Grand Rounds Presentation NURS 4340
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Transcript Grand Rounds Presentation NURS 4340
Grand Rounds Presentation
NURS 4340
Shannon Arender
February 14th, 2008
Collaboration of client management
Nurses
Doctors
Respiratory therapists
Physical therapists
Peers
Instructor
Client demographics
27 years old
Caucasian female
5’3’’, 123 Ibs
No religious affiliation
Divorced
1 child, 7 years old
+ Risk Factors
Congenial disease
Persistent heavy tobacco use, 1 pack per
day since age 14
Complete noncompliance with medical
therapy
Events leading to hospitalization
Discontinued Interferon Gamma injections
Admitted 1/2/2008 to Vanderbilt
Received argon ablation therapy
Left against medical advice
Admitted to St. Thomas 1/7/2008
Transferred to CCU from 7th floor after
sneaking to smoke a cigarette which
resulted in patient being intubated
Medical Diagnosis
Congenital squamous papillomatosis of
the trachea, larynx, and lung with
presumed tracheoesophageal (TE) fistula
Squamous papillomatosis
Squamous: scale-like epithelial cell
Papillomatosis: widespread development
of nipple-like growths on patient’s lungs,
larynx, and trachea that cause significant
airway obstruction
Tracheoesophageal fistula
A congenital malformation in which there is
an abnormal tubelike passage between
the trachea and esophagus
Puts the patient at risk for aspiration
pneumonia and breathing problems
Tracheoesophageal fistula
Abnormal labs
Lab
Glucose
Value
120 mg/dl H
Why?
Total protein
Albumin
6.0 g/dl L
3.2 g/dl L
Malnourished
Alkaline
phosphate
AST
164 IU
Antibiotics, decreased
liver function
64 IU
Patient is on opiates
and anticoagulants,
decreased liver
function
IV fluids containing
dextrose
Malnourished, NPO,
decreased liver
function
Abnormal labs
Lab
ALT
Value
51 IU
Why?
Urinalysis:
specific gravity
Hgb
Hct
MCH
RDW
1.047 H
Fever
10.9 g/dl L
33.9% L
26.8 H
15.3 H
Antibiotics, anemia
Decreased liver
function, hepatotoxic
drugs
Anemia
Anemia
Anemia
Diagnostic tests
CT scan of neck for soft tissue
Confirmed diagnosis of tracheoesophageal
fistula
Seen at level of lower cervical esophagus
X-RAY- video fluoroscopic swallow
Done post recent laser therapy for TE fistula
Patient was unable to handle secretions, had
one episode of frank aspiration
Diagnostic tests
X-RAY- lung
Extensive abnormalities found in lungs
Numerous masses, many that contain cavities
Range in size from less than 1 cm up to 4 cm
Lower lobes are the most severely affected
X-RAY- performed to verify PICC placement
All findings are consistent with clinical diagnosis of TE
fistula and papillomatosis
Pharmacological interventions
medication
class
dose
route
frequency rationale
Ampicillinsulbactam
Antibiotic
3 gm
IV
q6hrs
Fentanyl
Opioid
analgesic
50
mcg
Trans- q72hrs
dermal
patch
Bacterial
infection
Pain
Fluconazole Antibiotic
400mg IV
q24hrs
Bacterial
infection
Heparin
5000
units
q12hrs
Prevent deep
vein
thrombosis
and
pulmonary
embolism
Anticoagulant,
antithrombotic
subq
Pharmacological interventions
medication
class
Lorazepam
Nicotine
route
frequency
rationale
Benzo1 mg
diazepine
IV
q6hrs
Decrease
anxiety
Smoking
deterrent
14 mg
Trans- Everyday
dermal
patch
Deter
cigarrette
smoking
1000
mg
IV
Q12hrs
Bacterial
infection
Morphine
Opioid
4mg
analgesic
IV
PRN, q3hrs Pain
Insulin
regular
(Novolin R)
Antidiabetic
Subq
inj
q4hrs
Vancomycin Antiinfective
dose
Based
on BG
Control blood
sugar
Pharmacological interventions
medication class
dose
route
frequency
rationale
AlbuterolBronchoipratropium dilator
4 puff
Inhalation
q4hrs
Increase
ability to
breathe
Reduce
number of
lung
infections
Dornase
alfa
Unknown, 2.5 mL
synthetic
protien
Inhalation
q12hrs
Total
parenteral
nutrition
1680mL +
famotidine
40 mg
Antiulcer
agent
IV
Continuous
Nutrition
infusion rate: and
70ml/hr
prevention
of stomach
ulcers
1680
mL +
40 mg
Head to Toe Assessment
Neurological
Alert and awake
Oriented x 3
Pupil reaction equal and brisk
Psychosocial
Anxious
Agitated as a result of new tracheostomy and
inability to communicate
Head to Toe Assessment
Integumentary
Skin pink, dry, warm
Nail pink and intact
Surgical incision on neck, medial, edges
approximate, steri-strips present, intact, no
drainage
Braden skin integrity: score: 18
