Grand Rounds PresentationNURS 4340

Shannon Arender

February 14th, 2008

Collaboration of client management

NursesDoctorsRespiratory therapistsPhysical therapistsPeersInstructor

Client demographics

27 years oldCaucasian female5’3’’, 123 IbsNo religious affiliationDivorced1 child, 7 years old

+ Risk Factors

Congenial diseasePersistent heavy tobacco use, 1 pack per

day since age 14Complete noncompliance with medical

therapy

Events leading to hospitalization

Discontinued Interferon Gamma injectionsAdmitted 1/2/2008 to Vanderbilt Received argon ablation therapyLeft against medical adviceAdmitted to St. Thomas 1/7/2008Transferred to CCU from 7th floor after

sneaking to smoke a cigarette which resulted in patient being intubated

Medical Diagnosis

Congenital squamous papillomatosis of the trachea, larynx, and lung with presumed tracheoesophageal (TE) fistula

Squamous papillomatosis

Squamous: scale-like epithelial cellPapillomatosis: widespread development

of nipple-like growths on patient’s lungs, larynx, and trachea that cause significant airway obstruction

Tracheoesophageal fistula

A congenital malformation in which there is an abnormal tubelike passage between the trachea and esophagus

Puts the patient at risk for aspiration pneumonia and breathing problems

Tracheoesophageal fistula

Abnormal labs

Lab Value Why?

Glucose 120 mg/dl H IV fluids containing dextrose

Total protein 6.0 g/dl L Malnourished

Albumin 3.2 g/dl L Malnourished, NPO, decreased liver function

Alkaline phosphate

164 IU Antibiotics, decreased liver function

AST 64 IU Patient is on opiates and anticoagulants, decreased liver function

Abnormal labs

Lab Value Why?

ALT 51 IU Decreased liver function, hepatotoxic drugs

Urinalysis: specific gravity

1.047 H Fever

Hgb 10.9 g/dl L Antibiotics, anemia

Hct 33.9% L Anemia

MCH 26.8 H Anemia

RDW 15.3 H Anemia

Diagnostic tests

CT scan of neck for soft tissue Confirmed diagnosis of tracheoesophageal

fistula Seen at level of lower cervical esophagus

X-RAY- video fluoroscopic swallow Done post recent laser therapy for TE fistula Patient was unable to handle secretions, had

one episode of frank aspiration

Diagnostic tests

X-RAY- lung Extensive abnormalities found in lungs Numerous masses, many that contain cavities Range in size from less than 1 cm up to 4 cm Lower lobes are the most severely affected

X-RAY- performed to verify PICC placement All findings are consistent with clinical diagnosis of TE

fistula and papillomatosis

Pharmacological interventions

medication class dose route frequency rationale

Ampicillin-sulbactam

Antibiotic 3 gm IV q6hrs Bacterial infection

Fentanyl Opioid analgesic

50 mcg

Trans-dermal patch

q72hrs Pain

Fluconazole Antibiotic 400mg IV q24hrs Bacterial infection

Heparin Anti-coagulant, anti- thrombotic

5000 units

subq q12hrs Prevent deep vein thrombosis and pulmonary embolism

Pharmacological interventions

medication class dose route frequency rationale

Lorazepam Benzo-diazepine

1 mg IV q6hrs Decrease anxiety

Nicotine Smoking deterrent

14 mg Trans- dermal patch

Everyday Deter cigarrette smoking

Vancomycin Anti-infective

1000 mg

IV Q12hrs Bacterial infection

Morphine Opioid analgesic

4mg IV PRN, q3hrs Pain

Insulin regular (Novolin R)

Anti-diabetic

Based on BG

Subq

inj

q4hrs Control blood sugar

Pharmacological interventions

medication class dose route frequency rationale

Albuterol-ipratropium

Broncho-dilator

4 puff Inhala-tion

q4hrs Increase ability to breathe

Dornase alfa

Unknown, synthetic protien

2.5 mL Inhala-tion

q12hrs Reduce number of lung infections

Total parenteral nutrition 1680mL + famotidine 40 mg

Antiulcer agent

1680 mL + 40 mg

IV Continuous infusion rate: 70ml/hr

Nutrition and prevention of stomach ulcers

Head to Toe Assessment

Neurological Alert and awake Oriented x 3 Pupil reaction equal and brisk

Psychosocial Anxious Agitated as a result of new tracheostomy and

inability to communicate

Head to Toe Assessment

Integumentary Skin pink, dry, warm Nail pink and intact Surgical incision on neck, medial, edges

approximate, steri-strips present, intact, no drainage

Braden skin integrity: score: 18

Head to Toe Assessment

Pulses Jugular vein distention: 3+ (normal) Brachial, radial, and dorsal pedal pulses: 3+ No edema present Capillary refill < 3 seconds

