Download Nursing 4270: Transition to Professional Practice Autumn 2014

Nursing 4270: Transition to
Professional Practice
November 5, 2014
Jennifer Bauman, RN, BA, PCCN
PhD Student
The Ohio State University College of Nursing
Objectives
• Describe the nursing process (ADPIE) in relation
to inpatient management of the adult patient in
the acute care setting.
– Identify five expected assessment findings for the case
study patient.
– Identify three nursing diagnoses and accompanying
plan/goals of care.
– Identify at least five nursing interventions.
– Identify at least two medications used for this patient.
– Identify the major tool used for evaluation of this
patient.
Case Study
• Bob, a 67 year old Caucasian male, was admitted to your
unit four hours before shift change, at approximately 3pm.
He was transported to the emergency room via EMS. (His
daughter had not heard from him that morning; they usually
speak on the phone at 10am every day. Also, they had
dinner together yesterday evening, around 6 pm.) Per the
EMS transporters, he was found at the bottom of the stairs,
on his left side. His left arm appears to be fractured and is
immobilized with a sling. He has already gone for full body xrays and does not have any other fractures. He does have a
productive cough, with a moderate amount of yellow-green,
thick sputum. Bob has a history of CAD, with DES x2 about
four years ago. His EF is maintained at 60%, per a recent
echo about 6 months ago. (Remember, DES =
anticoagulation necessary, usually with Plavix. Bob is actually
on coumadin, because it’s cheaper.)
Assessment findings
• Assessment findings:
– Neuro: in C-spine precautions, contusion on L forehead,
A&Ox4, MOEx4 although limited ROM LUE d/t fractured
arm, PERRLA intact, no deficits noted at this time
– Cardiac: temp 101.3 oral, ST with PVCs on tele, HR 120’s, BP
95/56 with MAP 69, trace 1+ edema BLE (non-pitting)
– Respiratory: SpO2 87% on RA, RR 28 with mild accessory
muscle use, lungs with ronchi t/o and diminished in bases,
orthopnea and DOE, yellow-green sputum (moderate amt)
– GI/GU: last BM yesterday, BXx4, no tenderness or pain in
abd, foley has been placed but only 50ml dark and teacolored UOP
– Skin: Large bruise on L chest and flank, poor turgor
What else do you want to assess?
• What time did he fall? How long has been
been down? (What condition would you
suspect if down for an extended period of
time?)
• What medications does Bob take, and when
did he last take them? (Cardiac, especially!)
• He fell on his left side – what organ are you
concerned about?
•
Chemistry
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Labs
Na (normal 135-145) = 137 mg/dL
K (normal 3.5-4.5) = 5 mg/dL
Cl (normal 98-106) = 96 mEq/mL
Mag (normal 1.8-2.6) = 1.6 mg/dL
Creat (normal 1-2) = 2.1 mg/dL
BUN (normal 7-20) = 12.6 mg/dL
Calcium (normal 9-11) = 7.5 mg/dL
Phosphorous (normal 3-4.5) = 5mg/dL
Anion gap (normal 8-16) = 22 mmol/L
BUN/Creat ratio (normal 10:1) = 6:1
Hematology
– WBC (normal 4.5-11) = 18 x 103 /L
– RBC (normal 4.3-5.7) = 4 x 108 /L
– H/H (normal 13.5-17.5 and 39-49) = 12 g/dL and 32%
•
Why is the Hct lower than expected, given the Hgb?
– Platelets (normal 150-450) = 100 x 103 /L
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Coag panel
– INR (normal .9-1.1) = 2.6
•
Lactate (not worried if less than 2 mmol/L) = 3.7 mmol/L = increased H+ ions = acidosis (weak
correlation)
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“Lactate is a marker for cellular hypoxia. A level above 4.0 mmol/L is associated with a 27% mortality rate, compared
with a mortality rate of 7% for patients with a lactate level of 2.5-4.0 mmol/L and a death rate below 5% for those with
a lactate level below 2.5 mmol/L, said Dr Strehlow of the university” (Boschert, 2007).
CK (normal 36-137) = 10,000 U/L
– “CK is consisted of three isoenzyme which are: CK-MM mostly found in muscles, CK-MB mostly found
in heart and CK-BB mostly found in the brain and kidneys” (E et al., 2007).
What other diagnostics do you want?
