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Clinical Case Report Age: 66 Weight: 64.6 kg Allergies Student: Sara Freiheit NKDA Gender: Male Admitting Diagnosis (es) &/or injuries: Chest Pain: Possible MI, Respiratory Failure, Possible Stroke, GI bleed Past Medical History (chronic health problems): GERD, GI ulcer, tonsil cancer S/P chemo, radiation, throat surgery for cancer, smoker (2 packs a day for 45 years) Score: ________ / 25 possible points Choose one medicated drip the patient is receiving such as, diprivan, dopamine, heparin, insulin or others & calculate the dose in the appropriate mcg/min, mcg/kg/min, units/hr etc. State if the medication is within normal, low or high range for the dose. (1 pt.) This patient was getting diprivan (propofol) at 4 ml/hr. The concentration of this medication drip is 1000 mg/ 100 ml. Mcg/min- 666.67 mcg/min … Math: 10,000 X 4 / 60min Mcg/kg/min- 10.32 mcg/kg/min … Math: 10,000 X 4 / 60 / 64.6 This is a safe dose. It is a low range for the dose. IV ICU range for sedation in adults is 5-50 mcg/kg/min **Attach and interpret ECG strip** Normal Sinus Rhythm Rhythm: Regular Rate: 70 P waves: normal, one precedes each QRS, all the same size PR Interval: 0.12 QRS Complex: 0.08 Describe the pathophysiologic processes that led to in patient’s admission (major admitting diagnosis). Include relationship (s) of client’s chronic health problems, as relevant. Cite reference used. (2 pts.) This patient was having a sudden onset of a syncopal episode, right sided weakness and right sided facial droop. The patient was brought en route to ED in an ambulance when going into cardiac arrest (possible STEMI) at 0848. CPR was performed and a pulse returned at 0904. Because of this patient’s history as a smoker, it would be of no surprise that a MI would occur. Smokers’ risk factor of an MI is doubled than that of a non-smoker (Morton & Fontaine, 2009). When a patient experiences an MI, coronary atherosclerosis is usually the cause. With the amount of smoking this patient has done, it would be no surprise that this patient had a build up of LDL cholesterol, causing a thrombus formation, resulting in an MI (Morton & Fontaine, 2009). Furthermore, lung damage in this patient would be expected due to the fact that the bronchioles and alveoli lose their elasticity, impairing oxygen exchange along with cilia no longer being able to remove toxic/harmful particles, leading to high risks of heart disease or strokes (Morton & Fontaine, 2009). With the patient’s recent family stress, it comes as no shock that his body may have been compensating to the stress, which causes an increase in oxygen demand, increased heart rate and increased workload on the already stressed heart, leading to the ischemic event. Cardiac arrest causes a cease in blood flow which prevents oxygen delivery to the vital tissues and organs. After this, anaerobic metabolism begins. Lactic acid is generated through anarobiosis. When lactic acid increases, pH decreases and bicarbonate concentration in the body fluids that is caused by the high amounts of lactic acid all relate back to tissue hypoxia. This acidosis produces an end result of vasodilatation and depression of catecholamine action (Alkaissi, 2010). Meds – limit to most important medications (6-7 max) Medications (include – PO/NG/OG, IVP, IVPB, continuous drip): (2 pts.) Route Brand/trade name Use for this patient Major side effects IVP Pantoprazole (Protonix) This patient was experiencing a GI bleed from an ulcer at time of admittance to the hospital. This medication is used to heal duodenal ulcers. Abdominal pain, diarrhea, hyperglycemia, hypomagnesemia, bone fracture, headache IV Propofol (Diprivan) Sedation of the patient while intubated and on mechanical ventilator on ICU. bradycardia, apnea, hypotension, burning, pain, stinging, green urine, abdominal cramping OG (PO) Folic Acid (Folvite) Stimulates the production of red rash, irritability, difficulty blood cell function after the GI sleeping, malaise, bleed; restoration and confusion, fever maintenance of normal hematopoiesis. Special considerations for patient Monitor for increases in AST, ALT, alkaline phosphatase and bilirubin. Dilute with 0.9% NaCl. (Leeuwen et. al, 2006) Respiratory rate should be monitored along with pulse and blood pressure. Wakeup and assessment of CNS function should be done daily during maintenance to determine minimum dose required for sedation. Do not discontinue abruptly, may cause anxiety and agitation. (Leeuwen et. al, 2006) Assess the patient for signs of megaloblastic