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Concept Map

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. Imbalanced Nutrition

. Imbalanced Nutrition

L
E
G
E
N
D
L
E
G
E
N
D

Age:
BP: 146/92
HR: 124
RR: 22
Temp: 37.9 C

Age:
BP: 146/92
HR: 124
RR: 22
Temp: 37.9 C

Nursing Dx
Related to
Assessment
Interventions
Outcomes
Nursing Dx
Related to
Assessment
Interventions
Outcomes

. Imbalanced Nutrition

. Imbalanced Nutrition

. Imbalanced Nutrition

. Imbalanced Nutrition

. Imbalanced Nutrition

. Imbalanced Nutrition

. Imbalanced Nutrition

. Imbalanced Nutrition

. Imbalanced Nutrition

. Imbalanced Nutrition

. Imbalanced Nutrition

. Imbalanced Nutrition

G
A
S
T
R
I
T
I
S
G
A
S
T
R
I
T
I
S
ALLER: PCN
ALLER: PCN Patient R. N Patient R. N

2. Anxiety

2. Anxiety

3. Imbalanced Nutrition

3. Imbalanced Nutrition

* Monitor for signs of malnutrition: brittle hair, bruises, dry skin, pale skin and conjunctiva and muscle wasting * Consult with dietician regarding diet * Utilize nutritional screening tool * Compare usual food intake with food guide pyramid * Monitor for signs of malnutrition: brittle hair, bruises, dry skin, pale skin and conjunctiva and muscle wasting * Consult with dietician regarding diet * Utilize nutritional screening tool * Compare usual food intake with food guide pyramid
1. Acute Pain
1. Acute Pain
R/t Inadequate intestinal absorption of nutrients
R/t Inadequate intestinal absorption of nutrients
Alcoholism,
Vitamin deficiencies,
2 duodenal ulcers,
4 episodes of pancreatitis and recurrent gastritis

Alcoholism,
Vitamin deficiencies,
2 duodenal ulcers,
4 episodes of pancreatitis and recurrent gastritis

Tylenol (Acetaminophen) 650mg IV
Tylenol (Acetaminophen) 650mg IV
.9 NS with Multi vitamin additive 100ml/hr IV
.9 NS with Multi vitamin additive 100ml/hr IV
Ativan (Lorazepam) 2mg IV push NOW
Ativan (Lorazepam) 2mg IV push NOW
The client will have no episodes of headache for the next 3 months.

The client will have no episodes of headache for the next 3 months.

The client will have pain level of o on the scale from 0/10 by the end of the day.

The client will have pain level of o on the scale from 0/10 by the end of the day.

* Assess complaints of pain * Maintain bed rest during the acute phase during the shift. * Neck and back massage * Quiet room, dim the lights * Relaxation techniques, leisure time activities * Eliminate / minimize vasoconstriction activity * Collaboration of analgesic drugs * Assess complaints of pain * Maintain bed rest during the acute phase during the shift. * Neck and back massage * Quiet room, dim the lights * Relaxation techniques, leisure time activities * Eliminate / minimize vasoconstriction activity * Collaboration of analgesic drugs
Patient will follow up with rehabilitation for alcohol within 3 months.
Patient will follow up with rehabilitation for alcohol within 3 months.
Patient will identify nutritional requirement by discharge.
Patient will identify nutritional requirement by discharge.
Patient will not have uncontrollable feelings of anxiety within the next 3 months.
Patient will not have uncontrollable feelings of anxiety within the next 3 months.
Patient will use effective coping mechanisms by discharge and relay a decrease in anxiety.
Patient will use effective coping mechanisms by discharge and relay a decrease in anxiety. * Assess clients level of anxiety and physical reactions to anxiety * Rule out withdrawal from alcohol, sedatives and smoking as current cause of anxiety * Identify, limit, discontinue or beware of the use of any stimulants * Intervene when possible to remove or provide reassurance in times of anxiety * Use therapeutic technique to calm anxiety * Inform patient of everything occurring to limit anxiety * Assess clients level of anxiety and physical reactions to anxiety * Rule out withdrawal from alcohol, sedatives and smoking as current cause of anxiety * Identify, limit, discontinue or beware of the use of any stimulants * Intervene when possible to remove or provide reassurance in times of anxiety * Use therapeutic technique to calm anxiety * Inform patient of everything occurring to limit anxiety
Forgetfulness, Restlessness,
Irritability, Confusion, change in LOC
Forgetfulness, Restlessness,
Irritability, Confusion, change in LOC
R/t health status
R/t health status
Vital Signs: HR 124, BP 146/92, RR 22, SpO2 92%
Pain: throbbing headache, started upon arrival to the hospital, duration 1 hour, location “left side of the back of the head”, the lights make HA worse

Vital Signs: HR 124, BP 146/92, RR 22, SpO2 92%
Pain: throbbing headache, started upon arrival to the hospital, duration 1 hour, location “left side of the back of the head”, the lights make HA worse

R/t Headache
R/t Headache Concept map

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