NUR 101 Clinical Concept Map (Clinical Worksheet page 1)

NUR 101 Clinical Concept Map

NUR 101 Clinical Area – Student use ACTUAL data findings … Assess the patient. Develop one physiological/psychosocial nursing diagnosis- all parts of nursing diagnosis

NUR 101 Clinical Concept Map (Clinical Worksheet page 2)

Utilize the nursing diagnoses/Label on page 1 that you developed. Identify appropriate nursing interventions. This is your basis of your homework.

Actual Nursing Diagnosis/Problem/Label

NUR 101 Clinical Concept Map

Actual Nursing Diagnosis/Problem/Label (Second Physiological) Risk for impaired tissue integrity related to damage to the subcutaneous tissue secondary to surgical procedure

Goal: Patient will express willingness to participate in prevention of pressure ulcers while under my care

Interventions:

  1. Assess the condition of the tissue for and sign of inflammation
  2. Assess the characteristic of the wound, including color, size, drainage and
  3. Discourage rubbing or scratching
  4. Encourage a diet that meets nutritional needs
  5. Assess blood supple and sensation of affected area
  6. Encourage highest degree of mobility to avoid prolonged periods of

8..Assist with and encourage position changes. 9 Monitor labs studies for changes indicative of healing.

10 Collaborate with healthcare providers as indicated

9Evaulate skin and mucous membrane for hydration status and the degree of edema

  1. Protect tissue from pressure (drains, tubes, dressings).
  2. Protect tissue from pressure (drains, tubes, dressings).
  3. Frequently supplement full-body turns with minor shifts in body weight.

Fall 2019/Spring 2020 NUR101

(Psychosocial cultural) Disturbed sleep pattern related to inability to maintain sleep

Goal: Patient will verbalize 1 way to help improve her sleep pattern while under my care

Interventions:

  1. Assess for signs of new onset of depression: depressed mood state
  2. Observe client’s medication, diet, and caffeine Look for hidden sources of caffeine, such as over-the- counter medications.
  3. Provide pain relief shortly before bedtime and position client comfortably for
  4. Refer to physician or sleep specialist as indicated for specific interventions.
  5. Reduce daytime napping in the late afternoon; limit naps to short intervals as early in the day as possible
  6. Assess the patient usual bedtime routine and sleep environment
  7. Review patient regular medications which may interfere with the patient normal sleep wake cycle
  8. Assist the patient to identify ways to modify the sleep environment Room lighting, background noise, room temp.
  9. Listen to reports of sleep quality (e.g., “short, interrupted”) and response from lack of good sleep (e.g., feeling foggy, sleepy, and woozy; fighting sleep; fatigue).
  10. Manage environment for hospitalized client : Adjust ambient
  11. Provide privacy as indicated, such as closing room door, “quiet, patient sleeping” sign, etc.
  12. Encourage usual bedtime activities such as washing face and hands and brushing teeth.
  13. Provide HS care such as straightening bed sheets, changing damp linens or gown, back massage to promote physical comfort.
  14. Turn on soft music, calm TV program, or quiet environment, as client prefers, to enhance
  15. Minimize sleep-disrupting factors (e.g., shut room door, adjust room temperature as needed, reduce talking and other disturbing noises such as phones, beepers, alarms).

Explain how the focused Nursing Diagnosis relates to the patient problem(s)

(How the medical diagnosis (secondary to) connects to the (related to) and how that relates to the nursing diagnosis/problem)-use text for rationale. Start with the medical diagnosis- secondary to)

A herniated disk occurs when all or part of the nucleus pulposus (the soft, gelatinous, central portion of an intervertebral disk) forces through the weakened or torn anulus fibrosus (DiGiulio & Jackson, 2007, p.709). A herniated lumbar disk produces low back pain accompanied by varying degrees of sensory and motor impairment ( Hinkle & Cheever, 2017, p. 2001).

The patient may also experience motor and sensory loss in the area innervated by the compressed spinal nerve root and, in later stages, weakness and atrophy of leg muscles (DiGiulio & Jackson, 2007, p.709). According to Hinkle & Cheever (2017), “a herniated disk with accompanying pain may occur in any portion of the spine: cervical, thoracic (rare), or lumbar. In the lumbar region, surgical treatment includes lumbar disk excision through a posterolateral laminectomy and the newer techniques of micro discectomy and percutaneous discectomy ( Hinkle & Cheever, 2017, p.2001 NUR 101 Clinical Concept Map).

