I.

Concept Map Care Plan

1. Altered Fluid &
Electrolyte Imbalance
A: vomiting
- Recent NPO status
- drainage from recent NG
tube
- drainage from wound
- current full liquids diet
- post Sx lab results indicates
electrolyte imbalance
- metabolic alkalosis r/t
vomiting & NG tube drainage
- FBG: 151
- BMI: 34.5
Meds: TPN
- NS IV

9. Anxiety
A: post operation
- verbalized difficulty sleeping
- stated she was anxious.
- abd pain 9/10
Meds: PRN: 1mg Lorazapam tab
PO Q4H

8. Ineffective Breathing
Pattern
A: Abd incision pain
- abd distention
- tachycardia
- tachypnea
- dyspnea
- SOB
Tx: Turn, cough & deep
breathe Q2H
- Use IS
- Position with pillows as
needed.
- Splint abd incision by using
hands or a pillow.
- Ambulate in hallway TID
- Up in chair BID
- HOB elevated at least 30
degrees.
Meds: O2 as needed

Sheryl Sato

2. Deficit Fluid Volume

A: Blood loss from Sx
- Wound drainage
- Recent NPO status
- Drainage from recent NG tube
- Vomiting
- Dry skin
Tx: Provide oral fluids, as
allowed.
- Oral hygiene
Meds: NS IV
- PRN: 4mg Ondansetron inj. Q4H
MHx: nephrolithiasis
- Ureteroscopy c laser lithotripsy

Chief Medical Dx: Small

Bowel Obstruction/ Post-Op
Priority Assessments:
Pain, N/V, bowel distention,
bowel sounds, return of
flatus, wound drainage &
I&O.

7. Altered Bowel Elimination:

Post-operative ileus
A: hypoactive BS on auscultation
- No stooling or flatus
- Report of bloated feeling
- abd distention
Tx: Ambulate in hallway TID
- Encourage increased fluid
intake, unless contraindicated.
Meds: 8.6/50mg Sennosides/
Docusate Sodium BID

3. Pain
A: Abd surgical wound
- Rates pain btwn 8-9/10
Tx: Frequent position changes
- Healing Touch
Meds: 1,000mg Acetaminophen IV
Q6H
- PRN: 4mg Dilaudid tab PO Q4H
- PRN: 1-2mg Dilaudid inj. with
dressing changes.
MHx: Recurrent SBO
- Chronic Pain Syndrome
- Nephrolithiasis

4. Infection
A: WBC: 12.05
- 4+ Staph Aureus
- 4+ Strep Group B
Meds: 600mg Clindamycin IVPB
Q8H
- Topical Dakins 0.25% sol.

5. Impaired Skin Integrity

A: Abd surgical wound
- 4cm & 5cm tunneling at distal
ends of wound
- c/o itchiness to wound
Tx: W2D dressing change TID
- Keep HOB elevated 30 degrees.
- Splint abd wound by using hands or
a pillow before coughing.
Meds: PRN: 25mg diphenhydramine
cap BID
MHx: Ventral hernia, enterostomy &
tubal ligation

6. Imbalanced Nutrition:
Less Than Body
Requirements
A: post-laparoscopy
- Recent NPO status
- albumin: 3.1
- Trace of Ketones in urine
Meds: TPN: Standard
Formula @70mL/hr.
- Fat Emulsions (Intralipid)
20% 240mL 2x/wk.

II. Nursing Outcomes & Interventions

Desired Outcomes
1. Altered Fluid & Electrolyte
Imbalance:
1. The patient will not experience
fluid volume deficit, hypokalemia,
hypochloremia, hypomagnesemia &
acid-base imbalance as evidenced by
normal skin turgor, moist mucous
membranes, stable weight, BP & HR
within normal range, cap refill time
less than 3 seconds, balanced I&O,
urine specific gravity within normal
range, return of peristalsis within
expected time, usual mental status,
absence of cardiac dysrhthmias,
twitching, muscle weakness,
paresthesias, dizziness, headache,
N/V and BUN, serum electrolytes &
blood gases within normal range.

