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This Concept Map has information related to: nov 12 2007graded 10 points, pt demographics caucasian male 74 yrs old transferred from Mercy Hospital for resp distress previously had a first tracheostomy on sept 07. After pt was taken off he developed resp distress so on Nov 07 a second tracheostomy was put in placed., PMHx -DM -HTN, Interventions: -let pt and family watch a video -explain during the video session -demonstrate cleaning, suctioning techniques -provide literatures for take home -assess pt and family understanding of the materials -identify objectives to be achieved pt will -verbalize an understanding of home trach care -be confidence in his skills -pt able to explain things back -pt more comfortable with her conditions. -able to explain reasons for their actions in trach care -participate in learning process, nursing dx: ineffective airway clearance related to blood tinged mucus production in lungs as evidenced by suctioning and pt cough production ND: knowledge decifit related to home tracheostomy care as evidenced by pt and family questions. Good, Admission Dx Nursing Dx:impaired gas exchange related to mucus production as evidenced by oxygen therapy and production of mucus interentions: -suctioning -encourage deep breathing coughing -increase oxygen therapy if ordered -monitor VS and LOC, Admission Dx Nursing Dx:impaired gas exchange related to mucus production as evidenced by oxygen therapy and production of mucus nursing dx: ineffective airway clearance related to blood tinged mucus production in lungs as evidenced by suctioning and pt cough production, interentions: -suctioning -encourage deep breathing coughing -increase oxygen therapy if ordered -monitor VS and LOC pt will -deomonstrate effective breathing and coughing techniques -good VS with normal range of POX2, resp rate -decrease mucus production in lungs clear lung sounds, Test & Diagnostics CMP: Na: 140 K: 4.0 Cl: 105 H3CO: 23 Cr: 0.77 Ca: 8.9 Msg: 1.47 Phos: 3.5 all WNL, Maintainence fluid: 0.9% NaCl and free water 175 ml q6h increase fluid volume in circulation increase cardiac output and B/P, Test & Diagnostics coagulation screen: INR: 1.0 aPTT: 33 within normal ranges