Laminectomy, the most common procedure, involves excision of a portion of the lamina and removal of the protruding disk (DiGiulio & Jackson, 2007, p.701). In laminectomy, the surgeon removes one or more of the bony lam-inae that cover the vertebrae to relieve pressure on the spinal cord or spinal nerve roots resulting from a herniated disk (DiGiulio & Jackson, 2007, p.709). Spinal fusion may be necessary to overcome segmental instability if laminectomy doesn’t alleviate pain and disability. (DiGiulio & Jackson, 2007, p.712)

My patient has acute pain related to her surgical incision because there was danage done to the tissue by the insicion to perfore the laminectomy therefore the herniaqted disc was the cause of the patient having which cause the acute oain /

Collaborative/Interprofessional Care: What interdisciplinary members of the health care team did you speak/interact with and what did you learn?

I would have like to collaborate with pain management if my patient pain was sever and not relieved by pharmacological and non- pharmacological methods. I would also like to have collaborated with the nutritionist , because patient is diabetic and glucose is elevated to ensure proper would healing and check additional baseline of additional labs

 Focused Nursing Diagnosis:           Acute pain related to surgical incision secondary to herniated disc 

Defining Characteristics as per Davis Nurse’s Pocket Guide:

Unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Sudden or slow onset of any intensity from mild to severe and with a duration of less than 3 months. NUR 101 Clinical Concept Map

Utilize the information on page 1 and 2 to fill in information below. Briefly explain why/how the nursing intervention helps achieve the goal. Include any new interventions utilize. Insert and document patient’s actual response to the plan of care (compare and contrast to prior patient data and/or norms). Evaluate and summarize patient’s outcome.
Patient Outcome/Goal: Patient will verbalize a decrease and improvement in pain less than 4/10 on a pain scale of 0-10, while under my care .
Nursing Interventions: Perform a comprehensive assessment of pain to include location, characteristic, onset, duration, frequency, quality, intensity, severity and precipitating factors of pain. 

 

 

Scientific rationale

Accurate pain assessment is essential for effective pain management. Given the highly subjective and individually unique nature of pain, a comprehensive

 Actual patient response: My patient pain was assess using OLDCARTS. She described her pain as a sharp, radiating pain in her back at the incisional site that is uncomfortable when she moves. Patient JM pain started after surgery and she rated her pain on a rating scale of 0-10, 3/10 after her medication was administered. 

 

 

 

 

Evaluation: It was important for me as a nurse to assess my patient pain so
assessment of the pain experience provides the necessary foundation for optimal pain control. It is important to base clinical decision making on client assessment versus relying only on a severity rating score. For clients experiencing severe acute pain, the nurse may focus only on location, quality, and severity, and provide interventions to control the pain before conducting a more detailed evaluation. A simple screening question such as “Are you experiencing any discomfort right now?” will usually be adequate. 

 

(Berman, Frandsen, & Snyder,  p)

 that I can know what interventions to provide to her to control her pain. Patient evaluation was based on the subjective date which will now determine the appropriate intervention to relieve her pain.
Nursing Interventions: Administer pain medication before activity to increase participation and before pain gets severe. 

Scientific rationale: Providing an analgesic before the onset of pain is preferable to waiting for the client to report pain, when a larger dose may be required. A preventive approach to pain management involves the provision of measures to treat the pain before it occurs or before it becomes severe. Nurses can use a preemptive approach by providing an analgesic around the clock (ATC), and supplementing with as-needed (prn) doses after surgery

 

 

(Author, 652      )

 Actual patient response: Upon arrival on the unit my patient was administered pain medication by the primary RN. After assessing her pain intensity, which was a 2/10, patient requested to go for a walk which I assisted her with. 

 

 

 

 

Evaluation: My patient walked one lap around the unit and tolerated this activity with no complications or complaint about pain. It was important for her to receive pain medication before ambulating so that the activity can be tolerated with minimum discomfort. An acceptable level of pain was maintained with a combination of other medication like Tylenol and gabapentin. NUR 101 Clinical Concept Map
Nursing Interventions: Asses and monitor all vital sign for signs of Actual patient response: My patient vital signs was taken 2 hours after
pain. Including increase HR,BP and Respiration every 2-4 hours  

Scientific rationale: Physiologic responses vary with the origin and duration of the pain. Early in the onset of acute pain, the sympathetic nervous system is stimulated, resulting in increased blood pressure, pulse rate, respiratory rate, pallor, diaphoresis, and pupil dilation. The body does not sustain the increased sympathetic function over a prolonged period and, therefore, the sympathetic nervous system adapts, causing the responses to be less evident or even absent. Physiologic response are likely to be seen in patient with acute pain because of the sympathetic nervous system adaption

 

 

 

 

(Author, p     )

 ambulating. At 20:00 her vital sign was recorded as follows: T=98.6, P-98,R- 16, Bp- 126/57, Spo2- 95%, Pain 3/10. Her skin was cool to touch. 

