Grand Rounds Grand Rounds Presentation Presentation

Heather Harden SN, MTSUHeather Harden SN, MTSU

Nursing 4330 ClinicalNursing 4330 Clinical

Overview Overview

Patient demographicsPatient demographics Risk FactorsRisk Factors Medical DiagnosisMedical Diagnosis Laboratory Data and TestsLaboratory Data and Tests Pharmacological Pharmacological

InterventionsInterventions Assessment FindingsAssessment Findings Nursing DiagnosesNursing Diagnoses Research Based CareResearch Based Care

Patient Demographics Patient Demographics

RJ, 69 year old RJ, 69 year old Caucasian maleCaucasian male

Married with two sonsMarried with two sons Christian (Baptist)Christian (Baptist) 215 lbs., 72 inches tall215 lbs., 72 inches tall Full code with no Full code with no

Advanced DirectiveAdvanced Directive Allergies: Sulfa Drugs & Allergies: Sulfa Drugs &

TheophyllineTheophylline

Risk FactorsRisk Factors

Health HistoryHealth History Cardiac Cardiac Respiratory Respiratory UrinaryUrinary EndocrineEndocrine OtherOther SurgeriesSurgeries

Medical DiagnosisMedical Diagnosis

Medical Diagnosis- Respiratory Medical Diagnosis- Respiratory FailureFailure

Admitted on 1/2/2008 to the Admitted on 1/2/2008 to the emergency room for “trouble emergency room for “trouble

breathing”breathing” Dates of Care: January 24 & 25, Dates of Care: January 24 & 25,

20082008

Laboratory DataLaboratory Data

Abnormal ValuesAbnormal Values WBC- 13.1 HighWBC- 13.1 High

RBC- 4.35 LowRBC- 4.35 Low Hgb- 12.3 LowHgb- 12.3 Low MCHC- 30.7% MCHC- 30.7%

LowLow RDW- 17.1% HighRDW- 17.1% High Neut.- 84% HighNeut.- 84% High Lymph- 7% LowLymph- 7% Low

Mono- 9% HighMono- 9% High Glucose – 205 Glucose – 205

HighHigh AST- 21 LowAST- 21 Low BUN- 57 HighBUN- 57 High

Diagnostic TestsDiagnostic Tests

CXRCXR KUBKUB BroncoscopyBroncoscopy Stool CxStool Cx

MedicationsMedications

Albuterol-Albuterol-ipratopiuipratopiu

mm

BronchodiBronchodilatorlator

6 puffs6 puffs InhalationInhalation

q4hq4h

Qvar 80Qvar 80 Synthetic Synthetic GlucocortiGlucocorti

coidcoid

4puffs4puffs InhalationInhalation

q8hq8h

PrednisoPrednisonene

CorticostCorticosteroideroid

15 mg 15 mg PT DailyPT Daily

LasixLasix Loop Loop diureticdiuretic

40 mg40 mg PT BIDPT BID

AldactonAldactonee

K sparing K sparing diureticdiuretic

25 mg25 mg PT DailyPT Daily

Medications cont.Medications cont.LevaquinLevaquin AntibioticAntibiotic 750 mg750 mg IV q24hIV q24h

NystopNystop AntifungalAntifungal n/an/a TopicalTopical

BIDBID

LovenoxLovenox AnticoagulAnticoagulantant

AntithromAntithromb.b.

40 mg40 mg SQ q24hSQ q24h

NitrolNitrol AntianginaAntianginall

1gm1gm TransderTransdermm

q6hq6h

ZoloftZoloft AntidepreAntidepressantssant

50 mg50 mg PT HSPT HS

XanaxXanax AntianxietAntianxietyy

0.5 mg0.5 mg PT q8hPT q8h

MedicationsMedicationsMirapexMirapex AntiparkiAntiparki

nsoniannsonian1 mg 1 mg PT TIDPT TID

Sinemet Sinemet 25/10025/100

AntiparkiAntiparkinsonismnsonism

2 tab2 tab PT TIDPT TID

LantusLantus AntidiabeAntidiabetictic

12U12U

18U18USQ DailySQ Daily

SQ HSSQ HS

Novolin RNovolin R AntidiabeAntidiabetictic

8U +8U +

Based on Based on BGBG

SQ q6hSQ q6h

PulmocarPulmocaree

nutritionanutritiona

l supp.l supp.

1000ml1000ml PT PT continualcontinual

PRN MedicationsPRN Medications

acetaminacetaminophenophen

NonopioiNonopioid d

analgesicanalgesic

650 mg650 mg Q6h PRN Q6h PRN feverfever

Dextrose Dextrose syringesyringe

Caloric Caloric agentagent

25 ml25 ml Inj IV Inj IV PRNPRN

AtivanAtivan SedativeSedative 1 mg 1 mg Inj IV q6h Inj IV q6h PRN PRN

anxietyanxiety

Physical AssesmentPhysical AssesmentRespiratoryRespiratory

Lung soundsLung sounds Physical Physical

AssessmentAssessment VentilatorVentilator TracheostomyTracheostomy

AssessmentAssessmentCardiovascularCardiovascular

Heart soundsHeart sounds PulsesPulses Capillary RefillCapillary Refill

Assessment GI/GUAssessment GI/GU

Bowel SoundsBowel Sounds Dobbhoff TubeDobbhoff Tube Urine Urine

CharacteristicCharacteristicss

Foley CatheterFoley Catheter

Assessment Assessment IntegumentaryIntegumentary

Alterations in Alterations in skin integrityskin integrity ArmsArms ButtocksButtocks

Assessment Neuro.Assessment Neuro.

