Warning:
JavaScript is turned OFF. None of the links on this page will work until it is reactivated.
If you need help turning JavaScript On, click here.
This Concept Map, created with IHMC CmapTools, has information related to: 10-14-09, Patient will maintain patent airway and clear lung sounds during the duration of his hospital stay or by discharge. Evaluation Goal met. Patient's airway maintained patentcy for the duration of his hospital stay. Teach necessary interventions during discharge instructions., Ineffective airway clearance r/t presence of artificial airway AEB continual suction by RN and "gurgling" sound around tube. Goal #2 Patient will maintain a patent airway for the duration of his hospital stay or by discharge., 60yr old WM Doctor assessment Abnormal CXR - bilat perihilar and lower lung field interstitial infiltrates w/patchybibasilar atelectasis and/or air space disease; clinical COPD, consider element "cardiac asthma", high risk clinical setting for aspiration, tracheobronitis aspiration, and pneumonitis; respiratory failure post endotracheal intubation w/initiation of mechanical ventilation support in emergency prior to transfer; ACD, hypertensive cardiovascular disease status;↑ serum ammonia - uncertain etiology; Normochromic normocyctic anemia, 60yr old WM Nsg Dx #2 Impaired Gas Exchange r/t ventilation - perfusion imbalance secondary to hypercapnic respiratory failure AEB intubation, hypercapnia (PCO2 53), irritability, restlessness, abnormal ABG's., Risk for aspiration r/t presence of endotracheal tube and reduced LOC secondary to respiratory failure and mediation administration. Based on Abnormal CXR - bilat perihilar and lower lung field interstitial infiltrates w/patchybibasilar atelectasis and/or air space disease; clinical COPD, consider element "cardiac asthma", high risk clinical setting for aspiration, tracheobronitis aspiration, and pneumonitis; respiratory failure post endotracheal intubation w/initiation of mechanical ventilation support in emergency prior to transfer; ACD, hypertensive cardiovascular disease status;↑ serum ammonia - uncertain etiology; Normochromic normocyctic anemia, 1. Monitor respiratory rate, depth, effort. 2. Auscultate lung sounds frequently 3. Take vital signs frequently 4. Suction endotracheal tube frequently. 5. Maintain high fowler's position 6. Maintain wrist restraints to prevent patient from pulling out endotracheal tube. After completion Goal met. Patient's airway maintained patentcy for the duration of his hospital stay. Teach necessary interventions during discharge instructions., Risk for aspiration r/t presence of endotracheal tube and reduced LOC secondary to respiratory failure and mediation administration. Goal #2 Patient will maintain patent airway and clear lung sounds during the duration of his hospital stay or by discharge., Abnormal CXR - bilat perihilar and lower lung field interstitial infiltrates w/patchybibasilar atelectasis and/or air space disease; clinical COPD, consider element "cardiac asthma", high risk clinical setting for aspiration, tracheobronitis aspiration, and pneumonitis; respiratory failure post endotracheal intubation w/initiation of mechanical ventilation support in emergency prior to transfer; ACD, hypertensive cardiovascular disease status;↑ serum ammonia - uncertain etiology; Normochromic normocyctic anemia Medications dexamethasone (Decadron), digoxin (Lanoxin), diltiazem (Cardizem), enalapril (Vasotec), enoxaparin(Lovenox), ocular lubricant (Akwa Tears), pantoprazole (Protonix IV), piperacillin - tazobactan (Zosyn), vancomycin (Vancocin HCI), insulin regular (Novolin R)., Ineffective airway clearance r/t presence of artificial airway AEB continual suction by RN and "gurgling" sound around tube. Goal #1 Patient will have cyanotic free skin for the duration of my shift or by the end of my shift., Patient will have cyanotic free skin for the duration of my shift or by the end of my shift. Evaluation Goal met. Patient showed no cyanosis during my shift. Continue with interventions., 60yr old WM Nsg Dx #3 Risk for aspiration r/t presence of endotracheal tube and reduced LOC secondary to respiratory failure and mediation administration., Impaired Gas Exchange r/t ventilation - perfusion imbalance secondary to hypercapnic respiratory failure AEB intubation, hypercapnia (PCO2 53), irritability, restlessness, abnormal ABG's. Based on Abnormal CXR - bilat perihilar and lower lung field interstitial infiltrates w/patchybibasilar atelectasis and/or air space disease; clinical COPD, consider element "cardiac asthma", high risk clinical setting for aspiration, tracheobronitis aspiration, and pneumonitis; respiratory failure post endotracheal intubation w/initiation of mechanical ventilation support in emergency prior to transfer; ACD, hypertensive cardiovascular disease status;↑ serum ammonia - uncertain etiology; Normochromic normocyctic anemia, Patient will maintain a patent airway for the duration of his hospital stay or by discharge. To accomplish 1. Monitor ABG's and pulse oxygen saturation levels as available. 2. Position the pt to optimize respiration (30 - 45 degrees) 3. Explain the process of suctioning before and ensure the pt is not in pain or overly anxious. 4. Hyperoxygenate before and between endotracheal suction sessions. 5. Use a closed, in-line suction system 6. Document results of coughing and suctioning, particularly client tolerance and secretion characteristics such as color, odor, and volume., 1. Monitor respiratory rate, depth, and effort. 2. Auscultate breath sounds every 1 to 2 hours. 3. Monitor the patients behavior and mental status 4. Monitor oxygen saturation continuously 5. Observe for cyanosis of the skin 6. Position in semi-Fowler's position After completion Goal not met. Patient still on mechanical ventilation and restless. Continue interventions., Patient will maintain clear lung fields and remain free of signs of respiratory distress during my shift or by the end of my shift. To accomplish 1. Monitor respiratory rate, depth, and effort. 2. Auscultate breath sounds every 1 to 2 hours. 3. Monitor the patients behavior and mental status 4. Monitor oxygen saturation continuously 5. Observe for cyanosis of the skin 6. Position in semi-Fowler's position, Impaired Gas Exchange r/t ventilation - perfusion imbalance secondary to hypercapnic respiratory failure AEB intubation, hypercapnia (PCO2 53), irritability, restlessness, abnormal ABG's. Goal #1 Patient will maintain clear lung fields and remain free of signs of respiratory distress during my shift or by the end of my shift., Patient not aspirate on sputum from lungs during the duration of my shift or by the end of my shift. To accomplish 1. Monitor respiratory rate, depth, effort. 2. Auscultate lung sounds frequently 3. Take vital signs frequently 4. Suction endotracheal tube frequently. 5. Maintain high fowler's position 6. Maintain wrist restraints to prevent patient from pulling out endotracheal tube., 60yr old WM Diagnosed with Hypercapnia Respiratory Failure, Patient will demonstrate improved ventilation and adequate oxygenation by discharge from the hospital. Evaluate Goal not met. Refer patient to respiratory therapist consultation before discharge into homecare., 1. Monitor respiratory rate, depth, effort. 2. Auscultate lung sounds frequently 3. Take vital signs frequently 4. Suction endotracheal tube frequently. 5. Maintain high fowler's position 6. Maintain wrist restraints to prevent patient from pulling out endotracheal tube. After completion Goal met. Patient did not aspirate during my shift. Continue interventions.