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Grand Rounds Presentation. Heather Harden SN, MTSU Nursing 4330 Clinical. Overview. 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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Grand Rounds Presentation Heather Harden SN, MTSU Nursing 4330 Clinical
Overview • Patient demographics • Risk Factors • Medical Diagnosis • Laboratory Data and Tests • Pharmacological Interventions • Assessment Findings • Nursing Diagnoses • Research Based Care
Patient Demographics • 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
Health History Cardiac Respiratory Urinary Endocrine Other Surgeries Risk Factors
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
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 Laboratory Data
Diagnostic Tests • CXR • KUB • Broncoscopy • Stool Cx
Physical AssesmentRespiratory • Lung sounds • Physical Assessment • Ventilator • Tracheostomy
AssessmentCardiovascular • Heart sounds • Pulses • Capillary Refill
Assessment GI/GU • Bowel Sounds • Dobbhoff Tube • Urine Characteristics • Foley Catheter
Assessment Integumentary • Alterations in skin integrity • Arms • Buttocks
Assessment Neuro. • LOC • Reflexes • Pupils
Nursing Diagnoses # 1Ineffective Airway Clearancerelated 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 • Interventions • Positioning • Turning • Suction • Humidification
Nursing Diagnoses # 2 Ineffective Breathing Patternrelated 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 • Interventions • Positioning • Suction • Medication • Turning
Nursing Diagnoses # 3 Dysfunctional Ventilatory Weaning Responserelated 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 • Interventions • Positioning • Education • T-piece • Vitals
Nursing Diagnoses • 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
Ventilator Aquired Pneumonia • Oral Health Status and Development of Ventilator Associated Pneumonia • Sample • ORAL CARE • Results • Correlation
Assessment of Goals • Respiratory Rate • Oxygen • Airway • Sputum Production • Mental Status • Temperature
Collaboration • Physicians • Nurses • Respiratory Therapists • Physical Therapists • Hospitalists • Patient’s Family • Student Nurses and Instructors
Resources • 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 Ventilator-Associated Pneumonia: A Descriptive Study. American Journal of Critical Care, 15(5), 453.
