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This Concept Map, created with IHMC CmapTools, has information related to: Chronic pain in a person with hx of addiction, Elimination and Exchange: Respiratory Function O2 sat 90%. COPD mild. Continues to smoke but has cut down from 2 PPD to 1/2 PPD. Voices desire to quit smoking. Has had 2 episodes of aspiration pneumonia in past year after eating late at night lying flat in bed. ???? Problem # 3 Risk for impaired gas exchange r/t over inflation of alveoli and behaviors that cause insult to lung tissue Outcomes: ST: Pt will elevate HOB within 2 days. IT: Pt will stop smoking within one month. LT: Will have no decrease in lung function at anytime within one year. Interventions: 1. Monitor respiratory status including O2 sat, rate and work of respiration, air movement, and lung sounds 2. Assist to find resources for smoking cessation such as stop smoking classes at the local hospital and free nicotine patches 3. Utilize behavioral motivation to stop smoking such as taking money that would be spent on tobacco to treat self to desired reward 4. Encourage elevation of HOB and to not eat within four hrs of bedtime to decrease aspiration risks 5. Encourage compliance with pulmonologists recommendations (Smeltzer, Bare, Hinkle, & Cheever, 2010)., Nutrition: Ingestion Has GERD and impaired pancreatic function. Takes digestive enzyme (zen-pep). On Nexium for GERD. Diet is too high in fat. Majority of calories come from sodas. BMI is 16.5 (underweight). Reports early satiety and lack of appetite. ???? Problem # 2 Imbalanced nutrition: Less than body requirements r/t impaired digestive enzyme production, poor food choices, poor appetite, and depressed mood. Outcomes: ST: Pt will identify 10 nutritious foods he likes within first day IT: Pt will have 5 lb. wt. gain within one month. LT: Pt will have BMI between 18-5 and 24.5 and will have CMP within normal limits within six months. Interventions: 1. Evaluate diet and labs in context to nutritional needs 2. Encourage Pt to participate in diet planning and incorporate Pt's favorite foods that meet healthful criteria. 2. Educate regarding proper dose, timing, and side effects of medications 3. Teach optimal food choices to meet nutritional needs 4. Discourage empty calories, foods high in fat, and foods high in acid 5. Encourage elevation of HOB to decrease gastric reflux 6. Encourage frequent small meals 7. Discourage eating less than four hrs before sleeping 8. Collaborate with MD and dietitian optimize nutrition (Smeltzer, et al., 2010), Coping/Stress Tolerance: Coping responses Reports sleeping more than 10 hours and low self esteem due to not working. Has depressed mood due to health, finances, and pain. ???? Problem # 4 Chronic sorrow r/t pain, poor health, and finances Outcomes: ST: Will identify 3 positive self attributes within 24 hrs IT: Will rate improvement of depression by at least 50% within 1 month LT: Will have complete resolution of depression within 6 mo. Interventions: 1. Assess level of depression and risk for self harm at least weekly 2. Refer to psychiatrist or psychiatric nurse practitioner treatment of depression and prescribe anti depressants as needed 3. Address self-esteem issues by: A. Facilitate Pt to process feelings using rational emotive therapy (Townsend, 2008). B. Encouraging Pt to identify positive characteristics and skills C. Exploring part time work opportunities that could be done on line as tolerated ( and that would not jeopardize social security/disability unless work could support Patient without SS/Disability) D. Encouraging to volunteer to help others as able 4. Teach budgeting and money management as needed. 