Student Name:	Christina Weinzettle	Date of Service: 02/19/2013

Care Plan

Age Range (e.g. 60-65 yr): 66 years old

Gender: Male	Hospital Day #: 8	ICU Day #: 5	Intubated day #: 5

Advanced Directives (e.g. Living Will, Medical Durable Power of Attorney, Do Not Resuscitate or Allow Natural Death): Full Code with no other advanced directives discussed. No power of attorney. Emergency contact is neighbor who is taking care of patient’s house and dogs.

Allergies (Drug/Food/Environment): Precedex, Iodine-Iodine Containing products, and Mercurochrome.

Patients stated Chief Complaint: Alcohol Withdrawal Syndrome complicated by aspiration pneumonitis, acute respiratory failure, hypokalemia, hypomagnesaemia, hypotension from sedation medication requiring vasopressors, macrocytic anemia, and thrombocytopenia.

Briefly Describe Hospital Course: Patient presented to the emergency department at MIHS on 2/12 complaining of abdominal pain and dry heaves. Patient was assessed for abdominal pain following gallstone protocol and a psychiatric consult was ordered due to suicidal ideation/depression. During the workup the patient’s Ethanol level came back as 145 and patient admitted to heavy drinking (2 pitchers of beer and/or 6 to 8 shots of whiskey a day). Patient began to exhibit signs of alcohol withdrawal while in emergency department with tachycardia, anxiety, tremors, and confusion. Patient was admitted to the MICU South and placed on alcohol withdrawal protocol. Patient’s acuity decreased and was transferred to APCU. After transfer to APCU, patient condition deteriorated hemodynamically and patient developed aspiration pneumonic from vomiting. Patient was transferred back to MICU South and intubated to protect airway. The patient is currently under sedation in MICU undergoing sedation vacation trials and being assessed for possible nosocomial infection.

Previous 24 hour I & O totals: Intake= 4841. 74 & Output= 2848

Ht, Wt, and BMI: Ht.=182 cm; Wght.= 98 kg; BMI= 29.6

Current Orders (exclude labs/medications/diagnostic tests):

Activity: Bedrest

Diet: Enteral Nutrition Fibersource formula 55 ml/hr continuous feed

IV type/site: Arterial line L. radial artery; CVC triple lumen R. subclavian vein; and Peripheral IV 20 gauge L. forearm.

IV fluids: Dextrose 5%, 1000 ml with Multivitamin 10 ml, thiamine 100 mg, and folic acid 1 mg; NS 0.9% 1000 ml; Magnesium sulfate 1g/100ml IVPB; and Zosyn 3.375 g in 0.9% 100 ml NS

Others: 2 point soft restraints on upper extremities; SCD’s & heparin prophylaxis to prevent DVT’s; PPI; Foley catheter; Oral care q2hrs while on ventilator; and HOB at 30 degrees.

Interdisciplinary Services/Consults (e.g. PT, OT, ST, dietary, hospice):

Nutrition Consult: Patient had nutritional deficiencies due to alcohol dependency supplement with multivitamin, thiamine, and folic acid. Also, consult recommended increasing patient protein intake.

Respiratory Consult: Patient has albuterol nebulizing treatments and RT monitors ventilator.

Language spoken: English

Religious preference: Patient stated during intake that he has no religious preference.

Insurance: Medicare

Immunization status: Patient refused both flu and pneumococcal vaccinations on 2/13 during initial intake screening.

Domestic/Child/Elder abuse issues: None.

Briefly describe the Medical and Surgical History (Describe the medical diagnoses, surgical procedure(s) and/or chronic illness that initiate the admission or reason for the continuing condition. Include smoking history.).

