Grand Rounds

1. Grand Rounds Meg Tiongco March 20, 2008

2. Patient Demographics 73 year old Caucasian male Divorced Daughter living in Michigan Resident of a long term care facility Height: 67 inches, Weight: 233 lbs Full code Allergies: penicillin, Darvocet

3. Past Medical History Multiple strokes Coronary disease Chronic Obstructive Pulmonary Disease Non insulin-dependent diabetes Previous pressure ulcers Sleep apnea Schizophrenia Heavy smoker in the past

4. Events Leading to Hospitalization Presented to the ER in Fentress County in respiratory distress Bilateral infiltrates on chest x-ray Put on BiPAP, diuretics and steroids Progressed to respiratory collapse Transferred to St. Thomas for ICU management of respiratory failure

5. Medical Diagnosis: Respiratory Distress • Difficulty breathing resulting from inability to adequately ventilate and oxygenate • increased RR, use of accessory muscles, dyspnea, pale skin • Resulted from: • Pleural effusions – fluid compresses lungs, results in decreased ventilation • Pulmonary edema – accumulation of fluid in alveoli, makes lung expansion more difficult and impairs gas exchange in the lungs, decreasing oxygenation of the blood

6. Risk Factors • Heavy smoker • COPD • Age 73 years • Obesity • Sleep apnea • bedfast

7. Assessment • Vitals • HR: 62-87 bpm • BP: Day 1 average 158/84, Day 2 average 118/70 • RR: 12-26 breaths per minute • O2: 93-100% on ventilator • Temperature: 97.9°-98.8°

8. Assessment • Respiratory • Lung sounds: bilateral fine crackles in upper lobes, diminished bases • Mechanical ventilation: • Synchronized intermittent mandatory ventilation (SIMV): preset tidal volume and respiratory rate, with preset breaths are synchronized with patient’s breaths to prevent stacking • TV: 600, rate: 12, FiO2: 45%, PEEP: 5, pressure support: 20

9. Assessment • Respiratory continued • Afternoon 2/28, began process of weaning from the ventilator, changed settings to spontaneous ventilation with FiO2: 45%, TV: 600, PEEP: 5 and pressure support: 8 • Maintained these settings until morning of 2/29 • 02 dropped into the 80s • Changed back to SIMV

10. Assessment • Cardiovascular • Irregular rhythm, S1 & S2 present, no murmurs • Telemetry monitoring: Atrial fibrillation • Peripheral pulses 2+ • Peripheral edema 1+ • Capillary refill <3 seconds, no clubbing

11. Assessment • Integumentary • Skin warm, dry, pale • Heavy bruising on both calves • Stage II pressure ulcer on buttocks • Braden score: 13 (moderate risk) • Musculoskeletal • Generalized weakness • Full ROM, no contractures • Right leg shorter than left leg • Bedfast

12. Assessment • Gastrointestinal • Normal bowel sounds x4 • Abdomen softly distended • No bowel movement • PEG tube • Genitourinary • Foley catheter – clear, yellow urine, output averaged 75 ml/hr

13. Assessment • Neurological • 2/28 - awake, able to follow commands, unable to fully assess orientation due to intubation • Glasgow Coma Scale: 10E • 2/29 – sedated, opened eyes to speech, responded to localized pain • Glasgow Coma Scale: 8E • Pupils 3 mm, PERRLA

14. Arterial Blood Gases • Partially compensated metabolic alkalosis • COPD leads to respiratory acidosis. The body tries to compensate by retaining bicarbonate, which raises blood pH and leads to metabolic alkalosis. • Associated with hypokalemia & hypochloremia, treatment is potassium chloride – patient received KCl supplement and NS + 40 mEq KCl IV fluids

15. Abnormal Lab Values

16. Abnormal Lab Values

17. Medications

18. Medications

19. Medications

20. Medications

21. Nutrition Pulmocare ordered 2/28 Formulated for COPD & ventilator dependent patients Provides 1.5 Kcal/mL 68 g/L protein, 100 g/L carbohydrates, 11 g/L fat Began at 30 ml/hr, increased by 10/ml q4h until reached 70 ml/hr

22. Significant Tests • Chest X-Ray on admission (2/26) • Reason: Determine cause of respiratory distress • Findings: • Mild to moderate cardiomegaly • Bilateral infiltrates and edema • Small to moderate bilateral pleural effusions

23. Significant Tests • Chest X-Ray - 2/28 • Reason: follow up; check placement of ET tube • Findings: • Patchy infiltrates & some edema • Right pleural fluid collection • No pneumothorax • Satisfactory intubation

24. Collaborations Primary nurse and Instructor – evaluating patient’s status and plan of care Peers – hygiene and repositioning Respiratory Therapy – determine ventilator settings, provide breathing treatment Medical Nutrition Therapy – determine appropriate formulation for enteral feeding Wound Ostomy consult – evaluate Stage II ulcer on buttocks IV therapy – PICC line needed

