Grand Rounds Presentation Heather Harden SN, MTSU Nursing 4330 Clinical

Overview Patient demographics Risk Factors Medical Diagnosis Laboratory Data and Tests Pharmacological Interventions Assessment Findings Nursing Diagnoses Research Based Care

Patient Demographics RJ, 69 year old Caucasian male Married with two sons Christian (Baptist) 215 lbs., 72 inches tall Full code with no Advanced Directive Allergies: Sulfa Drugs & Theophylline

Risk Factors Health History Cardiac Respiratory Urinary Endocrine Other Surgeries RJ has a history of Cardiac problems such at a Coronary artery stent, an Internal Cardiac Drfibrillator, and a pacemaker. Concerning his respiratory status, he has a history of asthma, pneumonia, a tracheostomy and at home oxygen administration. He is prone to kidney stones and prostate problems. He is a type II Diabetic with a history of pancreatitis. Other pertinent aspects of his history include GERD, Anemia, previous blood transfusions, MRSA, and Parkinson’s Disease. The only surgeries noted on his health history included a heart valve replacement and pacemaker in 2002.

Medical Diagnosis Medical Diagnosis- Respiratory Failure Admitted on 1/2/2008 to the emergency room for “trouble breathing” Dates of Care: January 24 & 25, 2008 The Medical Diagnosis was defined as Respiratory Failure. Respiratory Failure, as defined in the book title Medical-Surgical Nursing is ventilatory failure, oxygenation failure, or a combination of both ventilatory and oxygenation failure. This patient was admitted on January 2, 2008 and stated that he had been having trouble breathing. No other significant events lead up to the hospitalization.

Laboratory Data Abnormal Values RBC- 4.35 Low Hgb- 12.3 Low WBC- 13.1 High RBC- 4.35 Low Hgb- 12.3 Low MCHC- 30.7% Low RDW- 17.1% High Neut.- 84% High Lymph- 7% Low Mono- 9% High Glucose – 205 High AST- 21 Low BUN- 57 High WBC high=norm (5-10x10^9/L) infection, stress RBC Low due to anemia Hgb- Low due to anemia MCHC-(32-36%) mean corpuscular hemaglobin conentration hemeglobin x 100 / hematocrit (amount of concentration of hemeglobin of each RBC) decreased due to anemia RDW- (11-14%) red cell distribution width ( indicates the variation in size of the RBC) Neutrophils – ( 55-70%) bacterial infection Lymphocytes (20-40%) Monocytes(2-8%) infection Glucose high due to diabetes AST (alpha- antitrypsin) (85-213) low protein- malnutrition BUN- blood urea nirtogen (10-20) excessive intake to protein r/t the protien supplements he was taking to help increase his AST..

Diagnostic Tests CXR KUB Broncoscopy Stool Cx Chest X-rays were done almost daily from the time of admission. Upon Admission, Pleural effusion was noted in left lower lung. Mild basilar atelectasis was also noted. By the twenty second of January, the effusion was noted to have decreased, but was still present. The chest x-rays were also done to check the placement of a central line in the right subclavian and for placement of a Dobbhoff tube for feeding. KUB’s were also done on the 22nd and showed that the DH tube was located in the second and third portion of the duodenum. Slight cardiomegaly was also noticed. Bronchoscopies were done on January 4th and 15th , 2008 to collect respiratory secretions needed for fungal and acid fast bacilli cultures. Both came back negative . Stool was also collected and sent to the lab for C.Diff culture. The labs were still pending when care was given

Medications Prednisone Corticosteroid 15 mg PT Daily Lasix Albuterol-ipratopium Bronchodilator 6 puffs Inhalation q4h Qvar 80 Synthetic Glucocorticoid 4puffs q8h Prednisone Corticosteroid 15 mg PT Daily Lasix Loop diuretic 40 mg PT BID Aldactone K sparing diuretic 25 mg Albuterol- bronchodilator (adrenergic beta2 agonist)---6 puffs inhaled q4h---Rationale– to help facilitate breathing (hx of asthma and trach) Qvar (beclomethasone)- (glucocorticoid)-----4 puffs inhaled q8h-----Rationale--- antiinflammatory to help open up the airways and facilitate breathing Prednisone- corticosteroid (glucocorticoid)---antiinflammatory agent---15 mg—PT Daily--- helps decrease inflammation of the resp tract Lasix- furosemide----Loop diuretic (acts on the lop of Henle inhibiting the reabsorption of sodium and chloride)---40 mg PT BID– Decreases edema in the lung tissue—(pt had pleural effusion) Aldactone(spironolactone)---potassium sparing diuretic (aldosterone antagonist)---25 mg PT Daily-----Helps reduce edema Nexium- (esomeprazole)—antiulcer (proton pump inhibitor)---40 mg PT BID--- helps decrease gastroesophageal reflux (pt has GERD)

