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Critical Care Ground Rounds Presentation April 17 th , 2008

Critical Care Ground Rounds Presentation April 17 th , 2008. Kelly Barker Middle Tennessee State University. Patient Demographics. Mr. T.S. 66 yr old, African American male Married and lived with wife; one adult son Retired foundry worker 268 lbs; 6 feet 2 inches tall; BMI 34.4 (obese)

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Critical Care Ground Rounds Presentation April 17 th , 2008

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  1. Critical CareGround Rounds PresentationApril 17th, 2008 Kelly Barker Middle Tennessee State University

  2. Patient Demographics • Mr. T.S. • 66 yr old, African American male • Married and lived with wife; one adult son • Retired foundry worker • 268 lbs; 6 feet 2 inches tall; BMI 34.4 (obese) • 45 PPD smoking history (quit 10 years ago) • NKDA • Code status: full code

  3. Medical History • Past medical history: • COPD • Type II DM • Hypertension • Arthritis • Surgical History: • “Back surgery”

  4. COPD • COPD consists of emphysema and chronic bronchitis • Emphysema: loss of elasticity of the alveolar sacs leading to airway narrowing and air trapping in the lungs • Chronic bronchitis: inflammation of the small and large airways and excess mucus production leading to a narrowing of the airway • Irreversible disease eventually leading to respiratory failure and death • Risk factors: smoking, increased age, working at a foundry

  5. Reason for Hospitalization • Presented to Manchester ED • Oxygen saturation: low 80s • Tachypneic with rapid/shallow respirations, rhonchi, and acrocyanosis • Placed on BiPAP; improvement with oxygenation but not ventilation • Very confused • Intubated • Diagnosis at ED: Chronic obstructive pulmonary disorder (COPD) exacerbation

  6. Abnormal Lab Values

  7. Abnormal Lab Values

  8. Abnormal Lab Values

  9. Diagnostic Tests • Chest Xray • Impression: No change in diffuse interstitial opacities superimposed on COPD. • Echocardiogram • Impression: Mild tricuspid regurgitation with moderate pulmonary hypertension. Right ventricle and atria enlargement.

  10. IV Line and Fluids • Triple lumen central line in right internal jugular • 0.45% Sodium Chloride (1/2 NS) 30 mL/hr IV every day • Hypotonic fluid • Rationale: hydration

  11. Medications • Combivent inhaler (Ipratropium/Albuterol) 6 puffs inhalation every 4 hours • Ipratropium: synthetic quaternary ammonium compound; bronchodilator • Albuterol: adrenergic beta2-agonist; bronchodilator • Rationale: produces bronchodilation and increases air flow to the lung • MethylPREDNISolone (Solu-Medrol) 20 mg IV every 12 hours • Glucocorticoid • Rationale: used during COPD exacerbations to decrease inflammation in the airways

  12. Medications • Meropenem (Merrem) 1 gm with NS IV every 12 hours • Carbapenem; antiinfective • Rationale: used to treat infection • Vancomycin 1gm with NS IV daily • Tricyclic glycopeptide; antiinfective • Rationale: used to treat infection • Fluconazole (Diflucan) 200 mg per tube at bedtime • Triazole derivative; systemic antifungal • Rationale: used to prevent oral thrush

  13. Medications • Enoxaparin (Lovenox) 40 mg SQ daily • Low molecular weight heparin; anticoagulant • Rationale: DVT prophylaxis • Metoclopramide (Reglan) 10 mg IV every 6 hours • Central dopamine receptor antagonist; antiemetic • Rationale: prevention of nausea and vomiting • Pantoprazole Sodium (Protonix) 40 mg per tube daily • Benzimidazole; proton pump inhibitor • Rationale: prevention of stress ulcers

