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Concept Map-Adult 2

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by

Annsley Holland

on 29 April 2013

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Transcript of Concept Map-Adult 2

TA- 20 year old male Concept Map Medical Diagnosis Traumatic Brain Injury Medical History Aspiration Pneumonia
Severe Malnutrition
Debility
Tracheostomy
PEG tube
Respiratory Distress
Hepatitis Medications Famotidine Mupirocin
Fluconazole Propanolol
Gentamicin Tizanidine
Heparin Ibuprofen
Levetiracetam Labetalol
Levofloxacin Metoprolol
Magnesium oxide Ondansetron
Metronidazole Assessment Data -Awake and alert
-PERRL
-R IJ w/TPN running at 40.
-Contractures present in upper and lower
extremities bilaterally
-Tachycardic at 116 bpm and diaphoretic
-Normal S1&S2 heard
-Lung soungs clear in all 4 lobes
-Bowel sounds present
-PEG tube present in LUQ no gross abnormalities.
-Urine clear, malodorous
-Stage 2 pressure sore on coccyx Nursing Diagnosis #1 Impaired skin integrity R/T
impaired circulation AMB
destruction of skin layer,
disruption of skin surface and
invasion of body structures. Nursing Diagnosis #2 Risk for aspiration R/T depressed
cough, depressed gag reflex, GI tubes,
impaired swallowing, medication
administration, neck surgery, presence
of endotrach tube, reduced LOC,
situations hindering elevation of
upper body elevation, and tube
feeding. Patient (&family) Goals 1. Adequate passive ROM/turning every 2 hours

2. No further breakdown of skin on backside each day

3. Will not be incontinent during each shift

**(This patient cannot make any body movements or speak therefore his patient goals have to be very simple. Unfortunately, the first goal his family will have to do for him.) Nursing Interventions 1. The nurse will turn the patient every two hours along with work with physical therapy to ensure adequate ROM during each shift.

2. The nurse will apply medicated cream to the patient's compromised skin as ordered by the physician each shift.

3. The nurse will check for incontinence and will change the linens/clean the patient as needed. Patient Goals 1. Maintain patent airway each day

2. Maintain clear lung fields in all four quadrants each day.

3. Digest tube feedings without aspiration each day. Nursing Interventions 1. The nurse will monitor O2 saturation and respiration Q4hr.

2. The nurse will auscultate lung sounds Q2hr.

3. The nurse will listen to bowl sounds before and after tube feedings to ensure digestion and maintain HOB at 30 degrees. References Ackley, B., & Ladwig, G. (2011). Nursing diagnosis handbook. (9th ed., pp. 151-154). United States: Mosby Elsevier. Skin integrity. (2010, March 29). Retrieved from http://www.health.vic.gov.au/older/toolkit/09SkinIntegrity/ Goodwin, R. (2009, April 22). Prevention of aspiration pneumonia: A research based protocol. Retrieved from http://www.pspinformation.com/disease/aspiration/pneu.shtml
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