Medications cont. Levaquin Antibiotic 750 mg IV q24h Nystop Antifungal Topical BID Lovenox Anticoagulant Antithromb. 40 mg SQ q24h Nitrol Antianginal 1gm Transderm q6h Zoloft Antidepressant 50 mg PT HS Xanax Antianxiety 0.5 mg PT q8h Levaquin-(levofloxacin)—Antiinfective (antibiotic---strep pneu., staph aureus, klebiella pneu., mycoplasma pneu., haemophilus influenza) lower respiratory infections----750 mg IV q24h----pt suspected to have pneumonia Nystop- Antifunfgal----topical BID---applied to the buttocks twice a day to create a barrier and help prevent further bed sores Lovenox- (enoxaparin)---antcoagulant/antithrombotic (low-molecular wieght heparin)---40 mg SQ q24h---Help prevent DVT Nitroglycerin---antianginal---coronary vasodilator---1gm transdermally q6h--- pt has a hx of coronary artery problems and a stent Zoloft- (sertraline)—antidepressant—increases the action of seritonin by preventing its reuptake---50 mg PT HS--- Xanax (alprazolam)- antianxiety/sedative/hypnotic- depresses subcortical levels of the CNS---0.5mg PT q8h---to keep pt calm and relaxed while on vent.

Medications Mirapex Antiparkinsonian 1 mg PT TID Sinemet 25/100 Antiparkinsonism 2 tab Lantus Antidiabetic 12U 18U SQ Daily SQ HS Novolin R 8U + Based on BG SQ q6h Pulmocare nutritional supp. 1000ml PT continual Mirapex- (Pramipexole) Antiparkisonian agent (dopamine receptor agonist)---1mg PT TID---helps to decrease involuntary movts.--- pt has parkinsons disease Sinemet (cabidopa-levadopa)- Antiparkinsonism- makes more levadopa available for transport to the brain and conversion to dopamine----2 tab PT TID- helps to decrease involuntary movements Lantus- (insulin glargine) Long acting---Antidiabetic---pancreatic hormone---decreases blood glucose---12 U SQ dialy and 18U SQ HS----pt has Diabetes Mellitus Novolin R- (regular insulin)—short acting-- Onset 30min-1hr---Peak 2-3 hr---Duration 3-6 hrs—Antidiabetic (pancreatic hormone)---- 8U + additional units depending on his BG level q6h--- Pt had type II diabetes

PRN Medications acetaminophen Nonopioid analgesic 650 mg Q6h PRN fever Dextrose syringe Caloric agent 25 ml Inj IV PRN Ativan Sedative 1 mg Inj IV q6h PRN anxiety Acetaminophen- non-opioid analgesic---PRN q6h for fever >101---pt was having fever possibly r/t pneumonia Dextrose- (glucose)---caloric agent---in the event of hypoglycemia---25 ml inj IV PRN Ativan---(lorazepam)---sedative/hypnotic, antianxiety----depresses CNS to decrease anxiety and promote relaxation---1 mg PRN inj IV q6h--- to help pt with vent

Physical Assesment Respiratory Lung sounds Physical Assessment Ventilator Tracheostomy Upon auscultation lungs sounded diminished in the lower lobes. This is possible due to the mild pleural effusion noted in the x-ray reports. He has a tracheostomy which was connected to a ventilator and he was on CPAP. There was thick, green drainage coming out of his trach. hole (not a new trach) and think off-white respiratory secretions collected from suctioning.

Assessment Cardiovascular Heart sounds Pulses Capillary Refill No abnormal heart sounds were noted. Radial and pedial pulses were present, strong and equal bilateraly. Capillary refill was less than 3 sec.

Assessment GI/GU Bowel Sounds Dobbhoff Tube Urine Characteristics Foley Catheter Patient’s bowel sound were present and active. He was NPO and had a Dobbhoff tube inserted on Jan 4, 2008 and was receiving Pulmocare at 75ml/hr. Patient had a Foley catheter which drained 100-200 ml of clear yellow urine per hour.

Assessment Integumentary Alterations in skin integrity Arms Buttocks RJ had two main areas of concern regarding skin integrity. His right arm was moderatly covered with scabs and bruises related to Iv sticks. His buttocks area was reddened and considered a risk for potential bed sore. Overall, only slight edema was noted in the extremeties and all other areas had good integrity. The skin was warm, pink and dry.

