CVD CONCEPT MAP

NDx #1: Ineffective airway clearance related to retained mucosal secretions as evidenced by mucosal secretions in tracheostomy tube. Subjective Cues: (09-19-2013,0800H)
  copious amounts of mucosal secretions in tracheostomy site. secretion characteristics on trache site: copious, green in color.

Mdx: CVD
Patient  44 y/o, Male, Married, admitted last 03-06-13 Admitting Diagnosis  CVD Objective data  Stuporous  Temp=37.7, RR=20, Pulse=76, BP= 110/80  good capillary refill in 2-3 secs. Subjective data  copious amounts of mucosal secretions in tracheostomy site.  secretion characteristics on trache site: copious, green in color.  Needs assistance in moving  On diaper, voiding freely  TEDS Stockings  G-Tube- Left  Patient on egg crate mattress  difficulty in speaking  facial paralysis  facial tension  limited ROM in upper and lower extremeties Orders:  Suction secretion every 4 hrs and as needed. especially after nebulization. SAP precautions  ankle pumps and knee ROM 0700H to 1900H every hour (10-15 reps) while awake.  Nutren fiber diet (340ml) + 30ml H2O post feeding  Accurate I&O  Turn side to side every 2 hours  with trache collar

NDx #2: impaired physical mobility related to neuromuscular damage involvement as manifested by limited ROM in upper and lower extremeties. Cues:
  limited ROM in upper and lower extremeties needs assistance in moving

NDx #3: Risk for aspiration related to present condition. Cues:
   Stuporous copious amounts of mucosal secretions in tracheostomy site. secretion characteristics on trache site: copious, green in color. Needs assistance in moving on bed

NDx #4: Risk for impaired skin integrity related to prolonged bed rest and altered circulation

Patient’s Initials: R.O.B. Age: 44 years old Gender: Male

Medical Diagnosis: CVD

Basis for Prioritization: ABC

Student Nurse: Estrella, Bien G.

and maintain patent airway. Goal: Airway patency. And for the client be able to participate in the interventions rendered by the nurse. the client will have no respiratory distress. Interventions Assess general health condition Maintain client on high back rest Observe strict aspiration precautions Provide adequate rest periods Assist in suctioning Assist in nebulization To loosen secretions Rationale To have a baseline data To promote lung expansion To prevent aspiration To conserve energy For airway patency Expected Outcome After 8 hours of nursing interventions. Rationale Expected Outcome Interventions . Expected Outcome: After 8 hours of nursing intervention. Nursing Diagnosis #02: : impaired physical mobility related to neuromuscular damage involvement as manifested by Goal: To promote mobility and to improve blood circulation Expected Outcome: After 8 hours of nursing intervention. understanding of the situation and therapy.the relative will be able to participate in therapeutic regimen as evidence by: Verbalization.Nursing Diagnosis #1: Ineffective airway clearance related to retained mucosal secretions as evidenced by mucosal secretions in tracheostomy tube. client had no respiratory distress and maintained patent airway.

Assist in moving the client Expected Outcome: After 8 hours of nursing interventions. Risk for aspiration related to present condition. the relative is able to participate in therapeutic regimen as evidence by: Verbalization understanding of the situation and therapy and client is able to participate in the interventions rendered by the nurse Provide rest periods Ankle pumps and knee ROM 0700H to 1900H every hour To promote (10-15 reps) while mobility. exercise. the client will have no case of aspirations. Goal: To prevent aspiration.Determine degree of mobility Support body with pillows while on bed To establish a baseline data To reduce risk of pressure ulcers To reduce fatigue and oxygen demand After 4 hrs of nursing intervention. blood circulation. Rationale Expected Outcome Interventions . Nursing Diagnosis #03: awake.

client had case of aspirations. Nursing Diagnosis #4: Risk for impaired skin integrity related to prolonged bed rest and altered circulation Goal: To prevent bed sores Expected Outcome: After 8 hours of nursing interventions.Assess general health condition Maintain client on high back rest Observe strict aspiration precautions Provide adequate rest periods Assist in suctioning Assist in nebulization Observe strict aspiration precautions To have a baseline data To promote lung expansion To prevent aspiration To conserve energy For airway patency To loosen secretions To prevent aspiration After 8 hours of nursing interventions. the relative will be able to verbalize and understand the factors that contribute to skin integrity impairment and take steps to correct the problem. Rationale Expected Outcome Interventions .

Determine age Older clients have normally less elastic skin. skin should have good turgor. warm to touch. . the relative was able to verbalize and understand the factors that contribute to skin integrity impairment. (<6 seconds) To prevent bed sores Change client's position in bed every 2 hours Assist in diaper change To prevent skin impairment and infection. Assess general condition of skin Health skin varies from each client. Do blanche's test Good capillary refill means good circulation in the extremities.Keep side rails up Place client in a comfortable position To promote safety To prevent backaches or muscle aches After 8 hours of nursing interventions. making for higher risk of skin impairment.