  14. Medications • Insulin NPH (Novolin N) SQ • Intermediate acting endogenous human insulin • Dosage based on sliding scale • Rationale: decrease blood sugar • Propofol (Diprivan) 5-20 mcg/kg/min IV • General anesthetic • Rationale: sedation • Hydrocodone & acetaminophen (Lortab) 5/500 per tube PRN every 6 hours for pain • Nonopioid analgesic • Rationale: pain reduction

  15. Nutrition • NG Tube • Residual checks every 4 hours • Promote enteral feeding 30 mL/hr per NG tube every day • High protein feeding • Rationale: nutritional support • Beneprotein 2 packets per NG tube every 8 hours • Protein supplement • Rationale: aids in healing and the immune response

  16. Vitals • AM Vitals: • BP: 121/78 • HR: 108 beats per minute • Respirations: 24 breaths per minute • Temperature: 98.1°F • SpO2: 92% • Pain: 0 (patient sleeping)

  17. Neurological Assessment • Unable to assess orientation to person, place, or time due to sedation • Drowsy, easy to arouse • Responded to painful stimuli • Unable to follow commands

  18. Musculoskeletal System • No movement of extremities but would move head • Full passive ROM • No muscle atrophy • Required total assistance with ADLs

  19. Integumentary Assessment • Skin color appropriate for ethnicity • Upper extremities: • Warm, dry • Edematous • Lower extremities: • Cool, dry • Edematous • Stage II decubitus ulcer over the coccyx

  20. EENT Assessment • PERRLA and 3mm in size; tearing present • Symmetrical ears; no redness or skin breakdown • Symmetrical nose with no skin breakdown; NG tube in right nare • Lips dry • Mouth, oral mucous membranes, and tongue moist and pink

  21. Respiratory Assessment • ET tube • Airway pressure release ventilation (APRV) settings: PH (high pressure) 30, PL (low pressure) 5, TH (time high) 2 seconds, TL (time low) 0.5 seconds • Tachypnea • Clear, diminished lung sounds (all lobes) • AP diameter: 1:1 • Thick yellow/brown sputum

  22. Cardiovascular Assessment • Normal heart rhythm • Diminished heart sounds • Tachycardia • Upper extremities: • Weak radial pulse • Capillary refill: < 3 seconds • Lower extremities • Unable to palpate posterior tibial or dorsalis pedis pulse • Capillary refill: > 3 seconds

  23. Gastrointestinal Assessment • NG tube in right nare, connected to continuous feeding • Hypoactive bowel sounds in all four quadrants • Distended, firm abdomen • No bowel movements • Vomited after suctioning

  24. Genitourinary Assessment • Foley catheter • Clear, yellow urine with no sediment • Drained around 1000 ml of urine in 8 hours

  25. Nursing Diagnosis #1 • Impaired gas exchange related to narrowing of the small airways and decrease in effective lung surface secondary to COPD as evidenced by tachypnea, shallow respirations, diminished breath sounds, tachycardia, decreased PaO2, and increased PaCO2

  26. Impaired Gas Exchange • Goals: • Patient’s respiratory rate will remain between 10-20 breaths per minute • Patient will exhibit an oxygen saturation > 95% • Patient’s ABGs will be within normal limits (PaO2 80-100 mm/Hg and PaCO2 35-45 mm/hg) • Patient will exhibit improved breath sounds

  27. Impaired Gas Exchange • Interventions: • Assess vitals and pulmonary status every 4 hours • Raise the HOB (30-45º) to facilitate chest expansion • Change the patient’s position every 2 hours • Suction secretions when needed to keep the airways clear • Monitor ventilator settings and ABGs

  28. Impaired Gas Exchange • Evaluation of goals (partially met): • Patient’s respiratory rate averaged 18 breaths per minute • Patient’s oxygen saturation remained between 92-100% • ABG results were abnormal but O2 levels did improve (PaO2 70 and PaCO2 71) • Patient’s breath sounds remained diminished

  29. Nursing Diagnosis #2 • Ineffective airway clearance related to excessive mucus production and inflammation of airways secondary to COPD as evidenced by tachypnea, diminished breath sounds, ineffective cough, thick yellow/brown sputum

