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This Concept Map has information related to: nov 26 2007graded 10 points, Interventions: -explain to the treatment plan -include pt in her own treatment -tell pt what the meds does before giving it to her -give pt comfort to the environment pt will -verbalize and understand her treatment plan -pt more comfortable with her environment. -participate in learning process, PMHx --anxiety -dementia -HTN, pt demographics caucasian female 88 yrs old admitted to tower 8 after a fall. Pt ambulates with walker at baseline. lives with husband in an assisted facitilty pt had a left ishcial fraxture, alprazolam anxiolytic Management of anxiety disorders or for short-term relief of anxiety symptoms., Admission Dx Nursing Dx:sleep deprivation as related to hospital environment as evidenced by lack of sleep, restlessness, and pt verbalization nursing dx: walking impaired related to fall as evidenced by ischal fracture, Admission Dx Nursing Dx:sleep deprivation as related to hospital environment as evidenced by lack of sleep, restlessness, and pt verbalization interventions: -determine presence of physical, psychological stressors -note environmental factors affecting sleep -evaluate patient's fear or anxiety -determine sleep pattern -observe signs of fatigue -sleeping medications -assess pain -provide a calming and quiet environment, 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, Maintainence fluid:LR 17ml/hr continuous maintain pt hydration maintain homeostasis, Test & Diagnostics CMP: Na: 138 K: 3.5 Cl: 98 H3CO: 28 Cr: 0.67 Ca: 9.8 all WNL, interventions: -determine presence of physical, psychological stressors -note environmental factors affecting sleep -evaluate patient's fear or anxiety -determine sleep pattern -observe signs of fatigue -sleeping medications -assess pain -provide a calming and quiet environment pt will -report improvement in sleep -be calm and more relax -identify interventions to pormote sleep -adjust to environment