CONCEPT MAP

Basis of Priority: Maslow’s Hierarch of Need

 MEDICAL DIAGNOSIS:
ND#2: IMPAIRED TISSUE ND#3: DISTURBED BODY
[INTEGUMENTARY]
CERVICAL IMAGE
INTEGRITY ADENOCARCINOMA R/t removal of female
r/t radical hysterectomy STAGE IB1 reproductive organs
as evidenced by As evidenced by “ganto
PRIORITY ASSESSMENTS:
abdominal incision GYNECOLOGICAL HISTORY ba talaga kapag
OB HISTORY tumatanda na?” as
PAST MEDICAL HISTORY
INTERNAL VAGINAL EXAMINATION verbalized by the patient.
PHYSICAL EXAMINATION
LABORATORY FINDINGS
CONTRAPTIONS
ND#1: ACUTE PAIN ELIMINATION PATTERN
ND#4: RISK FOR
r/t tissue trauma ACTIVITIES OF DAILY LIVING INFECTION
PROCEDURES PERFORMED
as evidenced by pain VITAL SIGNS r/t traumatized tissues
scale of 3/10. PAIN ASSESSMENT
MEDICATIONS
VERBALIZATIONS

ND#5: READINESS FOR

ENHANCED URINARY
ELIMINATION
 MEDICAL DIAGNOSIS:

CERVICAL
ADENOCARCINOMA
STAGE IB1
PRIORITY ASSESSMENTS:
GYNECOLOGICAL HISTORY
OB HISTORY
PAST MEDICAL HISTORY
INTERNAL VAGINAL EXAMINATION
PHYSICAL EXAMINATION
LABORATORY FINDINGS
CONTRAPTIONS
ELIMINATION PATTERN
ACTIVITIES OF DAILY LIVING
PROCEDURES PERFORMED
VITAL SIGNS
PAIN ASSESSMENT
MEDICATIONS
VERBALIZATIONS
 ND#1: ACUTE PAIN
r/t tissue trauma
as evidenced by pain scale of 3/10.

Subjective:
“Pananakit ng pantog.”
Pain scale of 3/10
Objective:
G9P5 (5045)
46 years old
BP: 120/80mmHg RR: 18cpm
Temp: 36.9°C HR: 70bpm
Recurrent stabbing pain at the hypogastric
area
Radical hysterectomy
Bilateral salpingo-oophorectomy
Bilateral pelvic lymph adenectomy
Irritability
Restlessness
Activity as tolerated
Bathe/shower, walk, eat, dress, toileting,
move to bed/chair independently
Conscious and coherent
Lidocaine, morphine and Demerol given for
pain management
Walks in the room frequently
 ND#2: IMPAIRED TISSUE
[INTEGUMENTARY] INTEGRITY
r/t radical hysterectomy
as evidenced by abdominal incision

Objective:
G9P5 (5045)
Temp: 36.9°C
BP: 120/80mmHg
PR: 70bpm
RR: 18cpm
Recurrent stabbing pain at the hypogastric
area
Radical hysterectomy
Bilateral salpingo-oophorectomy
Bilateral pelvic lymph adenectomy
No vaginal discharge
No vaginal bleeding
s/p suction curettage (for elective abortion
in Japan)-1989, 1990, 1991,2000
Activity as tolerated
Bathe/shower, walk, eat, dress, toileting,
move to bed/chair independently
Walks in the room frequently
 ND#3: DISTURBED BODY IMAGE
R/t removal of female reproductive organs
As evidenced by “ganto ba talaga kapag
tumatanda na?” as verbalized by the
patient.

Subjective:
“ganto ba talaga kapag tumatanda na?” as
verbalized by the patient.
Objective:
46 years old, married
G9P5 (5045)
Radical hysterectomy
Bilateral salpingo-oophorectomy
Bilateral pelvic lymph adenectomy
 s/p Removal of breast implantation-1994,
s/p suction curettage (for elective abortion
in Japan)-1989, 1990, 1991,2000
 ND#4: RISK FOR INFECTION
r/t traumatized tissues

Objective:
46 years old
G9P5 (5045)
Radical hysterectomy
Bilateral salpingo-oophorectomy
Bilateral pelvic lymph adenectomy
Abdominal incision
Temp: 36.9°C
With indwelling Foley catheter
Urinalysis: all within normal values.
No vaginal discharge
No vaginal bleeding
Instructions on Foley catheter care given to
patient by bedside nurse
 ND#5: READINESS FOR ENHANCED
URINARY ELIMINATION

Subjective:
“hindi na ako hirap umihi kaya sana
tanggalin na itong catheter”
Objective:
Chief complaint upon admission:
hypogastric pain & urinary retention
With indwelling Foley catheter
No vaginal discharge
No vaginal bleeding
Intake: 1050mL (Adequate)
Output: 855mL
Activity as tolerated
No dysuria
Bladder not distended
Voids freely
ND # 1: Acute pain related to tissue trauma as evidenced by pain scale of 3/10.
GOAL: To alleviate pain.
EXPECTED OUTCOME: At the end of 8 hours. Student nurse-client interaction, the client will able to manifest relief of pain
through the following:
 (-) restlessness
 (-) guarding gestures
 Vital signs within normal range
 Demonstrate use of relaxation skills, diversional activities, and nonpharmacological methods that provide relief

INTERVENTION PATIENT’S RESPONSE

Promotive/preventive: 1. The patient felt comfortable after repositioning herself in

