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This Concept Map, created with IHMC CmapTools, has information related to: graded 2, I. Patient Info & Medical Diagnosis T.S 55 y.o. white male Myocardial infarction, CVA, anoxic brain injury, diabetes, tracheostomy, cerebral aneurysm, sleep apnea, respiratory failure, morbid obesity, RKA. affects II. Pathophysiology of MI 1. Necrosis of myocardial cells. 2. Occurs when blood flow to a portion of cardiac muscle is completely blocked. 3. Coronary occlusion is usually caused by ulceration/rupture of atherosclerotic lesion 4. The vessel constricts and the thrombus interrupts blow flow to myocardial tissue distal to the obstruction. 5. When ischemia is prolonged for more than 20-45 minutes, irreversible hypoxemic damage causes cellular death and necrosis of the tissue. (Lemone & Burke 2008), V. Expected Outcomes 1. The patient will have impoved lung sounds by the end of my shift. 2. The patient will be able to remove more secretions by yankuer by the time of discharge. 3. The patient will be able to regulate blood sugar by the time of discharge. 4. The patient will be able to comprehend me by eye blinking by the end of my shift. 5. The patient will show an improvement r/t infection of RLE by the time of discharge. 6. The patient will show a decrease in MRSA infection by the time of discharge. 7. The patient will show a decrease in all around infection by the decrease of Abx by the time of discharge. ???? Interdisciplinary/Interventions 1. The nurse will manually suction out secretions. Rationale: To reduce gas exchange impairing secretions. 2. The nurse will monitor breath sounds closely Rationale: To assess amount of secretions. 3. The nurse will monitor blood glucose carefully Rationale: To try and regulate as much as possible 4. The nurse will administer abx Rationale: To redcue infection 5. The nurse will turn and reposition q 2 hour Rationale: To help heal skin tears 6. The nurse will support RLE Rationale: To reduce pain of RKA 7. The nurse will provide O2 through trach with humidifier. Rationale: To thin secretions and provide oxygen therapy. 8. The nurse will provide oral care q 4 hours Rationale: To decrease the risk of infection. (Lemone & Bourke 2008), II. Pathophysiology of MI 1. Necrosis of myocardial cells. 2. Occurs when blood flow to a portion of cardiac muscle is completely blocked. 3. Coronary occlusion is usually caused by ulceration/rupture of atherosclerotic lesion 4. The vessel constricts and the thrombus interrupts blow flow to myocardial tissue distal to the obstruction. 5. When ischemia is prolonged for more than 20-45 minutes, irreversible hypoxemic damage causes cellular death and necrosis of the tissue. (Lemone & Burke 2008) leads to III. Focused Data Assessment 1. Crackles in lung sounds prior to suctioning due to excess secretions. 2. 02 @ 5 L via trach with humidifier 3. Oral secretions suctioned out via yankauer 4. O2 sats 92-93% 5. TPN via G-tube 6. Skin tears on left elbow and coccyx 7. Right BKA on 3-11-09 8. Blood glucose 191 & 258 9. Decreased RBC levels due to infection (3.80) 10. Increased BUN due to MI (26), IV. Priority Nursing Diagnosis Airway Clearance, Ineffective due to excessive secretions. (Wilkinson & Ahern 2009) Expected Outcomes V. Expected Outcomes 1. The patient will have impoved lung sounds by the end of my shift. 2. The patient will be able to remove more secretions by yankuer by the time of discharge. 3. The patient will be able to regulate blood sugar by the time of discharge. 4. The patient will be able to comprehend me by eye blinking by the end of my shift. 5. The patient will show an improvement r/t infection of RLE by the time of discharge. 6. The patient will show a decrease in MRSA infection by the time of discharge. 7. The patient will show a decrease in all around infection by the decrease of Abx by the time of discharge., IV. Priority Nursing Diagnosis Airway Clearance, Ineffective due to excessive secretions. (Wilkinson & Ahern 2009) prioritizes IV. Other Nursing Diagnosis 1.Gas Excahnge, Impaired r/t excess secretions aeb crackles during auscultation. 2. Blood Glucose, Risk for Unstable r/t chronic diabetes aeb BS of 191-258 3. Skin Integrity, Impaired r/t immobility aeb skin tear on left elbow and coccyx. 4. Urinary incontinenece r/t impaired mental status aeb catheter 5. Infection, Risk For r/t RKA, tracheostomy, and skin tears 6. Bowel Incontinence r/t impaired mental status aeb rectal tube 7. Self-Care Deficit r/t impaired mental status aeb quality of skin and lack of oral care. (Wilkinson & Ahern 2009), V. Expected Outcomes 1. The patient will have impoved lung sounds by the end of my shift. 2. The patient will be able to remove more secretions by yankuer by the time of discharge. 3. The patient will be able to regulate blood sugar by the time of discharge. 4. The patient will be able to comprehend me by eye blinking by the end of my shift. 5. The patient will show an improvement r/t infection of RLE by the time of discharge. 6. The patient will show a decrease in MRSA infection by the time of discharge. 7. The patient will show a decrease in all around infection by the decrease of Abx by the time of discharge. ???? Evaluation of Expected Outcomes 1. The patients lung sounds improved after suctioning. Goal met. 2. The patient was able to remove secretions by nurse or wife by inline suction and yankuer. Goal met with assistance. 3. The patient's blood increased from 191 to 258. Goal not met. 4. The patient was still unable to respond to me with verbal cues, would react to pain stimuli. Goal not met. 5. The patient's infection was not able to be evaluated. Goal not able to evaluated. 6. The MRSA was not able to be evaluated for decrease by the end of my shift. Goal not met. 7. The patient's abx treatement was not decreased during my shift. Goal not met.