Kristina Valenzuela

1. Pain
Surgical wound
S/p pancreatectomy/splenectomy
PCA Fentanyl
PO Percocet
Pain assessment: 6/10, sharp
Pulse = 111
Crying, facial grimacing

4. Impaired Skin Integrity/Infection

Surgical incision (Steri strips - clean,
dry, intact)
JP drain (dressing soiled w/ small
amount of serosanguineous fluid
Clear liquid diet

6. Nausea
PCA Fentanyl, PO Oxycodone
Abdominal pain
Zofran

Concept Map Care Plan

11/13/15

2. Imbalanced Nutrition
Clear liquid diet
IV fluids
K = 3.4
P = 2.1
Ca = 8.1
BMI = 23
Hx. of GERD
Hx. of hypercholesterolemia

Chief Medical Diagnosis:

Pancreatic Neoplasm
S/p Pancreatectomy/splenectomy
Priority Assessments:
Pain, GI, Respiratory, Neuro, Skin,
Serum electrolytes, H&H, WBC,
I&O, Temp.

7. Risk for Infection

Temp = 36.8 C
S/p splenectomy
Surgical wound
JP drain
Clear liquid diet
WBC = 11.2
Incentive spirometer

3. Deficient Knowledge
New diagnosis
New surgical procedure
New treatment (JP drain)
Splenectomy involves major
lifestyle changes

5. Fluid/Electrolyte Imbalance
Clear liquid diet
Hx. of breast cancer
Hx. of osteopenia
S/p pancreatecomy, splenectomy
Phosphorous = 2.1
Calcium = 8.1
Potassium = 3.4
JP drain
IV Phosphorous replacement

8. Risk for Bleeding

BP = 118/74
Major abdominal surgery
Anticoagulant therapy
Hgb = 12.1
Hct = 36.3