1. Grand Rounds Presentation
Heather Harden SN, MTSU
Nursing 4330 Clinical

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

3. 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

4. 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.

5. 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.

6. Laboratory Data Abnormal Values RBC- 4.35 Low Hgb- 12.3 Low
WBC High
RBC Low
Hgb 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..

7. 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

8. 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) 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)

9. 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 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.

10. 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

11. 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

12. 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.

13. 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.

14. 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 ml of clear yellow urine per hour.

15. 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.

16. 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.

17. 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

18. 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

19. 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%

20. 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

21. 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%

22. 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 % Oxygen passing through
Monitor vital signs every hour

23. 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

24. 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.

25. 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.

26. 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

27. 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.