Concept Map

Sydney Early

Risk for Unstable Glucose Deficient Knowledge r/t Risk for Falls r/t decreased
Level r/t Nonadherence to lack of recall as evidenced level of consciousness
therapeutic regimen for by Nonadherence to
diabetes medication regimen

Imbalanced Nutrition, Less

Risk for Altered Cerebral Than Body Requirements
Tissue Perfusion r/t r/t poor nutrition intake as
inadequate glucose supply evidenced by pale mucous
to the brain Hypoglycemia membranes

Risk for Acute Confusion Fear r/t situational crisis as Activity Intolerance r/t
r/t electrolyte imbalances evidenced by crying and physical weakness as
“I’m scared” verbalized by evidenced by verbal report
pt. of fatigue and weakness
#2 Risk for Unstable Glucose #3 Knowledge Deficit r/t lack of #4 Risk for Falls r/t
Level r/t Nonadherence to recall as evidenced by decreased level of
therapeutic regimen for diabetes Nonadherence to medication consciousness
regimen
CM: CM:
Severely low BS of 47 CM: Tremors
Confusion Not eating Altered LOC
Altered LOC Administering Insulin Dizziness
improperly
Assessment/Interventions: Assessment/Intervention:
#1 Assessment/Interventions: Assist with ambulation #5
Frequently monitor BS levels
Provide education about DM
Risk for Altered Cerebral and insulin therapy w/ family Imbalanced Nutrition,
Tissue Perfusion r/t inadequate present Less Than Body
glucose supply to the brain Requirements r/t poor
nutrition intake as
CM: Reason for seeking care: feeling weak, pale, evidenced by pale mucous
Cool, pale skin dizzy membranes
Tremors
Low Hgb, Hct CM:
Low BS nausea
Medical Diagnosis: Hypoglycemia blood sugar 47
Assessment/Interventions: Assessment/Intervention:
Monitor for rapid changes or Provide education and
continued shifts in mental status. Key Assessments: make a meal plan
Use pulse oximetry to monitor Blood Sugar
oxygen saturation and pulse rate. Level of Consciousness Meds:
Skin color Ondansetron
Heart rate #6

#8
Risk for Acute Confusion Activity Intolerance r/t
physical weakness as evidenced
r/t delirium
Fear r/t situational crisis as by verbal report of fatigue and
#7
weakness
CM: evidenced by crying and “I’m
Decreased LOC scared” verbalized by pt.
CM:
Lack of motivation to initiate Fluctuation in level of
and/or follow through with CM:
Increased HR consciousness
goal-directed or purposeful Fatigue
Increased BP
behavior Increased Respirations Labored breathing
Increased agitation or Lack of Appetite
restlessness Assessments/Interventions:
Assessments/Interventions: VS at rest and during activity
Determine origin of fear Assess nutritional status
Assessments/Interventions: Aid in ambulation
Mental Status Exam
Meds:
Assess behavior both night
Alpraxolam 0.5mg PO
and day to compare
Determine baseline
 Problem # 1: Risk for Altered Cerebral Tissue Perfusion
General Goal: Improved Perfusion

Predicted Behavioral Outcome Objective (s): The patient will……

experience no episodes of syncope on the day of care.

Nursing Interventions Patient Responses

1.Administer fast acting sugar 1. BS improved

2. Check BS levels Q15-30
3.Encourage client to verbalize s/s from onset
4.Educate client to monitor BS
5. Frequent neuro checks
6. Position client with head elevated
7. Provide quiet environment
8. Monitor for appropriate LOC
2. Noticed BS was trending up
3. Client became aware of warning signs
4. Displayed new knowledge by checking BS
5. Changes in mental status were quickly noticed
6. Decreased headache
7. Pt was comfortable
8. Maintained acceptable LOC

Evaluation of outcomes objectives:

Patient showed great improvement through the shift and did not experience any episodes of syncope. She also
stayed at baseline with her mental status.

Problem # 2: Risk for Unstable Glucose

General Goal: Stabilize Blood Sugar

Predicted Behavioral Outcome Objective (s): The patient will……

Maintain a blood sugar of at least 70 on the day of care.

Nursing Interventions Patient Responses

1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6. 6.
7. 7.
8. 8.

Evaluation of outcomes objectives:

 Problem # 3: Deficient Knowledge
General Goal: Receive Proper Education

Predicted Behavioral Outcome Objective (s): The patient will……

be able to explain insulin regimen on the day of care.

Nursing Interventions Patient Responses

1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6. 6.
7. 7.
8. 8.

Evaluation of outcomes objectives:

Problem # 4: Risk for Falls

General Goal: No Falls

Predicted Behavioral Outcome Objective (s): The patient will……

not experience a fall on the day of care.