Medical History	Description of each Diagnosis
Hypertension Degenerative disk disease GERD Alcohol Withdrawal Syndrome (AWS) Acute encephalopathy Alcoholic gastritis Hepatitis mild Metabolic acidosis Transaminitis Cardiogenic shock Acute respiratory failure Aspiration pneumonia Alcohol dependence	Hypertension is described as an elevated blood pressure reading over 140 systolic and 90 diastolic (McCance & Huether, 2010, p. 1149). The patient is normally hypertensive when not on the sedation medication and when the patient is placed on sedation vacation his BP will spike above 200 systolic and 100 diastolic. Degenerative disk disease is a common finding in people over the age of 30 and results from biochemical/biomechanical changes to the intervertebral disks (McCance & Huether, 2010, p. 596). The changes to the patients disk are visible on CT. GERD is gastroesophageal reflux disease which is the reflux of chime from the stomach into the esophagus (McCance & Huether, 2010, p. 1458). GERD is a common syndrome for patients with alcoholism. Alcohol Withdrawal Syndrome (AWS) refers to the serious of life threatening symptoms (including seizures) that can occur when an alcoholic dependent person stops drinking (“Alcohol withdrawal”, 2012). The patient was admitted for AWS diagnosis. Encephalopathy is a general term that is used to describe any abnormalities in the brains function or structure (Wedro, 2012). The cause of the patient’s encephalopathy is his alcohol withdrawal syndrome and possibly liver damage the doctors are looking into the patient’s ammonia levels. Alcoholic gastritis is gastritis (inflammation of the lining of the stomach) caused exclusively by excessive alcohol consumption (McCance & Huether, 2010). The patient has malnutrition from impaired gastric absorption caused by his excessive alcohol intake. Hepatitis mild is a disease characterized by inflammation of the liver (McCance & Huether, 2010). The patient has hepatitis in addition to transaminitis. Metabolic acidosis is a pH imbalance in which the body has accumulated too much acid and does not have enough bicarbonate to effectively neutralize the effects of the acid (McCance & Huether, 2010). Transaminitis is a term for ↑ transaminases–AST, ALT, ALP coupled with non-specific hepatitis (McCance & Huether, 2010). The patient’s lab values on admission had severely high AST, ALT, and ALP and a diagnosis of mild hepatitis. Cardiogenic shock occurs whenever the heart is unable to pump as much blood as the body needs. One of the common causes is a very slow heart rhythm-bradycardia (“Cardiogenic Shock”, 2012). Signs and symptoms are low blood pressure with diastolic below 90 or drops in BP greater than 10 mm Hg and weak pulse (“Cardiogenic Shock”, 2012). This patient was diagnosed with shock that was induced by his sedation medication. The reaction was severe enough that the patient had to be placed on a continuous Levophed drip while he is on the sedation medications. This is complicating the patient’s recovery and extubation. Acute respiratory failure is when the blood does not get enough oxygen from the lungs (“What is respiratory failure”, 2012). Aspiration pneumonia is inflammation of the lungs and airways to the lungs (bronchial tubes) from breathing in foreign material (McCance & Huether, 2010). The patient aspirated on his vomit during the hospital stay resulting in this diagnosis. Patient fits the clinical profile for chronic alcohol abuse including withdrawal symptoms, tolerance, and having an ongoing desire to drink alcohol (“Alcoholism”, 2012).
Surgical History	Description of each Surgery
Patient has no prior surgical history.	Patient has no prior surgical history.

References:

McCance, K. L., & Huether, S. E. (2010). Pathophysiology: The Biological Basis for Disease in Adults and Children (6th ed., pp. 745-751). Missouri: Elsevier Health Sciences.

Mayo Clinic. Alcoholism: Tests and diagnosis. Retrieved February 22, 2013, from http://www.mayoclinic.com/health/alcoholism/DS00340/DSECTION=tests-and-diagnosis

National Heart Lung and Blood Institute. What is respiratory failure. Retrieved February 22, 2013, from

http://www.nhlbi.nih.gov/health/health-topics/topics/rf/

PubMed Health. Alcohol withdrawal. Retrieved February 22, 2013, from

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001769/

PubMed Health. Cardiogenic shock. Retrieved February 23, 2013, from

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001237/

Wedro, B. (2012). Encephalopathy. EmedicineHeatlh. Retrieved on November 10, 2012 from

http://www.emedicinehealth.com/encephalopathy/article_em.htm.

Pathophysiology Worksheet (Use additional sheets as needed)

Student____________________________________ Date___________

Describe pathophysiology for one medical diagnosis to the cellular level (in your own words/ use additional sheet if needed),

Personalized to your patient (link to labs, meds, and co-morbidities).

Medical/Surgical Diagnosis	Pathophysiology	Patient’s Manifestations (Signs and Symptoms)
Acute Respiratory Failure (ARF) due to alcohol withdrawal syndrome (AWS).	Acute respiratory failure (ARF) is a common complication that can develop with alcohol withdrawal syndrome. Especially, when you consider all of the risks factors associated with alcoholism. Respiratory failure is defined as inadequate gas exchange caused by either Type I hypoxemia (PaO2 </= 50 mm Hg) or Type II hypercapnia (Paco2 >/=50 mm Hg/ ph </=7.25) (McCance & Huether, 2010, p. 1271). ARF can be caused by direct injury to the lung, airway, or chest wall or indirectly due to a brain injury (McCance & Huether, 2010, p. 1271). This patient has Type I ARF caused by his pneumonia and has developed further with Type II ARF symptoms. Type I Hypoxemia ARF is mainly caused pathophysiologically by V/Q mismatch, shunt, and exacerbation by low venous O2 (SvO2) (Katyal & Gajic, 2013). Hypoxemia ARF etiological factors are alveolar unit failures due to collapse, flooding (edema, pus, aspiration), and fibrosis (Katyal & Gajic, 2013). Type I causes are pneumonia, PE, atelectasis, and pulmonary fibrosis. Type II Hypercapnic ARF is mainly caused by inadequate alveolar minute ventilation and requires ventilatory support. Hypercapnic ARF is characterized by a failure at the cellular level to exchange or remove carbon dioxide. Type II’s pathophysiological characteristics are decreased minute ventilation and increased dead space ventilation (Katyal & Gajic, 2013). Type II’s etiological factors include: airway failure due to obstruction/dysfunction, pneumothorax, and hemothorax (Katyal & Gajic, 2013). Causes of type II ARF include: central hypoventilation, COPD, asthma, and neuropathies. Pulmonary diseases such as pneumonia can also lead to ARF. This patient’s acute respiratory failure was caused by his aspiration pneumonia. The patient had several of the risk factors for the development of aspiration pneumonia. The patient had a decreased LOC due to the medications for AWS treatment, GERD diagnosis, and drinking large amounts of alcohol (“Aspiration Pneumonia”, 2012). Alcoholics have pathophysiological changes that occur because of the depression of the body’s natural defense mechanisms (Al-Sanouri, Dikin, & Soubani, 2005). Alcohol can cause depression of normal mucociliary function and hampers abilities of neutrophils and macrophages (Al-Sanouri, Dikin, & Soubani, 2005). “Other inhibited lower respiratory tract defenses include nonspecific antibacterial activity of surfactant, opsonization by immunoglobulin or complement, and intracellular killing by alveolar macrophages” (Al-Sanouri, Dikin, & Soubani, 2005, p. 372). Finally, patients with alcohol withdrawal syndrome can have diminished cough or reflexes that lead to aspiration of materials. For this patient his aspiration pneumonia developed when he aspirated his vomit.	The patient was admitted to the hospital with alcohol withdrawal syndrome and during the course of his hospitalization he developed aspiration pneumonia after he swallowed his vomit. The patient’s risks for aspiration pneumonia were decreased LOC from AWS, GERD, drinking large amounts of alcohol, and sedative medications (“Aspiration Pnuemonia”, 2012). As a complication of the aspiration pneumonia the patient developing acute respiratory failure (ARF). Also, contributing to the patient’s ARF was his decreased LOC and his PaCO2 being greater than 50 mm Hg.

