Grand Rounds Presentation

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

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

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Laboratory Data

• Abnormal Values
• 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

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Diagnostic Tests

• CXR
• KUB
• Broncoscopy
• Stool Cx

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Medications
Albuterol-ipratopium Bronchodilator 6 puffs Inhalation q4h
Qvar 80 Synthetic Glucocorticoid 4puffs Inhalation q8h
Prednisone Corticosteroid 15 mg PT Daily
Lasix Loop diuretic 40 mg PT BID
Aldactone K sparing diuretic 25 mg PT Daily
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Medications cont.
Levaquin Antibiotic Antibiotic 750 mg IV q24h
Nystop Antifungal Antifungal n/a Topical BID
Lovenox Anticoagulant Antithromb. Anticoagulant Antithromb. 40 mg SQ q24h
Nitrol Antianginal Antianginal 1gm Transderm q6h
Zoloft Antidepressant 50 mg 50 mg PT HS
Xanax Antianxiety 0.5 mg 0.5 mg PT q8h
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Medications
Mirapex Antiparkinsonian 1 mg PT TID
Sinemet 25/100 Antiparkinsonism 2 tab PT TID
Lantus Antidiabetic 12U 18U SQ Daily SQ HS
Novolin R Antidiabetic 8U Based on BG SQ q6h
Pulmocare nutritional supp. 1000ml PT continual
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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
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Physical AssesmentRespiratory

• Lung sounds
• Physical Assessment
• Ventilator
• Tracheostomy

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AssessmentCardiovascular

• Heart sounds
• Pulses
• Capillary Refill

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Assessment GI/GU

• Bowel Sounds
• Dobbhoff Tube
• Urine Characteristics
• Foley Catheter

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Assessment Integumentary

• Alterations in skin integrity
• Arms
• Buttocks

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Assessment Neuro.

• LOC
• Reflexes
• Pupils

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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

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Ineffective Airway Clearance

• Interventions
• Positioning
• Turning
• Suction
• Humidification

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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 Patients respiratory rate will remain
  below 25
• Patient will achieve maximum lung expansion
  and adequate ventilation
• Patients oxygen stat will remain above 90

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Ineffective Breathing Pattern

• Interventions
• Positioning
• Suction
• Medication
• Turning

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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 Patients respiratory rate will remain
  below 25
• Patients mental status will remain stable
• Patient will express comfort during weaning
• Patients oxygen level will remain above 90

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Dysfunctional Ventilatory Weaning Response

• Interventions
• Positioning
• Education
• T-piece
• Vitals

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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 Patients RR will remain less than 25
• Sputum production will be clear and minimal
• Patients temp will remain lt100

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Ventilator Aquired Pneumonia

• Oral Health Status and Development of Ventilator
  Associated Pneumonia
• Sample
• ORAL CARE
• Results
• Correlation

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Assessment of Goals

• Respiratory Rate
• Oxygen
• Airway
• Sputum Production
• Mental Status
• Temperature

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Collaboration

• Physicians
• Nurses
• Respiratory Therapists
• Physical Therapists
• Hospitalists
• Patients Family
• Student Nurses and Instructors

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Resources

• Ignatavicius, Donna (Ed.). (2006).
  Medical-Surgical Nursing. (5thed.). St. Louis
  Elsevier.
• Pagana, Kathleen (Ed.). (2005). Mosbys
  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.