Transcript Slide 1
Grand Rounds Meg Tiongco March 20, 2008 Patient Demographics 73 year old Caucasian male Divorced Daughter living in Michigan Resident of a long term care facility Height: 67 inches, Weight: 233 lbs Full code Allergies: penicillin, Darvocet Past Medical History Multiple strokes Coronary disease Chronic Obstructive Pulmonary Disease Non insulin-dependent diabetes Previous pressure ulcers Sleep apnea Schizophrenia Heavy smoker in the past Events Leading to Hospitalization Presented to the ER in Fentress County in respiratory distress Bilateral infiltrates on chest x-ray Put on BiPAP, diuretics and steroids Progressed to respiratory collapse Transferred to St. Thomas for ICU management of respiratory failure Medical Diagnosis: Respiratory Distress Difficulty breathing resulting from inability to adequately ventilate and oxygenate increased RR, use of accessory muscles, dyspnea, pale skin Resulted from: • Pleural effusions – fluid compresses lungs, results in decreased ventilation • Pulmonary edema – accumulation of fluid in alveoli, makes lung expansion more difficult and impairs gas exchange in the lungs, decreasing oxygenation of the blood Risk Factors Heavy smoker COPD Age 73 years Obesity Sleep apnea bedfast Assessment Vitals HR: 62-87 bpm BP: Day 1 average 158/84, Day 2 average 118/70 RR: 12-26 breaths per minute O2: 93-100% on ventilator Temperature: 97.9°-98.8° Assessment Respiratory Lung sounds: bilateral fine crackles in upper lobes, diminished bases Mechanical ventilation: • Synchronized intermittent mandatory ventilation (SIMV): preset tidal volume and respiratory rate, with preset breaths are synchronized with patient’s breaths to prevent stacking • TV: 600, rate: 12, FiO2: 45%, PEEP: 5, pressure support: 20 Assessment Respiratory continued Afternoon 2/28, began process of weaning from the ventilator, changed settings to spontaneous ventilation with FiO2: 45%, TV: 600, PEEP: 5 and pressure support: 8 Maintained these settings until morning of 2/29 02 dropped into the 80s Changed back to SIMV Assessment Cardiovascular Irregular rhythm, S1 & S2 present, no murmurs Telemetry monitoring: Atrial fibrillation Peripheral pulses 2+ Peripheral edema 1+ Capillary refill <3 seconds, no clubbing Assessment Integumentary Skin warm, dry, pale Heavy bruising on both calves Stage II pressure ulcer on buttocks Braden score: 13 (moderate risk) Musculoskeletal Generalized weakness Full ROM, no contractures Right leg shorter than left leg Bedfast Assessment Gastrointestinal Normal bowel sounds x4 Abdomen softly distended No bowel movement PEG tube Genitourinary Foley catheter – clear, yellow urine, output averaged 75 ml/hr Assessment Neurological 2/28 - awake, able to follow commands, unable to fully assess orientation due to intubation • Glasgow Coma Scale: 10E 2/29 – sedated, opened eyes to speech, responded to localized pain • Glasgow Coma Scale: 8E Pupils 3 mm, PERRLA Arterial Blood Gases pH 7.49 increased HCO3 38.1 mEq/L increased pCO2 50.3 mm Hg increased pO2 68 mm Hg decreased Partially compensated metabolic alkalosis COPD leads to respiratory acidosis. The body tries to compensate by retaining bicarbonate, which raises blood pH and leads to metabolic alkalosis. Associated with hypokalemia & hypochloremia, treatment is potassium chloride – patient received KCl supplement and NS + 40 mEq KCl IV fluids Abnormal Lab Values Test Normal Value Patient Value Reason Glucose 70-115 mg/dL 131 mg/dL (H) Diabetes Potassium 3.5-5.0 mEq/L 3.1 mEq/L (L) Metabolic alkalosis Chloride 98-109 mEq/L 88 mEq/L (L) Metabolic alkalosis, emphysema BNP 0-99 pg/mL 119 pg/mL (H) Coronary disease; indicates possible heart failure Abnormal Lab Values Test Normal Value Patient Value Reason Hemoglobin 14-18 g/dL 10.4 g/dL (L) anemia Hematocrit 40-54% 