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This Concept Map, created with IHMC CmapTools, has information related to: Conceptmap1complex family pg 1, 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.Hemoglobin low 8.4 10. Confused on and off 4. Currently no bloody stool especially during the night 5. Stomach soft and non tender 11. Row Belt for confusion during 6.RBC low 2.72 night 7. Hct Low 23.9 8. Protime High 14.2 9. PTT Low 25 Generate Nursing Diagnosis IV. Secondary Nursing Diagnosis 2.Risk for falls r/t confusion aeb wandering and not steady on his feet. Define: Increased susceptibility to falling that may cause physical harm. 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), V. Expected Outcomes 1.The client will demonstrate restoration of cognitive status to baseline aeb not wandering and knowing where he is and why by 1200 on 10/30/09. 2. The client will correctly identify what month it is aeb stating it is October and when his birthday is aeb answering 04/24/1923 by 1200 on 10/30/09. 3. The client will demonstrate decreased restlessness and agitation aeb sleeping and acting in a calm and friendly manner by 1200 on 10/30/09. 4. The client will open his eyes to external stimuli aeb opening his eyes when staff knocks and enters the room on 10/30/09. 5. The client will be awake at appropriate times aeb being awake and talkative during daytime hours by 1200 on 10/30/09. Interventions & Rationals VI. Interventions 1. The nurse will assess the client's behavior and cognition systematically and continually q2h starting at 0600 on 10/30/09. 2. The nurse will provide reality orientation, including identifying self by name at each contact with the client, calling the client by the preferred name; using orientation techniques; providing clocks, calenders, and gently correcting misconceptions during each contact with the client on 10/30/09. 3. The nurse will modulate sensory exposure and establish a calm environment during each contact with the client on 10/30/09. 4. The nurse will use appropriate communication techniques for the client at risk for confusion including communicating clearly and providing simple explanations during each contact with the client on 10/30/09. 5. The nurse will plan care that allows for an appropriate sleep-wake cycle whenever providing care on 10/30/09. (Lemone & Burke 2009), VI. Interventions 1. The nurse will assess the client's behavior and cognition systematically and continually q2h starting at 0600 on 10/30/09. 2. The nurse will provide reality orientation, including identifying self by name at each contact with the client, calling the client by the preferred name; using orientation techniques; providing clocks, calenders, and gently correcting misconceptions during each contact with the client on 10/30/09. 3. The nurse will modulate sensory exposure and establish a calm environment during each contact with the client on 10/30/09. 4. The nurse will use appropriate communication techniques for the client at risk for confusion including communicating clearly and providing simple explanations during each contact with the client on 10/30/09. 5. The nurse will plan care that allows for an appropriate sleep-wake cycle whenever providing care on 10/30/09. (Lemone & Burke 2009) ???? VI. Rational 1. Rapid onset and fluctuating course are hallmarks of delirium. The confusion assessment method is sensitive, specific, reliable, and easy to use. 2. Use of reality orientation can help improve cognition in clients with acute confusion. 3. Extraneous lights and noise can give rise to agitation, especially if misperceived. Sensory overload or sensory deprivation can result in increased confusion. 4. Communicating clearly and providing simple explanations helps prevent acute confusion for clients who are at high risk for an episode to occur. 5. Disruptions in usual sleep and activity patterns should be minimized because those clients with nocturnal exacerbations experience more complications from delirium or confusion. (Lemone & Burke 2009), 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.Hemoglobin low 8.4 10. Confused on and off 4. Currently no bloody stool especially during the night 5. Stomach soft and non tender 11. Row Belt for confusion during 6.RBC low 2.72 night 7. Hct Low 23.9 8. Protime High 14.2 9. PTT Low 25, 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.Hemoglobin low 8.4 10. Confused on and off 4. Currently no bloody stool especially during the night 5. Stomach soft and non tender 11. Row Belt for confusion during 6.RBC low 2.72 night 7. Hct Low 23.9 8. Protime High 14.2 9. PTT Low 25 Generate Nursing Diagnosis IV. Priority Nursing Diagnosis Acute confusion r/t unknown etiology aeb fluctuation 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. (Wilkenson & Ahern 2009), IV. Priority Nursing Diagnosis Acute confusion r/t unknown etiology aeb fluctuation 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. (Wilkenson & Ahern 2009) Expected Outcomes V. Expected Outcomes 1.The client will demonstrate restoration of cognitive status to baseline aeb not wandering and knowing where he is and why by 1200 on 10/30/09. 2. The client will correctly identify what month it is aeb stating it is October and when his birthday is aeb answering 04/24/1923 by 1200 on 10/30/09. 3. The client will demonstrate decreased restlessness and agitation aeb sleeping and acting in a calm and friendly manner by 1200 on 10/30/09. 4. The client will open his eyes to external stimuli aeb opening his eyes when staff knocks and enters the room on 10/30/09. 5. The client will be awake at appropriate times aeb being awake and talkative during daytime hours by 1200 on 10/30/09., 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.Hemoglobin low 8.4 10. Confused on and off 4. Currently no bloody stool especially during the night 5. Stomach soft and non tender 11. Row Belt for confusion during 6.RBC low 2.72 night 7. Hct Low 23.9 8. Protime High 14.2 9. PTT Low 25 ???? III. Abnormal Assessment Findings 1. Neu High 76.5 2. Lym Low 9.7 3. Mono High 12.8 4. A positive for blood products 5. Fluconazole 100 mg 1 tab 6. Venofear IV for 3 days 7. 22 LFA NS 100 ml/hr 8. Possible flexible sigmoid maybe done 9. Anemia, 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), 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.Hemoglobin low 8.4 10. Confused on and off 4. Currently no bloody stool especially during the night 5. Stomach soft and non tender 11. Row Belt for confusion during 6.RBC low 2.72 night 7. Hct Low 23.9 8. Protime High 14.2 9. PTT Low 25, IV. Secondary Nursing Diagnosis 2.Risk for falls r/t confusion aeb wandering and not steady on his feet. Define: Increased susceptibility to falling that may cause physical harm. 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 Acute confusion r/t unknown etiology aeb fluctuation 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. (Wilkenson & Ahern 2009), V. Expected Outcomes 1.The client will demonstrate restoration of cognitive status to baseline aeb not wandering and knowing where he is and why by 1200 on 10/30/09. 2. The client will correctly identify what month it is aeb stating it is October and when his birthday is aeb answering 04/24/1923 by 1200 on 10/30/09. 3. The client will demonstrate decreased restlessness and agitation aeb sleeping and acting in a calm and friendly manner by 1200 on 10/30/09. 4. The client will open his eyes to external stimuli aeb opening his eyes when staff knocks and enters the room on 10/30/09. 5. The client will be awake at appropriate times aeb being awake and talkative during daytime hours by 1200 on 10/30/09. Evaluation VII. Evaluation of expected Outcomes 1. The client demenstrated restoration of cognition to baseline aeb not wandering and being able to identify where he was and why by 1200 on 10/30/09. Goal Met 2.The client correctly identified what month it was and correctly identified his birthday by answering 04/24/1923 by 1200 on 10/30/09. Goal Met. 3. The client demonstrated decreased restlessness and agitation by sleeping and while awake he was calm and very friendly by 1200 on 10/30/09. Goal Met. 4. The client opened his eyese or reacted when ever an external stimuli occured whether it was a nurse knocking before entering or an aid taking his vitals on 10/30/09. Goal Met 5. The client remained awake and very talkative during daytime hours during my shift from 7 a.m. to 12 p.m. on 10/30/09. Goal Met