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Critical Care
Ground Rounds Presentation
April 17th, 2008
Kelly Barker
Middle Tennessee State University
Patient Demographics
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Mr. T.S.
66 yr old, African American male
Married and lived with wife; one adult son
Retired foundry worker
268 lbs; 6 feet 2 inches tall; BMI 34.4 (obese)
45 PPD smoking history (quit 10 years ago)
NKDA
Code status: full code
Medical History
• Past medical history:
– COPD
– Type II DM
– Hypertension
– Arthritis
• Surgical History:
– “Back surgery”
COPD
• COPD consists of emphysema and chronic
bronchitis
– Emphysema: loss of elasticity of the alveolar sacs
leading to airway narrowing and air trapping in the
lungs
– Chronic bronchitis: inflammation of the small and large
airways and excess mucus production leading to a
narrowing of the airway
• Irreversible disease eventually leading to
respiratory failure and death
• Risk factors: smoking, increased age, working at a
foundry
Reason for Hospitalization
• Presented to Manchester ED
• Oxygen saturation: low 80s
• Tachypneic with rapid/shallow respirations,
rhonchi, and acrocyanosis
• Placed on BiPAP; improvement with
oxygenation but not ventilation
• Very confused
• Intubated
• Diagnosis at ED: Chronic obstructive pulmonary
disorder (COPD) exacerbation
Abnormal Lab Values
Lab & Normal
Values
Patient’s
Value
Rationale
RBC (4,100,0005,100,00 mm3)
Hct (36-46%)
5,900,000
mm3
50.6%
COPD and chronic
hypoxia
COPD and chronic
hypoxia
WBC (5,00010,000 mm3)
Cl (95-108
mEq/L)
22,500 mm3
Possible sepsis
93 mEq/L
Respiratory acidosis,
MethylPREDNISolone
Abnormal Lab Values
Lab & Normal
Values
Glucose (70-105
mg/dl)
Patient’s
Value
264 mg/dl
BUN (7-25 mg/dl) 108 mg/dl
Creatinine (0.7-1.4 1.8 mg/dl
mg/dl)
Rationale
Type II DM ,
MethylPREDNISolone,
enteral feeding
Renal insufficiency
Renal insufficiency
Abnormal Lab Values
Lab &
Normal
Values
Patient’s
Value
Rationale
pH (7.35-7.45)
7.31
COPD
PaO2 (80-100
mm/Hg)
55 mm/Hg
COPD
PaCO2 (35-45
mm/Hg)
HCO3 (21-28
mEq/L)
64 mm/Hg
COPD
31.6 mEq/L
COPD
Diagnostic Tests
• Chest Xray
– Impression: No change in diffuse interstitial
opacities superimposed on COPD.
• Echocardiogram
– Impression: Mild tricuspid regurgitation with
moderate pulmonary hypertension. Right
ventricle and atria enlargement.
IV Line and Fluids
• Triple lumen central line in right internal
jugular
• 0.45% Sodium Chloride (1/2 NS) 30
mL/hr IV every day
– Hypotonic fluid
– Rationale: hydration
Medications
• Combivent inhaler (Ipratropium/Albuterol) 6
puffs inhalation every 4 hours
– Ipratropium: synthetic quaternary ammonium
compound; bronchodilator
– Albuterol: adrenergic beta2-agonist; bronchodilator
– Rationale: produces bronchodilation and increases air
flow to the lung
• MethylPREDNISolone (Solu-Medrol) 20 mg IV
every 12 hours
– Glucocorticoid
– Rationale: used during COPD exacerbations to
decrease inflammation in the airways
Medications
• Meropenem (Merrem) 1 gm with NS IV every 12
hours
– Carbapenem; antiinfective
– Rationale: used to treat infection
• Vancomycin 1gm with NS IV daily
– Tricyclic glycopeptide; antiinfective
– Rationale: used to treat infection
• Fluconazole (Diflucan) 200 mg per tube at
bedtime
– Triazole derivative; systemic antifungal
– Rationale: used to prevent oral thrush
Medications
• Enoxaparin (Lovenox) 40 mg SQ daily
– Low molecular weight heparin; anticoagulant
– Rationale: DVT prophylaxis
• Metoclopramide (Reglan) 10 mg IV every 6
hours
– Central dopamine receptor antagonist; antiemetic
– Rationale: prevention of nausea and vomiting
• Pantoprazole Sodium (Protonix) 40 mg per tube
daily
– Benzimidazole; proton pump inhibitor
– Rationale: prevention of stress ulcers
Medications
• Insulin NPH (Novolin N) SQ