33.6% (L) anemia Medications Class Dose Route Frequency Rationale carbidopalevodopa (Sinemet 25/100) Antiparkinsons agent 1 tab (25/100 mg) PT q8h relieves muscle stiffness, tremor, and weakness digoxin (Lanoxin) Inotropic antidysrhythmic 0.125 mg PT q24h Treatment for atrial fibrillation – increases contractility and decreases HR esomeprazole (Nexium) Proton pump inhibitor 40 mg PT q24h Suppresses gastric acid secretion fluconazole (Diflucan) antifungal 200 mg PT q24h Prophylaxis to prevent fungal infection Medication Scheduled Medications Medication Class Dose Route Frequency Rationale Insulin regular Pancreatic hormone >180=5 u >240=10 units >400=15 units SC q6h Decreases blood glucose levofloxacin (Levaquin) Antiinfective: fluoroquinolone 500 mg IV q24h Treats infiltrates in lungs lorazepam (Ativan) sedative 2 mg IV q8h Decreases anxiety potassium chloride electrolyte 40 mEq PT bid Corrects hypokalemia and hypochloridemia Medications Medication Class Dose Route Frequency Rationale vancomycin (Vancocin) Antiinfective: tricyclic glycopeptide 1000 mg IV q24h Treats infiltrates in lungs 40 mg IV q24h Decreases inflammation in lungs 14 mcg/ kg/min IV continuous Sedation during mechanical ventilation methylpredCorticonisolone (Solu- steroid Medrol) Infusion propofol Local anesthetic Medications Medication Frequency Rationale 25 mL IV prn Hypoglycemia 4 puffs q4h Increases ability to breathe Class Dose Caloric agent Bronchodilator Route PRN Dextrose 50% syringe Respiratory Therapy albuterolipratropium (Combivent) Aerosol inhalation Nutrition Pulmocare ordered 2/28 Formulated for COPD & ventilator dependent patients Provides 1.5 Kcal/mL 68 g/L protein, 100 g/L carbohydrates, 11 g/L fat Began at 30 ml/hr, increased by 10/ml q4h until reached 70 ml/hr Significant Tests Chest X-Ray on admission (2/26) Reason: Determine cause of respiratory distress Findings: • Mild to moderate cardiomegaly • Bilateral infiltrates and edema • Small to moderate bilateral pleural effusions Significant Tests Chest X-Ray - 2/28 Reason: follow up; check placement of ET tube Findings: • Patchy infiltrates & some edema • Right pleural fluid collection • No pneumothorax • Satisfactory intubation Collaborations Primary nurse and Instructor – evaluating patient’s status and plan of care Peers – hygiene and repositioning Respiratory Therapy – determine ventilator settings, provide breathing treatment Medical Nutrition Therapy – determine appropriate formulation for enteral feeding Wound Ostomy consult – evaluate Stage II ulcer on buttocks IV therapy – PICC line needed Nursing Diagnosis #1 Impaired Gas Exchange related to pulmonary edema and alveolarcapillary damage secondary to respiratory distress and COPD as evidenced by abnormal ABGs, hypercapnia, pale skin, restlessness and diaphoresis Impaired Gas Exchange Goals: Patient will: • have clear lung sounds • maintain RR < 30 bpm with regular breathing pattern • maintain 02 saturation > 90% Impaired Gas Exchange Interventions Administer humidified O2 via ventilator Auscultate lung sounds q4h Monitor respiratory rate and pattern q4h Monitor pulse oximetry hourly Position patient in semi-Fowler’s Turn and reposition q2h Impaired Gas Exchange Evaluation Goals: • Patient had fine crackles in upper lobes • Maintained RR<26 bpm with regular pattern • O2 saturation 93-100% Interventions • Not all goals were met, but patient maintained adequate gas exchange Nursing Diagnosis #2 Impaired Spontaneous Ventilation related to damage to alveolar capillary membrane and respiratory muscle fatigue secondary to respiratory distress and COPD as evidenced by dyspnea, decreased pO2 and increased pCO2 Impaired Spontaneous Ventilation Goals Patient will: • have respiratory rate < 30 bpm with regular pattern • remain free of dyspnea • breathe spontaneously