Head to Toe Assessment
Pulses
Jugular vein distention: 3+ (normal)
Brachial, radial, and dorsal pedal pulses: 3+
No edema present
Capillary refill < 3 seconds
Musculoskeletal
Upright posture
Generalized weakness in all extremities
Head to Toe Assessment
Respiratory
AP diameter: 1:1
Breath sound diminished in all lobes
Slight wheezing in upper lobes
Tracheostomy collar with 4L oxygen
Cardiovascular
NSR with sinus tachycardia
No abnormal heart sounds
Head to Toe Assessment
Gastrointestinal
Mucous membranes moist, pink, intact with no
lesions present
Difficulty swallowing
Hypoactive bowel sounds
No abdomen distention or tenderness
Urinary
Indwelling foley, gravity, intact
Concentrated, amber colored urine
Paraphernalia
Nasogastric tube
Connected to continuous low suction
Bloody drainage
PEG tube
Intact
gravity
Paraphernalia
PIV access-peripheral intravascular access
IV lock
Left antecubital
No complications
No drainage
VAD- vascular access device
Triple lumen
Peripherally inserted central catheter
Right upper arm
No complications
No drainage
Vital signs
Blood pressure: 118/70
Heart rate: 99
Temperature: 101.4˚F
Respirations: 23
SpO2: 95%
Pain: 10, chronic, continuous
Nursing diagnosis priority #1
Ineffective airway clearance related to new
tracheostomy and endotracheal tube as
manifested by decreased ability to cough
and thick, bloody secretions.
Goal: The patient will remain an open
airway free of secretions, and secretions
are easily moved.
Nursing diagnosis priority #1
Interventions
Assess for ETT suctioning
Watch for harsh breath sounds and audible secretions
Suction patient as needed
Reposition patient frequently
Outcome
The ability to maintain a clear airway will require several
days until the new tracheostomy heals and secretions
decrease.
Nursing diagnosis priority #2
Risk of pulmonary infection related
artificial airway as manifested by a new
tracheostomy and endotracheal tube, and
a temperature of 101.4˚F.
Goal: Patient will remain free of infection.
Nursing diagnosis priority #2
Interventions:
Monitor temperature q4hrs
Monitor color, consistency, and odor of secretions
Use sterile technique for suctioning
Provide oral care q2hrs
Monitor patient for increased breathing effort
Administer Ampicillin-sulbactam q6hrs, Fluconazole
q24hrs, and Vancomycin q12hrs
Outcome:
Patient remained free of pulmonary infection and a white
blood cell count within normal range.
Nursing diagnosis priority #3
Impaired verbal communication related to
mute state when the ET tube is in place as
manifested by not being able to speak.
Goal: The client will be able to communicate
with health team providers in order to have basic
needs met.
Nursing diagnosis priority #3
Interventions:
Keep a pencil and paper readily available
Be patient and willing to spend time
communicating
Evaluation: Patient was able to write down
feelings and communicate to the healthcare
team. Her anxiety and frustration was
decreased.
Nursing research
Tracheal Suctioning of Adults with an
Artificial Airway
Evidence based practice including the effects of
suctioning, suctioning techniques, oxygenation,
suctioning patient subgroups, summary of
evidence, and recommendations
Participants were adult patients (>15 years) in
the acute care setting with an endotracheal tube
or tracheostomy tube
Nursing research
Purpose
Review suction interventions that are currently
employed in the nursing management of
patients with an artificial airway
Results
Suctioning is a potentially harmful procedure
and should only be done when a thorough
assessment of the patient established the need
for such a procedure
References
Emedicine by WebMD.(2008). Recurrent Respiratory
Papillomatosis. Retrieved February 11, 2008, from
http://www.emedicine.com/med/topic2535.htm
Ignatavivius, D.D. & Workman, M.L.(2006). Medical-Surgical
nursing: Critical Thinking for Collaborative care.(5th ed.) Vol. I.
Philadelphia, PA: W.B. Saunders.
Thompson, L.(2000). Tracheal Suctioning of Adults with an Artificial
Airway. Johanna Briggs Institute for Evidence Based Nursing and
Midwifery Vol. 4(4). Australia: Blackwell Science-Asia.
Sole, M.L., Klein, D.G., & Moseley, M.J.(2005). Introduction to
Critical Care Nursing.(4th ed.) St. Louis, MO: Elsevier Saunders.