 

 

 

Evaluation: All my patient vital sign was within normal ranges except for her BP which was slightly abnormal but not elevated. Her vital indicated to me that my patient was not experiencing any symptoms of severe pain and that her pain was indeed mild.
Nursing Interventions:. Observe patient for nonverbal indicators of pain , including guarding ,moaning and grimacing and crying  

Scientific rationale: There are wide variations in nonverbal responses to pain. Facial expression is often the first indication of pain, and it may be the only one. Clenched teeth, tightly closed eyes, rapid blinking, biting of the lower lip, and other facial grimaces may indicate pain.

Vocalizations such as sighing, moaning and groaning, crying, and screaming are sometimes associated with pain. Immobilization of the body or a part of the body

may also indicate pain. The client with chest pain often holds the left arm across the chest. Purposeless body

 Actual patient response: My patient nonverbal indicator of discomfort was guarding when getting in and out of the bed. Other than that she showed no facial expression of pain nor did she cry or moaned. When patient was walked there was no indicators of pain but when she sat on the bed there was facial expressions seen 

 

 

 

 

Evaluation: My patient was very verbal and responded to all question asked. She did not show any indicators of pain
movements can also indicate pain—for example, tossing and turning in bed or flinging the arms about. It is important to note that  because  behavioral  responses are controllable, they may not be very revealing.  

 

 

 

 

(Author, p     )
Nursing Interventions: Provide and educate patient and caregiver non pharmacological measures including repositioning techniques such as relaxation, guided imagery, distraction, music therapy, massage, heat, and cold. 

 

Scientific rationale: NSAID work in peripheral tissue. Some blocks the synthesis of prostaglandin which stimulate nociceptors. They are effective in managing mild to moderate pain. The use of mental picture or an imagined event involves use of five senses to distract oneself from painful stimuli. The techniques heighten ones concentration upon nonpainful stimuli to decrease ones awareness and experience of pain. Heat reduces pain through improved blood flow to the area and through reduction of pain reflexes. Cold reduces pain inflammation and muscle spasticity by decreasing the release of pain inducing chemicals and slowing the conduction of pain impulses

 

 

 

(Gulanick, myers, p 147      )

 Actual patient response: The patient room was quiet and the environment was also quit and clam .I I=did provide my patient with comfort measures , like change in position and the use of relation techniques like guided imagery . I also gave my patient so distraction activities such as watching television which she did 

 

 

 

 

Evaluation: I did educated my patient by teaching us to the use of guided imagery when she does feel pain. I told her to think of a island in the Caribbean on the beach under a coconut tree drinking a refreshing drink and that should minimized any discomfort that she may experience. She loved the thought of this idea and told me she will try it again
Nursing Interventions: Evaluate gender, cultural, societal, and religious factors that may influence the patient’s pain perception and response to pain relief Actual patient response: My patient is a 77 year old female, window who is of Catholic religion and a Italian background. She lives alone and enjoys sewing and furniture refurnish when she is not in pain. As per my patient she would
Scientific rationale: Previous pain experiences alter a client’s sensitivity to pain. Clients who have personally experienced pain or who have been exposed to the suffering of someone close to them are often more threatened by anticipated pain than those without a pain experience.

Ethnic background and cultural heritage are factors that can influence an individual’s reaction to pain and the expression of that pain.

Behavior related to pain is a part of the socialization process. For example, individuals in one culture may learn to be expressive about pain, whereas individuals from another culture may have learned to keep those feelings to themselves.

Nurses must recognize their own attitudes and expectations about pain. To provide culturally sensitive pain management, nurses must be aware of their own personal beliefs, values, and behaviors about pain, and subsequently, be open to the cultural effects of how clients perceive and react to pain.

 

(Author, p 635  NUR 101 Clinical Concept Map   )

 use OTC medication when at home to control her pain. Every time my patient pain was evaluated she gave me the same pain score and told me she wants to go home and hope that the doctor discharge her soon. 

 

 

 

 

 

 

 

 

 

 

Evaluation: I educated my patient on distraction methods that I can help her to relieve her pain without using OTC medication. Patient stated that her daughter lives 2 houses away from her and her sister also lives on the same block with her. Her family would regularly make sure she is doing fine and she has a dog who is her companion. My patient believed that enduring pain was a sign of strength and he tell me she have less pain then she can get discharge sooner. NUR 101 Clinical Concept Map
Nursing Interventions:   Establish a trusting relationship between the patient and the nurse 

 

 

Scientific rationale: Convey your concern, and acknowledge that you believe that the client is experiencing pain.