while being weaned from ventilation • remain free of complications from mechanical ventilation Impaired Spontaneous Ventilation Interventions Monitor for nasal flaring, changes in respiratory rate and rhythm and use of accessory muscles Monitor ventilator settings at beginning of shift and after any changes Use soft wrist restraints to prevent selfextubation Assess for signs of skin or mucous membrane irritation around the ET tube at least once each shift Provide oral care q2h Impaired Spontaneous Ventilation Evaluation Goals • Patient maintained regular respiratory rate < 26 bpm • Patient did not demonstrate signs of dyspnea • Patient breathed spontaneously for approximately 12 hours during attempt at weaning • Patient did not have any complications Interventions • Effective for meeting the stated goals Nursing Diagnosis #3 Ineffective Airway Clearance r/t bronchoconstriction, presence of ET tube, decreased cough reflex as evidenced by crackles in upper lobes, diminished bases Ineffective Airway Clearance Goals Patient will: • have clear lung sounds • maintain a patent airway free of secretions • remain free of dyspnea Ineffective Airway Clearance Interventions Suction ET tube as needed Hyperoxgenate before and after suctioning Auscultate lung sounds q4h, after suctioning and prn as condition warrants Reposition patient q2h Position client in semi-Fowler’s Ineffective Airway Clearance Evaluation Goals • Patient had fine crackles in upper lobes • Patient maintained a patent airway free from secretions • Patient did not display symptoms of dyspnea Interventions • Interventions were effective in maintaining a clear airway Research Effect of a Nurse-Implemented Sedation Protocol on the Incidence of VentilatorAssociated Pneumonia Compared having sedation controlled only by physicians vs. sedation controlled by nurses using a protocol developed by physicians and nurses Protocol included a chart based on the patient’s weight, indicating doses for initial boluses and for adjustments of sedation using either propofol or midazolam Research Nurse initiated the sedation according to the physician’s prescription Nurse reassessed sedation level every 3 hours If needed, nurse adjusted the dose of sedative according to the developed protocol without having to call the physician for approval Research Results of using the nurse-implemented sedation protocol: Incidence of ventilator-associated pneumonia was significantly lower • 6% in nurse initiated protocol vs. 15% in physician controlled protocol Median duration of mechanical ventilation was significantly shorter • 4.2 days in nurse initiated protocol vs. 8 days in physician controlled protocol Research Conclusion: Eliminating the need for physician orders to adjust sedation allowed for more rapid clinical decision making and was beneficial in achieving the most desirable level of sedation for patients on a ventilator Protocol was safely implemented by nurses to improve patient outcomes References Ackley, B.J. & Ladwig, G.B. (2006). Nursing diagnosis handbook: A guide to planning care (7th ed). St Louis: Mosby Elsevier. Ignatavicius, D.D. & Workman, M.L. (2006). Medical-Surgical nursing: Critical thinking for collaborative care (5th ed.). St. Louis: Elsevier Saunders. Jaffe, M.S. & McVan, B.F. (1997) Davis’s laboratory and diagnostic handbook. Philadelphia: F.A. Davis. Porth, C.M. (2005). Pathophysiology: Concepts of altered health states (7th ed.). Philadelphia: Lippincott Williams & Wilkins. Quenot, J.-P., Ladoire, S., Devoucoux, F., Doise, J.-M., Cailliod, R., Cunin, N., et al. (2007). Effect of nurse-implmented sedation protocol on the incidence of ventilator-associated pneumonia. Critical Care Medicine, 35, 2031-2036. Skidmore, L. (2005) Mosby’s drug guide for nurses (6th ed.). St. Louis: Elsevier Mosby.