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