References:

Al-Sanouri, I., Dikin, M., & Soubani, A.O. (2005). Critical care aspects of alcohol abuse. Southern Medical Journal 98(3): 372-381. Retrieved on

February 23, 2013, from http://www.medscape.com/viewarticle/501977_3.

Katyal, P., & Gajic, O. (2013). Pathophysiology of respiratory failure and use of mechanical ventilation. Mayo Clinic Critical Care Clinical

Education. Retrieved on February 23, 2012, from http://www.thoracic.org/clinical/critical-care/clinical-education/respiratory-failure-

mechanical-ventilation.pdf

McCance, K. L., & Huether, S. E. (2010). Pathophysiology: The Biological Basis for Disease in Adults and Children (6th ed., pp. 745-751). Missouri: Elsevier Health Sciences.

PubMed Health. (2012). Aspiration Pneumonia. Retrieved on February 23, 2012, from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001179/

Health Perception-Health Management Pattern

Vital Signs

BP: 118/56	Pulse: 84 RR: 14 Temp: 38 C (100.4 F)

Pain Scale Type: Non-verbal pain scale (patient is sedated)

If this person has pain, describe characteristics and cause (PQRST):

No obvious signs of pain. The patient does not have physiological signs (vital sign changes of increased BP/RR). The patient also does not exhibit guarding or restlessness. He is currently on continuous pain and sedative medications.

Nutritional-Metabolic Pattern:

Assess patient’s nutritional status, daily patterns, and alterations (e.g. economics, social, cultural, religious):

The patient per his BMI of 29.6 is overweight and his diet pre-hospitalization was regular. Before being intubated the patient did answer nutritional questions upon admission and he admitted to “not taking good care of himself.” He admitted he was “unsure” of the last time he at food and that he does not think he ate any solid food for like “three days”. The patient admitted to alcohol dependency where he was drinking two pitchers of beer or 6-8 shots of whiskey a day. The patient also stated because of the grief over his wives passing he has experienced a loss of appetite.

The nutritionist assessment of the patient was he was malnourished with obvious nutritional and vitamin deficiencies from his alcohol dependency. The nutritionist advised that the patient be put on multivitamins, folic acid, and thiamine supplements. Also, while the patient has been intubated he has been put on a continuous enteral nutrition feed at 55 ml/hr.

Elimination Pattern:

Assess abdomen, bowel pattern (including LBM), urinary patterns, and alterations (e.g. foley, ostomy, tube/drains):

The patient’s abdomen upon assessment was non-tender, non-distended, not ridged and not tympanic. The patient has a foley catheter inserted while sedated and his output is 32-175 cc’s per hour. His urine is amber colored. On the day of treatment the patient had not had a bowel movement for two days. The patient’s bowel pattern was reported to the doctor during grand rounds and Colace/lactulose was ordered to help stimulate a bowel movement.

Activity-Exercise Pattern:

Assess mobility/exercise patterns including gait, restraints, assistive devices, safety measures, and musculoskeletal alterations.

Patient is currently on bedrest because he is under sedation for his alcohol withdrawal syndrome. The nurse performs passive range of motion qShift. The patient has orders for 2-point soft restraints on his upper extremities because of side effects from his alcohol withdrawal syndrome, agitation/pulling out lines, and RASS score of 2+ when off of sedation. The patient is a fall risk and has bed down and 2x side rails up as safety measures.

Fall risk score:	High	Tool used: MIHS Standardized tool

Sleep-Rest Pattern:

Assess sleep habits, disturbances, and alterations.

The patient is currently sedated except for sedation vacation trials. During the sedation vacation trials, the patient is agitated and disturbed. Prior to hospitalization, the patient admitted to being depressed because of his wives passing and that he had been having difficulty sleeping. Also, prior to his intubation and sedation for his alcohol withdrawal syndrome the patient was restless and agitated.

