Transcript Grand Rounds Presented by: Bobbi Bowman, SN, ODU

Grand Rounds
Presented by: Bobbi Bowman, SN, ODU
Introduction of Patient
TD is a 68 y/o female that was
admitted to Riverside
Rehabilitation Institute with a
diagnosis of General Debility.
Focus of Grand Rounds
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Past and pertinent health history
Possible nursing diagnosis with
rationales for use
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Possible interventions
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Current research
Past Pertinent History
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Admitted to Riverside ED on 3-11-13
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Extensive health history
Reason for Rehabilitation
General Debility
Past / Psychosocial History
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One of eight children
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Interned at Pentagon
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30+ year career
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Current living situation
Physical Assessment Data
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Morbid obesity
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Pain medications
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Assistive aids
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SPO2 % and HR
Possible Nursing Diagnosis
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Self-care deficit related to activity intolerance, impaired physical
mobility and depression
Risk for increased depression related to decrease function
Activity intolerance related to fatigue, general debility, muscle
wasting and discomfort.
Impaired physical mobility related to activity intolerance,
deconditioning, decreased gas exchange, pain and obesity.
Impaired skin integrity related to comprised immunologic status,
severe edema, and comprised bowel status related to medication
regimen.
Risk for injury and bleeding related to altered clotting mechanism.
Risk for ineffective therapeutic regimen management related to
multiple medications.
Risk for disturbed self-concept related to appearance.
3. Activity intolerance related to fatigue, general
debility, muscle wasting and discomfort.
COPD exacerbation, Anemia, Myasthenia Gravis,
Morbid obesity (possible sleep apnea),
Fibromyalgia, Congestive HF, A-fib with rapid
ventricular response
Ferrous sulfate, Imuran, dilaudid, fentanyl, flexeril,
flovent, mestinon, b-12, B-2, dilitiazem CD
O2 therapy (2 liters) and frequent rest periods, use
of w/c (change from status prior to hosp admit).
PT response: this patient requires frequent rest
periods and tires quickly. She became tachy (hr
>250) after less than 15 mins of continuous light
exercise. Yet this is an improvement from the day
prior due to not performing any exercises in the gym
and retiring to her room early (after lunch) for the
rest of the evening.
Pt Initials: TD
Age: 68 y/o female
Admitting Diagnoses:
General Debility
•COPD exacerbation
•Bronchitis
•Hypokalemia
•Anemia
•Myasthenia Gravis
•Morbid obesity (possible sleep apnea)
•Fibromyalgia
•Chronic lymphedema
•A-fib with rapid ventricular response
•Obsessive compulsive disorder
•Chronic anxiety
•Depression
•Hyperlipidemia
•Congestive HF
•Hx of fall on 22MAR13
5. Impaired skin integrity related to compromised
immunologic status, severe edema, and compromised
bowel status related to medication regimen.
Morbid obesity (possible sleep apnea), decreased functional
level, increased edema and increased ecchymosis due to
fall on 22MAR13, increased areas of weeping of clear
drainage – dressings applied to these areaas.
Prednisone, Imodium, fleet enema, insulin, pradaxa,
senna,nystatin,
Performing skin assessment under all “folds” due to pt not
allowing OT to assist with bathing d/t self-esteem r/t size.
Special inflatable mattress, wide w/c and walker as well as
larger bedside commode utilized to accommodate. mepaplex
patch to right rear thigh. Barrier cream being applied to gluts
and inner thighs.
Pt is uncomfortable with skin assessments being performed
and is also self-conscious of increased weight/ edema and
ecchymosis.
4. Impaired physical mobility related to activity
intolerance, deconditioning, decreased gas exchange,
pain and obesity.
2. Risk for increased Depression related to
decreased function.
Obsessive compulsive disorder,
Chronic anxiety, Depression, requires increase assist
with ADL, has decreased functional level, hosp stay/
rehab admit increase her feeling of depression
Bupropion, klonopin, Lexapro.
COPD exacerbation, Bronchitis, Anemia, Myasthenia Gravis,
Morbid obesity (possible sleep apnea),
Fibromyalgia, Congestive HF, A-fib with rapid ventricular
response, hx of fall on 22MAR13
Albuterol, Ferrous sulfate, Imuran, dilaudid, fentanyl, flexeril,
flovent, mestinon, b-12, B-2, dilitiazem CD, oversized w/c and
bedside commode, walker for transfers
PT – encouraged to wheel self in w/c up and down hallways,
performed 5 knee extensions, hip hikes, and 20 toe touches
per lower extremity
OT – encouraged to assist with transfers OOB and with
dressing and grooming each morning
RT – passing/ catching small thera-ball while performing
cognitive recall word game
Pt frequently request pain meds (c/o greatest pain to b/l knees)
prefers RT the most due to “stimulation of thought” and did not
tolerate gym exercises very well (increased hr and MD
cancelled all PT.
1. Self-care deficit related to activity intolerance,
impaired physical mobility and depression.
General Debility, admit to hosp, admit to rehab,
requires increased assist with ADL, hx of fall on
22Mar13
PT – focuses on increasing activity tolerance and
mobility to promote increased self-care.
OT – working on ADL in morning care
RT – focuses on cognitive recall while “playing
game”
Patient gets discouraged often when she focuses on
increases in self-care deficits noted since her dx and
subsequent admit to hosp/ rehab. She is very limited
as to what she can perform indep d/t fear of falling
(hx of 8 falls within last 6 months), activity
intolerance, weakness, etc
Neuro / Psych as part of rehab process(increased
sessions with trail of new anti-depressant – homework
assignments given), continuous encouragement from
staff, family members call often.
Patient becomes tearful and exhibits signs of
depression when she speaks of 9or focuses) on her
prior health/ activity state prior to myasthenia gravis
dx. She admits to increased self-esteem concerns and
does not want to feel as if she is a burden to anyone.
She has a great deal of self-pride and “hates her
current state”
Top Three
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Self-care deficit related to activity intolerance, impaired
physical mobility and depression
Risk for increased depression related to decrease function
Activity intolerance related to fatigue, general debility,
muscle wasting and discomfort.
Management Concern
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Why may these methods not work??
What would be some alternative
interventions??
Potential Problems
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Self defeat
Lack of decision making process for
self-management
Then & Now
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Physical
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Psychological
Current Research
Tzeng, H., & Yin, C. (2010). Nurses' response
time to call lights and fall occurrences.
MEDSURG Nursing, 19(5), 266-272.
Thank you