5. Advocate for patient if stigmatized by health care providers (Townsend, 2008), Patient Data 60 y.o. divorced male with spinal stenosis causing neuropathy, osteo and rheumatoid arthritis, and neurofibromyalgia. Also has mild COPD, tobacco addiction, history of severe ETOH abuse with 10 yr sobriety, clinical depression, and pancreatic atrophy resulting in difficulties digesting fat. Ht 5'6', Wt. 105 #. Management of back pain is complicated and requires multiple treatment modalities (Falvo, 2008). Pain is frequently under treated in patients with a history of addiction (Baldacchno, Gilchrist, Fleming, & Bannister, 2010) ???? Problem # 4 Chronic sorrow r/t pain, poor health, and finances Outcomes: ST: Will identify 3 positive self attributes within 24 hrs IT: Will rate improvement of depression by at least 50% within 1 month LT: Will have complete resolution of depression within 6 mo. Interventions: 1. Assess level of depression and risk for self harm at least weekly 2. Refer to psychiatrist or psychiatric nurse practitioner treatment of depression and prescribe anti depressants as needed 3. Address self-esteem issues by: A. Facilitate Pt to process feelings using rational emotive therapy (Townsend, 2008). B. Encouraging Pt to identify positive characteristics and skills C. Exploring part time work opportunities that could be done on line as tolerated ( and that would not jeopardize social security/disability unless work could support Patient without SS/Disability) D. Encouraging to volunteer to help others as able 4. Teach budgeting and money management as needed. 5. Advocate for patient if stigmatized by health care providers (Townsend, 2008), Resources Recieves social security and Medicare due to disability. Family supportive and has many friends. Has computer skills and online access. ???? ????, Nutrition: Ingestion Has GERD and impaired pancreatic function. Takes digestive enzyme (zen-pep). On Nexium for GERD. Diet is too high in fat. Majority of calories come from sodas. BMI is 16.5 (underweight). Reports early satiety and lack of appetite. ???? Problem # 2 Imbalanced nutrition: Less than body requirements r/t impaired digestive enzyme production, poor food choices, poor appetite, and depressed mood. Outcomes: ST: Pt will identify 10 nutritious foods he likes within first day IT: Pt will have 5 lb. wt. gain within one month. LT: Pt will have BMI between 18-5 and 24.5 and will have CMP within normal limits within six months. Interventions: 1. Evaluate diet and labs in context to nutritional needs 2. Encourage Pt to participate in diet planning and incorporate Pt's favorite foods that meet healthful criteria. 2. Educate regarding proper dose, timing, and side effects of medications 3. Teach optimal food choices to meet nutritional needs 4. Discourage empty calories, foods high in fat, and foods high in acid 5. Encourage elevation of HOB to decrease gastric reflux 6. Encourage frequent small meals 7. Discourage eating less than four hrs before sleeping 8. Collaborate with MD and dietitian optimize nutrition (Smeltzer, et al., 2010), Problem # 4 Chronic sorrow r/t pain, poor health, and finances Outcomes: ST: Will identify 3 positive self attributes within 24 hrs IT: Will rate improvement of depression by at least 50% within 1 month LT: Will have complete resolution of depression within 6 mo. Interventions: 1. Assess level of depression and risk for self harm at least weekly 2. Refer to psychiatrist or psychiatric nurse practitioner treatment of depression and prescribe anti depressants as needed 3. Address self-esteem issues by: A. Facilitate Pt to process feelings using rational emotive therapy (Townsend, 2008). B. Encouraging Pt to identify positive characteristics and skills C. Exploring part time work opportunities that could be done on line as tolerated ( and that would not jeopardize social security/disability unless work could support Patient without SS/Disability) D. Encouraging to volunteer to help others as able 4. Teach budgeting and money management as needed. 