Cognitive-Perceptual Pattern:

Assess LOC, GCS, neurological status/alterations (speech, hearing, vision, PERRLA, motor, and sensation).

The patient’s LOC is sedation so he is unresponsive to commands. When the patient has a sedation vacation he is not alert and unable to respond to commands due to his alcohol-induced encephalopathy. The patient’s RASS score off of sedation is 2+. The patient while sedated is unable to speak but prior to intubation he was coherent, verbal, and had no difficulty with hearing. His pupils are 2mm and are PERRL. His calculated GCS score for the day of care was 7. His motor responses are diminished while on sedation, but he has movement to painful stimulus on all for extremities. The patient also has spontaneous movement of all extremities.

Respiratory System

Breathing Pattern (e.g. depth, rate, rhythm, use of accessory muscles):

The patient is intubated and on a ventilator. His breaths are shallow, regular, and the vent is set at a respiratory rate of 14. Upon assessment there are not obvious signs of accessory muscle use.

Breath Sounds (e.g. clear, course, wheezes, location, etc.):

The patient’s breath sounds are shallow and diminished bilaterally in the bases.

Describe any Cyanosis (e.g. location, severity):

No signs of cyanosis are present and the patient’s capillary refill is less than 2 seconds.

Cough (e.g. productive, nonproductive):

The patient has an endotracheal tube in place. He has no obvious signs of a cough.

Sputum (e.g. color, amount, consistency, odor, how obtained):

The patient has a scant to moderate about of sputum that is clear, white, and thin that was obtained from inline suctioning.

Use of O2 (e.g. nasal cannula, mask, trach collar, other):

The patient is on a ventilator.

Oxygen sat: 100%

Humidification: On per vent settings	Type of airway: Endotracheal tube with a 7.5 cm

diameter

cm mark: 25 cm

Vent settings: TV: 400 Rate: 14 Mode: PRVC FIO2: 40 PEEP: 5	PS: None

Cardiovascular system

Pulses (e.g. strong, weak, bilateral, with locations):

The patient’s pulses upon assessment were strong 2+ bilaterally on both upper and lower extremities.

Capillary Refill (in seconds):

Less than 2 seconds

Jugular Vein Distention (JVD):

No obvious signs of JVD.

Edema (e.g. location, degree, pitting):

The patient has slight edema in his hand and left foot (1+) with no pitting.

Extremity temperatures:

The patient’s extremities are normothermic.

Sounds (e.g. S1, S2, regular/irregular, murmur):

Upon auscultation the patient’s has both S1 and S2 sounds with no murmur and a regular rhythm.

Chest pain (e.g. PQRST):

None.

Other (Pacemaker, AICD, etc.):

None.

Telemetry (describe cardiac rhythm):

The patient has a normal sinus rhythm with both PAC’s and PVC’s present.

Other monitor devices (swan, a-line, CVP, IABP)

The patient’s blood pressure is monitored directly through his A-line.

Skin and Wounds

Assess patient’s skin, wounds, pressure ulcer (stage), dressings, and drains.

Patient’s skin is clean, dry, and intact with no signs of pressure ulcer development.

Risk for pressure ulcer score:	9	Tool used:	Braden Scale

Risk interpretation: Very High Risk

Eyes, Ears, Nose, Throat (EENT)

Assess patient’s EENT:

The patients EENT is within normal limits. The patient’s mucous membranes are moist. The patient is intubated so he has an endotracheal tube placed that is secured at 25 cm at the teeth. There are scant thin, white, and clear secretions brought up with inline suctioning. The patient’s has poor teeth dentition.

Coping-Stress Pattern

Assess patient and family’s coping strategies with psychological, medical, socioeconomic, cultural, and spiritual issues:

The patient currently lives alone in his trailer with his 2 dogs. His second wife passed away four weeks ago and the patient on admission was screened for possible suicidal ideation and depression. The psychiatrist diagnosed the patient with bereavement and determined he had ineffective coping mechanism. The patient increased his intake of hard liquor after his wife’s passing as his coping mechanism. During his admission interview he admitted that it had gotten to the point where he would wake up and have to take a shot of whiskey to stop the tremors and dry heaves. He came to the hospital because he did not have the money for any more whiskey to stop the signs of withdrawal. The patient also admitted he drank in excess the same way when his first wife died.

Socioeconomically, the patient is retired and on a fixed income. He lives in a trailer alone with two dogs. His second wife had been sick with COPD for a long time before passing and the medical bills were concerning him.

Role-Relationship Pattern

Assess patient’s primary relationships, marital status, support systems, education level, and occupation.

The patient is recently widowed for the 2nd time. His only living relatives are two daughters and a brother, but they are all estranged. He is retired with a 40+ year history of alcohol abuse and two DUI’s. He gave up his driver license after the 2nd dui and no longer drives. Currently, his only support systems are his neighbors at the trailer park. The neighbors are taking care of his trailer and dogs. During the shift, the neighbors came and visited the patient in the MICU. They expressed concerned over his condition and requested that we tell the patient when he was again conscious of their visit and to “not worry about the dogs”. The neighbor said his wife went in and cleaned the patient’s trailer of alcohol.

