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Concept Map Angie Stahlman

Diagnosis/Current Problem: End Stage Renal Failure KEY Assessments: ments R 24, BP 157/90 HR 72 LOC- drowsy, but could be woken up to ask questins. Pain- 0 on 0-10 scale. Support System- 2 daughters. T 98.2, espiratory #3 m, and sleeps inof fluid on lower legs. gs but pockets chair. ng Diagnosis ghter stated "the swelling had gone down a little." d because she slept." t Volume


apatient. Give pain meds if weeping and fluid pockets on legs. in lower extremities with needed to keep pain under control. es outif legs areBoth wheezingstate.eating. daughters sharegauze to try to soakand the got along well linens I was with them. The daughter who lives out of town stated, "I feel g tient, of her weeping cover with power of attorney it up and change bed when to keep pt. comfortable. o promote and little crackles ear. She stated, " It does make me feel better to meet everyone that is going to be dealing with her. ck.awake she will eat more. from baseline. is pkeep level ofas normal as possible and help keep her awake. meal times edema as low as it can be. see how much any breakdown.she is putting out, color, clarity (kidney function) oing to receive. Helps down. situation better and feel more confident that their mother is in good hands. help keep edema in legs them understand the for patient. and family to provide the best care possible g including meal time. their fell asleep whenever possible to help keep edema down. woken up continually to get her to eat. to handle the loss of She mother. every 2 hours and keep legs elevated about every 20 seconds at lunch and had to be elationship so the monitor for fluid in concerns they may have. unds every shift tofamily will voice anylungs. in place. This will help pedal pulses every that to "loose heart function care of and they wont 2, cap. Refill, radial andin making them feelshift themonitorends" are takenand quality circulation. have to make any decisions when they are grieving. control in a situation that glomular filtration alues like BUN, creatnine, is uncontrollable. rate to monitor kidney function. I couldnt find any of these in her records, but I did see a note stating she w o keep her legs elevated whenever possible to keepNo grimacing or restlessness. of 0 on 0-10 scale while I am with her on 9/10/11. edema down. orkers wheezing life and have or needs order for Albuterol level of 3 on a healthy scale. ment untilexpressand discuss getting on they maypain over aprn.will show 0-10 pain grieving process(expression of feelings) during this time and after pass about to end of any feelings no complaints of have. Family