2. Deficient Fluid Volume:

1. Patient is normovolemic, as
evidenced by stable blood pressure
at or above 90/60 mmHg, heart rate

Interventions
1. Assess for S&S of fluid volume
deficit (decreased skin turgor, dry
mucous membranes, thirst, sudden
weight loss of 2% or greater, postural
hypotension or low BP, weak &
thready pulse, cap refill time >3
seconds, change in mental status
and elevated BUN.
2. Assess for S&S of hypokalemia
(cardiac dysrhythmias, postural
hpotension, muscle weakness, N/V,
continued abd distention, hypoactive
or absent BS and low serum
potassium.
3. Assess for hypochloeia &
metabolic alkalosis (dizziness,
irritability, paresthesias, muscle
twitching or spasms, hypoventilation,
low serum chloride, elevated pH &
TCO2.
4. Administer Protonix (and
Ondansetron PRN)as scheduled to
prevent N/V.
5. Perform actions to reduce fever if
present (administer antypyretics,)
sponge client with tepid water,
remove excessive clothing or
bedcovers, in order to prevent
diaphoresis & subsequent loss of
fluid.
6. Measure drainage (pt had NG tube
before) & administer replacement
fluids as ordered.
7. Adminiser fluid & electrolyte
replacements (NS IV & TPN.)
8. Maintain a fluid intake of at least
2,500 mL/day, unless
contraindicated.
1. Monitor & report any postoperative
bleeding (intraabdominal,
intraluminal & incisional.)
2. Assess hydration status by
monitoring BP & HR and checking

of 60-100 bpm, urine output of at

least 30mL/hr & good skin turgor.

mucouus membranes, skin turgor

and thirst.
3. Monitor urine output.
4. Monitor, record & report output of
emesis, NG tube output, output from
wound dressing & prior wound vac.
5. Monitor Hgb & Hct & coagulation
profile.
6. Administer IV fluid as ordered; be
prepared to increase fluids if signs of
fluid volume deficit appear.
7. Provide oral fluids of patients
choice, as allowed.
8. Provide oral hygiene every 4
hours.
3. Pain:
1. Assess the location, quality, onset,
frequency, radiation & duration of
1. Patient reports satisfactory pain
pain. Have the patient rate pain
control at a level less than 3-4 on a 0- intensity on a scale.
10 rating scale.
2. Assess for abd distention. Check
2. Patient uses both pharmacological abd for rigidity (hard, boardlike) &
& nonpharmacological pain relief
rebound tenderness.
strategies.
3. Assist the patient to a comfortable
position. (Usually semi-Fowlers is
the most comfortable.)
4. Administer pain medication
(1,000mg Acetaminophen & PRN
Dilaudid,) before pain becomes too
severe.
5. Use nonpharmacological treatment
measures (Healing Touch.)
4. Infection:
1. Monitor temperature.
2. Monitor WBC count. (Current WBC
1. Patient is free of infection as
is 12.05.)
evidenced by healing wound that is
3. Assess wound for redness,
clean, dry, well approximated, free of drainage, swelling & increased pain.
redness, swelling, purulent discharge 4. Assess all IV sites for redness,
& pain.
sweling, warmth purulent drainage &
2. Venous access sites free of
pain.
redness & purulent drainage.
5. Assess color, clarity & odor of
3. WBCs within normal range.
urine.
4. Clear breath sounds without cough 6. Obtain specimens of wound
or sputum production.
drainage, sputum, blood & urine in
sterile containers.
7. Assess quality of breath sounds,
cough & sputum production.

5. Impaired Skin Integrity:

1. Patient has intact open wound
without complications such as fistula.

6. Imbalanced Nutrition: Less

Than Body Requirements:
1. The patient will gain 2lbs and have
intact mucus membranes in 7 days.
2. The patient will have albumin
levels between 3.8-4.5dL.
3. The patient will have no ketones
in the urine.