Musculoskeletal Upright posture Generalized weakness in all extremities

Head to Toe Assessment

Respiratory AP diameter: 1:1 Breath sound diminished in all lobes Slight wheezing in upper lobes Tracheostomy collar with 4L oxygen

Cardiovascular NSR with sinus tachycardia No abnormal heart sounds

Head to Toe Assessment

Gastrointestinal Mucous membranes moist, pink, intact with no

lesions present Difficulty swallowing Hypoactive bowel sounds No abdomen distention or tenderness

Urinary Indwelling foley, gravity, intact Concentrated, amber colored urine

Paraphernalia

Nasogastric tube Connected to continuous low suction Bloody drainage

PEG tube Intact gravity

Paraphernalia

PIV access-peripheral intravascular access IV lock Left antecubital No complications No drainage

VAD- vascular access device Triple lumen Peripherally inserted central catheter Right upper arm No complications No drainage

Vital signs

Blood pressure: 118/70Heart rate: 99Temperature: 101.4˚FRespirations: 23SpO2: 95%Pain: 10, chronic, continuous

Nursing diagnosis priority #1

Ineffective airway clearance related to new tracheostomy and endotracheal tube as manifested by decreased ability to cough and thick, bloody secretions.

Goal: The patient will remain an open airway free of secretions, and secretions are easily moved.

Nursing diagnosis priority #1

Interventions Assess for ETT suctioning Watch for harsh breath sounds and audible secretions Suction patient as needed Reposition patient frequently

Outcome The ability to maintain a clear airway will require several

days until the new tracheostomy heals and secretions decrease.

Nursing diagnosis priority #2

Risk of pulmonary infection related artificial airway as manifested by a new tracheostomy and endotracheal tube, and a temperature of 101.4˚F.

Goal: Patient will remain free of infection.

Nursing diagnosis priority #2

Interventions: Monitor temperature q4hrs Monitor color, consistency, and odor of secretions Use sterile technique for suctioning Provide oral care q2hrs Monitor patient for increased breathing effort Administer Ampicillin-sulbactam q6hrs, Fluconazole

q24hrs, and Vancomycin q12hrs Outcome:

Patient remained free of pulmonary infection and a white blood cell count within normal range.

Nursing diagnosis priority #3

Impaired verbal communication related to mute state when the ET tube is in place as manifested by not being able to speak.

Goal: The client will be able to communicate with health team providers in order to have basic needs met.

Nursing diagnosis priority #3

Interventions: Keep a pencil and paper readily available Be patient and willing to spend time

communicating

Evaluation: Patient was able to write down feelings and communicate to the healthcare team. Her anxiety and frustration was decreased.

Nursing research

Tracheal Suctioning of Adults with an Artificial Airway

Evidence based practice including the effects of suctioning, suctioning techniques, oxygenation, suctioning patient subgroups, summary of evidence, and recommendations

Participants were adult patients (>15 years) in the acute care setting with an endotracheal tube or tracheostomy tube

Nursing research

Purpose Review suction interventions that are currently

employed in the nursing management of patients with an artificial airway

Results Suctioning is a potentially harmful procedure

and should only be done when a thorough assessment of the patient established the need for such a procedure

References

Emedicine by WebMD.(2008). Recurrent Respiratory Papillomatosis. Retrieved February 11, 2008, from http://www.emedicine.com/med/topic2535.htm

Ignatavivius, D.D. & Workman, M.L.(2006). Medical-Surgical nursing: Critical Thinking for Collaborative care.(5th ed.) Vol. I. Philadelphia, PA: W.B. Saunders.

Thompson, L.(2000). Tracheal Suctioning of Adults with an Artificial Airway. Johanna Briggs Institute for Evidence Based Nursing and Midwifery Vol. 4(4). Australia: Blackwell Science-Asia.

Sole, M.L., Klein, D.G., & Moseley, M.J.(2005). Introduction to Critical Care Nursing.(4th ed.) St. Louis, MO: Elsevier Saunders.