anemia throughout therapy. Monitor plasma folic acid levels, hemoglobin, hematocrit, and reticulocyte count. Any antacids should be given at least two hours after folic acid. (Leeuwen et. al, 2006) PO Nitroglycerin (Nitrostat) Increases coronary blood flow by dilating coronary arteries and improving collateral flow to ischemic regions (from MI). Reduces myocardial oxygen consumption. Treatment of HF associated with acute MI. dizziness, headache, hypotension, tachycardia, syncope, restlessness, blurred vision, nausea, vomiting There will be additive hypotension with antihypertensives, beta blockers, calcium channel blockers, haloperidol or phenothiazines. This pt was receiving haloperidol so hypotension was at increased risk. (Leeuwen et. al, 2006) IV Dexmedetomidine (Precedex) Additive sedation for mechanically ventilated patient. bradycardia, sinus arrest, hyptotension, hypoxia, dry mouth, anemia, nausea, vomiting, fever Should not be used for more than 24 hours. Monitor ECG and BP continuously. Assess level of sedation throughout therapy. Dose should be adjusted based on level of sedation. (Leeuwen et. al, 2006) Inhaln Albuterol (Proventil) Used as a quick-relief agent for acute bronchospasm. Pt needed bronchodilation after extubation when experiencing trouble breathing and anxiety. Nervousness, restlessness, tremor, headache, paradoxical bronchospasm, chest pain, palpitations, angina, arrhythmias, hypertension, nausea, vomiting, hyperglycemia, hypokalemia Assess lung sounds, pulse and BP before administration and during peak of medication. Note amount, color and character of sputum. Monitor pulmonary function tests. Observe for paradoxical bronchospasm. (Leeuwen et. al, 2006) (___/5 points) Identify 2 priority NURSING PROBLEMS (10 points for each problem = total 20 points) 1. Ineffective airway related to grossly edematous vocal cords, airway swelling, reintubation trauma and alveoli damange as evidence by strider, restlessness, fatigue, abnormal trends of ABG’s and increased respiratory rates. (Include causative factors leading to problem) (1 pt.) Identify at least 2 measurable patient outcomes/goals related to the problem (relevant subjective and/or objective assessment and diagnostic & laboratory findings). (1 pt. each) A. Patient’s lungs will remain clear and pt will show no signs of distress, stridor, dyspnea, wheezing or use of accessory muscles. B. Patient will demonstrate adequate oxygenation by improving the ABG’s to within normal limits and oxygen saturation will remain within normal limits. (Ackley & Ladwig, 2008). Identify the trend changes of relevant: 1) physical assessment, 2) laboratory data 3) vital signs (as appropriate for the Nursing Problem chosen) over a 3 day period around the day(s) you cared for this patient. Include a brief explanation of the trend as r/t pathophysiology. Vent settings must be included if ABGs are trended. (3 pts. total) Day 1 11/11/12 Day 2 11/12/12 Day 3 11/13/12 Interpretation Respirations: Respirations: Respirations: The fast rate of respirations once the patient was Ventilator Ventilator respirations Ventilator respirations extubated indicates respiratory distress. This also respirations range range was a low of 13 were at an average of suggests that the patient is most likely dyspneic therefore was a low of 14 and and a high of 24. The 18. After extubation, needing to breath more times a minute to increase a high of 20. The average was 18. patient’s respirations oxygenation. average ranged from a low of (LeMone & Burke, 2008) respirations were 24 to a high of 34. 16. Arterial Blood Arterial Blood Gases: Arterial Blood Gases: The first two days ABG’s were done while the patient was Gases: pH: 7.44 pH: 7.53 H mechanically ventilated. The third day ABG was done pH: 7.47 H pCO2: 46.3 H pCO2: 31.4 L when the patient had been extubated for one hour. The pCO2: 48.7 H pO2: 116.7 H pO2: 95.3 first day shows that the patient is partially compensated pO2: 84.8 HCO3: 31.0 H HCO3: 25.9 H whereas the second day shows the patient has fully HCO3: 34.6 H FiO2: 40 FiO2: 100 compensated since the pH is within normal limits. FiO2: 40 Vent Settings: Vent Settings: However, on the third day, the patient is completely Vent Settings: FiO2: 40% FiO2: 40% uncompensated. The low pCO2 is not being compensated FiO2: 40% TV: 500 TV: 500 by the HCO3. The pCO2 is low because the patient is TV: 500 Mode: Spont Mode: Spont hyperventilating, blowing out all of the carbon dioxide. The Mode: Spont PEEP/PSV: 8/10 The nurses’ notes RASS scores were consistently -1 throughout