College of Nursing and Health ACNP Program Weekly ACNP Clinical Log CLINICAL FACULTY: Student: Beth Croucher Teresa Siefke Course / Quarter / Year: Date 1 Diagnosis F M Age Clinical Site: Miami Valley Hospital-Critical Care Preceptor: Johnnie Dillinger, ACNP-BC Each week, complete this document each date, make an entry for every patient you see. Wk For There may be multiple entries for the same patient, i.e., a long-term patient in your caseload ___ would be listed again for each date. Under comments, list any procedures performed, or other pertinent information. 2/7 Facial swelling X 2/7 Pancreatitis 2/7 ST depression, hypotension X 6 2 Angioedema. Intubated with failed extubations x 3. Surgery consult for tracheotomy 2/7 Hypokalemia, colitis, lymphadenopathy X 6 1 2/7 Near syncope 2/7 Acute respiratory failure X 6 8 2/7 Septic shock X 5 4 2/7 Unresponsive, respiratory failure, found down X 6 7 2/7 Respiratory failure, COPD X 7 8 2/8 Facial swelling 2/8 Pancreatitis X 2/8 Cardiac arrest, MVC X X 2 3 4 X 5 7 2 6 7 8 9 1 0 1 1 1 2 Comments / Activities X 6 8 Alcohol abuse with pancreatitis. Now extubated. Remains confused. Tolerating minimal duodenal feedings with NG to LIWS Cardiac cath 2 days prior was without coronary occlusion. Demonstrated LAD bridge. Remains Hypotensive requiring vasopressor support. Pan cytopenic. Respiratory failure, mechanical ventilation. Renal failure requiring CRRT. Near syncope without fall. c/o R leg pain, ortho evaluated as hamstring sprain and not fracture. Anemia of unknown etiology. Morbid obesity with noncompliance with home medications. Acute on chronic respiratory failure with difficult to wean vent. Changed to Bumex IV TID for aggressive diuresis Feeling ill with diarrhea for 3-5 days prior to presentation. Septic shock, fluid resuscitation, blood and urine cultures pending. Broad spectrum antibiotics (Vancomycin, Zosyn, Levaquin) Transfer from outside hospital after being found down, unresponsive, questionable seizure. Mechanical ventilation. Improving neurologic status, appropriate to extubate. Mechanical ventilation, IV steroids, empiric antibiotics Trach placed overnight d/t significant facial swelling and multiple failed attempts at extubation. Pancreatitis slowly resolving. Tolerating duodenal feedings, NG to LIWS. Transfer out of ICU MVC found by police & paramedics to be in cardiac arrest. CPR & shocked. Hypothermic protocol initiated E/M Code 1 3 2/8 Acute on chronic respiratory failure x 6 8 2/8 Septic shock X 5 4 2/8 Unresponsive, respiratory failure, found down X 6 7 2/8 Respiratory failure, COPD X 7 8 2/8 Failed kidney transplant, initiation of HD X 5 7 2/24 Sepsis, acute respiratory failure 2/24 CHF 2/24 1 4 1 5 Improved UO with bumex. FiO2 weaned to 50%, increased pressure support to 20. Tolerating well. Septic shock with AKI. Continue maintenance fluids. Consult Renal d/t no improvement in renal function after fluid resuscitation. blood cultures with G+ cocci resembling staff. Broad spectrum antibiotics (Vancomycin, Zosyn, Levaquin) Extubated yesterday, doing well on RA. Hypotensive, fluid bolus given. Somnolent but awakens easily. Mechanical ventilation, IV steroids, empiric antibiotics. CPAP trials, tolerating well today. 6 2 Afib/aflutter started on heparin gtt. Overnight developed rectus abdominis hematoma and acute anemia. Received 4 units RBCs overnight. Levophed for hypotension. Found to have leukemia upon admission w/u. Failure to wean, remains severe septic shock X 6 1 Significant cardiac history, has AICD. Continue to diurese. Pending f/u ECHO. Cirrhosis, liver failure X 6 4 2/24 Fall at home, c2 fracture, severe AS, evaluation for TAVR X 7 7 2/24 Fever, infection X 5 9 3/3 Respiratory failure, sepsis X 6 2 Platelet count 14, end-stage liver disease. Consulted hospice and discussed withdrawal of care. Severe AS and pending TAVR. Has dental abscess being treated and gangrene of toe. Has c2 fracture that needs surgery, but infection and cardiac status complicate both surgeries (spine and TAVR) Splenic abscess, with drainage. Needs nutrition but GI not ready to use enteral route. Discuss need for TPN. Sepsis, newly diagnosed leukemia. Respiratory failure with mechanical ventilation. 