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#1 Pain Management #2 Risk for impaired gas #3 Risk for deficient fluid
 Type of pain exchange problem
 Distraction  Deep breathe  Oral intake
 Meds  Semi-fowlers  Monitor I&O
 Relaxation  Ambulate  Oral hygiene
techniques  Oxygen is SpO2  Prevent sweating
drops  nutrition
 Incentive
spirometer
 Suction

#4 Risk for infection

#8 Risk for impaired skin Reason For Needing Health Care:  Handwashing
integrity Pneumonia & hemophagocytic  Rest
 Turn Q2h lymphohistiocytosis (HLH)  Nutrition
 Ambulation Chief complaint: dehydration, drowsiness,  Limit visitors
 Nutrition & headache  Antibiotics
hydration Key assessments:  precautions
 Proper skin care 1. Lung sounds
 Bruising 2. Pain
precautions 3. Pulse ox
4. Dehydration symptoms
5. Respiratory rate & effort
6. Lab values
7. Cap refill #5 Knowledge deficit
Risk for bleeding
#7 8. Heart rate  How much do
 Signs &
9. BP they already
symptoms of
10. Skin know?
bleeding or
11. Bleeding  Home care needs
bruising
 Prolonged  When to call
bleeding doctor
 Pain and swelling  Write info down
 H&H levels  Follow up
 Bleeding appointments
#6 Caregiver role strain  Med
precautions
 Other family administration
members?  Med compliance
 Self-care
 Reduce stress
 Support groups

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis

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P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis