Transcript Patient Demographics

Grand Rounds Presentation
Heather Harden SN, MTSU
Nursing 4330 Clinical
Overview
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Patient demographics
Risk Factors
Medical Diagnosis
Laboratory Data and Tests
Pharmacological Interventions
Assessment Findings
Nursing Diagnoses
Research Based Care
Patient Demographics
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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
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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
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Laboratory Data
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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
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CXR
KUB
Broncoscopy
Stool Cx
Medications
Albuterolipratopium
Bronchodilat
or
6 puffs
Inhalation
q4h
Qvar 80
Synthetic
Glucocorticoi
d
4puffs
Inhalation
q8h
Prednisone Corticostero
id
Lasix
Loop
diuretic
Aldactone
K sparing
diuretic
15 mg
PT Daily
40 mg
PT BID
25 mg
PT Daily
Medications cont.
Levaquin
Antibiotic
750 mg
IV q24h
Nystop
Antifungal
n/a
Lovenox
Anticoagulant
Antithromb.
Antianginal
40 mg
Topical
BID
SQ q24h
Zoloft
Antidepressa
nt
50 mg
Transderm
q6h
PT HS
Xanax
Antianxiety
0.5 mg
PT q8h
Nitrol
1gm
Medications
Mirapex
Antiparkinso
nian
1 mg
PT TID
Sinemet
25/100
Antiparkinso
nism
2 tab
PT TID
Lantus
Antidiabetic
12U
18U
SQ Daily
SQ HS
Novolin R
Antidiabetic
SQ q6h
Pulmocare
nutritional
supp.
8U +
Based on
BG
1000ml
PT continual
PRN Medications
acetaminoph
en
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
Physical Assesment
Respiratory
Lung sounds
 Physical
Assessment
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Ventilator
 Tracheostomy
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Assessment
Cardiovascular
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
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Alterations in skin
integrity
 Arms
 Buttocks
Assessment Neuro.
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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
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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: 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
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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: 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
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Interventions
Positioning
 Education
 T-piece
 Vitals
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Nursing Diagnoses
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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
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Ventilator Aquired Pneumonia
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Oral Health Status and Development of
Ventilator Associated Pneumonia
Sample
 ORAL CARE
 Results
 Correlation
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Assessment of Goals
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Respiratory Rate
Oxygen
Airway
Sputum Production
Mental Status
Temperature
Collaboration
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Physicians
Nurses
Respiratory
Therapists
Physical Therapists
Hospitalists
Patient’s Family
Student Nurses and
Instructors
Resources
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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 VentilatorAssociated Pneumonia: A Descriptive Study. American
Journal of Critical Care, 15(5), 453.