to perform ROM exercise. 5. Watch for signs of depression with chronic pain; Pt is difficult to arouse. Nurse states, that she sleeps sleepiness, not eating, flat effect, statements of throughout the day if not performing ADL's and depression, or suicidal ideation exercises with therapy. Pt has flat facial expression and cries out when moved or manipulated. Summarize patient progress toward outcome objectives: Pt pain is not control and need further evaluation from her physician or pain management center. She needs further education based on the prescribed medication. PT/OT and ST needs to be scheduled around breakfast and lunch.

Problem #2: Disturbed Sensory Perception at Risk For Prone Health Behavior General Goal: Predicted Behavioral Outcome Objective(s): Pt will recognize and correct or compensate for sensory impairments by demonstrating an increasing interest/participation in self-care Nursing Strategies Patient Responses 1. Perform a physical and/or psychological Pt is difficult to arouse. Nurse states, that she sleeps assessment throughout the day if not performing ADL's and exercises with therapy. Pt has flat facial expression and cries out when moved or manipulated. Pt is guarded and reluctant to be assessed, asks "why and would prefer to left alone" Pt refuses to allow assessment of her abdomen and L lower extremity. 2. Explore the expression of emotion signifying Pt has flat facial effect, cries out when moved or impaired adjustment manipulated. Pt is guarded and reluctant to perform ADLs and Therapy. Pt's states, "I am unable to hear you and cannot understand you." And "I am not going to answer you." 3. Use therapeutic communication skills Discussed the reason for care and therapy, offered open communication and feedback. Expressed that I would like to help her remain comfortable and safe. 4. Assess the ability to speak, hear, interpret and Pt had decreased vision and hearing loss. She has respond to simple commands. corrective lenses and hearing aids. CNA stated that she refused to wear her hearing aids. Pt states that, "They block her hearing" 5. Observe for behavioral response and encourage Pt is encouraged to wear her hearing aids. Pt is the use of listening device reluctant and states that, "They block her hearing" When she wears her hearing aids communication improves. Summarize patient progress toward outcome objectives: Need to re-evaluate interventions and contributing factors such as pain. Continue to encourage self-care and positive reinforcement. Provide patient with option for care, such as time, days and interventions to help maintain pt autonomy and control over self.

Problem #3: Ineffective Peripheral Tissue Perfusion At Risk For Infection General Goal: Pt will remain free of infection Predicted Behavioral Outcome Objective(s): The client will demonstrate progressive healing of tissue, as evi-denced by the Granulating and epithelizing wounds with low to moderate amounts of exudates with approximated edges. Wounds will be kept clean and dry. Wound will be monitored for signs of infection, oral temperature will remain between 96.8 - 99.9 F (37 - 37.7C) daily Nursing Strategies Patient Responses 1. Note the current condition that can effect Pt. is insulin dependent diabetic, Hypertension, CHF, perfusion to all body systems ovarian cancer, immobility and pressure ulcers 2. Assess the skin texture, presence of edema, Pts skin is dry and fragile; slight tenting present; peripheral pulses and cap refill. Peripheral pulses are palpable and cap refill <3 sec bilaterally pedialas. Slight non-pitting edema bilateral lower extremities. Pt has a stage l pressure ulcer R-heel and sacrococcygeal area and stage ll pressure ulcer L heel 3. Observe wound for Redness, swelling, increased R-heel -Intact skin, nonblanchable erythema, painful to pain, or purulent drainage touch, soft, and warm. Sacrococcygeal area - Intact skin; nonblanchable erythema, painful to touch, soft, and warm. L -heel - superficial nonblanchable blackened tissues, 6 cm, painful to touch. 4. Monitor vitals signs - temp, pulse, respiration, BP - 168/80; Radial Pulse - 91; RR - 20; Temp - Pt auscultate lungs for crackles or rhonchi refused. Lung fields, clear breath sounds on auscultation 5. Monitor white blood count (WBC). Lab draw -1/21/13 WBC's were elevated at 17.8. 6. Administer antibiotic medication as prescribed Pt is prescribed flagyl TID at 0800, 1400 and 2000 and Levaquin daily at 0800 as an anti-infective; flagyl and levaquin given at 0800 this shift Summarize patient progress toward outcome objectives: OT states, that the pressure ulcers are responding to current antibiotic treatment and therapies. Pt exhibits reluctance to therapy related to pain. Reassess pain management therapy.

Problem #4: Impaired Physical Mobility / Self-Care Deficit At Risk For Falls General Goal: Maintain or increase strength and function of affected and/or compensatory body part Predicted Behavioral Outcome Objective(s): Pt will demonstrate understanding of situation and individual treatment regimen and safety as evidence by comfort and willingness to participate in self-care. Nursing Strategies Patient Responses 1. Determine extent of immobility Pt is immobile due to pressure ulcers on bilateral heels. She is bed and wheel chair bound; Hoyer lift prescribed for transfer. 2. Assess the degree of pain Pts is flat facial effect, body is rigid with limited movement while at rest. Pt grimaces and cries out; she is guarded and tense during physical assessment, OT , ST and PT. 3. Assess pt perception of activity and exercise needs Pt is reluctant to participate in prescribed therapy. She exhibits no-verbal signs of discomfort, such as facial grimacing, guarded, winces to touch. 4. Determine presence of complications R/T Pt has bilateral clear breath sounds on auscultation, immobility capillary refill is <3 sec bilaterally upper and lower extremities, exhibits bilateral slight non-pitting edema in her ankles; bilateral heel pressure ulcers and nonverbal indications of pain. 5. Reposition q2h Pt is reposition and comfort assessment provided Q2h 6. Support affected body parts or joints using pillow, Pt is positioned with air boots bilaterally to prevent rolls, foot support or shoes. pressure on heels while in bed. Summarize patient progress toward outcome objectives: OT, PT and ST are order daily to prevent further complications. Pt joints remain without contracture, passive ROM, grip strength equal and but weak; Fine motor skills are limited; Able to eat and drink with no assistance; needs assistance with repositioning Pt is reluctant to care due to her pain level. Reassess pain management. Adapted from Schuster, P.M. (2002) Concept Mapping: A Critical Thinking Approach to Care Planning. Used with permission. (Rev 12/11)