• Lower respiratory culture
• Strep/pnemo urine (Legionella pneumophila and Streptococcus
pneumoniae)
• Blood cultures
• Urine culture
• Differential added on to hematology labs
• Chest Xray
• Uric acid
• CT of head and abdomen – use contrast? Why/why not?
• Toxicity panel (urine and blood)
• If indicated due to severity of symptoms, can also assess CVP with
CVC …
• ABG?
Diagnoses
• Risk for falls related to recent fall.
• Risk for hemorrhage related to chronic
anticoagulation.
• Decreased fluid volume related to rhabdo aeb
dark urine, low urine output, poor skin turgor.
• More ???
Plan/Goals of Care
• Bob will be free from falls while in the
hospital.
• Bob will remain free from signs/symptoms of
hemorrhage while in the hospital.
• Bob will experience adequate fluid volume, as
evidenced by increased UOP, less
concentrated urine, and improved skin turgor.
• More ???
Rhabdomylosis
• Muscle breakdown causes cell lysis, which
releases the intracellular components.
• “When reperfusion starts, leukocytes migrate into
the damaged area, cytokines and prostaglandins
increase whereas free radicals are produced in
the presence of oxygen.”
• Myoglobin clogs the renal tubules +
vasoconstriction + hypovolemia  acute renal
failure
• Metabolic acidosis
Pneumonia
• Community Acquired Pneumonia (CAP)
• Healthcare Associated Pneumonia (HCAP)
• What are the differences?
• Which of these do you think Bob has?
SIRS/Sepsis
• SIRS: systemic inflammatory response syndrome
– from an infectious or non-infectious insult
• Sepsis: a complication of severe infection,
characterized by dysregulated inflammation;
from SIRS  sepsis  severe sepsis  septic
shock
– Increased capillary permeability
– Vasodilation
– Leukocyte accumulation
Risk Factors
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Bacteremia
Advanced age (over 65 yo)
Immunosuppression
Community acquired PNA
Genetic factors
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Temperature >38.3 or <36ºC
Heart rate >90 beats/min or more than two standard deviations above the normal value
for age
Tachypnea, respiratory rate >20 breaths/min
Altered mental status
Significant edema or positive fluid balance (>20 mL/kg over 24 hours)
Hyperglycemia (plasma glucose >140 mg/dL or 7.7 mmol/L) in the absence of diabetes
Inflammatory variables
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Leukocytosis (WBC count >12,000 microL–1) or leukopenia (WBC count <4000 microL–1)
Normal WBC count with greater than 10 percent immature forms
Plasma C-reactive protein more than two standard deviations above the normal value
Plasma procalcitonin more than two standard deviations above the normal value
Hemodynamic variables
– Arterial hypotension (systolic blood pressure SBP <90 mmHg, MAP <70 mmHg, or an SBP decrease >40
mmHg in adults or less than two standard deviations below normal for age)
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Organ dysfunction variables
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Arterial hypoxemia (arterial oxygen tension [PaO2]/fraction of inspired oxygen [FiO2] <300)
Acute oliguria (urine output <0.5 mL/kg/hr for at least two hours despite adequate fluid resuscitation)
Creatinine increase >0.5 mg/dL or 44.2 micromol/L
Coagulation abnormalities (international normalized ratio [INR] >1.5 or activated partial thromboplastin
time [aPTT] >60 seconds)
– Ileus (absent bowel sounds)
– Thrombocytopenia (platelet count <100,000 microL–1)
– Hyperbilirubinemia (plasma total bilirubin >4 mg/dL or 70 micromol/L)
•
Tissue perfusion variables
– Hyperlactatemia (>1 mmol/L)
– Decreased capillary refill or mottling
Early goal-directed therapy targets — Although evidence is conflicting regarding the
routine measurement of early goal-directed therapy targets, we suggest measuring the
following targets for fluid management in patients with sepsis:
●Mean arterial pressure (MAP) ≥65 mmHg (MAP = [(2 x diastolic) + systolic]/3)
●Urine output ≥0.5 mL/kg/hour
●Static or dynamic predictors of fluid responsiveness, eg, central venous pressure (CVP)
8 to 12 mmHg when central access is available (static measurement) or respiratory
changes in the radial artery pulse pressure (dynamic measurement).
●Central venous (superior vena cava) oxyhemoglobin saturation (ScvO2) ≥70 percent
(when central access is available) or mixed venous oxyhemoglobin saturation (SvO2) ≥65
percent (if a pulmonary artery catheter is being used).
