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This Concept Map, created with IHMC CmapTools, has information related to: conceptmap1complexfamily pg 2, II. Pathophysiology GI Bleed 1. Blood in the GI tract is irritating to the stomach, and typically leads to nausea and vomiting (Hematemasis, Vomiting blood). 2. If the blood has been present in the stomach for a period of time and is partially digested, it may have a "coffee-grounds" appearance, rather than presenting as bright red blood. 3. Stools may be black and tarry (melena) or frankly bloody (hematochezia); stools containing partially digested blood has a characteristic odor. 4. No visible blood may be present in the stool, occult (or hidden) bleeding may be detected by chemical means. (Lemone & Burke, 2008) leads to III. Focused Assessment 1.VS HR 72 , O2 100 (room air), Temp 97.9, Resp 20, pulse 72, and B/P 116/70 2. Clear Liquid diet 3. Confused on and off especially during the night 4. Currently no bloody stool 5. Row Belt for confusion during the night 6. 22 LFA NS 100 ml/hr 7. Forgot birthday and where he was 8. Does a tripping type motion with his walk, III. Focused Assessment 1.VS HR 72 , O2 100 (room air), Temp 97.9, Resp 20, pulse 72, and B/P 116/70 2. Clear Liquid diet 3. Confused on and off especially during the night 4. Currently no bloody stool 5. Row Belt for confusion during the night 6. 22 LFA NS 100 ml/hr 7. Forgot birthday and where he was 8. Does a tripping type motion with his walk ???? III. Abnormal Assessment Findings 1. Neu High 76.5 12. RBC Low 2.72 2. Lym Low 9.7 13. Stomach soft and non tender 3. Mono High 12.8 14. Hemoglobin Low 8.4 4. A positive for blood products 5. Fluconazole 100 mg 1 tab 6. Venofear IV for 3 days 7. PTT low 25 8. Possible flexible sigmoid maybe done 9. Anemia 10. Protime High 14.2 11. Hct low 23.9, V. Expected Outcomes 1. The client will remain free of falls aeb not falling during the shift from 7 a.m. to 12 p.m. on 10/30/09. 2. The client will explain methods to prevent injury aeb giving examples of ways to prevent falls or getting rid of throw rugs as a safety precaution by 1200 on 10/30/09. 3. The client will maintain a safe environment aeb eliminating clutter and spills by 1200 on 10/30/09. 4. The client will use his call light to ask for assistance when he feels the urge to go to the bathroom aeb pressing his call light on 10/30/09. 5. The client will use assistance device as needed such as a walker whenever transporting on 10/30/09. Evaluation VII. Evaluation of expected Outcomes 1. The client remained free of falls aeb not falling during the shift on 10/30/09. Goal Met. 2.The client explained methods to prevent injury aeb giving examples of using floor mats in the shower, getting rid of clutter, and not having loose rugs on the floor by 1200 on 10/30/09. Goal Met. 3. The client maintained a safe environment by reporting any spills to an aid and by keeping his area clean by 1200 on 10/30/09. Goal Met 4.The client was sure to use his call light whenever he needed to go to the bathroom so that someone could assist him to the toilet on 10/30/09. Goal Met 5. The client used his assistance device in the presence of an aid or the nurse whenever transporting on 10/30/09., V. Expected Outcomes 1. The client will remain free of falls aeb not falling during the shift from 7 a.m. to 12 p.m. on 10/30/09. 2. The client will explain methods to prevent injury aeb giving examples of ways to prevent falls or getting rid of throw rugs as a safety precaution by 1200 on 10/30/09. 3. The client will maintain a safe environment aeb eliminating clutter and spills by 1200 on 10/30/09. 4. The client will use his call light to ask for assistance when he feels the urge to go to the bathroom aeb pressing his call light on 10/30/09. 5. The client will use assistance device as needed such as a walker whenever transporting on 10/30/09. Interventions & Rationals VI. Interventions 1. The nurse will determine risk of falling by using an evaluation tool by 0900 on 10/30/09. 2. The nurse will explain methods to prevent injury and ways to prevent falls by 1200 on 10/30/09. 3. The nurse will scan the clients environment each time she enters the room for any safety issues that could harm the client or cause a fall on 10/30/09. 4. The nurse will routinely assist the client with toileting when the client requests the need to go or check q2h to see if the client needs to go on 10/30/09. 5. The nurse will check the walker assigned to the client fits and has no defects present by 0900 on 10/30/09. (Lemone & Burke 2009)., III. Focused Assessment 1.VS HR 72 , O2 100 (room air), Temp 97.9, Resp 20, pulse 72, and B/P 116/70 2. Clear Liquid diet 3. Confused on and off especially during the night 4. Currently no bloody stool 5. Row Belt for confusion during the night 6. 22 LFA NS 100 ml/hr 7. Forgot birthday and where he was 8. Does a tripping type motion with his walk Generate Nursing Diagnosis IV. Secondary Nursing Diagnosis 2. Acute confusion r/t unknown etiology aeb fluctualion in cognition such as location, time, and date of birth. Define: Abrupt onset of reversible disturbances of consciousness attention, cognition, and perception that develop over a short period of time. 3. Activity intolerance r/t anemia and fatigue aeb tiring easily with minimal activity. define: Insufficient physiological or psychological energy to endure or complete required daily activiities. 