3/3 Hypotension X 6 5 Hypotension, fluid resuscitated. Now off pressors. Transfer to hospitalist service. 3/3 Acute on chronic respiratory failure, COPD exacerbation X 5 8 SBT as tolerated. ECHO with EF 20-25%. 3/3 Encephalopathy 6 8 3/3 Hypotension, shock, AKI Metabolic encephalopathy, respiratory failure requiring mechanical ventilation. Unclear cause of mental status. AKI 2nd dehydration, hypotension. Fluid rescusitation and improving BP & renal function 3/3 AKI, hyperkalemia 3/3 Acute respiratory failure 2nd CHF exacerbation 3/3 Cardiac arrest 3/3 Acute respiratory failure, OSA 3/3 Cardiac arrest, hypothermic protocol X X X 4 8 X 8 6 Received cancer treatments outpatient. AKI likely 2nd tumor lysis. Kayexalate, dextrose, insulin, calcium. No indication for dialysis. No extubated. Transfer out of ICU and transfer to hospitalist service. 6 1 Without neurologic recovery s/p arrest. Family decision to w/draw care. X 3 5 X 3 8 Morbid obesity with untreated OSA. Acute respiratory failure with mechanical ventilation. Without evidence of infection. ARDS with refractory hypoxemia. No clear indication for cardiac arrest. TNI not significantly elevated, no cardiac history, no medical history, no home meds, current X X 6 1 5 3 smoker. ECHO pending, serial cardiac enzymes. Cardiology consulted, hypothermic for 24 hours. Sudden SOB, found PEA with CPR & 2 epi. ?seizure-like activity. Started Keppra, ECHO pending, cardiac enzymes pending. ESRD on dialysis, difficult to dialyze d/t drops BP. EF ~10%. Mechanical ventilation X 8 8 Rate controlled, normotensive, will sign off. Transfer care to hospitalist and/or cardiology X 6 6 Failure to wean, pending trach & peg vs palliative care. Awaiting family decisions. 7 4 5 4 Hyponatremia 2nd fluid overload from CHF. Remains on 2 pressors. Needs further diureses for HF. Extubated to BiPap. Added steroids. Blood cultures negative. X 4 2 Cirrhosis, likely variceal bleeding. GI consulted. Colostomy and enterostomy complications X 6 0 3/5 Acute renal failure, encephalopathy X 6 2 Multiple chronic medical problems including chronic pancreatitis, adrenal insufficiency, RA, and bowel ischemia. LP with pending cultures, ? HSV encephalitis. AKI 2nd dehydration, shock. 3/5 Acute on chronic respiratory failure X 7 5 Aspiration pneumonia. Extubated, needs PEG d/t recurrent aspiration. 3/5 Myelodysplasia X 6 3 Leukapheresis. 3/10 Cardiac arrest X 4 8 Consult palliative care. Remains on ventilator but no neurologic improvement. 3/10 Cardiac arrest X 3 8 3/10 CHF with acute on chronic respiratory failure X 7 1 EEG did not demonstrate seizures. Continues to have myoclonic jerks. Discussion with procurement for organ donation On bumex drip for dieresis. Chronic afib, hold Coumadin d/t supratherapeutic INR 3/10 GIB, cath with MVD, needs CABG 3/10 ESRD, ischemic bowel, s/p open resection 3/10 Encephalopathy X 6 8 3/10 Myelodysplasia X 6 3 3/10 Facial edema, infection, s/p tooth extraction X 6 5 3/11 Cardiac arrest X 4 8 3/3 MVA, found PEA arrest X 3/3 ESRD, shock, respiratory failure 3/5 Afib with RVR, hypotension 3/5 Sepsis, C2 fracture, respiratory failure 3/5 Chronic systolic HF 3/5 Acute on chronic respiratory failure X 3/5 Upper GI bleed 3/5 7 4 X X X X 5 3 7 3 EGD demonstrated ulcers with clots, did not band as were note bleeding. Needs CABG, but is high risk with coagulopathy r/t ETOH and liver