the day. The pt was on versed until 1145 when it was turned off. The pt still maintained a -1 RASS score. PEEP/PSV: 8/10 Documentation states that lungs are CTA and respirations are unlabored. No stridor or accessory muscle use. A size 8 ET tube in place. Documentation states the respirations are unlabored and lungs have scattered rhonchi that improves with suctioning. No stridor or accessory muscle use. A size 8 ET tube in place. Blood Pressure: 106/66 Heart Rate: 105 Blood Pressure: 124/69 Heart Rate: 110 Oxy Sat. Oxy Sat. The pt’s RASS scores were +2 until precedex was started at 1100. RASS dropped to -2 until 1800 when RASS was +4. Propofol was started at 1800 and pt’s RASS dropped to -1. PEEP/PSV: 5 PEEP loss of this carbon dioxide results in respiratory alkalosis. (Morton & Fontaine, 2009) Pt’s RASS before The patient’s restlessness after extubation indicates that extubation maintained the patient is not receiving enough oxygen. Low oxygen at -1. Pt was still on levels cause restlessness, fatigue and anxiety. On the day propofol and precedex. that I was caring for the patient, he was relaxed while on Pt extubated at 1240. the ventilator in the morning. About a half hour after At 1330 nurses’ notes extubation, the patient became very anxious, constantly state the pt was very moving around and turning in different directions. restless, not listening to commands, leaning over the side rail and trying to leave. Documentation after The patient’s unlabored respirations while on the ventilator extubation states indicate he is under no stress related to breathing. The respirations are respirations on the day I cared for the patient became very labored, use of labored and the patient was struggling to get air in and out. accessory muscles, Stridor was clearly heard. The patient’s accessory muscles stridor. Reintubation were being used with each breath. During reintubation, a with a size 7 ET tube. size 8 ET tube was initially tried, but unsuccessful due to airway swelling. The tube was quickly pulled out and lung sounds of stridor were more intense. A size 7 ET tube was then put in place. The use of accessory muscles shows that the patient is needed extra muscle to try to get more oxygen in. The stridor indicates airway damage, making it more difficult to breath. A decrease in size of the ET tube also indicates airway swelling and decreased ability to breath. (LeMone & Burke, 2008) Blood Pressure: Airway swelling and distress on the patient causes blood 111/65 (before pressure and heart rate to increase. The pt’s HR and BP extubation) were stable on the days leading up to extubation. The high 207/146 (after anxiety is shown with the increases after extubation. extubation) Heart Rate before extubation: 85 Heart Rate after extubation: 130 Oxy Sat. Like blood pressure and heart rate, the oxygen saturation 100 100 100- before extubation 96- after extubation on 2L nasal cannula will decrease when there is airway swelling and distress. The oxygen started dropping quickly so the oxygen was increased from a nasal cannula to a venti-mask at 100% before reintubated. The patient was never strictly on room air. Identify the interdisciplinary team plan for problem interventions. Include Nursing (1.5 pts) and other disciplines (1.5 pts.) Nursing: Continue to monitor respirations, including the pattern, rate and depth. Assess for signs of distressed breathing, anxiety and restlessness. Interpret the ABG readings. Monitor oxygen saturation, capillary refill and for signs of cyanosis/pallor. Auscultate lung sounds for any worsening or adventitious sounds. Suction the patient when hearing adventitious sounds or every two hours. Oral/teeth care every four hours and head of bed elevated at least 30 degrees to prevent ventilator associated pneumonia. Respiratory Therapist: Auscultate lung fields for adventitious sounds. Interpret ABG’s and vent settings. Monitor vent tube and equipment, look for any disconnections or leaks. Monitor vent settings and recommend changes to physician. Albuterol and racemic epinephrine aerosols to relieve bronchospasms. Inhaled steroids to decrease inflammation and swelling. Monitor the swelling by performing occlusion tests with weaning parameters such as decreasing FiO2. Suction patient per hospital protocol (q4h) or when hearing crackles/ rhonchi. Assist the physician with intubation. Physician: Monitor the vent settings/ make changes. Assess and interpret ABG readings and change the settings based on the ABG’s. Intubate. Make sure the pH level of the patient remains stable. Order aerosols