concept map (tetanus)

1. Ineffective airway clearance r/t excessive mucus secretions

4. Impaired skin integrity r/t mechanical factors secondary to surgery.

2. Disturbed sleep pattern r/t biochemical agents such as medicines

3. Impaired physical mobility r/t prescribed movement restriction. (Functional level IV; Dependent, does not participate in activity.)

5. Risk for infection related to inadequate primary defense

Demographic Profile:

Name: Ms. PGender: FemaleAge: 76 years oldMarital status: MarriedReligion: AglipayOccupation: FarmerEducational Background: Grade 1

Vital Signs:

BP: 120/80 mmHgRR: 29 cpmPR: 83bpmTemperature: 36.5 C

(+) Tracheostomy

(+) productive cough

(+)Wide eyed

(+) Leg muscle weakness

(+)Restlessness

(+) Weakness

(+) Sunken eyeballs

(+) Floppy skin

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