Nursing Interventions Patient Responses

1. Guarantee appropriate room lighting
2. Move items to within reach
3. Provide heavy furniture
4. Provide some identification of the risk
5. Keep bed at lowest position
6. Encourage pt to wear slippers
7. Allow pt to exercise as often as possible
8. Ask family to stay with patient
1. Room stayed well-light through the day
2. Pt had easy access to necessities
3. Pt was able to put weight on furniture in the room for support
4. Pt. wore her falls risk bracelet all shift
5. Bed stayed at a low position all day
6. Pt. wore footwear while ambulating as requested
7. Pt performed ADL’s and ambulated in the hall
8. Patient was accompanied all day

Evaluation of outcomes objectives:

Patient was free from falls during my shift. By utilizing the interventions provided, a safe environment was
maintained.
 Problem # 5: Imbalanced Nutrition, Less Than Body Requirements
General Goal: Improve Nutrition Habits

Predicted Behavioral Outcome Objective (s): The patient will……

Eat 70% of breakfast, lunch, and dinner on the day of care.

Nursing Interventions Patient Responses

1.Promote proper positioning 1. Patient was able to comfortably eat

2.Provide good oral hygiene
3.Schedule rest periods during meals
4.Provide companionship
5.Encourage family to bring food
6.Encourage a diet journal
7.Provide a pleasant environment
8.Educate the importance of eating with diabetes
2. Was able to enjoy the taste of food
3. Patient conserved energy
4. Patient ate most of her food
5. Patient enjoyed the home cooked meals
6. She was able to establish a routine
7. Decreased stress
8. Patient restated and used info given during this shift

Evaluation of outcomes objectives:

Patient ate most of her meals and was able to establish a routine during the day. This is important because she
was not eating and taking her insulin anyways.

Problem # 6: Activity Intolerance

General Goal: Increase Activity

Predicted Behavioral Outcome Objective (s): The patient will……

Ambulate safely once around the hall on the day of care.

Nursing Interventions Patient Responses

1. Dangle legs for 10-15 mins. 1. Built up tolerance and was able to ambulate
2.Assist with ADL’s 2. Independence maintained as much as possible
3.Encourage activity with increased energy 3. Was able to complete necessary tasks
4.Refrain from performing nonessential activities 4. Pt saved energy and was able to perform other activities
5.Perform ROM exercises 5. Stayed mobile while unable to exercise
6.Provide bedside commode 6. Independence maintained
7.Turn pt in bed 7. Patient avoided pressure ulcers
8.Teach energy conservation techniques 8. Pt. demonstrated what was taught

Evaluation of outcomes objectives:

By end of shift, my patient was able to ambulate around the hall. I attribute that to the small exercises and
energy conservation techniques used throughout the day.
 Problem # 7: Fear
General Goal: Eliminate Fear

Predicted Behavioral Outcome Objective (s): The patient will……

Verbalize no fear after education is complete on the day of care.

Nursing Interventions Patient Responses

1. Alternative therapies 1. Pt. was distracted with a movie

2. Discuss situation 2. Additional education decreased fear of the unknown
3.Discuss awareness of the fear 3. After pt. noticed I was aware, she opened up more
4. Give reassurance 4. Realized fear was normal
5. Use simple language 5. Patient was able to understand and follow commands
6. Provide safety measures 6. Began to feel safe in the situation
7. Allow rest time 7. Relaxation improved stress
8. Suggest comfort items from home 8. Gave patient comfort in stressful times like during procedures

Evaluation of outcomes objectives:

During the shift, the patient remained calm, and discussed problems when she was stressed, but she did not
meet my goal as she was still a bit fearful thinking about what happened when she had really low blood sugar.

Problem # 8: Risk for Acute Confusion

General Goal: Return to baseline mental status

Predicted Behavioral Outcome Objective (s): The patient will……

Display an appropriate LOC at all times on the day of care.

Nursing Interventions Patient Responses

1. Limit sensory exposure 1. Pt was comfortable and not overwhelmed

2. Treat underlying condition 2. As BS returned to normal pt returned to baseline
3. Orient pt. to surroundings and staff 3. Safety was ensured as pt was aware
4. Give simple directions 4. Reduced anxiety
5. Provide safety needs 5. Incidents prevented
6. Limit caffeine intake 6. Reduced agitation and restlessness
7.Plan to allow an appropriate sleep/wake cycle 7. With adequate sleep status improved
8. Avoid use of restraints 8. Pt. did not get violent

Evaluation of outcomes objectives:

Patient was able to maintain an appropriate level of consciousness throughout the shift. She reacted well to the
nursing interventions.