8. Wash hands before contact with

postoperative patient.
9. Encourage adequate nutritonal
intake.
Educate the patient & family on the
S&S of infection: elevated tempeatre,
redness, swelling of the incisional
area & purulent or fowl-smelling
wound drainage,
10. Administer abx (Clindamycin) and
antipyretics (Acetaminophen) as
prescribed.
11. Change abd wound dressing TID
with packed wet Dakins solution
dressing.
1. Assess wounds & dressings for
suspicious drainage.
2. Prevent strain on the abd wound
by keeping HOB elevated 30 degrees.
3. Encouage pt to splnt the incision
with pillow or hands before coughing.
4. Educate the pt to spling the
incision wen transfering from bed to
chair or when getting up to
ambulate.
5. Change abd wound dressing TID
with packed wet Dakins solution
dressing.
6. Administer 25mg
Diphenhydramine cap PRN for
itching.
1. Daily weight
2. Monitor lab values that indiacte
nutritional well-being or
deterioration: Serum albumin,
Transferrin, RBC & WBC counts and
serum electrolytes.
3. Monitor ketones in urine.
4. Involve patient in all aspects of
their nutritional care.
5. Strict I&O
6. Administer TPN & lipids for
nutritional support, as appropriate.
7. Patient on full liquid diet. Provide
a pleasant environment & facilitate
proper position.

7. Altered Bowel Elimination:

Post-Operative Ileus:
1. Display active bowel sounds/
peristaltic activity.
2. Maintain usual pattern of
elimination.

8. Ineffective Breathing Pattern:

1. The patient will maintain an
effective breathing pattern, as
evidenced by relaxed breathing at
normal rate and depth and absence
of dyspnea.

8. Provide oral hygiene.

9. Encourage exercise (ambulation.)
1. Auscultate bowel sounds every 8
hours while the persn is awake.
2. Assess the abdomen for distention.
(A distended abd with absent or highpitched bowel sounds may indicate
paralytic ileus.)
3. Determine whether the person is
passing flatus.
4. Monitor for passage of stool,
including amount & consistency.
5. Encourage early ambulation within
prescribed limits.
6. Encourage adequate fluid intake,
including fruit juices.
7. Provide privacy when the person is
using the bathroom.
8. Administer medication (8.6/50mg
Sennosides/ Docusate Sodium,) BID
as ordered.
1. Assess RR , rhythm, depth, O2 sat
& monitor breathing patterns.
2. Assess for abdominal pain &
distention.
3. Assess for use of accessory
muscles (scalene &
sternocleidomastoid.)
4. Inquire about preipitating &
allevitating factors.
5. Assess level of anxiety, changes in
LOC, skin color & temperature.
6. Assess nutritional status (weight,
albumin & electrolytes.)
7. Position the pt with proper body
alignment for optimal breathing
pattern (HOB 30 degrees or higher)
and use pillows as needed every 2
hours.
8. Maintain O2 sat at or above 90%.
9. Encourage sustained deep breaths
by using demonstration &/or use of
the incentive spirometer every 2
hours.
10. Encourage the patient to clear
her own secretions with effective

9. Anxiety:
1. The patient uses effective coping
mechanisms.
2. The patient describes a reduction
in the level of anxiety experienced.

coughing every hour. If secretions

cannot be cleared, suction as
needed.
11. Plan activity and rest to maximize
the patients energy.
12. Splint abdominal incision by using
hands or a pillow.
13. Use pain management as
appropriate.
14. Encourage ambulation as
tolerated.
1. Assess & acknowledge patients
level of anxiety.
2. Use simple language and brief
statements when instruting the
patient about self-care measures.
3. Reduce sensory stimuli by
maintaining a quet environment;
keep threatening equipment out of
sight.
4. Encourage the patient to talk
about anxious feeling and examine
anxiety-provoking situations if they
are identifiable. 5. Assist patient in
asessing the situation realizstically
and recognizeing factors leading to
the anxious feelings. Avoid false
reassurances.
6. Assist the patient in develping new
anxiety-reducing skills )i.e.
relaxation, deep breathing, postiie
visualization and reassurig selfstatements.)
7. Teach the patient to limit use of
CNS stimulants (caffeine & nicotine
can increase physical sumptoms of
anxiety).
8. Instruct the patient in the proper
use of medications & educate her to
recogize adverse reactions.
9. Administer anti-anxiety
medications (PRN 1mg Lorazapam,)
as ordered.