4. Fear r/t hospitalization aeb verbally stating concerns about his health. Define: Response to perceived threat that is consciously recognized as danger. (Wilkenson & Ahern 2009), IV. Priority Nursing Diagnosis Risk for falls r/t acute confusion aeb wandering and not steady on his feet. Define: Increased susceptibility to falling that may cause physical harm. (Wilkenson & Ahern 2009) Expected Outcomes V. Expected Outcomes 1. The client will remain free of falls aeb not falling during the shift from 7 a.m. to 12 p.m. on 10/30/09. 2. The client will explain methods to prevent injury aeb giving examples of ways to prevent falls or getting rid of throw rugs as a safety precaution by 1200 on 10/30/09. 3. The client will maintain a safe environment aeb eliminating clutter and spills by 1200 on 10/30/09. 4. The client will use his call light to ask for assistance when he feels the urge to go to the bathroom aeb pressing his call light on 10/30/09. 5. The client will use assistance device as needed such as a walker whenever transporting on 10/30/09., I.Patients Info & Medical Diagnosis S.O. age 86 year old white male Medical Diagnosis: 1. GI bleed affects II. Pathophysiology GI Bleed 1. Blood in the GI tract is irritating to the stomach, and typically leads to nausea and vomiting (Hematemasis, Vomiting blood). 2. If the blood has been present in the stomach for a period of time and is partially digested, it may have a "coffee-grounds" appearance, rather than presenting as bright red blood. 3. Stools may be black and tarry (melena) or frankly bloody (hematochezia); stools containing partially digested blood has a characteristic odor. 4. No visible blood may be present in the stool, occult (or hidden) bleeding may be detected by chemical means. (Lemone & Burke, 2008), III. Focused Assessment 1.VS HR 72 , O2 100 (room air), Temp 97.9, Resp 20, pulse 72, and B/P 116/70 2. Clear Liquid diet 3. Confused on and off especially during the night 4. Currently no bloody stool 5. Row Belt for confusion during the night 6. 22 LFA NS 100 ml/hr 7. Forgot birthday and where he was 8. Does a tripping type motion with his walk Generate Nursing Diagnosis IV. Priority Nursing Diagnosis Risk for falls r/t acute confusion aeb wandering and not steady on his feet. Define: Increased susceptibility to falling that may cause physical harm. (Wilkenson & Ahern 2009), VI. Interventions 1. The nurse will determine risk of falling by using an evaluation tool by 0900 on 10/30/09. 2. The nurse will explain methods to prevent injury and ways to prevent falls by 1200 on 10/30/09. 3. The nurse will scan the clients environment each time she enters the room for any safety issues that could harm the client or cause a fall on 10/30/09. 4. The nurse will routinely assist the client with toileting when the client requests the need to go or check q2h to see if the client needs to go on 10/30/09. 5. The nurse will check the walker assigned to the client fits and has no defects present by 0900 on 10/30/09. (Lemone & Burke 2009). ???? VI. Rational 1. Risk factors for falling include recent history of falls, confusion, depression, altered elimination patterns, and dizziness. Identifying risk for falls allows for precautions to be taken to prevent the fall from occuring. 2. Explaining methods and providing education to the client allows the client to take precautions to prevent falls from occuring. 3. Scanning the environment for safety issues or anything that could cause a fall prevents harm and/ or falls for the client. Prevention is key to safety. 4. Always take the client to the bathroom on awakening, before bedtime, and whenever requested by the patient prevents the patient from trying to go by himself thus preventing falls. 5. Checking the walker for any defects and that it is properly fitted to the client prevents accidents and/or falls from occuring. (Lemone & Burke 2009), IV. Secondary Nursing Diagnosis 2. Acute confusion r/t unknown etiology aeb fluctualion in cognition such as location, time, and date of birth. Define: Abrupt onset of reversible disturbances of consciousness attention, cognition, and perception that develop over a short period of time. 3. Activity intolerance r/t anemia and fatigue aeb tiring easily with minimal activity. define: Insufficient physiological or psychological energy to endure or complete required daily activiities. 4. Fear r/t hospitalization aeb verbally stating concerns about his health. Define: Response to perceived threat that is consciously recognized as danger. (Wilkenson & Ahern 2009) Prioritized to IV. Priority Nursing Diagnosis Risk for falls r/t acute confusion aeb wandering and not steady on his feet. Define: Increased susceptibility to falling that may cause physical harm. (Wilkenson & Ahern 2009), I.Patients Info & Medical Diagnosis S.O. age 86 year old white male Medical Diagnosis: 1. GI bleed assess III. Focused Assessment 1.VS HR 72 , O2 100 (room air), Temp 97.9, Resp 20, pulse 72, and B/P 116/70 2. Clear Liquid diet 3. Confused on and off especially during the night 4. Currently no bloody stool 5. Row Belt for confusion during the night 6. 22 LFA NS 100 ml/hr 7. Forgot birthday and where he was 8. Does a tripping type motion with his walk