concept map (tetanus)
TRANSCRIPT
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