III. Evaluation

1. Altered Fluid & Electrolyte Imbalance:

Desired Outcome:
1. The patient will not experience fluid volume deficit, hypokalemia,
hypochloremia, hypomagnesemia & acid-base imbalance as evidenced
by normal skin turgor, moist mucous membranes, stable weight, BP &
HR within normal range, cap refill time less than 3 seconds, balanced
I&O, urine specific gravity within normal range, return of peristalsis
within expected time, usual mental status, absence of cardiac
dysrhthmias, twitching, muscle weakness, paresthesias, dizziness,
headache, N/V and BUN & serum electrolytes within normal range.
Evaluation: Desired outcome has been MET based on the following:
1. Patient has normal skin turgor. Mucous membranes are pink and
moist. Weight has been slightly increasing. Blood pressure is 117/77
and heart rate is 98bpm & regular. Denies chest pain. Bilateral
exterior pulses are 2+, regular & symmetrical. Cap refill <3 seconds.
Urine specific gravity is at 1.020. Bowel sounds are hypoactive on all 4
quadrants. Mental status is A&Ox3. Denies dizziness & headache.
Occassional N/V. Bilateral grips, pushes & pulls of upper and lower
extremities are strong & equal. Denies twitching, muscle weakness,
paresthesias. Serum electrolytes within normal range. BUN is within
normal range of 6, but trending downwards.
2. Deficient Fluid Volume:
Desired Outcome:
1. Patient is normovolemic, as evidenced by stable blood pressure at or
above 90/60 mmHg, heart rate of 60-100 bpm, urine output of at least
30mL/hr & good skin turgor.
Evaluation: Desired outcome has been MET based on the following:
1. Patient has a stable blood pressure of 117/77 and a heart rate of 98
bpm. Pt states she urinates a lot and frequently. Cap refill is <3
seconds. Mucous membranes are pink & moist. Urinalysis specific
gravity is 1.020 and within the normal range.

3. Pain:
Desired Outcome:
1. Patient reports satisfactory pain control at a level less than 3-4 on a 010 rating scale.
2. Patient uses both pharmacological & nonpharmacological pain relief
strategies.
Evaluation: Desired outcome has been NOT MET based on the following:
1. Patient consistently rates pain between 8-9 on a 0-10 rating scale.

2. Patient states Healing Touch nonpharmacological pain relief strategy

does not work. Also states Acetaminophen does not reduce her
abdominal pain. After Dilaudid medication administration, patient
rates pain from a 9 to an 8, then immediately goes to sleep.
4. Infection:
Desired Outcome:
1. Patient is free of infection as evidenced by healing wound that is clean,
dry, well approximated, free of redness, swelling, purulent discharge &
pain.
2. Venous access sites free of redness & purulent drainage.
3. WBCs within normal range.
4. Clear breath sounds without cough or sputum production.
Evaluation: Desired outcome has been PARTIALLY MET based on the
following:
1. Patients open midline abdominal wound tissue is pink/ beefy red &
moist. Slight erythema and edema. No purulent discharge or odor.
Patient complains of pain 9/10 on abdominal wound.
2. PICC on left upper arm is free of redness and purulent drainage.
Patient denies pain to PICC line area.
3. WBCs are elevated at 12.05. Currently being treated with 600mg of
Clindamycin antibiotics.
4. Bilateral breath sounds are clear on all bases without cough with no
sputum production.
5. Impaired Skin Integrity:
Desired Outcome:
1. Patient has intact open wound without complications such as fistula.
Evaluation: Desired outcome has been PARTIALLY MET based on the
following:
1. Pt has a 33cm x 6cm x 5cm deep mid-line abdominal open wound.
Distal left end tunnels 2cm & distal right ends tunnels at 3cm. Tissue
is pink/ beefy red with no odor. Abd is saturated with moderate serous
drainage. Packed kerlix roll has moderate serosanguinous drainage.
No fistula noted.