Assessment Neuro. LOC Reflexes Pupils Patient was awake and alert. He was not able to verbalize orientation to time and place, but was able to recognize familiar faces. He was able to squeeze his fist equally bilaterally and create resistance with his feet against my hands. His pupils were equal, round and reactive to light and accommodation.

Nursing Diagnoses # 1 Ineffective Airway Clearance related to the presence of tracheobronchial secretions as evidence by an increased respiratory rate, fever, frothy sputum production, and decreased lung sounds. Goals: Breath sounds will no longer be diminished Airway will remain patent CXR will reveal no pleural effusion Patient will produce normal sputum

Ineffective Airway Clearance Interventions Positioning Turning Suction Humidification Patient will remain in the Semi or Fowlers position to aide in breathing Patient will be turned every 2 hours to help loosen secretions Suction will be administered as need to help expel secretions Adequate humidification will be provided with ventilation

Nursing Diagnoses # 2 Ineffective Breathing Pattern related to fatigue as evidence by rapid, shallow respirations, shortness of breath and the need for ventilatory support. Goals: Patient’s respiratory rate will remain below 25 Patient will achieve maximum lung expansion and adequate ventilation Patient’s oxygen stat will remain above 90%

Ineffective Breathing Pattern Interventions Positioning Suction Medication Turning Patient will be placed in Semi/Fowlers position to help facilitate breathing. Airway will be suctioned as PRN to help breathing. Administration of anti-anxiety medication to help patient feel calm and not resist the ventilator. Patient will be turned every two hours to help loosen secretions

Nursing Diagnoses # 3 Dysfunctional Ventilatory Weaning Response related to diminished ventilator support as evidence by breathing dicomfort, increased need for oxygen, restlessness, increase in respiratory rate, and shallow respirations. Goals: Patient’s respiratory rate will remain below 25 Patient’s mental status will remain stable Patient will express comfort during weaning Patient’s oxygen level will remain above 90%

Dysfunctional Ventilatory Weaning Response Interventions Positioning Education T-piece Vitals Patient will be placed in a comfortable position that allows for adequate breathing All procedures will be described beforehand to help decrease anxiety Once patient is stable with CPAP, a T-piece may be tried with 30-50 % Oxygen passing through Monitor vital signs every hour

Nursing Diagnoses Risk for Infection related to the aspiration of ventilator condensation as evidence by diminished lung sounds, increased respiratory rate, increased frothy sputum production and fever. Goals: Patient’s RR will remain less than 25 Sputum production will be clear and minimal Patient’s temp will remain <100

Ventilator Aquired Pneumonia Oral Health Status and Development of Ventilator Associated Pneumonia Sample ORAL CARE Results Correlation A recent study done by Virginia Commonwealth University showed the correlation of Oral care in Vent. Patients and VAP. The results showed that there was a strong relationship between a patients oral health and their risk for acquiring vent. Associated pneumonia. 66 patients were enrolled in this study within 24 hours of intubation and were closely studied over the next seven days. Areas that were of greatest concern were salivary volume, colonization of bacteria, and overall oral health. The patients were evaluated upon admission, day4 and day 7. As the pt’s amount of time in the ICU increased, less attention was given to their oral care. Bacterial colonization greatly increased with time and salivary volume greatly decreased. The overall recommendations for patients on ventilators were that oral care should be a major priority. An increase in salivary volume helps to flush out bactiria and oral care should be administered regularly. RJ was a vent patient and oral care was given to him every two hours even though he had a trach. He was having problem with a fever and it was suspected that he had pneumonia.

Assessment of Goals Respiratory Rate Oxygen Airway Sputum Production Mental Status Temperature Patients rr reamined below 25 and Oxygen stat remained above 90% while at rest His ariway remained patent throughout time of care Sputum production remained frothy, but decreased in overall volume. His mental status did not decline, and he remained Alert, Awake and oriented to person. His temperature was kept under 101 degrees with the help of acetaminophen.

Collaboration Physicians Nurses Respiratory Therapists Physical Therapists Hospitalists Patient’s Family Student Nurses and Instructors Physicains, Nurses, RT, PT, hospitalists, patient’s family, students nurses and instructors

Resources Ignatavicius, Donna (Ed.). (2006). Medical-Surgical Nursing. (5thed.). St. Louis: Elsevier. Pagana, Kathleen (Ed.). (2005). Mosby’s Diagnostic and laboratory Test Reference. (7th ed.). St. Louis: Elsevier. Munro,C., Grap,M., Elswick R., McKinney J. (2006). Oral Health Status and Development of Ventilator-Associated Pneumonia: A Descriptive Study. American Journal of Critical Care, 15(5), 453.