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 • 2/29 – sedated, opened eyes to speech, responded to localized pain • Glasgow Coma Scale: 10E Glasgow Coma Scale: 8E  Pupils 3 mm, PERRLA

Arterial Blood Gases

pH HCO3 pCO2 pO2 7.49

38.1 mEq/L 50.3 mm Hg 68 mm Hg increased increased increased 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

Test

Glucose Potassium Chloride BNP

Abnormal Lab Values

Normal Value

70-115 mg/dL 3.5-5.0 mEq/L 98-109 mEq/L 0-99 pg/mL

Patient Value

131 mg/dL (H) 3.1 mEq/L (L) 88 mEq/L (L) 119 pg/mL (H)

Reason

Diabetes Metabolic alkalosis Metabolic alkalosis, emphysema Coronary disease; indicates possible heart failure

Abnormal Lab Values

Test

Hemoglobin Hematocrit

Normal Value Patient Value

14-18 g/dL 40-54% 10.4 g/dL (L) 33.6% (L)

Reason

anemia anemia

Medication

Scheduled carbidopa levodopa (Sinemet 25/100) digoxin (Lanoxin)

Medications

Class Dose Route Frequency Rationale

Anti parkinsons agent 1 tab (25/100 mg) PT Inotropic anti dysrhythmic 0.125 mg PT esomeprazole (Nexium) fluconazole (Diflucan) Proton pump inhibitor antifungal 40 mg 200 mg PT PT q8h q24h q24h q24h relieves muscle stiffness, tremor, and weakness Treatment for atrial fibrillation – increases contractility and decreases HR Suppresses gastric acid secretion Prophylaxis to prevent fungal infection

Medications

Medication

Insulin regular levofloxacin (Levaquin)

Class

Pancreatic hormone

Dose

>180=5 u >240=10 units >400=15 units 500 mg Anti infective: fluoroquin olone sedative 2 mg

Route

SC IV IV

Frequency

q6h q24h q8h lorazepam (Ativan) potassium chloride electrolyte 40 mEq PT bid

Rationale

Decreases blood glucose Treats infiltrates in lungs Decreases anxiety Corrects hypokalemia and hypochloridemia

Medications

Medication

vancomycin (Vancocin) methylpred nisolone (Solu Medrol)

Class

Anti infective: tricyclic glyco peptide Cortico steroid

Dose

1000 mg 40 mg

Route

IV

Frequency

q24h

Rationale

Treats infiltrates in lungs IV q24h Decreases inflammation in lungs Infusion propofol Local anesthetic 14 mcg/ kg/min IV continuous Sedation during mechanical ventilation

Medication

Medications

Class Dose Route

PRN Dextrose 50% syringe Caloric agent 25 mL IV

Frequency Rationale

prn Hypo glycemia Respiratory Therapy albuterol ipratropium (Combivent) Bronchodilator 4 puffs Aerosol inhalation q4h Increases ability to breathe

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 alveolar capillary 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 self extubation 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 Ventilator Associated 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).

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Davis’s laboratory and diagnostic handbook.

Philadelphia: F.A. Davis.

Porth, C.M. (2005).

Pathophysiology: Concepts of altered health states (7 th 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.

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