Erickson’s developmental stage (mastery or maladjustment):

The patient is 66 years old and in the maturity stage with the basic conflict of ego integrity vs. despair. The patient’s current condition places him in the despair category of the conflict of this stage.

Rationale: The patient has been diagnosed with bereavement and is in the hospital for alcohol withdrawal syndrome from his maladaptive coping mechanism and alcohol dependency.

Self-Perception-Self-Concept Pattern

Assess patient’s view of self:

Prior to the patient’s sedation the chart notes suggest the patient had a dim outlook on his life. He is diagnosed with bereavement and depressed over the passing of his second wife. The patient no longer has family connections but does express gratitude toward his neighbor friend. The patient in his psychosocial assessment said he had lost his appetite and was having trouble sleeping. He felt like life was not worth living and the alcohol was the only thing making it bearable. Also, the patient did not express a good opinion of himself to the psychiatrist during his consultation.

Sexuality-Reproductive Pattern

Assess patient’s sexuality:

The patient has been widowed twice and prefers female sexual partners. Currently, this is not a concern for the patient because he is still grieving the death of his second wife.

Value-Belief Pattern

Assess patient’s cultural, ethnic, religious, and/or regional values and beliefs:

The patient told the nurse during the admission spiritual assessment that he does not prescribe to any religious belief. The patient is Caucasian and refused to see the spiritual consult that was ordered after his bereavement diagnosis.

Additional information to obtain from clinical units specific to patient diagnosis

Standardized Nursing Care Plan:

Problem: Maintain 02 saturation

Goal: Respiratory rate within specified parameters.

Outcome: Ongoing. Patient on mechanical vent support.

Problem: Knowledge deficit

Goal: Knowledge of disease process and hospitalization. Knowledge level of medications, surgical procedures, prescribed diet, activity, and discharge

Outcome: Ongoing. Unable to assess due to medical condition of sedation

Problem: Communication, Coping, Social work

Goal: Ability to express medications and understand communication

Outcome: Not met. Patient is intubated and sedated

Problem: Restraint: non-violent

Goal: Address needs using least restrictive measures; avoid use of physical intervention if possible

Outcome: Ongoing. Bilateral upper extremities soft restraint in place for patient’s safety because of confused and agitated state when off sedation and the pulling of tubes.

Problem: Circulation

Goal: Optimal hemodynamic status

Outcome: Ongoing. Patient hemodynamically unstable, levophed gtt. continued.

Patient education provided (e.g. medications, post procedure, etc.):

The patient was sedated and so he was unable to be provided with education related to his knowledge deficit problems.

Evidenced-Based Practice

Summarize (in your own words) one nursing journal article that is evidence-based which supports the nursing care plan for your patient. Cite your source(s). Use APA style, 6th Edition.

The article “Preventing aspiration: A common and dangerous problem for patient’s with cancer” was a beneficial resource for the development of this nursing care plan. It was a systematic review meant to review and discuss evidence based nursing interventions to prevent patient aspiration. The patient being assessed for this care plan has multiple risk factors for aspiration, and had already developed one case of aspiration pneumonia. This made the Risk for Aspiration nursing diagnosis a priority for his care. The Guy & Smith article begins by defining aspiration and then discusses the common causes of aspiration in vulnerable populations. The authors define aspiration as, “…the inhalation of oropharyngeal or gastric contents into the lower airways, which can lead to pneumonitis or pneumonia” (Guy & Smith, 2009, p. 105). They list some of the common causes of aspiration as drug or alcohol intoxication, diminished level of consciousness, issues with the swallowing or gag refluxes, seizures, VAP, and tube feedings (Guy & Smith, 2009). The article then delves into the signs and symptoms of aspiration including gagging with oral intake, coughing, adventitious lung sounds, and increased secretions (Guy & Smith, 2009).

After the authors discuss the common ways to diagnose aspiration they begin to assess the possible appropriate nursing interventions to implement to prevent aspiration. The authors discuss that the appropriate position for the patient is in semi-fowlers with the head of bed elevated 30 to 45 degrees (Guy & Smith, 2009). The authors also address how patients on tube feedings should be managed and how gastric contents should be aspirated before initiating a tube feeding (Guy & Smith, 2009). Finally, the article discusses artificial airways and how they increase the risk for aspiration due to, “…decreased laryngeal elevation and laryngeal sensation, abnormal laryngeal closure, and loss of protective reflexes” (Guy & Smith, 2009, 108).

The article was really relevant to my care plan because it addressed so many important nursing interventions that can be implemented to help prevent a patient from aspirating. The article is from a reputable nursing journal (Clinical Journal Oncology Nursing) and cited evidence based practice to support its recommended nursing interventions.

Reference:

Guy, J.L., & Smith, L.H. (2009). Preventing aspiration: a common and dangerous problem for

patient’s with cancer. Clinical Journal Oncology Nursing 13(1): 105-108. Retrieved on

February 23, 2013, from http://www.medscape.com/viewarticle/588931

Medication Worksheet In your own words.