disease. On octreotide drip. Continue CIWA Remains mechanically vented requiring pressor support. Unable to tolerate HD and was started on CVVHD. Unable to close abdomen d/t edema Decline in ADL and MS over several years. No clear explanation for decreased MS/encephalopathy. Remains failure to wean from vent s/p leukapheresis. Ready to transfer to floor. Overall prognosis is poor. Tooth extraction 5 days prior, non-compliant with PO antibiotic. Significant facial swelling with tracheal deviation. Concern for necrotizing fasciitis. To OR for drainage. Arranging family meeting to determine goals of care. No neurologic improvement. 3/11 Admitted to floor with HA and fevers. Transferred to ICU d/t no improvement. Sepsis, acute respiratory failure X 5 1 3/11 Cardiac arrest X 3 8 3/11 GI bleed, pending CABG 3/11 ESRD, ischemic bowel, s/o open resection 3/11 Encephalopathy X 6 8 3/11 Idiopathic pulmonary fibrosis X 8 3 Remains vented on CVVHD and pressors. Will return to surgery for closure soon. Evaluations daily d/t edema Discuss with family goals of care. Pt has made little improvement and sill no explanation for mental status. Worsening edema and renal function Transfer from outside hospital for acute on chronic respiratory failure. 3/12 Cardiac arrest X 4 8 Family meeting planned today. Possible medical extubation and transfer to hospice. 3/12 Sepsis, acute respiratory failure X 5 1 3/12 HCAP 3/12 Cardiac arrest 3/12 CHF exacerbation, acute on chronic respiratory failure 3/12 CHF, acute on chronic respiratory failure 3/12 AMI, cardiac arrest X 6 8 Multiple cultures pending, including rare and unlikely organisms. Everything to date has been negative. Still requires high amount of vasopressor support and worsening renal function Metastatic cancer. Pleural effusions and pneumonia. Limited treatment measures. Pt wants hospice. Family decided to pursue organ donation. Plan withdrawal of care and donation tomorrow. ECHO pending. On dobutrex drip, high-dose diuretics, remains on high FiO2 and PEEP to maintain oxygenation UTI positive on admission, recheck UA. Worsening renal failure. No indications for acute dialysis. Cardiac arrest with immediate bystander CPR. 2 DES to LAD, IABP, and ventilator support. 3/12 GI bleed, pending CABG X 5 3 3/12 ESRD, ischemic bowel, s/o open resection 3/12 GI bleed, NASH X 4 5 3/12 Idiopathic pulmonary fibrosis X 8 3 3/12 Abdominal pain, sickle cell crisis X 4 4 Sedation vacation and SBT. Discuss with pt and wife about goals of care. Underlying disease process has overall poor prognosis and intubation is not helpful long-term. Discuss extubation and no reintubation. Pt was extubated and doing well. Transfer from floor requiring intubation and erythroparesis for sickle cell crisis. 313 Cardiac arrest 4 8 Family discussion of w/draw of care. Will transfer to hospice if does not pass quickly X X 7 3 X X 6 4 3 8 X X 7 4 7 1 X X 5 3 7 3 May require intubation d/t fatigue and for airway management. W/u for septic sources. LP done and negative. Blood cultures NGTD. Empiric antibiotics and fluid resuscitation. Remains unresponsive and without neurologic improvement. No clear cause for arrest. Presumptive viral myocarditis. Remains on CIWA with protonix and ostreotide for upper GI. Pending CABG on 3/13 Remains on CIWA with no evidence of DT. Pending CABG on 3/13. Remains stable and good mentation, no s/s of bleeding. Remains vented on CVVHD and minimal pressors. SBT and respiratory vitals. Borderline, RVs and d/t planned return to surgery will remain vented. Serial H&Hs. Hb 6.8, received 2 PRBCs. Awaiting recheck. 