Grand Rounds Presentation NURS 4340 Shannon Arender February 14th, 2008 Collaboration of client management Nurses Doctors Respiratory therapists Physical therapists Peers Instructor Client demographics 27 years old Caucasian female 5’3’’, 123 Ibs No religious affiliation Divorced 1 child, 7 years old + Risk Factors Congenial disease Persistent heavy tobacco use, 1 pack per day since age 14 Complete noncompliance with medical therapy 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 Medical Diagnosis Congenital squamous papillomatosis of the trachea, larynx, and lung with presumed tracheoesophageal (TE) fistula 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 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 Tracheoesophageal fistula Abnormal labs Lab Glucose Value 120 mg/dl H Why? Total protein Albumin 6.0 g/dl L 3.2 g/dl L Malnourished Alkaline phosphate AST 164 IU Antibiotics, decreased liver function 64 IU Patient is on opiates and anticoagulants, decreased liver function IV fluids containing dextrose Malnourished, NPO, decreased liver function Abnormal labs Lab ALT Value 51 IU Why? Urinalysis: specific gravity Hgb Hct MCH RDW 1.047 H Fever 10.9 g/dl L 33.9% L 26.8 H 15.3 H Antibiotics, anemia Decreased liver function, hepatotoxic drugs Anemia Anemia Anemia 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 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 Pharmacological interventions medication class dose route frequency rationale Ampicillinsulbactam Antibiotic 3 gm IV q6hrs Fentanyl Opioid analgesic 50 mcg Trans- q72hrs dermal patch Bacterial infection Pain Fluconazole Antibiotic 400mg IV q24hrs Bacterial infection Heparin 5000 units q12hrs Prevent deep vein thrombosis and pulmonary embolism Anticoagulant, antithrombotic subq Pharmacological interventions medication class Lorazepam Nicotine route frequency rationale Benzo1 mg diazepine IV q6hrs Decrease anxiety Smoking deterrent 14 mg Trans- Everyday dermal patch Deter cigarrette smoking 1000 mg IV Q12hrs Bacterial infection Morphine Opioid 4mg analgesic IV PRN, q3hrs Pain Insulin regular (Novolin R) Antidiabetic Subq inj q4hrs Vancomycin Antiinfective dose Based on BG Control blood sugar Pharmacological interventions medication class dose route frequency rationale AlbuterolBronchoipratropium dilator 4 puff Inhalation q4hrs Increase ability to breathe Reduce number of lung infections Dornase alfa Unknown, 2.5 mL synthetic protien Inhalation q12hrs Total parenteral nutrition 1680mL + famotidine 40 mg Antiulcer agent IV Continuous Nutrition infusion rate: and 70ml/hr prevention of stomach ulcers 1680 mL + 40 mg 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 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 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 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 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 Paraphernalia Nasogastric tube Connected to continuous low suction Bloody drainage PEG tube Intact gravity 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 Vital signs Blood pressure: 118/70 Heart rate: 99 Temperature: 101.4˚F Respirations: 23 SpO2: 95% Pain: 10, chronic, continuous 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. 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. 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. 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. 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. 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. 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 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 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.