Drug Name Generic and Brand & TIME DUE	Classification/ Mechanism of action	Actions/Indications (Reason MY patient is on this medication)	Patient dose/ route/ frequency	Most common or serious side effects	Contraindications & Major Interactions (Food/Drug)	Nursing Interventions / Patient Teaching (What you need to know/ do before administering)
Albuterol	Albuterol acts by producing the physiological effects of the sympathetic nervous symptom. Albuterol’s main mechanism of action to stimulate the receptors of the smooth muscle in the lungs (Deglin, Vallerand, & Sanoski, 2012, p. 112).	My patient was diagnosed with aspiration pneumonia and this drug was ordered because of his right lower lobe airspace opacities.	5 mg, nebulizer, q4day	Albuterol has multiple adverse reactions including: edema, abdominal pain, ataxia, angina, cough, diaphoresis, fever, glossitis, conjunctivitis, hyperglycemia, hypokalemia, and lymphadenopathy (Deglin, Vallerand, & Sanoski, 2012, p.113).	Contraindications for the drug are hypersensitivity to adrenergic amines (Deglin, Vallerand, & Sanoski, 2012, p.113).	Nurse should assess respiratory status and pulse ox. Suction secretions to improve adventitious lung sounds and respiratory rate.
Chlorhexidine gluconate	Chlorhexidine gluconate is a salt and acts a germicidal mouthwash.	The patient is taking this medication because it is used for ventilated patients to help prevent aspiration pneumonia and mouth sores.	15 ml, q3day, swish and spit	Change in the taste of food/drink, tongue/tooth staining, and mouth/throat irritation (Deglin, Vallerand, & Sanoski, 2013).	Hypersensitivity.	Nurse should assess the patient for any signs of hypersensitivity or severe side effects.
Folic acid	Folic acid is classified as an antianemic and vitamin. Required for protein synthesis and red blood cell function. Stimulates the production of red blood cells, white blood cells, and platelets (Deglin, Vallerand, & Sanoski, 2012, p. 606).	The patient is diagnosed with AWS and alcoholics typically have deficiencies related to this vitamin. Also, the patient has low H & H values and folic acid is a vitamin that helps with the stimulation of red and white blood cells production.	1 mg; qday; oral	The common and serious side effects of the vitamin are rash, irritability, difficulty sleeping, and malaise (Deglin, Vallerand, & Sanoski, 2012, p. 606).	The contraindications are using the drug for uncorrected pernicious, aplastic, or normocytic anemia (Deglin, Vallerand, & Sanoski, 2012, p. 607).	Explain to the patient the negative effects of alcohol on the absorption of essential nutrients. Encourage the patient to comply with dietician’s recommendation and eat a diet with a lot of fruits and vegetables (Deglin, Vallerand, & Sanoski, 2012, p. 608). Ask patient to notify nurse is rash appears indicating hypersensitivity.
Heparin	The drug is an anticoagulant and acts by inhibiting the effects of antithrombin on factor Xa and thrombin (Deglin, Vallerand, & Sanoski, 2013, p. 644).	Patient is on the medication prophylaxis to prevent DVT because on bed rest while he is under sedation.	5,000 units; q12hrs; subq	The side effects are drug induced hepatitis, HIT, alopecia, anemia, osteoporosis, and urticarial (Deglin, Vallerand, & Sanoski, 2013, p. 644).	Hypersensitivity, uncontrolled bleeding, severe thrombocytopenia, and risk of increased bleeding with use of NSAIDs (Deglin, Vallerand, & Sanoski, 2013, p. 644).	Assess for signs of bleeding and hemorrhage and monitor injection sites for hematomas (Deglin, Vallerand, & Sanoski, 2013, p. 644).
Multivitamin liquid	The drug is a complex of vitamins that act as coenzymes or catalysts in numerous metabolic processes (Deglin, Valleran, & Sanoski, 2013).	The patient has been diagnosed with malnutrition and prior to hospitalization was not eating regularly. Also, the patient has alcohol dependency and alcoholic gastritis, which has damaged lining of intestines/stomach affect vitamin absorption.	5ml, oral qmorning	Side effects are rare as long as recommended dose are followed. Some of B complex vitamins have potential for an anaphylaxis (Deglin, Vallerand, & Sanoski, 2013).	Hypersensitivity and use cautiously in undiagnosed anemia’s.	Assess for signs of vitamin deficiencies before and after administration. Encourage patient to eat a nutritious diet with high amounts of fruits and vegetables (Deglin, Vallerand, & Sanoski, 2013).
Pantoprazole	The drug is a proton pump inhibitor and acts by decrease the acid in the gastric area (Deglin, Valleran, & Sanoski, 2013).	The drug is used for treatment of GERD, which the patient has but can also be ordered as prophylactic against development of stress ulcers while in ICU.	40 mg; qmorining; IV	Headache, abdominal pain, diarrhea, hyperglycemia, hypomagnesmia, and flatulence (Deglin, Valleran, & Sanoski, 2013).	Hypersensitivity and prolonged use can increase risk bone fractures (Deglin, Valleran, & Sanoski, 2013).	Assess patient routinely signs of abdominal pain and for frank or occult blood in stool or aspirate. Watch lab values because may cause hypomagnesemia (Deglin, Valleran, & Sanoski, 2013).
Zosyn	The drug is an antibiotic and is used for nosocomial pneumonia.	The patient has a case of aspiration pneumonia and this is the antibiotic being used to treat it.	3.375 g; q8hrs; IV	Seizures in high doses, confusion, dizziness, rashes, bleeding, and hypersensitivity (Deglin, Valleran, & Sanoski, 2013).	Hypersensitivity to penicillins and increase risk of hepatotoxicity with other hepatotoxic agents (Deglin, Valleran, & Sanoski, 2013).	Assess patient for signs of infection (VS, appearance of wound, sputum, and urine) at beginning or at end of therapy. Observe for signs of anaphylaxis (Deglin, Valleran, & Sanoski, 2013).
KCL	Mineral used as an electrolyte replacement.	The patient is receiving KCL as a replacement therapy to prevent hypokalemia.	40 mEQ; qday; oral	Confusion, abdominal pain, diarrhea, flatulence, arrhythmias, and paresthesia (Deglin, Valleran, & Sanoski, 2013).	Contraindication with hyperkalemia and renal impairment (Deglin, Valleran, & Sanoski, 2013).	Assesses patient for signe of hypokalemia (weakness, fatigue, U on ECG, polyuria) and hyperkalemia (slow, irregular HB, fatigue, and muscle weakness) (Deglin, Valleran, & Sanoski, 2013).