1. Provide comfort measures (e.g. touch, repositioning, use
of heat/cold packs, nurse’s presence), quiet
environment, and calm activities to promote
nonpharmacological pain management.
2. Accept client’s description of pain. Acknowledge the pain
experience and convey acceptance of client’s response
to pain. Pain is subjective and cannot be felt by others,
3. Monitor skin color/ temperature and vital signs, which
are usually altered in acute pain.
4. Evaluate/ document client’s response to analgesia.
Notify physician if regimen is inadequate to meet pain
control goal.
5. Encourage rest periods. To prevent fatigue.
semi-fowler position and watching television.
2. The client described the pain as stabbing and mild
3. The client’s temperature was 36.9°C which is within
normal range. The client’s skin was pink with no signs of
cyanosis or pallor.
4. The client responded well to her Demerol, morphine and
Lidocaine gel. After receiving the medication, the client
felt relief.
5. The client walks inside her room from time to time.
ND#2: Impaired tissue [integumentary] integrity r/t radical hysterectomy as evidenced by abdominal
incision
GOAL: To display timely healing of skin lesions without complications
EXPECTED OUTCOME: At the end of 8 hours student nurse-client interaction, the patient will be able to demonstrate the
following:
 (-) itching
 (-) pain
 (-) bleeding
 Body temperature within normal range of 36.5C – 37.5C

INTERVENTION PATIENT’S RESPONSE

Promotive/Preventive: 1. The client has an abdominal incision which has minimal

1. Inspect skin on a daily basis, describing wound/ lesion bleeding.
characteristics and changes observed. 2. The client’s lacerated area was kept well cleaned and
2. Keep area clean/dry, carefully dress wounds, prevent dry. No signs of infection were noted.
infection, manage incontinence and stimulate circulation 3. The client walks inside her room from time to time.
surrounding areas to assist body’s natural process of 4. The client is well rested for the entire shift.
repair.
3. Encourage early ambulation/mobilization. Promotes
circulation and reduce risks associated with immobility.
4. Encourage adequate periods of rest and sleep to limit
metabolic demands, maximize energy available for
healing, and meet comfort needs.
ND#3: Disturbed body image related to removal of female reproductive organs as evidenced by “ganto ba
talaga kapag tumatanda na?” as verbalized by the patient.
Goal: To gain acceptance of body changes.
EXPECTED OUTCOME: At the end of 8 hours. Student nurse-client interaction, the client will able to manifest relief of pain
through the following:
 Verbalize understanding of body changes
 Verbalize acceptance of self in situation
Recognize and incorporate body image change into self-concept in accurate manner without negating self-esteem.

INTERVENTION PATIENT’S RESPONSE

Rehabilitative: 1. Client verbalizes “ganto na talaga kapag tumatanda na,

1. Assess mental/physical influence of illness/condition on dumadami na ang problema sa katawan, sadyang life
the client’s emotional state begins at 40, hahaha, kaya itong apo ko, ngayon pa lang
2. Assess client’s current level of adaptation and progress. sinasabihan ko na wag masyadong abusuhin ang
3. Establish therapeutic nurse-client relationship, katawan niya”
conveying an attitude of caring and developing a sense
of trust.
4. Listen to client’s comments and responses to the
situation.
5. To promote wellness: provide information at client’s
level of acceptance and in small pieces to allow easier
assimilation.
ND # 4: Risk for infection related to traumatized tissues.
GOAL: To prevent infection.
EXPECTED OUTCOME: At the end of 8 hours student nurse-client interaction, the client will be able to
manifest freedom from infection through the following:
 Body temperature within normal range of 36.5C- 37. 5C9
 (-) pus

INTERVENTION PATIENT’S RESPONSE

Promotive/Preventive: 1. The client was noted to have no signs of

1. Stress proper hand hygiene by all caregivers
between therapies/clients. A first line defense
against health care-associated infection.
2. Change surgical/ wound dressing, as indicated,
using proper technique for changing/disposing of
contaminated materials.
3. Monitor body temperature.
4. Instruct client in techniques in caring for lesions,
Foley catheter care and proper way of perineal
washing.
infection.
2. The client’s body temperature was 36.8C which
was within normal range.
3. The client verbalized knowledge of foley catheter
care, doing proper perineal washing and of how
to care for lesions after discharge.
ND#5: Readiness for enhanced urinary elimination
Goal: To achieve acceptable normal elimination pattern
EXPECTED OUTCOME: At the end of 8 hours. Student nurse-client interaction, the client will able to
manifest relief of pain through the following:
 Achieve normal/acceptable elimination pattern emptying bladder/voiding in appropriate amounts.
 Alter lifestyle/environment to accommodate individual needs.
 Verbalize understanding of condition that has potential for altering elimination.

INTERVENTION PATIENT’S RESPONSE

Promotive/Preventive: 1. Hypogastric pain and urinary retention with

1. Identify physical conditions that can impact indwelling Foley catheter.
elimination pattern 2. Intake: 1050mL
2. Observe voiding patterns, time, color, and amount Output: 1600H: 250mL
voided 1800H: 175mL
3. Encourage fluid intake, including water and 2000H: 220mL
cranberry juice, to help maintain renal function, 2200H: 210mL
prevent infection. 3. “Umiinom ako ng madaming tubig at hindi na ako
hirap umihi kaya sana tanggalin na itong
catheter” as verbalized by the patient.