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This Concept Map, created with IHMC CmapTools, has information related to: Acute Care 2.27.08, Assess level of anxiety and coping through out shift outcome Patient seemed relieved when family present. Showed emotions of sadness and anxiety when doctor explained plan for home treatment and when family left for the night., Patient is 59 year old Caucasian Female admitted on 2/25/08 with SVC Syndrome Nursing Diagnoses Nursing Diagnosis: Ineffective Airway Clearance, Assessment G/U Up to toilet urine yellow,clear Output: 300ml/shift, Discuss understanding of concept of what can and cannot be changed interventions Assist patient to develop a stress management program possibly including relaxation, meditation, involvement in activities, Assessment Neuro/muscular Alert and Oriented x3 Muscle Strength: 5 BUE, 5 BLE, Up out of bed, walks without assist Uses note pad to communicate by writing, Assessment Vital Signs Vitals at 1400 Temp:36.6 C Pulse: 81 Resp: 18 B/P: 104/66 O2: 100%/ Trach collar Pain: 2/10, Change dressing on wound as ordered. Assess drainage type, healing and skin integrity around the wounds outcome Dry sterile dressing placed over lesions on neck. The two larger ones were packed with dry nu gauze., Docusate oral soln 100mg PEG BID (2100) used for Stool softener, decrease constipation, Discuss understanding of concept of what can and cannot be changed interventions Assess level of anxiety and coping through out shift, Readiness for enhanced coping related to CA and current diagnosis as evidenced by patient seeking of family support, awareness of environmental/lifestyle changes, motivation for self-care. Expected Outcome Patient will assess current situation accurately, express feelings that match her behavior, identify options and use resources available through the hospital and her family/community, Assessment Respiratory Lung sounds: Clear, symmetrical chest rise no accessory muscle use Trach- Shiley, size 4 Patient able to suction with assistance Humidity with 02, Fi02: 0.35 Weaning to RA to keep Satᢕ%, Risk for Infection (further/spread) related to open lesions, obstruction of fluid in face, tissue destruction by CA Interventions Change dressing on wound as ordered. Assess drainage type, healing and skin integrity around the wounds, Patient will assess current situation accurately, express feelings that match her behavior, identify options and use resources available through the hospital and her family/community interventions Assess level of anxiety and coping through out shift, Ineffective airway clearance related to tracheostomy, excessive mucus, as evidenced by ineffective cough, change in respiratory rhythm interventions Provide trach care every shift and as needed, Risk for Infection (further/spread) related to open lesions, obstruction of fluid in face, tissue destruction by CA Interventions Assess for signs and symptoms of progressing infection: increase temp, increased WBC, decreased tissue perfusion, Assess respiratory rate rhythm and breath sounds during shift outcome Patient's respiratory rate and SaO2 within normal limits Breath sounds clear. No signs of respiratory distress, Patient will assess current situation accurately, express feelings that match her behavior, identify options and use resources available through the hospital and her family/community interventions Assist patient to develop a stress management program possibly including relaxation, meditation, involvement in activities, Assessment Cardiac Apical Pulse regular Radial pulse +2 Bil Femoral pulse +2 Bil Dorsalis Pedis +2 Bil Post Tibia +2 Bil Cap refill brisk Warm temperature no numbness or tingling Bil +2 pitting edema in feet +1 edema in ankles/calf bil warm to touch, no pain, Patient is 59 year old Caucasian Female admitted on 2/25/08 with SVC Syndrome Nursing Diagnoses Nursing Diagnonsis: Risk for infection (further), Ineffective airway clearance related to tracheostomy, excessive mucus, as evidenced by ineffective cough, change in respiratory rhythm interventions Suction patient as needed