Interventions for Bob
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Establish IV access
Fluids
– What should be added to your IVF?
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Measure intake/output (probably every 2h)
VS q1h
Continue tele and pulse ox
Trend labs
Oxygen therapy
Neuro checks q4h (for now…)
Cooling measures
– Antipyretic
– Cooling blanket, if tolerated
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Electrolyte replacements
– What do you do about the high K?
– Tell me about the Phos/Calcium relationship
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Antbx
Safety measures
What am I missing?!?!
Bob’s Condition Worsens
You have been caring for Bob for six hours (10
hours post admission). On your hourly rounds,
you walk into Bob’s room and notice that he is
sitting at the edge of the bed, picking at his skin
and pulling at his foley and monitor wires. He
does not know the year or where he is, and you
notice that his hands are shaking. Bob is also
diaphoretic and anxious. His HR and BP are
elevated, and he has taken off his oxygen, so his
SpO2 has dropped to 85%. What do you do?
Your shift continues …
You put Bob back in bed, replace his oxygen (his SpO2 is
now 94% on 2L NC). You assess Bob’s CIWA score; it is 16,
indicating moderate etoh withdrawal. You contact the LIP,
who enters the CIWA order set but also requests that you
contact Bob’s daughter, to rule out other types of
withdrawal. You call Bob’s daughter, and she states that
Bob drinks a fifth of whiskey per day, which he has been
doing since his wife died two years ago. He has never been
admitted for withdrawal in the past and does not take any
other medications from which withdrawal would be
considered. She said that Bob ran out of whiskey two days
ago, but he drank two beers at dinner last night. What else
do you want to do???
(Ethyl) Alcohol = Ethanol
• Ethyl alcohol is the only type of consumable ethanol.
• Central nervous system (CNS) depressant
• Simultaneously enhances inhibitory tone via
modulation of gamma-aminobutyric acid (GABA)
activity and dampens excitatory tone via modulation of
excitatory amino acid activity
• To keep the inhibitory and excitatory tones balanced
(i.e., homeostasis), must have constant presence of
ethanol.
• Abrupt cessation of ethanol creates an imbalance (i.e.,
interrupts homeostasis) = overactivity of CNS
Long term effects of Alcohol Misuse
• Liver disease
– Cirrhosis
• “Among all cirrhosis deaths in 2009, 48.2 percent were alcohol related. The
proportion of alcohol-related cirrhosis was highest (70.6 percent) among
decedents ages 35–44”(NIAAA, 2014).
• However, only 5-10% of alcoholics develop cirrhosis
– Fatty liver disease
– Hepatitis
– 1 in 3 liver transplants in 2009 were due to alcohol-related disease
(NIAAA, 2014)
• Increased risk for cancer of mouth, esophagus, pharynx, larynx,
liver, and breast
• Pancreatitis
• Malnutrition
• Wernicke’s Encephalopathy
• Higher risk for injury, especially falls
• Impaired judgement = high risk behavior = increased risk for STIs,
sexual assault, etc.
Alcohol Withdrawal
(If it doesn’t work, use this link:
http://www.youtube.com/watch?v=bAEcA4mCMfc)
Symptoms of Withdrawal
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Insomnia
Anxiety and/or Fear
Restlessness
Nausea and/or Vomiting
Headache
Seizures – may need CT scan, lumbar puncture
Altered Sensory Perceptions, including visual (common),
tactile (common), auditory
• Tremors
• Diaphoresis
• Tachycardia, which may/may not be accompanied by
palpitations (why??)
Delirium Tremens (DT)
• “… hallucinations, disorientation, tachycardia, hypertension, fever, agitation,
and diaphoresis in the setting of acute reduction or abstinence from alcohol.”
• Last up to 7 days, mortality rate of 5%
• Increased cardiac indices, oxygen delivery, and oxygen consumption
• Arterial pH rises due to hyperventilation (respiratory alkalosis) = decrease in
cerebral blood flow
• Fluid and electrolyte status:
• Hypovolemic r/t diaphoresis, hyperthermia, vomiting, and tachypnea
• Hypokalemia r/t renal and extrarenal losses, alterations in aldosterone
levels, and changes in potassium distribution across the cell membrane
• Hypomagnesemia r/t malnutrition; may predispose to dysrhythmia
(torsades des pointes) and seizures
• Hypophosphatemia r/t malnutrition; may contribute to cardiac failure and
rhabdomyolysis.
