Clinical Concept Map Activity - Week 13 PDF

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Summary

CLINICAL CONCEPT MAP...

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S Concept Map Name: References: Thomson Delmar Learning’s Medical Surgical Nursing Care Plans Shielda Glover Rodgers. Diagnostic Tests / Medications Diagnostic MRI Direct laryngoscopy Hoarseness Color changes in mouth or tongue Radiographs CT scan Medications

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Dr. Rose, this is Precious, calling from emergency department. I have Mrs. Rodriguez in Room 100, a 55yr-old woman who looks restless and is complaining of hoarseness that has lasted for more than 2 weeks. Background: She has history of prolonged use of alcohol and tobacco. On observation her tongue and mouth appear white and gray respectively.

A

Assessment: Pt. Vital signs are as follows: BP 95/55, RR 100, O₂ 85%. I think she has hoarseness / change in vocal quality.

R

Recommendation: I need for you to evaluate her right away. I’d like to get a prescription for an MRI.

Patient Problem: Cancer of the Larynx

Areas for Teaching -

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List Abnormal Signs and Symptoms  Hoarseness or a change in vocal quality that lasts more than 2 weeks  Color changes in mouth or tongue (White, gray, dark brown, black, or patchy.)

Allow client and Family to observe and handle tracheostomy tubes and suctioning equipment. Explain how and why suctioning Consider literacy level Refer client to speech pathologist Discuss the planned rehabilitation program. Plan for acceptable communication method after surgery.

Independent Nursing Actions - Assess for dysphagia, dyspnea, cough, hemoptysis, etc.

 Radiation therapy  Adjuvant chemotherapy  Laryngectomy (Surgical Removal of larynx

- Keep call bell/light within reach at all times - Promote respiratory functioning - Provide Pre/postoperative care

Body System Affected / Focus of Care -

Follow up Assessment related to interventions/Treatments for patient problem.

Respiratory System Larynx

- Provide tracheostomy care every 2 – 4 hours and as needed (PRN) - Encourage ambulation as early as possible

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Referral for speech rehabilitation with artificial larynx or to learn esophageal speech Keep bed in semi-Fowler position at all times Keep laryngeal airway humidified at all times Auscultate lung sounds every 2-4

- Humidification of environment - Administer tube feedings as prescribed....