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