Who is at risk for DT?
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A history of sustained drinking
A history of previous DT
Over age 30
The presence of a concurrent illness
The presence of significant alcohol withdrawal in the
presence of an elevated alcohol level
• A longer period since the last drink (ie, patients who
present with alcohol withdrawal more than two days
after their last drink are more likely to experience DT
than those who present within two days)
Other diagnoses to consider
• “A premature diagnosis of alcohol withdrawal can
lead to inappropriate use of sedatives, which can
further delay accurate diagnosis.”
• Infection (e.g., meningitis)
• Trauma (e.g., intracranial hemorrhage)
• Metabolic derangements
• Drug overdose
• Hepatic failure
• Gastrointestinal bleeding
Assessment: Clinical Institute
Withdrawal Assessment (CIWA)
Assessment: CIWA Calculation
• http://www.mdcalc.com/ciwa-ar-for-alcoholwithdrawal/
Assessment – beyond CIWA
• Questions to ask:
– CAGE questions (Kosten et al, 2003)
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Can you cut down on your drinking?
Are you annoyed when asked to stop drinking?
Do you feel guilty about your drinking?
Do you need an eye opener drink in the morning when you wake up?
– How long have you gone without alcohol in the past six months?
– Has anyone ever advised that you cut down on your drinking?
– When was the last drink (i.e., the most recent alcohol
consumption)?
– How much alcohol per day?
– How long has the patient been dependent on alcohol?
– Has he/she ever experienced withdrawal or delirium tremens
before?
• If so, how many times has this occurred, and did he/she ever have
seizures?
Continued assessment …
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Vital signs – what would you expect to find, and why?
See “Symptoms” slide for signs/symptoms of withdrawal
Risk for elopement, falls, aspiration
Smoking status
Blood sugar – Accucheck
Urine drug/toxicity screen
Blood work to collect:
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Chemistry
Complete Blood Count (CBC) with differential and platelet
Coagulation panel (PT, INR, PTT)
Liver Function Tests (LFT)
Uric acid
Alcohol, whole blood
Drug/toxicity screen – should be collected at the same time as the urine, if
possible
Diagnoses (examples)
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Risk for Injury (especially falls!)
Risk for Elopement
Risk for Sensory-Perceptual Alterations
Anxiety and/or Fear r/t alcohol withdrawal
aeb restlessness, tachycardia, hypertension
• Risk for Aspiration (Ineffective Breathing
Pattern)
• Risk for Seizures
Plan and Goals of Care (examples)
• The patient will remain free from falls during the
hospital stay by using bed exit alarm and frequent
monitoring by staff.
• The patient will not elope from the hospital
during his/her stay through frequent monitoring,
purple gown, security alert.
• The patient will not aspirate during his/her stay
by keeping HOB > 30 degrees, monitoring during
PO intake, staff evaluation for safe swallow.
Interventions
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IV access
Administer medications (as ordered by LIP)
Possible sitter/safety coach and/or to be closer to nurses’ station
If at risk for elopement, place in special gown (at OSUWMC, it is bright
purple), notify security of increased risk, and keep close to nurses’ station,
away from elevators.
Going off the unit is contraindicated, both due to risk for elopement and
medication administration
Avoid the use of restraints, especially LBB
Bed exit alarm
Seizure pads on bedrails
HOB at 30 degrees or greater, if no contraindications
Quiet, dark, calm environment
Fan or cool washcloths
Nurse should present calm demeanor
Limit setting
Nicotine replacement
Consults: social work, nutrition, psychiatry, nicotine dependence
Interventions: Medications
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Chlordiazepoxide (Librium) – long-acting benzodiazepine
Diazepam (Valium) – long-acting benzo
Lorazepam (Ativan) – short-acting benzo
Flumazenil (Romazicon) – reversal agent for benzo
Clonidine (Catapres) - centrally acting alpha-2 agonist, for
severe DT, but may mask symptoms of worsening status
Phenobarital – anticonvulsant, if severe DT or status
epilecticus
AVOID the routine use of anticonvulsants, beta blockers
(mask symptoms) and antipsychotics (lower the seizure
threshold)
Vitamins, especially folic acid and thiamine
Electrolytes, especially glucose, magnesium, phosphate,
and potassium
Intravenous fluids, if not contraindicated
Interventions: Medications used at
OSUWMC
Evaluation
• Back to assessment – check CIWA score per
the protocol
• Re-assess
Back to Bob …
• Your shift is coming to an end. Bob is resting
peacefully after receiving 2mg of IVP Ativan every
hour during your shift. His head CT was completed,
and he has small, 2mm hematoma on the right
frontal lobe. You continue to perform neuro checks
every hour, and you’re reversing his warfarin
(Coumadin) with vitamin K and FFP. He continues to
receive IVF (with sod. Bicarb.), antbx, and oxygen
therapy. His urine output is improving in amount
and color. What do you want to pass onto the
oncoming shift? (You can give me a sample shift
report, if you want!)
