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This Concept Map has information related to: clinical sept 24 2007graded 10 points, PMHx seaonal allergies and danders nasonex spray (see home med), interventions: -meds for bronchodilation -elevate HOB 30 -encourage deep breathing/coughing -keep environment allergen free patient will -maintain patent airway -demonstrate reduction of congestion -clear lung sounds -demonstrate behaviors to improve airway, interventions: -assessment of pain -accept pt's description of pain -observe for non-verbal cues -monitor vital signs -encourage pt to relax patient will -report pain relieved/decreased -followed med regime -demonstrate relaxation skills, nursing dx: ineffective peripheral tissue perfusion related to surgery and immobility, risk for thrombophlebitis interventions: -assess capillary refill -check distal pulses -assess VS -assess lower extremeties, note skin color pt will: -ambulate early -no DVT -demonstrate increase perfusion, Scheduled Meds docusate stool softener, tx constipaton relate to immobility, and a/e of hydromorphone, Scheduled Meds docusate nursing dx: constipation related to immobility and a/e of hydromorphone, Test & Diagnostics ECG: 63 BPM NSR no ischemia normal, Home Meds xopenex inhaler beta-adrenergic agonist, nursing dx: risk for infection related to left hip replacement interventions: -daily or as ordered for wound dressing -clean incision site -encourage early ambulation -administer prophylaxis meds pt will: -identify interventions to decrease risk of infection -achieve timely wound healing, nasonex nursing dx: ineffective airway clearance see xopenex