Grand Rounds Presentation Caring for Adult Clients II Spring Semester 2008 Linda J. Calderwood

Client Demographics Client: MF 77 Year old Caucasian female 5’0” tall, 104 lbs. Widowed (< 1 year) Assisted living One adult child lives locally Religious preference not specified –EMS called to client residence for respiratory distress. –Client was unresponsive with labored breathing & cyanosis Admitted to CCU 1/20/08; date of care 1/23/08.

History & Risk Factors Recent hospitalization for pneumonia - 2 weeks prior COPD Home O 2 CHF CAD Hyperlipidemia HTN Hx smoking - quit > 1 year

Physical Assessment EENT Oral endotracheal tube –Size 7.5 –21 at lip Orogastric tube No excess secretions, drooling No ulcerations, swelling Vision intact Hearing intact Vital Signs Apical Pulse Respirations 15 – 20 B/P –Systolic 80 – 118 –Diastolic 39 – 50 Pulse oximetry % Temperature 98.2 Pain 0 on 0-10 scale

Physical Assessment cont. Cardiovascular Apical pulse regular Cap refill < 3 sec Radial pulses 3+, equal Pedal pulses 2+, equal Non-pitting, moderate, weeping edema of hands, wrists, arms Cardiac monitoring –Bedside monitor –SR / ST Respiratory Ventilator support –Assist/control mode –V t 450, FiO 2 30% ETT secured with holder; backup airway at bedside; inline suctioning Cough by suctioning Scant sputum; clear, thin Breath sounds diminished both lower lobes Trachea midline

Physical Assessment cont. Gastrointestinal Hypoactive bowel sounds Abdomen soft, no tenderness No N/V Last stool: 1/22/08 Genitourinary Indwelling catheter –Urine clear, yellow –No foul odor UOP 250 mL/8h No bladder distension Genitals without lesions, edema or discharge

Physical Assessment cont. Musculoskeletal Generalized weakness Dependent Joint stiffness Neurological Arousable to stimuli: verbal Oriented x 3 Follows commands Moves all extremeties Grips equal Calm, cooperative Normal eye contact Pupils 3mm, round, equal, reactive to light RASS score: -1 Drowsy

Physical Assessment cont. Integumentary Skin warm, dry; color appropriate for ethnicity Skin thin, fragile Stage I pressure ulcer, left heel Protective foam boots Psychosocial Without apparent emotional distress Daughter at bedside