– Intermediate acting endogenous human insulin
– Dosage based on sliding scale
– Rationale: decrease blood sugar
• Propofol (Diprivan) 5-20 mcg/kg/min IV
– General anesthetic
– Rationale: sedation
• Hydrocodone & acetaminophen (Lortab) 5/500
per tube PRN every 6 hours for pain
– Nonopioid analgesic
– Rationale: pain reduction
Nutrition
• NG Tube
• Residual checks every 4 hours
• Promote enteral feeding 30 mL/hr per NG tube
every day
– High protein feeding
– Rationale: nutritional support
• Beneprotein 2 packets per NG tube every 8
hours
– Protein supplement
– Rationale: aids in healing and the immune response
Vitals
• AM Vitals:
– BP: 121/78
– HR: 108 beats per minute
– Respirations: 24 breaths per minute
– Temperature: 98.1°F
– SpO2: 92%
– Pain: 0 (patient sleeping)
Neurological Assessment
• Unable to assess orientation to person, place, or
time due to sedation
• Drowsy, easy to arouse
• Responded to painful stimuli
• Unable to follow commands
Musculoskeletal System
• No movement of extremities but would move
head
• Full passive ROM
• No muscle atrophy
• Required total assistance with ADLs
Integumentary Assessment
• Skin color appropriate for ethnicity
• Upper extremities:
– Warm, dry
– Edematous
• Lower extremities:
– Cool, dry
– Edematous
• Stage II decubitus ulcer over the coccyx
EENT Assessment
• PERRLA and 3mm in size; tearing present
• Symmetrical ears; no redness or skin breakdown
• Symmetrical nose with no skin breakdown; NG
tube in right nare
• Lips dry
• Mouth, oral mucous membranes, and tongue
moist and pink
Respiratory Assessment
• ET tube
• Airway pressure release ventilation (APRV)
settings: PH (high pressure) 30, PL (low pressure)
5, TH (time high) 2 seconds, TL (time low) 0.5
seconds
• Tachypnea
• Clear, diminished lung sounds (all lobes)
• AP diameter: 1:1
• Thick yellow/brown sputum
Cardiovascular Assessment
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Normal heart rhythm
Diminished heart sounds
Tachycardia
Upper extremities:
– Weak radial pulse
– Capillary refill: < 3 seconds
• Lower extremities
– Unable to palpate posterior tibial or dorsalis pedis
pulse
– Capillary refill: > 3 seconds
Gastrointestinal Assessment
• NG tube in right nare, connected to continuous
feeding
• Hypoactive bowel sounds in all four quadrants
• Distended, firm abdomen
• No bowel movements
• Vomited after suctioning
Genitourinary Assessment
• Foley catheter
• Clear, yellow urine with no sediment
• Drained around 1000 ml of urine in 8 hours
Nursing Diagnosis #1
• Impaired gas exchange related to
narrowing of the small airways and
decrease in effective lung surface
secondary to COPD as evidenced by
tachypnea, shallow respirations,
diminished breath sounds, tachycardia,
decreased PaO2, and increased PaCO2
Impaired Gas Exchange
• Goals:
– Patient’s respiratory rate will remain between 10-20
breaths per minute
– Patient will exhibit an oxygen saturation > 95%
– Patient’s ABGs will be within normal limits (PaO2 80100 mm/Hg and PaCO2 35-45 mm/hg)
– Patient will exhibit improved breath sounds
Impaired Gas Exchange
• Interventions:
– Assess vitals and pulmonary status every 4 hours
– Raise the HOB (30-45º) to facilitate chest expansion
– Change the patient’s position every 2 hours
– Suction secretions when needed to keep the airways
clear
– Monitor ventilator settings and ABGs
Impaired Gas Exchange
• Evaluation of goals (partially met):
– Patient’s respiratory rate averaged 18 breaths per
minute
– Patient’s oxygen saturation remained between 92100%
– ABG results were abnormal but O2 levels did improve
(PaO2 70 and PaCO2 71)
– Patient’s breath sounds remained diminished
Nursing Diagnosis #2
• Ineffective airway clearance related to
excessive mucus production and
inflammation of airways secondary to