Questions?
http://whatshouldwecallnursing.tumblr.com/post/100024997786/when-i-think-abouthow-prepared-i-feel-to-handle-ebola
And
http://whatshouldwecallnursingschool.tumblr.com/post/74607297818/my-high-falls-riskpatient-going-to-the-bathroom
Thank you for having me, and enjoy the rest of your semester!
References
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American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA:
American Psychiatric Publishing. Retrieved September 30, 2014, from
http://dsm.psychiatryonline.org/book.aspx?bookid=556.
Boschert, S. (2007). Is it septic shock? Check a lactate level. American College of Emergency Physicians. Retrieved November
4, 2014, from http://www.acep.org/Clinical---Practice-Management/Is-It-Septic-Shock--Check-Lactate-Level/
Criddle, L.M. (2003). Rhabdomylosis: Pathophysiology, recognition, and management. Critical Care Nurse, 23(6), 14-30.
Efstratiadis, G., Voulgaridou, A., Nikiforou, D., Kyventidis, A., Kourkouni, E., & Vergoulas, G. (2007). Rhabdomylosis updated.
Hippokratia, 11(3), 129-137.
Hoffman, R.S., & Weinhouse, G.L. (2013). Management of moderate and severe alcohol withdrawal syndromes. In S.J. Traub
& J. Grayzel (Eds.), UpToDate. Retrieved from http://www.uptodate.com/.
Kosten, T.R., & O’Connor, P.G. (2003). Management of drug and alcohol withdrawal. New England Journal of Medicine,
348(18), 1786-95.
Mandell, L.A., Wunderink, R.G., Anzueto, A., Bartlett, J.G., Campbell, G.D., Dean, N.C., Dowell, S.F., File, T.M., Musher, D.M.,
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MDCalc. (2014). CIWA-Ar for Alcohol Withdrawal. Retrieved September 20, 2014, from http://www.mdcalc.com/ciwa-ar-foralcohol-withdrawal.
National Institute on Alcohol Abuse and Alcoholism (NIAAA). (2014). Alcohol facts and statistics. Alcohol and Your Health.
Retrieved September 30, 2014, from http://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-factsand-statistics.
National Institute on Alcohol Abuse and Alcoholism. (n.d.). What is a standard drink?. Alcohol and Your Health. Retrieved
September 30, 2014, from http://www.niaaa.nih.gov/alcohol-your-health/overview-alcohol-consumption/standard-drink.
Neviere, R. (2014). Sepsis and the systemic inflammatory response syndrome: Definitions, epidemiology, and prognosis. In
P.E. Parsons & G. Finlay (Eds.), UpToDate. Retrieved from http://www.uptodate.com/.
Nurselabs.com (n.d.). 5 Alcohol Withdrawal Nursing Care Plans. Retrieved September 30, 2014, from
http://nurseslabs.com/5-alcohol-withdrawal-nursing-care-plans/.
Office of Women’s Health at the U.S. Department of Health and Human Services. (2013). Straight talk about alcohol.
GirlsHealth.gov. Retrieved September 30, 2014, from www.girlshealth.gov.
Schmidt, G.A., & Mandel, J. (2014). Evaluation and management of severe sepsis and septic shock in adults. In P.E. Parsons ,
D.J. Sexton, R.S. Hockberger, & G. Finlay (Eds.), UpToDate. Retrieved from http://www.uptodate.com/.
Weed, H.G. (2011). Clinician’s Guide to Alcohol Withdrawal as a Secondary Diagnosis. 2nd Edition. From The Ohio State
University Medical Center Evidence Based Practice Clinical Resources. Retrieved September 20, 2014, from
http://www.osumc.edu.