and inhaled steroids to decrease airway swelling such as albuterol, bitolterol, metaprotenerol ect. Physical Therapy: Do range of motion to keep calcium loss from bones at a minimum and to avoid muscle wasting. Mobilizing patient (when stable) to chair will decrease swelling. What are the potential complications for this patient related to this nursing problem and treatment interventions? (1 pt.) One potential complication for this patient would be the CO2 continually decreasing. When CO2 decreases, it causes the blood to be more viscous. When this happens, it causes more workload on the heart and harder pumping is needed. This is not going to be adequate on a heart that is already struggling due to an MI. A low pH usually accompanies a low CO2. When a patient hyperventilates such as this patient, the pH of the stomach and gut becomes lower. This causes a more likely chance for gastritis, ulcers and stones (Morton & Fontaine, 2009). This pt has already had ulcers, so the likelihood of developing another is already greater as it is. Another complication is the fact that this patient was reintubated. Reintubating a patient causes more vocal damage and airway swelling, especially considering an ET tube size that was too big was first tried before removing it. Being on a trach and ventilator because of the inability to maintain his own oxygenation increases this patient’s risk of ventilator associated pneumonia, aspiration, pneumothorax, decreased cardiac output and much more (Morton & Fontaine, 2009). Because this patient had a swollen airway, he will be put on steroids to get the swelling to go down before extubation again. The side effects of steroids include but are not limited to loss of calcium from the bones, fluid retention and increased blood sugar (Leeuwen et. al, 2006). This patient is on bed rest while on the ventilator, so he is already experiencing loss of calcium from the bones. He also has a heart that is not working as efficiently, causing fluid build up. Also, he is a diabetic with high blood sugar. All of these are only going to be worsened by being on steroids. Due to all of the complications of a trach and peg, there is an increased hospital stay and a permanent trach may be needed for a patient who is unable to be weaned off a ventilator. This creates a worry of an inability to return home, pain, distress and of course the risk of death. 2. At risk for bleeding/hemorrhage related to GI ulcer as evidence by decreased hemoglobin and hematocrit, black, tarry stools, pallor, hypotension and decreased urine output. (Include causative factors leading to problem) (1 pt.) Identify at least 2 measurable patient outcomes/goals related to the problem (relevant subjective and/or objective assessment and diagnostic & laboratory findings). (1 pt. each) A. Patient’s H&H and platelets will be within normal limits. B. Patient will have an absence of tarry stools and an absence of signs of gastric bleeding. C. Patient’s urine output will be within normal limits (about 1500 ml in 24 hours, 50-60 cc in one hour, or about 1 ml/kg/hr) D. Patient will have a stable blood pressure above 90 mmHg systolic. (Ackley & Ladwig, 2008). Identify the trend changes of relevant: 1) physical assessment, 2) laboratory data 3) vital signs (as appropriate for the Nursing Problem chosen) over a 3 day period around the day(s) you cared for this patient. Include a brief explanation of the trend as r/t pathophysiology. Vent settings must be included if ABGs are trended. (3 pts. total) Day 1 11/11/12 Day 2 11/12/12 Day 3 11/13/12 Interpretation Hemoglobin: 11.1 L Hemoglobin: 11.4 L Hemoglobin: 11.0 This patient was experiencing a GI bleed on the day of Hematocrit: 32.2 L Hematocrit: 31.9 L Hematocrit: 34.2 admittance to the hospital. On 11/6 the patient’s hemoglobin was 9.6 and hematocrit was 31.1. Therefore, the numbers have increased since his admittance, which means he is trending in the right direction. This patient received packed RBC’s for three days. The low hemoglobin count from the GI bleed decreases the amount of oxygen that can be carried to muscles and organs. The low hematocrit is from the loss of blood, which decreases the total RBC volume. (LeMone & Burke, 2008) No stool passage Nurses’ Notes The patient had a When the patient was admitted on the 5th of November, he on 11/11/12. indicate the patient bowel movement. The had black stool which is indicative of a GI bleed. The had a bowel stool was dark brown patient’s bowl movement descriptions and consistencies movement with dark and liquidy. were not