COPD as evidenced by tachypnea,
diminished breath sounds, ineffective
cough, thick yellow/brown sputum
Ineffective Airway Clearance
• Goals:
– Patient’s respiratory rate will remain between 10-20
breaths per minute
– Patient’s oxygen saturation will remain > 95%
– Patient will exhibit no abnormal breath sounds
(crackles, wheezes)
– Patient will produce normal sputum (clear)
– ABG results will be within a normal range (PaO2 80100 mm/Hg and PaCO2 35-45 mm/hg)
Ineffective Airway Clearance
• Interventions:
– Assess vitals and pulmonary status every 4 hours
– Suction secretions when needed to clear the airway
– Elevate the HOB (30-45º) to enhance lung expansion
– Turn the patient every 2 hours
– Check ventilator settings and humidification
Ineffective Airway Clearance
• Evaluation of goals (partially met):
– Patient’s respiratory rate averaged 18 breaths per
minute
– Patient’s oxygen saturation remained between 92100%
– Patient did not exhibit any adventitious breath sounds
such as crackles or wheezes, however they were very
diminished
– Patient’s sputum remained very thick and
yellow/brown in color
– ABG results were still abnormal but O2 levels did
improve (PaO2 70 mm/Hg and PaCO2 71 mm/Hg)
Nursing Diagnosis # 3
• Impaired skin integrity related to
immobility as evidenced by redness and
skin breakdown over the coccyx
Impaired Skin Integrity
• Goals:
– Patient will show no additional redness over the
coccyx (redness will stay 4 x 5 inches or less)
– Patient will exhibit no further skin breakdown
– Patient will exhibit no purulent drainage or signs of
infection (increased redness and swelling)
Impaired Skin Integrity
• Interventions:
– Inspect patient’s skin every shift
– Turn patient every 2 hours
– Clean the area every shift
– Apply barrier cream every 8 hours
Impaired Skin Integrity
• Evaluation of goals (met):
– Redness stayed 4x5 inches in size
– There was no further breakdown of skin
– No purulent drainage or signs of infection
Collaboration of Patient
Management
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Physicians
Nurses
Dietician
Pharmacy staff
Lab technicians
Respiratory therapist
Peers
Systemic Glucocorticoids in
Severe Exacerbations of COPD
• Objective: To compare the effectiveness of 3
day and 10 day courses of methylprednisolone
• Design: Prospective, randomized, single-blind
study
• Sample: Consisted of 36 patients who were
randomized into 2 groups (3 day and 10 day
group). All patients were ex-smokers with a
smoking history > 20 pack-years. All had severe
airway obstruction and presented with a COPD
exacerbation that required hospitalization
Systemic Glucocorticoids in
Severe Exacerbations of COPD
• Method: Patients in the study were randomly
assigned to one of two treatment groups. One
group received methylprednisolone for 3 days
while the other group received it for 10 days
• Results: Both groups showed improvements in
PaO2 levels however group 2 (10 day course of
methylprednisolone) had a more marked
improvement in dyspnea
• Conclusion: In severe COPD exacerbations, a
10 day course of steroids is more effective then a
3 day course
References
• Ignatavicius, D.D., Workman, M.L. (2006). MedicalSurgical Nursing: Critical Thinking for Collaborative
Care Vol. I&II. St. Louis: Elsevier Saunders.
• Pagana, K.D., Pagana, T.J. (2007). Mosby’s Diagnostic
and Laboratory Test Reference 8th Edition. St. Louis:
Elsevier.
• Ralph, S.S., Taylor, C.M. (2005). Sparks and Taylor’s
Nursing Diagnosis Reference Manual 6th Edition.
Philadelphia: Lippincott Williams & Wilkins.
• Saymer, A., Aytemur, Z.A., & Cirit, M. Systemic
Glucocorticoids in Severe Exacerbations of COPD. Chest
Journal, 119 (3), 726-730.
• Skidmore-Roth, L. (2007). Mosby’s Drug Guide for
Nurses 7th Edition. St. Louis: Mosby Elsevier.