Grand Rounds St. Thomas 2A Erin Woodby Middle Tennessee State University School of Nursing April 17, 2008
Client Demographics-R.M. 86 y/o; DOB 3/31/22 Male Caucasian Retired military Protestant Married Four living children; 3 boys and 1 girl Lives in LTC facility English speaking Weight=167lbs (75.9 kgs) Height=72 inches (6 ft) BMI=22.7 Allergies: ACE inhibitors, Hydrocodone, Micardis, Percocet, Prinvil, Quinidine, Versed
Assessment: Vital Signs at 0700 Blood Pressure: 127/59 Heart Rate: 80 Mean Arterial Pressure: 82 Respiratory Rate: 13 Oxygen Saturation: 99% Temperature: 97.7°F axillary
Assessment: EENT Eyes- open to speech, conjunctivae pink and moist, no drainage noted Ears- bilateral hearing aides Nose- L nostril has dobhoff tube; no breakdown noted Mouth- contained endotracheal tube, lips were cracked and dry, drooling, teeth still present
Assessment: Integumentary Skin- warm, pick, dry CVP line in L jugular; dressing dry and intact; Continuous infusion of 75cc/h; 1445 Splint on L forearm Double lumen PICC line placed in R 0957; dressing dry and intact Ecchymosis all over arms and large bruise on R hip Perineal dermatitis
Assessment: Cardiovascular No abnormal heart sounds noted Telemetry 6 second strip indicates a fib with v paced P-P: uc; R-R: 70; PRI: uc; QRS: 0.08; QTI: uc All peripheral pulses palpable and equal bilaterally Capillary refill < 3 seconds 3+ peripheral pitting edema on all extremities
Assessment: Respiratory Continuous Positive Airway Pressure FiO2: 40% TV: 650 PEEP/PSUPP: 5/ Coarse breath sounds in RUL, RML, and LUL Diminished breath sounds in RLL and LLL Suction revealed thick white sputum/secretions
Assessment: Gastrointestinal Bowel sounds present in all 4 quadrants Two large brown stools Receiving Pulmocare through dobhoff tubing at 55cc/h for nutrition
Assessment: Genitourinary Foley catheter draining to gravity Urine clear and yellow Total UOP from was 1250cc
Assessment: Neurological Opened eyes to verbal stimulation; motor response to tactile stimulation pupils measured 2mm with sluggish reaction to light, and no deviation Weakness in all extremities
Assessment: Musculoskeletal Generalized weakness in all extremities Passive range of motion Stiff joints
Assessment: Psychosocial Wife and children present at bedside and participating in care When extubated showed signs of confusion and psychosis