6. Imbalanced Nutrition: Less Than Body Requirements:

Desired Outcome:
1. The patient will gain 2lbs and have intact mucus membranes in 7 days.
2. The patient will have albumin levels between 3.8-4.5dL.

3. The patient will have no ketones in the urine.

Evaluation: Desired outcome has been PARTIALLY MET based on the
following:
1. The patient has gained 2lbs & has intact mucus membranes.
2. The patients albumin levels are still low at 3.1dL. Hypoalbuminemia
indicates protein depletion.
3. The patients most recent urinalysis reveal trace of ketones presence.
This indicates the body is breaking down stored fat to supply the body
with glucose, since the patient doesnt have enough carbohydrates to
use for energy. This is due to patient being on NPO diet.
7. Altered Bowel Elimination: Post-operative ileus
Desired Outcome:
1. Display active bowel sounds/ peristaltic activity.
2. Maintain usual pattern of elimination.
Evaluation: Desired outcome has been PARTIALLY MET based on the
following:
1. Bowel sounds are hypoactive on all 4 quadrants. Patient states she
has been passing gas.
2. Per patient, last bowel movement was this morning. It was described
as small, brown and formed.
8. Ineffective Breathing Pattern:
Desired Outcome:
1. The patient will maintain an effective breathing pattern, as evidenced
by relaxed breathing at normal rate and depth and absence of
dyspnea.
Evaluation: Desired outcome has been MET based on the following:
1. Patients respirations rate is at 18 breaths per minute with regular
rhythm and eupnea effort. Breath sounds are clear to all bilateral
bases. Chest rise is symmetrical with no secretions. O2 sat is at 96%
in room air. Patient is able to demonstrate deep breathing exercises
and ambulates at least three times a day without difficulty.
9. Anxiety:
Desired Outcomes:
1. The patient monitors signs & intensity of anxiety.
2. The patient uses effective coping mechanisms.
3. The patient describes a reduction in the level of anxiety experienced.
Evaluation: Desired outcomes has been MET based on the following:
1. Patient informs RN when she feels anxiety.
2. Coping mechanisms patient uses include doing deep breathing
exercises, watching tv, talking with friends and family and taking
anxiolytic medication (Lorazapam.)
3. Patient states anxiety is reduced after taking her Lorazapam. Patient
immediately goes to sleep after taking medication.

IV. Discharge Plan/ Patient Teaching

The patient/ familys discharge planning begins on the day of admission
including preparation for education. Assessment continues during
hospitalization.
1. Placement/ type of dwelling: The patient lives in a house with
family support on the west side of Oahu, Hawaii.
2. Support systems: The patient lives at home with her husband and
adopted son. Her daughter is currently on the mainland for college.
Patient also has extended family including her sisters and cousins as
well as many close friends for support.
3. Assistance needed with ADLs: Patient is independent and
performs their own ADLs. Pt independently ambulates in hallway with
steady gait.
4. Anticipated Equipment/ Supply needs: Patient is independent and
ambulatory without assistive devices. However, she may need a
home health nurse to visit her daily to provide wound care services.
The patient may be given a supply list before discharge. Patients are
encouraged to obtain their supplies from an outside provider.
5. Patient teaching: On the day of dischage, patient/ family will receive
verbal and written instructions in laymans terms concerning:
-

Disease process: A small bowel obstruction is a blockage in the

intestines that makes it difficult for food to digest properly. Typical
symptoms are abdominal pain, nausea and vomiting. Sometimes
intravenous fluids, medications and bowel rest can help resolve this
problem. If this does not work, surgery is typically needed to correct
the blockage to enable food to pass through the body normally. If left
untreated, this may lead to decreased blood flow to the tissue, tissue
death (which leads to small bowel death) & then death.