5. Advocate for patient if stigmatized by health care providers (Townsend, 2008) ???? ????, Patient Data 60 y.o. divorced male with spinal stenosis causing neuropathy, osteo and rheumatoid arthritis, and neurofibromyalgia. Also has mild COPD, tobacco addiction, history of severe ETOH abuse with 10 yr sobriety, clinical depression, and pancreatic atrophy resulting in difficulties digesting fat. Ht 5'6', Wt. 105 #. Management of back pain is complicated and requires multiple treatment modalities (Falvo, 2008). Pain is frequently under treated in patients with a history of addiction (Baldacchno, Gilchrist, Fleming, & Bannister, 2010) ???? Problem # 3 Risk for impaired gas exchange r/t over inflation of alveoli and behaviors that cause insult to lung tissue Outcomes: ST: Pt will elevate HOB within 2 days. IT: Pt will stop smoking within one month. LT: Will have no decrease in lung function at anytime within one year. Interventions: 1. Monitor respiratory status including O2 sat, rate and work of respiration, air movement, and lung sounds 2. Assist to find resources for smoking cessation such as stop smoking classes at the local hospital and free nicotine patches 3. Utilize behavioral motivation to stop smoking such as taking money that would be spent on tobacco to treat self to desired reward 4. Encourage elevation of HOB and to not eat within four hrs of bedtime to decrease aspiration risks 5. Encourage compliance with pulmonologists recommendations (Smeltzer, Bare, Hinkle, & Cheever, 2010)., Comfort: Physical Comfort Rates pain 9 of 10, Best pain level in past 24 hr is 7 of 10, worst is 9 of 10. Cannot take NSAIDs due to stomach irritation and hx of bleeding ulcer. Family MD reluctant to order opioids due to fear of triggering ETOH use and aberrant drug seeking behaviors ???? Problem # 1 Chronic pain r/t multiple physiological insults and inadequate treatment. Outcomes: ST: Will rate pain 4 of 10 within 2 weeks IT: Will engage in 2 complementary therapies of Pt's preference within 1 month LT. Will not have relapse of ETOH use or engage in drug seeking behavior or misuse of prescribed medication at anytime in future Interventions 1. Refer to pain clinic 2. Contract to have one physician prescribe and manage pain medications 3. Encourage and teach complimentary therapies such as meditation, healing touch, and acupuncture/acupressure 4. Collaborate with physicians including family MD, pain specialist, and psychiatrist to optimize comfort and optimal medication regimen 5. Assess effectiveness of medical and non-pharmacological interventions and notify MD of pain not adequately controlled or mis-use of medications. (Falvo, 2008; Townsend, 2008), Problem # 1 Chronic pain r/t multiple physiological insults and inadequate treatment. Outcomes: ST: Will rate pain 4 of 10 within 2 weeks IT: Will engage in 2 complementary therapies of Pt's preference within 1 month LT. Will not have relapse of ETOH use or engage in drug seeking behavior or misuse of prescribed medication at anytime in future Interventions 1. Refer to pain clinic 2. Contract to have one physician prescribe and manage pain medications 3. Encourage and teach complimentary therapies such as meditation, healing touch, and acupuncture/acupressure 4. Collaborate with physicians including family MD, pain specialist, and psychiatrist to optimize comfort and optimal medication regimen 5. Assess effectiveness of medical and non-pharmacological interventions and notify MD of pain not adequately controlled or mis-use of medications. (Falvo, 2008; Townsend, 2008) ???? Problem # 4 Chronic sorrow r/t pain, poor health, and finances Outcomes: ST: Will identify 3 positive self attributes within 24 hrs IT: Will rate improvement of depression by at least 50% within 1 month LT: Will have complete resolution of depression within 6 mo. Interventions: 1. Assess level of depression and risk for self harm at least weekly 2. Refer to psychiatrist or psychiatric nurse practitioner treatment of depression and prescribe anti depressants as needed 3. Address self-esteem issues by: A. Facilitate Pt to process feelings using rational emotive therapy (Townsend, 2008). B. Encouraging Pt to identify positive characteristics and skills C. Exploring part time work opportunities that could be done on line as tolerated ( and that would not jeopardize social security/disability unless work could support Patient without SS/Disability) D. Encouraging to volunteer to help others as able 4. Teach budgeting and money management as needed. 