  30. Ineffective Airway Clearance • Goals: • Patient’s respiratory rate will remain between 10-20 breaths per minute • Patient’s oxygen saturation will remain > 95% • Patient will exhibit no abnormal breath sounds (crackles, wheezes) • Patient will produce normal sputum (clear) • ABG results will be within a normal range (PaO2 80-100 mm/Hg and PaCO2 35-45 mm/hg)

  31. Ineffective Airway Clearance • Interventions: • Assess vitals and pulmonary status every 4 hours • Suction secretions when needed to clear the airway • Elevate the HOB (30-45º) to enhance lung expansion • Turn the patient every 2 hours • Check ventilator settings and humidification

  32. Ineffective Airway Clearance • Evaluation of goals (partially met): • Patient’s respiratory rate averaged 18 breaths per minute • Patient’s oxygen saturation remained between 92-100% • Patient did not exhibit any adventitious breath sounds such as crackles or wheezes, however they were very diminished • Patient’s sputum remained very thick and yellow/brown in color • ABG results were still abnormal but O2 levels did improve (PaO2 70 mm/Hg and PaCO2 71 mm/Hg)

  33. Nursing Diagnosis # 3 • Impaired skin integrity related to immobility as evidenced by redness and skin breakdown over the coccyx

  34. Impaired Skin Integrity • Goals: • Patient will show no additional redness over the coccyx (redness will stay 4 x 5 inches or less) • Patient will exhibit no further skin breakdown • Patient will exhibit no purulent drainage or signs of infection (increased redness and swelling)

  35. Impaired Skin Integrity • Interventions: • Inspect patient’s skin every shift • Turn patient every 2 hours • Clean the area every shift • Apply barrier cream every 8 hours

  36. Impaired Skin Integrity • Evaluation of goals (met): • Redness stayed 4x5 inches in size • There was no further breakdown of skin • No purulent drainage or signs of infection

  37. Collaboration of Patient Management • Physicians • Nurses • Dietician • Pharmacy staff • Lab technicians • Respiratory therapist • Peers

  38. Systemic Glucocorticoids in Severe Exacerbations of COPD • Objective: To compare the effectiveness of 3 day and 10 day courses of methylprednisolone • Design: Prospective, randomized, single-blind study • Sample: Consisted of 36 patients who were randomized into 2 groups (3 day and 10 day group). All patients were ex-smokers with a smoking history > 20 pack-years. All had severe airway obstruction and presented with a COPD exacerbation that required hospitalization

  39. Systemic Glucocorticoids in Severe Exacerbations of COPD • Method: Patients in the study were randomly assigned to one of two treatment groups. One group received methylprednisolone for 3 days while the other group received it for 10 days • Results: Both groups showed improvements in PaO2 levels however group 2 (10 day course of methylprednisolone) had a more marked improvement in dyspnea • Conclusion: In severe COPD exacerbations, a 10 day course of steroids is more effective then a 3 day course

  40. References • Ignatavicius, D.D., Workman, M.L. (2006). Medical-Surgical Nursing: Critical Thinking for Collaborative CareVol. I&II. St. Louis: Elsevier Saunders. • Pagana, K.D., Pagana, T.J. (2007). Mosby’s Diagnostic and Laboratory Test Reference 8th Edition. St. Louis: Elsevier. • Ralph, S.S., Taylor, C.M. (2005). Sparks and Taylor’s Nursing Diagnosis Reference Manual 6th Edition. Philadelphia: Lippincott Williams & Wilkins. • Saymer, A., Aytemur, Z.A., & Cirit, M. Systemic Glucocorticoids in Severe Exacerbations of COPD. Chest Journal, 119 (3), 726-730. • Skidmore-Roth, L. (2007). Mosby’s Drug Guide for Nurses 7th Edition. St. Louis: Mosby Elsevier.

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