LOCLOC ReflexesReflexes PupilsPupils

Nursing DiagnosesNursing Diagnoses# 1# 1 Ineffective Airway ClearanceIneffective Airway Clearance

related to the presence of related to the presence of tracheobronchial secretions as evidence tracheobronchial secretions as evidence by an increased respiratory rate, fever, by an increased respiratory rate, fever, frothy sputum production, and decreased frothy sputum production, and decreased lung sounds.lung sounds.

Goals: Breath sounds will no longer be Goals: Breath sounds will no longer be diminisheddiminished

Airway will remain patentAirway will remain patent CXR will reveal no pleural effusionCXR will reveal no pleural effusion Patient will produce normal sputumPatient will produce normal sputum

Ineffective Airway Ineffective Airway ClearanceClearance

InterventionsInterventions PositioningPositioning TurningTurning Suction Suction HumidificationHumidification

Nursing DiagnosesNursing Diagnoses# 2 Ineffective Breathing Pattern# 2 Ineffective Breathing Pattern

related to fatigue as evidence by rapid, related to fatigue as evidence by rapid, shallow respirations, shortness of breath shallow respirations, shortness of breath and the need for ventilatory support.and the need for ventilatory support.

GoalsGoals: Patient’s respiratory rate will remain : Patient’s respiratory rate will remain below 25below 25

Patient will achieve maximum lung Patient will achieve maximum lung expansion expansion and adequate ventilationand adequate ventilation

Patient’s oxygen stat will remain Patient’s oxygen stat will remain above 90%above 90%

Ineffective Breathing Ineffective Breathing PatternPattern

InterventionsInterventions PositioningPositioning SuctionSuction MedicationMedication TurningTurning

Nursing DiagnosesNursing Diagnoses# 3 Dysfunctional Ventilatory Weaning # 3 Dysfunctional Ventilatory Weaning

ResponseResponse related to diminished ventilator support related to diminished ventilator support as evidence by breathing dicomfort, increased need as evidence by breathing dicomfort, increased need for oxygen, restlessness, increase in respiratory rate, for oxygen, restlessness, increase in respiratory rate, and shallow respirationsand shallow respirations..

Goals: Patient’s respiratory rate will remain below 25Goals: Patient’s respiratory rate will remain below 25

Patient’s mental status will remain stablePatient’s mental status will remain stable

Patient will express comfort during weaningPatient will express comfort during weaning

Patient’s oxygen level will remain above 90%Patient’s oxygen level will remain above 90%

Dysfunctional Ventilatory Dysfunctional Ventilatory Weaning ResponseWeaning Response

InterventionsInterventions PositioningPositioning EducationEducation T-pieceT-piece VitalsVitals

Nursing DiagnosesNursing Diagnoses

Risk for InfectionRisk for Infection related to the related to the aspiration of ventilator condensation as aspiration of ventilator condensation as evidence by diminished lung sounds, evidence by diminished lung sounds, increased respiratory rate, increased increased respiratory rate, increased frothy sputum production and fever.frothy sputum production and fever. Goals:Goals: Patient’s RR will remain less than Patient’s RR will remain less than

2525 Sputum production will be clear and Sputum production will be clear and

minimalminimal Patient’s temp will remain <100Patient’s temp will remain <100

Ventilator Aquired Ventilator Aquired PneumoniaPneumonia

Oral Health Status and Development Oral Health Status and Development of Ventilator Associated Pneumoniaof Ventilator Associated Pneumonia SampleSample ORAL CAREORAL CARE ResultsResults CorrelationCorrelation

Assessment of GoalsAssessment of Goals

Respiratory Respiratory RateRate

OxygenOxygen AirwayAirway Sputum Sputum

ProductionProduction Mental StatusMental Status TemperatureTemperature

CollaborationCollaboration PhysiciansPhysicians NursesNurses Respiratory Respiratory

TherapistsTherapists Physical TherapistsPhysical Therapists HospitalistsHospitalists Patient’s FamilyPatient’s Family Student Nurses Student Nurses

and Instructorsand Instructors

ResourcesResources

Ignatavicius, Donna (Ed.). (2006). Ignatavicius, Donna (Ed.). (2006). Medical-Medical-Surgical NursingSurgical Nursing. (5. (5ththed.). St. Louis: Elsevier.ed.). St. Louis: Elsevier.

Pagana, Kathleen (Ed.). (2005). Pagana, Kathleen (Ed.). (2005). Mosby’s Mosby’s Diagnostic and laboratory Test Reference.Diagnostic and laboratory Test Reference. (7(7thth ed.). St. Louis: Elsevier. ed.). St. Louis: Elsevier.

Munro,C., Grap,M., Elswick R., McKinney J. Munro,C., Grap,M., Elswick R., McKinney J. (2006). (2006). Oral Health Status and Oral Health Status and Development of Ventilator-Associated Development of Ventilator-Associated Pneumonia: A Descriptive Study. Pneumonia: A Descriptive Study. American American Journal of Critical Care, Journal of Critical Care, 15(5), 453. 15(5), 453.