Thiamine	Classified as a vitamin and is required for carbohydrate metabolism (Deglin, Vallerand, & Sanoski, 2012, p.1210).	This vitamin’s absorption is hindered in patients with alcohol dependency. It is ordered as a supplement for this patient because of his AWS diagnosis.	100 mg; qday; oral	The side effects are restlessness, weakness, pulmonary edema, respiratory distress, GI bleeding, and cyanosis (Deglin, Vallerand, & Sanoski, 2012, p.1211).	Contraindications are hypersensitivity and known alcohol intolerance (Deglin, Vallerand, & Sanoski, 2012, p. 1211).	Nurses should assess respiratory status due to medication side effects. Encourage patient to eat recommended diet (Deglin, Vallerand, & Sanoski, 2012, p. 1212).
Fentanyl	Opiate agonists; Its mechanism of action is to act as an opiate receptor at u and kappa receptors in the body (“Fentanyl” 2012).	Patient taking medication because fentanyl is used to aid in induction and maintenance of his sedation (“Fentanyl” 2012).	2ml/hr; continuous; IV	Respiratory depression because it is an opioids. Arrhythmias, excessive sedation, and extrapyramidal reactions (Deglin, Vallerand, & Sanoski, 2013).	Opioid naïve patients; and use cautiously in patients on MAO inhibitors within 14 days (Deglin, Vallerand, & Sanoski, 2013).	A nurse should evaluate respiratory status before and after administrations and for allergies.
Midazolam/ Versed	The drug is classified as a benzodiazepines, antianxiety agent, and sedative/hypnotics. The drug acts by affecting multiple CNS receptors to cause CNS depression (Deglin, Vallerand, & Sanoski, 2012, p.860).	Versed is used for ventilated patient in critical care settings as one of his sedation medications (Deglin, Vallerand, & Sanoski, 2012, p.860).	0.02-4 ml/hr; continuous; IV	The side effects are respiratory depression, apnea, laryngospasm, cardiac arrest, and excess sedation (Deglin, Vallerand, & Sanoski, 2012, p. 861).	Contraindications for the drug are hypersensitivity, shock, cross-sensitivity with benzodiazepines, and uncontrolled severe pain (Deglin, Vallerand, & Sanoski, 2012). Major interactions are alcohol, valerian, St. John’s wart, and grapefruit juice (Deglin, Vallerand, & Sanoski, 2012, p.861).	A nurse should evaluate the patient for respiratory depression and over sedation.
Levophed	The drug is a vasopressor and acts mainly by stimulating alpha -receptors in blood vessels. The drug increases BP and cardiac output (Deglin, Valleran, & Sanoski, 2013).	The patient was put on Levophed because he became hemodynamically unstable and severely bradycardic while on the Propofol for sedation. As long as the patient is under sedation he will need this medication to remain stable. The doctors have been unsuccessful weaning him off both drugs.	1.88-36.25 ml/hr; continuous; IV	Arrhythmias, decreased urine output, hypertension, metabolic acidosis, fever, and anxiety (Deglin, Valleran, & Sanoski, 2013).	Use cautiously with patient that have hypertension and cardiovascular disease. Alpha-adrenergic blockers can prevent pressor response (Deglin, Valleran, & Sanoski, 2013).	Monitor BP every 5 minutes and maintain systolic 80-100 or 30-40 mm Hg below previous systolic. ECG monitored continuously. Monitor urine output and notify doctor if less than 30 ml/hr. (Deglin, Valleran, & Sanoski, 2013).
Propofol	General anesthetics; The drug is a short-acting hypnotic whose exact mechanism of action is unknown (Deglin, Vallerand, & Sanoski, 2013).	The drug is used as an anesthetic to maintain the patient’s state of sedation (Deglin, Vallerand, & Sanoski, 2013).	10 mg/ml; 0.56-41.9 ml/hr; continuous; IV	Apnea, burning, stinging, bradycardia, hypotension, and pain (Deglin, Vallerand, & Sanoski, 2013).	Hypersensitivity to propofol, soybean oil, egg lecithin, or glycerol (Deglin, Vallerand, & Sanoski, 2013).	Monitor patient’s respiratory status, heart rate, and BP throughout administration (Deglin, Vallerand, & Sanoski, 2013).
Magnesium sulfate	Mineral used as an electrolyte replacement and is essential for the activity of many enzymes (Deglin, Valleran, & Sanoski, 2013).	The drug is used PRN for electrolyte replacement when the patient’s lab values indicate it is needed.	1 g/100 ml; PRN electrolyte replacement; IV	Drowsiness, decreased respiratory rate, arrhythmias, diarrhea, muscle weakness, and hypothermia (Deglin, Valleran, & Sanoski, 2013).	Contraindicated in hypermagnesemia, hypocalcemia, anuria, and heart block (Deglin, Valleran, & Sanoski, 2013).	Monitor pulse, BP, RR, and ECG frequently. Monitor intake and output ratios (Deglin, Valleran, & Sanoski, 2013).
Haldol	The drug is a butyrophenones and acts by altering the effects of dopamine in the CNS (Deglin, Valleran, & Sanoski, 2013).	The drug is part of the PRN set of orders MIHS implements for patients diagnosed with alcohol withdrawal syndrome.	5mg; q6hrs; PRN psychotic agitation; IM	Agranulocytosis, urinary retention, impotence, constipation, dry mouth, hypotension, tachycardia, and ECG change (QT prolongation) (Deglin, Valleran, & Sanoski, 2013).	Contraindicated in hypersensitivity, CNS depression, severe liver, or cardiovascular disease (Deglin, Valleran, & Sanoski, 2013).	Assess mental status and monitor BP, pulse, and ECG for QT prolongation (Deglin, Valleran, & Sanoski, 2013).
Lorazepam	The drug is a benzodiazepine and acts by depressing the CNS (Deglin, Vallerand, & Sanoski, 2013).	This drug is ordered PRN for this patient as part of MIHS Alcohol withdrawal protocol. The dosage is based on the score and whether or not the patient is showing signs of psychotic agitation.	2-8mg; q4hrs; IV; PRN Alcohol withdrawal score	Dizziness, drowsiness, blurred vision, rashes, lethargy, and respiratory depression (Deglin, Vallerand, & Sanoski, 2013).	Contraindications are hypersensitivity, uncontrolled severe pain, angle-closure glaucoma, and sleep apnea (Deglin, Vallerand, & Sanoski, 2013).	Regularly assess for continued need for treatment (Deglin, Vallerand, & Sanoski, 2013).

