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Grand Rounds St. Thomas 2A

This detailed clinical assessment covers an 86-year-old Caucasian male retired military patient residing in a long-term care facility. Vital signs show stable blood pressure, heart rate, and oxygen saturation. Significant findings include an endotracheal tube, peripheral edema, and respiratory challenges evidenced by coarse breath sounds and thick secretions. Neurological assessment indicates confusion and weakness. Ongoing support and care involve monitoring fluid intake via a Foley catheter and managing psychosocial involvement from the patient's family.

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Grand Rounds St. Thomas 2A

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  1. Grand RoundsSt. Thomas 2A Erin Woodby Middle Tennessee State University School of Nursing April 17, 2008

  2. 86 y/o; DOB 3/31/22 Male Caucasian Retired military Protestant Married Four living children; 3 boys and 1 girl Lives in LTC facility English speaking Weight=167lbs (75.9 kgs) Height=72 inches (6 ft) BMI=22.7 Allergies: ACE inhibitors, Hydrocodone, Micardis, Percocet, Prinvil, Quinidine, Versed Client Demographics-R.M.

  3. Assessment: Vital Signs at 0700 • Blood Pressure: 127/59 • Heart Rate: 80 • Mean Arterial Pressure: 82 • Respiratory Rate: 13 • Oxygen Saturation: 99% • Temperature: 97.7°F axillary

  4. Assessment: EENT • Eyes- open to speech, conjunctivae pink and moist, no drainage noted • Ears- bilateral hearing aides • Nose- L nostril has dobhoff tube; no breakdown noted • Mouth- contained endotracheal tube, lips were cracked and dry, drooling, teeth still present

  5. Assessment: Integumentary • Skin- warm, pick, dry • CVP line in L jugular; dressing dry and intact; Continuous infusion of NS @ 75cc/h; removed @ 1445 • Splint on L forearm • Double lumen PICC line placed in R brachial @ 0957; dressing dry and intact • Ecchymosis all over arms and large bruise on R hip • Perineal dermatitis

  6. Assessment: Cardiovascular • No abnormal heart sounds noted • Telemetry • 6 second strip indicates a fib with v paced • P-P: uc; R-R: 70; PRI: uc; QRS: 0.08; QTI: uc • All peripheral pulses palpable and equal bilaterally • Capillary refill < 3 seconds • 3+ peripheral pitting edema on all extremities

  7. Assessment: Respiratory • Continuous Positive Airway Pressure • FiO2: 40% • TV: 650 • PEEP/PSUPP: 5/5 • Extubated @ 1200 • Coarse breath sounds in RUL, RML, and LUL • Diminished breath sounds in RLL and LLL • Suction revealed thick white sputum/secretions

  8. Assessment: Gastrointestinal • Bowel sounds present in all 4 quadrants • Two large brown stools • Receiving Pulmocare through dobhoff tubing at 55cc/h for nutrition

  9. Assessment: Genitourinary • Foley catheter draining to gravity • Urine clear and yellow • Total UOP from 0700-1400 was 1250cc

  10. Assessment: Neurological • Opened eyes to verbal stimulation; motor response to tactile stimulation • pupils measured 2mm with sluggish reaction to light, and no deviation • Weakness in all extremities

  11. Assessment: Musculoskeletal • Generalized weakness in all extremities • Passive range of motion • Stiff joints

  12. Assessment: Psychosocial • Wife and children present at bedside and participating in care • When extubated showed signs of confusion and psychosis

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