3/13 Fevers, sepsis, acute respiratory failure 3/13 HCAP 3/13 Cardiac arrest 3/13 CHF exacerbation, acute respiratory failure 3/13 ESRD, ischemic bowel, s/o open resection 3/13 AMI, cardiac arrest 3/13 CHF, acute on chronic respiratory failure 3/13 Idiopathic pulmonary fibrosis 3/16 AMI, thrombectomy and PCI 3/16 Cardiac arrest, s/p DES x 2 to LAD 3/16 Fever of unknown origin, sepsis 3/16 HCAP & metastatic cancer 3/16 CHF exacerbation 3/16 X 5 1 X X 6 4 3 8 Worsening renal function, metabolic acidosis, consult to renal. Presumption of toxic shock d/t no evidence of infectious source.. Pleural effusions, possible thoracentesis. 5 7 Withdraw of care today. To OR for w/draw and possible organ donation. She did not pass within the hour window and returned to the room. She passed 2 hours later. Will remain a tissue and eye donor. SBT and ABG. Remains on dobutrex with highdose dieresis. RVs are good, ABG acceptable, may have trial extubation to BiPap Remains vented on CVVHD. SBT but remain vented d/t return to surgery for closure planned tomorrow. Cardiac arrest with immediate bystander CPR. 2 DES to LAD, IABP, and ventilator support. Extubated and doing well. Transfer out of ICU. Worsening renal failure. No indications for acute dialysis. Possible ileus. Afib but hold cardizem drip d/t low BP. Extubated yesterday. Code status changed with no reintubation. Doing well and can transfer out of ICU. s/p thombectomy, DES t LAD, EF 30-40%. R leg & R UE DVT 6 8 Transferred to floor last week. Up and walking, developed acute BL PE 5 1 Still no answers as to source of infection. Acts like toxic shock. Slowly clinically improving. 6 4 d/c home with hospice today. X 7 3 TAVR X 8 5 s/p aspiration with immediate bronch. Progressive worsening over the weekend requiring intubation, rotoprone, and began CVVHD Remained on ventilator s/p TAVR. SBT and RVs. Possible extubation today. 3/16 ESRD s/p ischemic bowel resection X 7 3 3/16 CAD with OSA X 6 3 3/20 Acute on chronic CHF X 8 0 3/20 Fever of unknown origin 3/20 CHF exacerbation 3/20 CHF with acute on chronic respiratory failure X 7 3 3/20 AS s/p TAVR X 8 5 X X 7 4 7 3 X X 6 8 7 1 X X X X X X 8 3 5 1 X 7 4 Brady arrest, with ACLS. On epinephrine drip, levophed, vasopressin. Continues with CVVHD without fluid removal, ventilator support. Questionable neurologic status. Evaluate for BiPap rather than CPAP at home. Ok to transfer to floor. Mechanical ventilation, on neosynephrine. Transition to levophed rather than neo. Not ready for extubation. Now off pressors, SBT daily. Still not quite ready to extubate. Transfuse platelets and RBCs. Extubated to Bipap for a couple days. Reintubated. Continue dieresis but is likely at end stage CHF and cardio-renal syndrome Remains on rotoprone with CVVHD. Showing improvements with oxygenation in prone position. Will trial prolonged periods supine. Delerium. Extubated and weaning oxygen. Increase mobility as tolerated. PT/OT 3/20 ESRD s/p ischemic bowel resection X 7 3 3/20 Syncope 3/20 Overdose, suicide attempt X 4 5 3/20 Failure to wean, planned trachestomy X 5 8 3/20 Altered mental status X 4 9 X 6 8 Minimal neurological responses. Possible CVA but too unstable for head CT. Continue CVVHD, pressors, & vent management. Bronch for possible mucus plugging. Noted patchy erythema down bronchioles suspicious for viral etiology Pancreatic cancer s/p gamma knife laser radiation and current chemotherapy. Now with GI bleed and Hb 4.6 on admission. Transfuse RBCs and fluid resuscitation for SBP >90 OD on multiple drugs including TCA. Prolonged QT interval. On sodium bicarbonate drip with serial EKGs. Prolonged vent time with need for BiPap and LTAC. Failure to wean and admitted for planned trach. Due to refractory hypoxemia trach was cancelled. On nitric oxide and high FiO2 and PEEP for oxygenation. Long medical history. Intubated for acute respiratory failure. Possible extubation today. MS is a concern d/t does not follow commands and unsure of ability to clear secretions.