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Grand Rounds

Grand Rounds. Shelaina Lewis April 17, 2008. Client Demographics-R.C. 69 year old, DOB 7/12/38 Caucasian Male Single – lives alone No children No Form of Religion English Speaking Height: 177.80 cm (70 in) — Weight: 145 lb (65.91kg) BMI: 18.8 No known allergies DNR. Risk Factors.

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Grand Rounds

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  1. Grand Rounds Shelaina LewisApril 17, 2008

  2. Client Demographics-R.C. • 69 year old, DOB 7/12/38 • Caucasian • Male • Single – lives alone • No children • No Form of Religion • English Speaking • Height: 177.80 cm (70 in) — Weight: 145 lb (65.91kg) • BMI: 18.8 • No known allergies • DNR

  3. Risk Factors • Recurrent bilateral pneumonia c pleural effusions • Severe malnutrition • Smoker – 2ppd, 30 years • Chronic alcohol abuser • Gastroesophageal reflux disease (GERD) • Left lung abscess in 2003 • Patient history of: • COPD • Diabetes Mellitus Type II • Atrial Fibrillation • Gastrointestinal Bleed • Coronary Artery Disease • Anemia • Hypertension • Alcoholic Hepatitis • Right-sided heart failure (RHF)

  4. Physical Assessment: Vital Signs Head and Neck • Blood pressure: 98-132/61-98 • Map: 71 • Pulse: 78-92 • Respirations: 30-52 • Temperature (axillary): 97.5o-98oF • CVP: 8-10 • Oxygen Saturation: 90-94% • Head – bitemporal wasting, dry and brittle hair, some hair loss • Neck – tracheotomy with mechanical ventilation midline, neck ties dry and intact

  5. Physical Assessment: EENT Integumentary • Eyes – closed, brisk reactive to light, conjunctivae pink and moist • Ears – equal size bilaterally, able to hear when spoken to close to ear • Nose – symmetric and midline • Mouth – poor dental health, several teeth missing, six caries, mucous membranes pink and moist EENT • Skin cool, dry, pale • Reddened abrasion on right hip • Stage III pressure ulcer on coccyx • Stage II pressure ulcer on upper back-right • Stage I pressure ulcers on left and right heel • Mild (2+) peripheral edema in upper extremities and lower extremities • Triple lumen central line in right subclavian • Peripheral IV in left forearm • All IV sites: dressing dry and intact

  6. Physical Assessment: Cardiovascular Respiratory • Telemetry: • 6 second strip indicate Normal Sinus Rhythm borderline tachycardia • PR interval: 0.16 • QRS: 0.08 • QT interval: 0.32 • Normal rate and rhythm with no abnormal heart sounds noted • Capillary refill < 3 seconds • All pulses palpable and equal bilaterally • Continuous Mandatory Ventilation • AC: 12 • TV: 450 • FiO2: 70 • PEEP: 7.5 • Abnormal coarse rhonchi on right side • Diminished or absent breath sounds on left side • Copious, thick, foul smelling secretions with yellowish-tan color

  7. Physical Assessment: Gastrointestinal Genitourinary • Active bowel sounds in all four quadrants • Abdomen softly distended • Two large, loose, non-odiferous stools • Percutaneous endoscopic gastrostomy tube (PEG tube) in upper left quadrant, patent, residual 20 cc • Foley catheter draining to gravity • Urine yellow and clear • Output 175 ml at A.M. assessment

  8. Physical Assessment: Neurological Musculoskeletal • Eyes open to pain, pupil size 2 mm, brisk reaction bilateral • Unable to respond due to tracheotomy • Responds to localized pain • Briefly awakens to voice (eye opening and contact < 10 seconds) • Mild weakness in all extremities • Passive range of motion to prevent contractures

  9. Physical Assessment: Psychosocial • Family present at bedside for several hours • Decision made to terminally wean • No request for clergy

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