Saying “I believe you are in pain, and I am going to do

 Actual patient response: From the moment I enter the room, I introduced myself to the patient and explained to her what I will be doing for her throughout the night. She gave me a warm smile, was very friendly and welcoming. Every time I left the room and told her I would be right back, I did and she appreciated that and trust that I would.
whatever I can to help you” will promote this trusting relationship. A trusting relationship is essential for the effective assessment of the patient self-concept for providing help and support and motivating client behavior change. 

 

 

 

(Author, p 641     )

  Evaluation: My patient was very friendly, and was in a good mood. She opened up to me about her family, religion, her culture and her family. She seem very eggar to leave the hospital and go back to her ADL and doing what she loved the most which is sewing and spending time with her dog .
Nursing Interventions: Evaluate the effectiveness of the pain control measures used through ongoing assessment of patient pain experience 

Scientific rationale: To demonstrate improvement in the status or to identify worsening of underlying condition developing complications. Research shows the most common reason for unrelieved pain is failure to routinely assess pain and pain relief. Many patient silently tolerate pain if not specifically asked about it.

 

 

 

(Author, p     ) 635 doenges

 Actual patient response:  

 

 

 

Evaluation:
Nursing Interventions: Collaborate with pain management team if the patient pain is not relieve by medication. 

Scientific rationale: Pain management is the alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the client. Even if the original cause of the pain heals, the changes in the nervous system resulting from suboptimal pain management may  increase  the risk of the development of persistent or chronic pain.

Persistent pain also contributes to insomnia, weight gain or loss, constipation, hypertension, deconditioning,

 Actual patient response: My patient pain was relieve by the following medications: Gabapentin 300mg TID oral, (nerve pain) Oxycodone 5mg, q4h oral (moderate pain 4-6) severe pain (7-10) Dilaudid 0.5 ml q4h, prn injection for pain. 

 

 

 

 

Evaluation: There was not a need to collaborate with pain management because my patient pain remain at a mild level throughout my shift
chronic stress, and depression. These effects can interfere with work, recreation, domestic activities, and personal care activities to the point at which many sufferers question whether life is worth living. Effective pain management is an important aspect of nursing care to promote healing, prevent complications, reduce suffering, and prevent the development of incurable pain states. To be a true client advocate, nurses must realize their role as advocates for pain relief. Pain is more than a symptom of a problem; it can be a high-priority problem.

 

 

 

 

(Author, p     )
Nursing Interventions: Assess patient anxiety and fatigue level.  

Scientific rationale: Anxiety often accompanies pain. Prolonged anxiety associated with pain can lead to other emotional disturbances, such as depression or difficulty coping. Fear of the unknown and the inability to control the pain or the events surrounding it often raises pain perception. When clients are experiencing pain, they often become fatigued. Fatigue reduces a client’s ability to cope, thereby increasing pain perception. With anxiety, depression, and fatigue, sleep disturbances can occur. When pain interferes with sleep, fatigue and muscle tension often result and increase the pain; thus, a cycle of pain, fatigue, and increased pain develops.

 Actual patient response: Although mu patient did not show any signs of anxiety it was seen in her medical history she suffers from depression. Patient told me she lives alone and her husband is deceased. She had been suffering with her back pain for the last 21 years and this is her second surgery. She hopes with this surgery he is able to do the things she used to love doing before her back pain , like sewing which is a hobby of hers. NUR 101 Clinical Concept Map 

 

 

 

 

Evaluation: my patient did not show any clinical manifestations of anxiety. She did show some signs of fatigue, for example tiredness, restlessness and sleepiness after her walk she wanted to lay back in bed and watch television. Patient is currently taking medication for depression .If patient cannot sleep because of back pain then there is a possibility she will be depressed. She also complains of nocturia and polyuria which is also a contributing factor to her fatigue.
(Author, p 645      )
Overall Evaluation of Goal attainment (was the overall goal met/ not met/partially met and explain why or why not): Overall , I believe my goals has been achieved by assessing monitored observing , administering patient medication and preventing intense pain. I assessed her vital signs since, I administered her pain medication, I educated her on the use of non pharmocological method , I used distraction and guised imagery to lessen her pain and discomfort . The most important tool was establishing a therapeutic relationship with my patient to build trust and allow her to express any feeling or concern so that she is able to ask for pain mediation when her symptoms become worst .I patient pain remained at a level of 3/10.

NUR 101 Clinical Concept Map Reference List (APA format)

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