25. Nursing Diagnosis #1 Impaired Gas Exchange related to pulmonary edema and alveolar-capillary damage secondary to respiratory distress and COPD as evidenced by abnormal ABGs, hypercapnia, pale skin, restlessness and diaphoresis

26. Impaired Gas Exchange • Goals: • Patient will: • have clear lung sounds • maintain RR < 30 bpm with regular breathing pattern • maintain 02 saturation > 90%

27. Impaired Gas Exchange • Interventions • Administer humidified O2 via ventilator • Auscultate lung sounds q4h • Monitor respiratory rate and pattern q4h • Monitor pulse oximetry hourly • Position patient in semi-Fowler’s • Turn and reposition q2h

28. Impaired Gas Exchange • Evaluation • Goals: • Patient had fine crackles in upper lobes • Maintained RR<26 bpm with regular pattern • O2 saturation 93-100% • Interventions • Not all goals were met, but patient maintained adequate gas exchange

29. Nursing Diagnosis #2 Impaired Spontaneous Ventilation related to damage to alveolar capillary membrane and respiratory muscle fatigue secondary to respiratory distress and COPD as evidenced by dyspnea, decreased pO2 and increased pCO2

30. Impaired Spontaneous Ventilation • Goals • Patient will: • have respiratory rate < 30 bpm with regular pattern • remain free of dyspnea • breathe spontaneously while being weaned from ventilation • remain free of complications from mechanical ventilation

31. Impaired Spontaneous Ventilation • Interventions • Monitor for nasal flaring, changes in respiratory rate and rhythm and use of accessory muscles • Monitor ventilator settings at beginning of shift and after any changes • Use soft wrist restraints to prevent self-extubation • Assess for signs of skin or mucous membrane irritation around the ET tube at least once each shift • Provide oral care q2h

32. Impaired Spontaneous Ventilation • Evaluation • Goals • Patient maintained regular respiratory rate < 26 bpm • Patient did not demonstrate signs of dyspnea • Patient breathed spontaneously for approximately 12 hours during attempt at weaning • Patient did not have any complications • Interventions • Effective for meeting the stated goals

33. Nursing Diagnosis #3 Ineffective Airway Clearance r/t bronchoconstriction, presence of ET tube, decreased cough reflex as evidenced by crackles in upper lobes, diminished bases

34. Ineffective Airway Clearance • Goals • Patient will: • have clear lung sounds • maintain a patent airway free of secretions • remain free of dyspnea

35. Ineffective Airway Clearance • Interventions • Suction ET tube as needed • Hyperoxgenate before and after suctioning • Auscultate lung sounds q4h, after suctioning and prn as condition warrants • Reposition patient q2h • Position client in semi-Fowler’s

36. Ineffective Airway Clearance • Evaluation • Goals • Patient had fine crackles in upper lobes • Patient maintained a patent airway free from secretions • Patient did not display symptoms of dyspnea • Interventions • Interventions were effective in maintaining a clear airway

37. Research • Effect of a Nurse-Implemented Sedation Protocol on the Incidence of Ventilator-Associated Pneumonia • Compared having sedation controlled only by physicians vs. sedation controlled by nurses using a protocol developed by physicians and nurses • Protocol included a chart based on the patient’s weight, indicating doses for initial boluses and for adjustments of sedation using either propofol or midazolam

38. Research • Nurse initiated the sedation according to the physician’s prescription • Nurse reassessed sedation level every 3 hours • If needed, nurse adjusted the dose of sedative according to the developed protocol without having to call the physician for approval

39. Research • Results of using the nurse-implemented sedation protocol: • Incidence of ventilator-associated pneumonia was significantly lower • 6% in nurse initiated protocol vs. 15% in physician controlled protocol • Median duration of mechanical ventilation was significantly shorter • 4.2 days in nurse initiated protocol vs. 8 days in physician controlled protocol

40. Research • Conclusion: • Eliminating the need for physician orders to adjust sedation allowed for more rapid clinical decision making and was beneficial in achieving the most desirable level of sedation for patients on a ventilator • Protocol was safely implemented by nurses to improve patient outcomes

41. References Ackley, B.J. & Ladwig, G.B. (2006). Nursing diagnosis handbook: A guide to planning care (7th ed). St Louis: Mosby Elsevier. Ignatavicius, D.D. & Workman, M.L. (2006). Medical-Surgical nursing: Critical thinking for collaborative care (5th ed.). St. Louis: Elsevier Saunders. Jaffe, M.S. & McVan, B.F. (1997) Davis’s laboratory and diagnostic handbook. Philadelphia: F.A. Davis. Porth, C.M. (2005). Pathophysiology: Concepts of altered health states (7th ed.). Philadelphia: Lippincott Williams & Wilkins. Quenot, J.-P., Ladoire, S., Devoucoux, F., Doise, J.-M., Cailliod, R., Cunin, N., et al. (2007). Effect of nurse-implmented sedation protocol on the incidence of ventilator-associated pneumonia. Critical Care Medicine, 35, 2031-2036. Skidmore, L. (2005) Mosby’s drug guide for nurses (6th ed.). St. Louis: Elsevier Mosby.