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71 yo Full code Allergy: Amoxicillin BMI:26 (INTERVENTIONS: (Hand…
71 yo
Full code
Allergy: Amoxicillin
BMI:26
MDX:
Laryngeal cancer
increased stridor
Tracheostomy placement
PMH:
HTN
Hyperlipidemia
MEDS:
Atorvastatin
Amlodipine-benazepril
Prednisone
Pantoprazole
LABS:
Neutrophils 83 H
IMAGING:
Chest xray-
Confirms proper tracheostomy placement
Degenerative changes to bilat AC joints
Possible NDX:
Ineffective airway clearance
Impaired verbal communication
Risk for infection
Disturbed body image
Readiness for enhanced health management
INTERVENTIONS:
Hand hygiene and PPE (gown, gloves, mask)
Assess WBC and labs Q shift
Assess temp, BP, HR, RR, SPO2 Q4 hr and PRN
Assess sputum and cough effort
suction ready
Humidified trach collar 7L 21%
Provide education on trach care
Assess self confidence and support
Assess nutritional intake