5. Advocate for patient if stigmatized by health care providers (Townsend, 2008), Problem # 3 Risk for impaired gas exchange r/t over inflation of alveoli and behaviors that cause insult to lung tissue Outcomes: ST: Pt will elevate HOB within 2 days. IT: Pt will stop smoking within one month. LT: Will have no decrease in lung function at anytime within one year. Interventions: 1. Monitor respiratory status including O2 sat, rate and work of respiration, air movement, and lung sounds 2. Assist to find resources for smoking cessation such as stop smoking classes at the local hospital and free nicotine patches 3. Utilize behavioral motivation to stop smoking such as taking money that would be spent on tobacco to treat self to desired reward 4. Encourage elevation of HOB and to not eat within four hrs of bedtime to decrease aspiration risks 5. Encourage compliance with pulmonologists recommendations (Smeltzer, Bare, Hinkle, & Cheever, 2010). ???? Problem # 5 Fatigue r/t deconditioning of multiple chronic illnesses, poor nutrition, and depressed mood Outcomes: ST: Pt will identify one activity he is willing to engage in within one day IT: Pt will be able to tolerate walking two blocks within 3 weeks LT: Pt will engage in moderate activity for one hour four times a week within six months Interventions 1. Encourage Pt to comply with interventions to improve pain, nutrition, and chronic sorrow found elsewhere in this concept map 2. Encourage Pt to have evaluation from MD to assess which activity is safe for Pt to engage in 3. Facilitate Pt to identify two low impact exercises that are acceptable to him such as short walks with friends or family 4. Monitor tolerance to increased activity and instruct to stop and rest if physical distress occurs 5. Encourage increase in activity as stamina increases until Pt can tolerate a moderate level activity for one hour (Smeltzer, et al., 2010), Problem # 3 Risk for impaired gas exchange r/t over inflation of alveoli and behaviors that cause insult to lung tissue Outcomes: ST: Pt will elevate HOB within 2 days. IT: Pt will stop smoking within one month. LT: Will have no decrease in lung function at anytime within one year. Interventions: 1. Monitor respiratory status including O2 sat, rate and work of respiration, air movement, and lung sounds 2. Assist to find resources for smoking cessation such as stop smoking classes at the local hospital and free nicotine patches 3. Utilize behavioral motivation to stop smoking such as taking money that would be spent on tobacco to treat self to desired reward 4. Encourage elevation of HOB and to not eat within four hrs of bedtime to decrease aspiration risks 5. Encourage compliance with pulmonologists recommendations (Smeltzer, Bare, Hinkle, & Cheever, 2010). ???? Problem # 4 Chronic sorrow r/t pain, poor health, and finances Outcomes: ST: Will identify 3 positive self attributes within 24 hrs IT: Will rate improvement of depression by at least 50% within 1 month LT: Will have complete resolution of depression within 6 mo. Interventions: 1. Assess level of depression and risk for self harm at least weekly 2. Refer to psychiatrist or psychiatric nurse practitioner treatment of depression and prescribe anti depressants as needed 3. Address self-esteem issues by: A. Facilitate Pt to process feelings using rational emotive therapy (Townsend, 2008). B. Encouraging Pt to identify positive characteristics and skills C. Exploring part time work opportunities that could be done on line as tolerated ( and that would not jeopardize social security/disability unless work could support Patient without SS/Disability) D. Encouraging to volunteer to help others as able 4. Teach budgeting and money management as needed. 