Grand Rounds P resented by: Bobbi Bowman, SN, ODU

1. Grand RoundsPresented by: Bobbi Bowman, SN, ODU

2. TD is a 68 y/o female that was admitted to Riverside Rehabilitation Institute with a diagnosis of General Debility. Introduction of Patient

3. Past and pertinent health history • Possible nursing diagnosis with rationales for use • Possible interventions • Current research Focus of Grand Rounds

4. Admitted to Riverside ED on 3-11-13 • Extensive health history Past Pertinent History

5. General Debility Reason for Rehabilitation

6. One of eight children • Interned at Pentagon • 30+ year career • Current living situation Past / Psychosocial History

7. Morbid obesity • Pain medications • Assistive aids • SPO2 % and HR Physical Assessment Data

8. Self-care deficit related to activity intolerance, impaired physical mobility and depression • Risk for increased depression related to decrease function • Activity intolerance related to fatigue, general debility, muscle wasting and discomfort. • Impaired physical mobility related to activity intolerance, deconditioning, decreased gas exchange, pain and obesity. • Impaired skin integrity related to comprised immunologic status, severe edema, and comprised bowel status related to medication regimen. • Risk for injury and bleeding related to altered clotting mechanism. • Risk for ineffective therapeutic regimen management related to multiple medications. • Risk for disturbed self-concept related to appearance. Possible Nursing Diagnosis

9. 5. Impaired skin integrity related to compromised immunologic status, severe edema, and compromised bowel status related to medication regimen. Morbid obesity (possible sleep apnea), decreased functional level, increased edema and increased ecchymosis due to fall on 22MAR13, increased areas of weeping of clear drainage – dressings applied to these areaas. Prednisone, Imodium, fleet enema, insulin, pradaxa, senna,nystatin, Performing skin assessment under all “folds” due to pt not allowing OT to assist with bathing d/t self-esteem r/t size. Special inflatable mattress, wide w/c and walker as well as larger bedside commode utilized to accommodate. mepaplex patch to right rear thigh. Barrier cream being applied to gluts and inner thighs. Pt is uncomfortable with skin assessments being performed and is also self-conscious of increased weight/ edema and ecchymosis. 3. Activity intolerance related to fatigue, general debility, muscle wasting and discomfort. COPD exacerbation, Anemia, Myasthenia Gravis, Morbid obesity (possible sleep apnea), Fibromyalgia, Congestive HF, A-fib with rapid ventricular response Ferrous sulfate, Imuran, dilaudid, fentanyl, flexeril, flovent, mestinon, b-12, B-2, dilitiazem CD O2 therapy (2 liters) and frequent rest periods, use of w/c (change from status prior to hosp admit). PT response: this patient requires frequent rest periods and tires quickly. She became tachy (hr >250) after less than 15 mins of continuous light exercise. Yet this is an improvement from the day prior due to not performing any exercises in the gym and retiring to her room early (after lunch) for the rest of the evening. Pt Initials: TD Age: 68 y/o female Admitting Diagnoses: General Debility • COPD exacerbation • Bronchitis • Hypokalemia • Anemia • Myasthenia Gravis • Morbid obesity (possible sleep apnea) • Fibromyalgia • Chronic lymphedema • A-fib with rapid ventricular response • Obsessive compulsive disorder • Chronic anxiety • Depression • Hyperlipidemia • Congestive HF • Hx of fall on 22MAR13 4. Impaired physical mobility related to activity intolerance, deconditioning, decreased gas exchange, pain and obesity. COPD exacerbation, Bronchitis, Anemia, Myasthenia Gravis, Morbid obesity (possible sleep apnea), Fibromyalgia, Congestive HF, A-fib with rapid ventricular response, hx of fall on 22MAR13 Albuterol, Ferrous sulfate, Imuran, dilaudid, fentanyl, flexeril, flovent, mestinon, b-12, B-2, dilitiazem CD, oversized w/c and bedside commode, walker for transfers PT – encouraged to wheel self in w/c up and down hallways, performed 5 knee extensions, hip hikes, and 20 toe touches per lower extremity OT – encouraged to assist with transfers OOB and with dressing and grooming each morning RT – passing/ catching small thera-ball while performing cognitive recall word game Pt frequently request pain meds (c/o greatest pain to b/l knees) prefers RT the most due to “stimulation of thought” and did not tolerate gym exercises very well (increased hr and MD cancelled all PT. 2. Risk for increased Depression related to decreased function. Obsessive compulsive disorder, Chronic anxiety, Depression, requires increase assist with ADL, has decreased functional level, hosp stay/ rehab admit increase her feeling of depression Bupropion, klonopin, Lexapro. Neuro / Psych as part of rehab process(increased sessions with trail of new anti-depressant – homework assignments given), continuous encouragement from staff, family members call often. Patient becomes tearful and exhibits signs of depression when she speaks of 9or focuses) on her prior health/ activity state prior to myasthenia gravis dx. She admits to increased self-esteem concerns and does not want to feel as if she is a burden to anyone. She has a great deal of self-pride and “hates her current state” 1. Self-care deficit related to activity intolerance, impaired physical mobility and depression. General Debility, admit to hosp, admit to rehab, requires increased assist with ADL, hx of fall on 22Mar13 PT – focuses on increasing activity tolerance and mobility to promote increased self-care. OT – working on ADL in morning care RT – focuses on cognitive recall while “playing game” Patient gets discouraged often when she focuses on increases in self-care deficits noted since her dx and subsequent admit to hosp/ rehab. She is very limited as to what she can perform indep d/t fear of falling (hx of 8 falls within last 6 months), activity intolerance, weakness, etc

10. Self-care deficit related to activity intolerance, impaired physical mobility and depression • Risk for increased depression related to decrease function • Activity intolerance related to fatigue, general debility, muscle wasting and discomfort. Top Three

11. Why may these methods not work?? • What would be some alternative interventions?? Management Concern

12. Self defeat • Lack of decision making process for self-management Potential Problems

13. Physical • Psychological Then & Now

14. Tzeng, H., & Yin, C. (2010). Nurses' response time to call lights and fall occurrences. MEDSURG Nursing, 19(5), 266-272. Current Research

15. Thank you