Diet: After surgery, the diet will start first with a clear diet with sips
then advancing to half-cup to one-cup portions. Foods allowed on the
clear diet are broths, gelatin, ice pops, jice and carbonated beverages
that are clear in color. Then you will advance to the full liquid diet.
This includes all of the foods allowed in the clear liquid diet in addition
to milk, smooth yogurt, pudding, creamed soups without chunks, and
hot cereals. Since this diet is limited in calories and protein & your
bowel need to rest, you will get additional nutrients from your TPN &
lipids. Then you will advance to the low fiber diet. This temporarily
limits the amount of fiber you get to encourage diet tolerance and
bowel healing. High fiber foods such as fruits, vegetables, beans and
whole grains (whole grain bread, cereal, rice.) Select foods low in fiber
or with 3g of fiber or less. To transition back to a regular diet, your
doctor will gradually incorporate fiber-containing foods such as a

variety of fruits, vegetables, beans & whole grains. Also, focus on

drinking plenty of fluids, especially fluids.
Eat small amounts of food 5-8 times a day. Do not eat 3 large meals.
Space out your meals and add new foods back into your diet slowly.
Some foods may cause gas, loose stool or constipation. Avoid those
foods. If you become sick to your stomach or have diarrhea, avoid
solid foods for a whle and try drinking only clear fluids.

- Medications (including food/ drug interactions):

1. 600mg Clindamycin (Cleocin): Antibiotics to treat infections.
- Side effects: dizziness, headache, hypotension, skin rash, diarrhea,
nausea & vomitting.
- Food interactions: None. May be taken with or without meals.
- Drug interactions: Kaolin/ pectin may decrease GI absorption. May
enhance the neuromuscular blocking action of other neromuscular
blocking agents.
2. Dakins 0.25% solution strength (topical): A hypochlorite solution
that has been made from bleach but that has been diluted to treat
infeciton and decrease irritaiton.
- Side effect: rash, itchiness & swelling
- Food interactions: None.
- Drug interactions: None
3. metoclopramide (Raglan): used short-term to enhance gastric
emptying.
- Side effects: drowsiness, restlessness, anxiety, depression, irritability,
tardive dyskinesia (lip smacking), hypotension, constipation, diarrhea,
dry mouth & nausea.
- Food interactions: None. Take 30 min before meals & at bedtime.
- Drug interactions: Alcohol, antidepressants, antihistamines, opioid
analesics & sedative/ hypnotics. May increase absorption & risk of
toxicity from cyclosporine. Increase risk of extrapyramidial reactions
with antipsychotics like haloperidol. Opipoids and anticholinergics may
antagonize the GI effects of metoclopramide.
4. pantoprozole (Protonix): reduce gastric secretions and promote healing
of the stomach.
- Side effects: headache, abdoninal pain, diarrhea, flatulence,
hyperglycemia, hypomagnesemia & increased risk of bone fracture.
- Food interactions: None. May be taken with or without meals.
- Drug interactions: ketoconazole, itraconazole, atazanacir, ampicillin
esters and iron salts may decrease absortion of drugs requiring an acid
pH. Warfarin may increase risk of bleeding. May decrease the
antiplatelet effects of clopidogrel. Hypomagnesemia increases risk of
digoxin toxicity.

