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.