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

Patients Initials: R.O.B. Age: 44 years old Gender: Male

Medical Diagnosis: CVD

Basis for Prioritization: ABC

Student Nurse: Estrella, Bien G.

Nursing Diagnosis #1: Ineffective airway clearance related to retained mucosal secretions as evidenced by mucosal secretions in tracheostomy tube.
Goal: Airway patency. Expected Outcome: After 8 hours of nursing intervention, the client will have no respiratory distress, and maintain patent airway. 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, client had no respiratory distress and maintained patent airway.

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,the relative will be able to participate in therapeutic regimen as evidence by: Verbalization, understanding of the situation and therapy. And for the client be able to participate in the interventions rendered by the nurse. Rationale Expected Outcome

Interventions

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, 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, Nursing Diagnosis #03: awake. Risk for aspiration related to present condition. blood circulation.

Goal: To prevent aspiration. Assist in moving the client Expected Outcome: After 8 hours of nursing interventions, the client will have no case of aspirations. Rationale Expected Outcome 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, 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, 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

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, the relative was able to verbalize and understand the factors that contribute to skin integrity impairment.

Determine age

Older clients have normally less elastic skin, making for higher risk of skin impairment.

Assess general condition of skin

Health skin varies from each client. skin should have good turgor, warm to touch.

Do blanche's test

Good capillary refill means good circulation in the extremities. (<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.