5. 8.6/ 50mg Sennosides/ Docusate Sodium tablet 2x/day: Stool softener

& laxative combination. It works by softening the stool & increasing
water to allow easier passage of the stool.
- Side effects: stomach ache, nausea, vomiting, no bowel movement,
gas, bloating, diarrhea, mild nausea
- Food interactions: None. May be taken with a full glass of water or
juice. May be aken on an empty stmoach for more rapid results.
- Drug interactions: None significant.
6. Hydromorphone (Dilaudid): Treats moderate to severe pain.
- Side effects: confusion, sedation, dizziness, dysphoria, hallucinations,
headache, uusual dreams, blurred vision, diplopia, respiratory
depression, hypotension, constipation, dry mouth, nausea, vomitting &
sweatng, physical dependence.
- Food interactions: None. May take with food or milk to minimize GI
irritaiton.
- Drug interactions: Exercise extreme caution with MAOI (may produce
severe, unpredictable reactions). Increases risk of CNS depression giwh
alcohol, antidepressants, antihistamines & sedative/ hypnotics
including benzodiazapines and phenothiazines. Administration of
partial antagonists may preciptate opioid withdrawal in physically
deendent patients. Nalbuphine or pentazocine may decrease
analgesia. Natural drug products of concomitant use of kava-kava,
valerian, chamomile or hops can increase CNS depression.
-

Safety Issues: Do not strain (val salva) when having a bowel

movement. Take your stool softener, if having difficulty having a bowel
movement. Do not bend at the waist, especially after eating. Avoid
restrictive clothig that increases intra-abdominal pressure. When
changing the dressings, wash your hands thoroughly with soap and
warm water before and after each dressing change. Put on a pair of
non-sterile gloves. After removing the old dressing, put on a new pair
of non-sterile gloves.

Health Promotion Behaviors: Reinforce instructions for

postoperative use of splnting abdomen, using the incentive spirometer,
coughing and deep breathing exercises, ambulation, activity & wound
care. Take medications as prescribed. Lose weight if overweight to
decrease intra-abdominal pressure. Raise head of bed by using 6-8
inche concrete or wooden blocks (or wedge) to reduce nighttime reflux.

When to Seek Medical Attention: Call your doctor if you have

vomiting, nausea, diarrhea that does not go away, pain that does not
go away or is getting worse, a swollen or tender stomach, little or no
gas or stools to pass, fever (above 100.4F or 38C for more than 4
hours) or chills and/or blood in your stool. For the wound, seek medical
attention if wound worsens or becomes more red, increased pain,

swelling, bleeding, looks larger or deeper, looks dried out or dark, there
is increased drainage (from and around the wound), if the drainage is
increasing, the drainage becomes thick, tan, yellow and if there is a
bad smell.
-

Medical Follow-up: Follow-up with PCP for outpatient physical

therapy referral if unable to resume all prior functional activities
including vocational duties. May follow up with PT after surgical
wound. Follow-up with nephrologist for eventual removal of
nephrolithiasis.

Patient and family will verbalize their understanding of the discharge

instructions and give a demonstration of any care procedures. The patient
will sign the discharge instrcution sheet attesting to the receipt of the
information.

Works Cited
Gulanick, Meg & Myers, Judith L. (2011). Nursing Care Plans (7th ed). St.
Louis, Missouri: Elsevier.
Lewis, S.L. Dirkensen, S., Heitkemper, M. Bucher, L. & Camera, I. (2011).
Medical-Surgical Nursing (8th ed). St. Louis, Missouri: Elsevier.

NURS 360- Health & Illness III

Concept Map Care Plan Grading Rubric
Yes
The chief medical
diagnosis (this is the
actual, not just the
admitting diagnosis,
as these are often
different) is listed.
All relevant priority
assessments related to
the chief medical
diagnosis are listed
All ACTUAL nursing
diagnosis are listed
All pertinent
assessment data,
treatments,
medications, and
medical history

No

Instructor comments

related to each of the

nursing diagnosis are
listed in the
corresponding nursing
diagnosis box
Interrelatedness of the
patient problems is
made clear with
different colored
lines. All relevant
relationships are
reflected.
Presentation is wellorganized and
creative.
Research is provided
to support work.
Accurate grammar,
punctuation, and
spelling.