Grand Rounds Presentation NURS 4340

1. Grand Rounds PresentationNURS 4340 Shannon Arender February 14th, 2008

2. Nurses Doctors Respiratory therapists Physical therapists Peers Instructor Collaboration of client management

3. Client demographics • 27 years old • Caucasian female • 5’3’’, 123 Ibs • No religious affiliation • Divorced • 1 child, 7 years old

4. + Risk Factors • Congenial disease • Persistent heavy tobacco use, 1 pack per day since age 14 • Complete noncompliance with medical therapy

5. 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

6. Medical Diagnosis • Congenital squamous papillomatosis of the trachea, larynx, and lung with presumed tracheoesophageal (TE) fistula

7. 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

8. 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

9. Tracheoesophageal fistula

10. Abnormal labs

11. Abnormal labs

12. 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

13. 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

14. Pharmacological interventions

15. Pharmacological interventions

16. Pharmacological interventions

17. 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

18. 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

19. 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

20. 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

21. 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

22. Paraphernalia • Nasogastric tube • Connected to continuous low suction • Bloody drainage • PEG tube • Intact • gravity

23. 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

24. Vital signs • Blood pressure: 118/70 • Heart rate: 99 • Temperature: 101.4˚F • Respirations: 23 • SpO2: 95% • Pain: 10, chronic, continuous

25. 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.

26. 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.

27. 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.

28. 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.

29. 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.

30. 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.

31. 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

32. 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

33. 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.