Grand Rounds Presentation Heather Harden SN, MTSU Nursing

Grand Rounds Presentation Heather Harden SN, MTSU Nursing 4330 Clinical

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

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

Risk Factors Health History Cardiac Respiratory Urinary Endocrine Other Surgeries

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

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

Diagnostic Tests CXR KUB Broncoscopy Stool Cx

Medications Albuterol- Bronchodi ipratopiu lator m Qvar 80 Synthetic Glucocorti coid 6 puffs Inhalation q4h 4puffs Inhalation q8h Predniso Corticost ne eroid Lasix Loop diuretic Aldacton K sparing e diuretic 15 mg PT Daily 40 mg PT BID 25 mg PT Daily

Medications cont. Levaquin Antibiotic Nystop Antifungal 750 mg n/a Lovenox Anticoagul ant Antithrom b. Nitrol Antiangina l 40 mg Zoloft Antidepre ssant 1gm 50 mg IV q24h Topical BID SQ q24h Transder m q6h PT HS

Medications Mirapex Sinemet 25/100 Lantus Antiparki nsonian Antiparki nsonism Antidiabe tic 1 mg PT TID 2 tab PT TID 12U 18U SQ Daily SQ HS Novolin R Antidiabe 8U SQ q6h tic Based on BG Pulmocar 1000ml PT e nutritiona continual

PRN Medications acetamin ophen Nonopioi d analgesic Dextrose Caloric syringe agent Ativan Sedative 650 mg Q6h PRN fever 25 ml Inj IV PRN Inj IV q6h PRN anxiety 1 mg

Physical Assesment Respiratory Lung sounds Physical Assessment Ventilator Tracheostomy

Assessment Cardiovascular Heart sounds Pulses Capillary Refill

Assessment GI/GU Bowel Sounds Dobbhoff Tube Urine Characteristic s Foley Catheter

Assessment Integumentary Alterations in skin integrity Arms Buttocks

Assessment Neuro. LOC Reflexes Pupils

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

Ineffective Airway Clearance Interventions Positioning Turning Suction Humidification

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%

Ineffective Breathing Pattern Interventions Positioning Suction Medication Turning

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%

Dysfunctional Ventilatory Weaning Response Interventions Positioning Education T-piece Vitals

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

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

Assessment of Goals Respiratory Rate Oxygen Airway Sputum Production Mental Status Temperature

Collaboration Physicians Nurses Respiratory Therapists Physical Therapists Hospitalists Patient’s Family Student Nurses and Instructors

Resources Ignatavicius, Donna (Ed.). (2006). MedicalSurgical 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.