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    Medical DX Ineffective airway clearance related to presence of artificial airway Impaired skin integrity related to moisture Assess (Subjective and Objective) Assess (subjective and objective) goal (Must be realistic and measurable) maintain patent airway. Expectorate secretions. Improvemen t in lung sounds Diminished lung sound in lower bases bilaterally with ronchi in upper bases bilaterally. Localized erytherma 2+ edema in lower extremities bilaterally, 1+

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    Medical DX Ineffective airway clearance related to presence of artificial airway Impaired skin integrity related to moisture Assess (Subjective and Objective) Assess (subjective and objective) goal (Must be realistic and measurable) maintain patent airway. Expectorate secretions. Improvemen t in lung sounds Diminished lung sound in lower bases bilaterally with ronchi in upper bases bilaterally. Localized erytherma 2+ edema in lower extremities bilaterally, 1+

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    5K views1 page

    Critical Care Concept Map

    Uploaded by

    konniep69
    Medical DX Ineffective airway clearance related to presence of artificial airway Impaired skin integrity related to moisture Assess (Subjective and Objective) Assess (subjective and objective) goal (Must be realistic and measurable) maintain patent airway. Expectorate secretions. Improvemen t in lung sounds Diminished lung sound in lower bases bilaterally with ronchi in upper bases bilaterally. Localized erytherma 2+ edema in lower extremities bilaterally, 1+

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    of 1

    Nursing DX 1

    Ineffective airway clearance Nursing DX 2 Nursing DX 3


    related to
    presence of artificial airway Impaired skin integrity Impaired oral mucosa
    Medical DX
    related to related to
    moisture decreased salivation
    Respiratory
    Failure
    Assess (Subjective & Objective) Assess (Subjective & Objective) Assess (Subjective & Objective)

     Diminished lung sound in lower  3 1x1 skin tears and 4 blisters  Edema noted in gums
    bases bilaterally with ronchi in noted on trunk and upper  Pale and dry mucous membranes
    upper bases bilaterally extremities bilaterally  Cracked lips with bleeding
     Excessive secretions  Localized erytherma present
    Goal
    (Must be realistic and  Absent cough  2+ edema in lower extremities  Oral ulcers present on palate
    measurable)  Sinus tachycardia sustained at bilaterally, 1+ pitting edema in
    115-120 BPM upper extremities bilaterally
     Maintain
    patent airway Plan/Goal/Outcome Plan/Goal/Outcome
    Plan/Goal/Outcome
     Remain (short/long term goal) (short/long term
    (short/long term goal)
    afebrile goal)
     Improvemen  Keep lesions
     Maintain patent
    t in lung sounds clean and dry  Knowledge of
    airway
     Remain causative factors
     Expectorate
    afebrile  Maintain IV fluid
    secretions
     Display timely replacement
     Improvement in
    healing of skin  Exhibit signs of
    Teaching lung sounds
    lesions healing and
     Teach wife to keep
    decreased
    patients head midline to
    inflammation
    facilitate drainage of
    secretions Implement (Must be specific with Implement (Must be specific with Implement (must be specific with
     Informed patients wife times) times) times)
    that skin breakdown on
    forearms is d/t excessive  Elevate HOB  Monitor axillary temp q4h  Perform mouth care q4h
    moisture from previous  Suction trach PRN  Turn q2h  Lubricate lips with petroleum
    edema in upper jelly PRN
     Auscultate lung sound q2h  Change wound dressing q4h
    extremities  Inspect oral mucosa for lesions,
     Monitor vital signs q1h  Remove any wet linens and
     Teach patents family to
    be gentle with skin on Evaluate-Goal Met or Not Met? How was it
    met? Evaluate-Goal Met or Not Met? How was it Evaluate-Goal Met or Not Met? How was it
    forearms due to decreased met? met?
    integrity of dermis
    Goal met in maintaining patent
     Informed patients wife airway by suctioning PRN and Goal met in maintaining afebrile Goal not met in exhibiting signs of
    that oral mucosa is dry d/t elevating HOB temp healing and decreased
    decreased salivation No improvement lung sounds Skin lesions remained clean and inflammation in oral mucosa
    dry by changing dressings q4h

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