Introducing
Your new presentation assistant.
Refine, enhance, and tailor your content, source relevant images, and edit visuals quicker than ever before.
Trending searches
Perioperative Concept Map
260
Pre-Operative Concept Map
Stormy Simpson
J.S. / 17 yo male admitted through ED post MVA with multiple fractures and possible concussion. Admitted to orthopedic floor at 0200 for pain control and neuro-evaluation prior to 0600 surgery. Mother at bedside, Father is currently deployed overseas active duty. Three other passengers in car were ejected at impact and pronounced dead at the scene. Client agitated and crying. States “Why am I still alive?” Mother states that client and his girlfriend were on a double date with “their best friends” when MVA occurred.
Pain uncontrolled with IV dilaudid PRN, Patient controlled analgesia pump ordered pre-operatively.
Nursing Diagnosis
1. Risk for falls
- Patient is a risk for falls due to multiple fractures
2. Risk for suicide
- Patient is a suicide risk due to guilt from surviving the crash
Safety
Planning
Implementations
- Risk for falls
- Patient will be in a room close to the nurse's station
- Nurse will respond as quickly as possible to the call button of patient
- Nurse and family will keep the room clear of all clutter
- Risk for suicide
- Nurse will demonstrate concern for his well-being
- Nurse will watch patient take all medications appropriately throughout hospital stay
- Nurse will keep room free from dangerous objects
Patient Goals
- Short Term: Patient remains free from falls for 6 weeks.
- Long Term: Patient responds positively to treatment plan and counseling for 1 year.
Nursing Diagnosis
1. Risk of Spiritual Distress
- Due to survivor's gulit
2. Risk of Grieving
- Due to the loss of his girlfriend and best friends
Spirituality
Interventions
Interventions
- Risk of Spiritual Distress
- Create an accepting, non-judgemental atmoshpere
- Assist him in expressing and reflecting on his anger
- Encourage the use of spiritual resources and counseling
- Risk for Grieving
- Acknowledge the patient’s need to review the loss experience
- Support patient and significant others share mutual fears, concerns, plans, and hopes for each other
- Anticipate increased or exaggerated affective behavior
Patient Goals
Patient Goals
- Short Term Goal: Have the patient express his anger and spiritualiy revolving the accident within 1 week
- Long Term Goal: The patient will realize the accident was not his fault within 1 year
Nursing Diagnosis
1. Risk of Mobility; Physical, Impaired
- Patient is physically impaired due to multiple fractures
2. Risk of Sleep Deprivation
- Patient can have sleep deprivation due to the guilt of the accident
Comfort
Interventions
1. Mobility; Physical, Impairment
- Check daily for skin integrity and turn patient frequently
- Note intake and outtake because immobility can lead to constipation
- Monitor nutritional needs because the immobility can decrease the amount of calories needed per day
2. Sleep Deprivation
- Determine how the accident is affecting sleep and have the patient talk about it
- Observe administering of medications that could effect his sleep patterns
- Determine what medications could help the patient and not interfere with other medications he is currently on
Interventions
Patient Goals
- Short Term Goal: Patient will obtain optimal amount of sleep consecutively for 2 weeks.
- Long Term Goal: Patient will start moving with help (via gait belt or assistive devices) as soon as fractures are healed and physical therapy will help maintain ROM 1 day after surgery
Nursing Diagnosis
Communication
1. Risk of inability to remember familiar words, names of popular people, places, and objects
- Patient has the possibility of a concussion
2. Risk of difficulty to vocalize words, discern and maintain the normal communication pattern
- Due to the level of conciousness
Interventions
- Risk of inability to remember familiar words, names of popular people, places, and objects
- Provide practice sessions within the day
- Try asking "yes" or "no" questions when possible
- Correct errors
- Risk of difficulty to vocalize words, discern and maintain the normal communication pattern
- Have a speech therapist work with the patient
- Assess the patient's ability to understand written word, gestures and pictures
- Assess the presence of expressive dysphagia
Patient Goals
- Short Term Goals: Patient will be able to remember long term and short term memories within 3 days
- Long Term Goals: Patient will be able to cohiesively speak and understand others within 2 weeks