5. Advocate for patient if stigmatized by health care providers (Townsend, 2008), Activity Rest: Energy Balance Reports low energy. Tires with less than 30 min. of light activity. Driving more than 20 miles causes fatigue. Has pain, nerve damage, depression, malnutrition, and multiple chronic illnesses that impacts activity. ???? Problem # 5 Fatigue r/t deconditioning of multiple chronic illnesses, poor nutrition, and depressed mood Outcomes: ST: Pt will identify one activity he is willing to engage in within one day IT: Pt will be able to tolerate walking two blocks within 3 weeks LT: Pt will engage in moderate activity for one hour four times a week within six months Interventions 1. Encourage Pt to comply with interventions to improve pain, nutrition, and chronic sorrow found elsewhere in this concept map 2. Encourage Pt to have evaluation from MD to assess which activity is safe for Pt to engage in 3. Facilitate Pt to identify two low impact exercises that are acceptable to him such as short walks with friends or family 4. Monitor tolerance to increased activity and instruct to stop and rest if physical distress occurs 5. Encourage increase in activity as stamina increases until Pt can tolerate a moderate level activity for one hour (Smeltzer, et al., 2010), Patient Data 60 y.o. divorced male with spinal stenosis causing neuropathy, osteo and rheumatoid arthritis, and neurofibromyalgia. Also has mild COPD, tobacco addiction, history of severe ETOH abuse with 10 yr sobriety, clinical depression, and pancreatic atrophy resulting in difficulties digesting fat. Ht 5'6', Wt. 105 #. Management of back pain is complicated and requires multiple treatment modalities (Falvo, 2008). Pain is frequently under treated in patients with a history of addiction (Baldacchno, Gilchrist, Fleming, & Bannister, 2010) ???? Problem # 1 Chronic pain r/t multiple physiological insults and inadequate treatment. Outcomes: ST: Will rate pain 4 of 10 within 2 weeks IT: Will engage in 2 complementary therapies of Pt's preference within 1 month LT. Will not have relapse of ETOH use or engage in drug seeking behavior or misuse of prescribed medication at anytime in future Interventions 1. Refer to pain clinic 2. Contract to have one physician prescribe and manage pain medications 3. Encourage and teach complimentary therapies such as meditation, healing touch, and acupuncture/acupressure 4. Collaborate with physicians including family MD, pain specialist, and psychiatrist to optimize comfort and optimal medication regimen 5. Assess effectiveness of medical and non-pharmacological interventions and notify MD of pain not adequately controlled or mis-use of medications. (Falvo, 2008; Townsend, 2008), Problem # 4 Chronic sorrow r/t pain, poor health, and finances Outcomes: ST: Will identify 3 positive self attributes within 24 hrs IT: Will rate improvement of depression by at least 50% within 1 month LT: Will have complete resolution of depression within 6 mo. Interventions: 1. Assess level of depression and risk for self harm at least weekly 2. Refer to psychiatrist or psychiatric nurse practitioner treatment of depression and prescribe anti depressants as needed 3. Address self-esteem issues by: A. Facilitate Pt to process feelings using rational emotive therapy (Townsend, 2008). B. Encouraging Pt to identify positive characteristics and skills C. Exploring part time work opportunities that could be done on line as tolerated ( and that would not jeopardize social security/disability unless work could support Patient without SS/Disability) D. Encouraging to volunteer to help others as able 4. Teach budgeting and money management as needed. 5. Advocate for patient if stigmatized by health care providers (Townsend, 2008) ???? Problem # 5 Fatigue r/t deconditioning of multiple chronic illnesses, poor nutrition, and depressed mood Outcomes: ST: Pt will identify one activity he is willing to engage in within one day IT: Pt will be able to tolerate walking two blocks within 3 weeks LT: Pt will engage in moderate activity for one hour four times a week within six months Interventions 1. Encourage Pt to comply with interventions to improve pain, nutrition, and chronic sorrow found elsewhere in this concept map 2. Encourage Pt to have evaluation from MD to assess which activity is safe for Pt to engage in 3. Facilitate Pt to identify two low impact exercises that are acceptable to him such as short walks with friends or family 4. Monitor tolerance to increased activity and instruct to stop and rest if physical distress occurs 5. Encourage increase in activity as stamina increases until Pt can tolerate a moderate level activity for