1 / 9

Grand Rounds

Grand Rounds. Shelaina Lewis April 17, 2008. Client Demographics-R.C. 69 year old, DOB 7/12/38 Caucasian Male Single – lives alone No children No Form of Religion English Speaking Height: 177.80 cm (70 in) — Weight: 145 lb (65.91kg) BMI: 18.8 No known allergies DNR. Risk Factors.

maille
Download Presentation

Grand Rounds

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Grand Rounds Shelaina LewisApril 17, 2008

  2. Client Demographics-R.C. • 69 year old, DOB 7/12/38 • Caucasian • Male • Single – lives alone • No children • No Form of Religion • English Speaking • Height: 177.80 cm (70 in) — Weight: 145 lb (65.91kg) • BMI: 18.8 • No known allergies • DNR

  3. Risk Factors • Recurrent bilateral pneumonia c pleural effusions • Severe malnutrition • Smoker – 2ppd, 30 years • Chronic alcohol abuser • Gastroesophageal reflux disease (GERD) • Left lung abscess in 2003 • Patient history of: • COPD • Diabetes Mellitus Type II • Atrial Fibrillation • Gastrointestinal Bleed • Coronary Artery Disease • Anemia • Hypertension • Alcoholic Hepatitis • Right-sided heart failure (RHF)

  4. Physical Assessment: Vital Signs Head and Neck • Blood pressure: 98-132/61-98 • Map: 71 • Pulse: 78-92 • Respirations: 30-52 • Temperature (axillary): 97.5o-98oF • CVP: 8-10 • Oxygen Saturation: 90-94% • Head – bitemporal wasting, dry and brittle hair, some hair loss • Neck – tracheotomy with mechanical ventilation midline, neck ties dry and intact

  5. Physical Assessment: EENT Integumentary • Eyes – closed, brisk reactive to light, conjunctivae pink and moist • Ears – equal size bilaterally, able to hear when spoken to close to ear • Nose – symmetric and midline • Mouth – poor dental health, several teeth missing, six caries, mucous membranes pink and moist EENT • Skin cool, dry, pale • Reddened abrasion on right hip • Stage III pressure ulcer on coccyx • Stage II pressure ulcer on upper back-right • Stage I pressure ulcers on left and right heel • Mild (2+) peripheral edema in upper extremities and lower extremities • Triple lumen central line in right subclavian • Peripheral IV in left forearm • All IV sites: dressing dry and intact

  6. Physical Assessment: Cardiovascular Respiratory • Telemetry: • 6 second strip indicate Normal Sinus Rhythm borderline tachycardia • PR interval: 0.16 • QRS: 0.08 • QT interval: 0.32 • Normal rate and rhythm with no abnormal heart sounds noted • Capillary refill < 3 seconds • All pulses palpable and equal bilaterally • Continuous Mandatory Ventilation • AC: 12 • TV: 450 • FiO2: 70 • PEEP: 7.5 • Abnormal coarse rhonchi on right side • Diminished or absent breath sounds on left side • Copious, thick, foul smelling secretions with yellowish-tan color

  7. Physical Assessment: Gastrointestinal Genitourinary • Active bowel sounds in all four quadrants • Abdomen softly distended • Two large, loose, non-odiferous stools • Percutaneous endoscopic gastrostomy tube (PEG tube) in upper left quadrant, patent, residual 20 cc • Foley catheter draining to gravity • Urine yellow and clear • Output 175 ml at A.M. assessment

  8. Physical Assessment: Neurological Musculoskeletal • Eyes open to pain, pupil size 2 mm, brisk reaction bilateral • Unable to respond due to tracheotomy • Responds to localized pain • Briefly awakens to voice (eye opening and contact < 10 seconds) • Mild weakness in all extremities • Passive range of motion to prevent contractures

  9. Physical Assessment: Psychosocial • Family present at bedside for several hours • Decision made to terminally wean • No request for clergy

More Related