documented every day, but the patient had a brown stools. bowel movement while I was at clinical. The stool did not appear black, just a dark brown color. This indicates the GI bleeding has stopped, at least to the point of not seeing it Balance of intake and output: -736 Balance of intake and output: -233 Balance of intake and output: -701 Blood Pressure: 106/66 Blood Pressure: 124/69 Blood Pressure: 111/65 in the stool anymore. On 11/5/12 the patient had an intake of 1155 and output of 670, with a balance of positive 485. A complication of a GI bleed includes a decreased urine output, therefore resulting in positive balances. Seeing as how the past three days the patient has had a negative balance, shows that the urine output has increased and he is no longer experiencing this complication as a result of a GI bleed. (LeMone & Burke, 2008) On 11/5 the patient’s blood pressure averaged to be about 66/35 mmHg. This is also a complication of a GI bleed. The drop in blood volume is what produces the decreased blood pressure. Now that the blood volume has been increased since the GI bleed has ceased, the blood pressures are increasing as seen on the left. (LeMone & Burke, 2008) Identify the interdisciplinary team plan for problem interventions. Include Nursing (1.5 pts) and other disciplines (1.5 pts.) Nursing: Monitor intake and output. The balances should be as close to even as possible. Blood pressures should be monitored and a drastic increase or decrease in it should be reported to the physician. Monitor the stool for a black color, indicating GI bleed. Monitor hemoglobin and hematocrit results and report abnormalities to the physician. Watch for changes in skin color, temperature, moisture or slow capillary refill which shows a decreased cardiac output, another complication of a GI bleed. Measure gastric output hourly if on a low suction. Maintain two peripheral intravenous lines for fluid and blood transfusions. Replace gastric drainage with balanced electrolytes. Physician: Determine complications/treatments for results of blood pressure, urine output, H&H and gastric output. Prepare for surgery or endoscopy. Monitor pH. Have GI consult with an EGD. Avoid anticoagulants if the patient is bleeding or monitor the use of them. Ordered three blood transfusions over a three day period (5th, 6th, 7th of Nov.) along with daily medications of folic acid and vitamin B12. Dietary: Ensure adequate balance of nutrition What are the potential complications for this patient related to this nursing problem and treatment interventions? (1 pt.) Complications of this patient related to the problem and treatment interventions are endless. Like discussed early, the loss of blood volume decreases H&H which decreases oxygenation to tissues, decreases urine output and decreases blood pressure. Also, with renal failure and limited or inadequate restoration of circulating volume, initiation of inflammatory changes can be expected. Shock is a result and it causes neutrophil activation and liberation of adhesion molecules, which promote binding of neutrophils to lung and vascular endothelium. Shock results in acidosis and pain, weight loss and malnutrition are likely to happen. Capillary leak is then initiated in the lungs which results in respiratory distress syndrome. The liver is damaged due to microischemia (MI) which means the liver is not able to process and metabolize drugs and chemicals (Garrioch, 2004). An impaired fuel delivery to the heart and brain is also a major concern. This would cause a decrease in level of consciousness and death would be a possibility. Continual treatment with folic acid to increase RBC production can cause the patient to be confused and develop a rash and/or fever. References: Ackley, B.J., Ladwig, G.B. (2008). Nursing diagnosis handbook: an evidence-based guide to planning care. (8th ed.) Philidelphia: Mosby Elsevier Alkaissi, A. (2010). What is cardiac arrest? An-Najah National University. A.M. Van Leeuwen, T.R. Kranpitz & L.S. Smith (Eds.) (2006), Davis’s comprehensive handbook of laboratory diagnostic tests- with nursing implications (version 9.0.8/2008.05.12) [Skyscapes Constellation Plus version]. Garrioch, M. (2004). The body’s response to blood loss. Blackwell Publishing Ltd. Vox Sanguinis (2004) 87 (Suppl. 1), Pg. 74–76. LeMone, P., Burke, K. (2008). Medical-Surgical Nursing: Critical Thinking in Client Care. (4th ed.). New Jersey: Pearson Prentice Hall. Morton, P.G., Fontaine, D.K. (2009). Critical care nursing: a holistic approach. (9th ed.). Philadelphia: Lippincott Co.