one hour (Smeltzer, et al., 2010), Patient Data 60 y.o. divorced male with spinal stenosis causing neuropathy, osteo and rheumatoid arthritis, and neurofibromyalgia. Also has mild COPD, tobacco addiction, history of severe ETOH abuse with 10 yr sobriety, clinical depression, and pancreatic atrophy resulting in difficulties digesting fat. Ht 5'6', Wt. 105 #. Management of back pain is complicated and requires multiple treatment modalities (Falvo, 2008). Pain is frequently under treated in patients with a history of addiction (Baldacchno, Gilchrist, Fleming, & Bannister, 2010) ???? Problem # 2 Imbalanced nutrition: Less than body requirements r/t impaired digestive enzyme production, poor food choices, poor appetite, and depressed mood. Outcomes: ST: Pt will identify 10 nutritious foods he likes within first day IT: Pt will have 5 lb. wt. gain within one month. LT: Pt will have BMI between 18-5 and 24.5 and will have CMP within normal limits within six months. Interventions: 1. Evaluate diet and labs in context to nutritional needs 2. Encourage Pt to participate in diet planning and incorporate Pt's favorite foods that meet healthful criteria. 2. Educate regarding proper dose, timing, and side effects of medications 3. Teach optimal food choices to meet nutritional needs 4. Discourage empty calories, foods high in fat, and foods high in acid 5. Encourage elevation of HOB to decrease gastric reflux 6. Encourage frequent small meals 7. Discourage eating less than four hrs before sleeping 8. Collaborate with MD and dietitian optimize nutrition (Smeltzer, et al., 2010), Patient Data 60 y.o. divorced male with spinal stenosis causing neuropathy, osteo and rheumatoid arthritis, and neurofibromyalgia. Also has mild COPD, tobacco addiction, history of severe ETOH abuse with 10 yr sobriety, clinical depression, and pancreatic atrophy resulting in difficulties digesting fat. Ht 5'6', Wt. 105 #. Management of back pain is complicated and requires multiple treatment modalities (Falvo, 2008). Pain is frequently under treated in patients with a history of addiction (Baldacchno, Gilchrist, Fleming, & Bannister, 2010) ???? Problem # 5 Fatigue r/t deconditioning of multiple chronic illnesses, poor nutrition, and depressed mood Outcomes: ST: Pt will identify one activity he is willing to engage in within one day IT: Pt will be able to tolerate walking two blocks within 3 weeks LT: Pt will engage in moderate activity for one hour four times a week within six months Interventions 1. Encourage Pt to comply with interventions to improve pain, nutrition, and chronic sorrow found elsewhere in this concept map 2. Encourage Pt to have evaluation from MD to assess which activity is safe for Pt to engage in 3. Facilitate Pt to identify two low impact exercises that are acceptable to him such as short walks with friends or family 4. Monitor tolerance to increased activity and instruct to stop and rest if physical distress occurs 5. Encourage increase in activity as stamina increases until Pt can tolerate a moderate level activity for one hour (Smeltzer, et al., 2010), ???? ???? Problem # 4 Chronic sorrow r/t pain, poor health, and finances Outcomes: ST: Will identify 3 positive self attributes within 24 hrs IT: Will rate improvement of depression by at least 50% within 1 month LT: Will have complete resolution of depression within 6 mo. Interventions: 1. Assess level of depression and risk for self harm at least weekly 2. Refer to psychiatrist or psychiatric nurse practitioner treatment of depression and prescribe anti depressants as needed 3. Address self-esteem issues by: A. Facilitate Pt to process feelings using rational emotive therapy (Townsend, 2008). B. Encouraging Pt to identify positive characteristics and skills C. Exploring part time work opportunities that could be done on line as tolerated ( and that would not jeopardize social security/disability unless work could support Patient without SS/Disability) D. Encouraging to volunteer to help others as able 4. Teach budgeting and money management as needed. 5. Advocate for patient if stigmatized by health care providers (Townsend, 2008)