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This Concept Map has information related to: oct 29, 2007, interventions: -measure and record I&O -note source of fluid loss/intake -monitor B/P response pt will -pt maintain normal B/P increase in volume -pt will be hydrated -pt will be tolerate fluctuation in fluid level, Test & Diagnostics CMP: Na: 139 K: 4.4 Cl: 103 H3CO: 28 BUN: 10 Cr: 1.07 all normal ranges, cefazolin Antibiotic active against many gram-positive organisms prophylaxis for right knee replacement, effective tx for bone and joints infection (prevention), nursing dx: Anxiety related to change in health status, unfamiliar environment, and surgery recovery process deficit as evidenced by increased tension, apprehension, fear of pain, restlessness ND: knowledge decifit related to the tx of TKR, the medications, the CPM machined as evidenced by pt asking what CPM is for, why she was on a liquid diet, and pt not knowing the purpose of each medication. Interventions: - explain the procedure that pt had done -explain the risk and complications as well and things she can do to help the healing process -hand out pamphlets or pt education letters -before giving med, tell pt what the med does -find resources available to answer any questions pt may have, Warfarin ???? ND: ineffective tissue perfusion related to right knee surgery, Maintainence fluid: lactated Ringers increase fluid volume in circulation KVO maintain homeostasis, oxycodone opiods analgesic treatment of pain from knee, eszopiclone a seadtive also called a hypnotic affects chemicals in your brain that may become unbalanced and cause insomnia cause relaxation to help pt sleep and stay asleep, interentions: -assessment of pain level, LOC, VS within normal limits -relaxation teaching such as deep breathing, mediatation -change of position as necessary for pt comfort -note location of surgery -note pt perception of pain -provide adequate resting time pt will -pt report reduction of pain from 12 (ststed by the pt) to a 6 end of the shift -pt will be able to demonstrate use of relaxation skills -pt will use PCA pump appropriately and less tries -Pt will verbalize methods that provide relief, pt demographics 43 yrs old Caucasian female admitted to tower 8th for total right knee replacement