References:

Deglin, J. H., Vallerand, A. H., & Sanoski, C. A. (2013). Davis’s drug guide for nurses 13th edition (13th ed.). Philadelphia, PA: E.A. Davis Company.

Fentanyl: Drug monograph. (2012). MD Consult. Retrieved from

http://www.mdconsult.com.ezproxy2.library.arizona.edu/das/pharm/body/362442955-3/1354927978/full/245

Laboratory Values Worksheet

Lab Data (per Level)	Description of Lab Test	Normal Value	Result/ Date 2/17/13	Result/ Date 2/18/13	Result/ Date 2/19/13	Pathophysiology : explanation of abnormal lab value, including trends and correlation with disease process. In your own words.
WBC	WBC’s are components of the blood that respond to allergies, infections and inflammation. The test measures the amount present in the blood (Chabner, 2011, p. 508).	5.0-10.01^3/ µl	8.6	7.7	6.1	Patient lab values are within normal limits.
Neutrophils	Neutrophils are WBC’s that accumulate at the site of infection (Chabner, 2011, p. 508). The test measures the amount present in the blood.	1.3-5.4 x 109 L	7.0 (H)	4.5	4.0	The patient was diagnosed/developed aspiration pneumonia around the result date, which would cause an increase in neutrophils.
Lymphocyte	Lymphocytes are WBC’s that accumulate at the site of infection and inflammation (Chabner, 2011, p. 508). The test measures the amount present in the blood.	1.0-3.9 x 109 L	0.7 (L)	1.2 (L)	0.9 (L)	Low values of lymphocytes indicate the presence of a bacterial infection, which correlates with the patient’s diagnosis of aspiration pneumonia. Also, during the shift the patient had an increased temperature that we performed pancultures for.
Monocytes	Monocytes are WBC’s that accumulate at the site of injuries and inflammation (Chabner, 2011, p. 508). The test measures the amount present in the blood.	0.1-0.8 x 109 L	0.8	1.6 (H)	1.0 (H)	The patient was diagnosed/developed aspiration pneumonia around the result date, which would cause an increase in neutrophils.
Hemoglobin (Hgb)	Hgb is a blood protein that is part of the erythrocyte. It is the portion that contains iron to carry oxygen (Chabner, 2011, p. 990). The test measures the amount present in the blood.	13.5-17.5 g/dl	9.1 (L)	9.0 (L)	9.0 (L)	Low values indicate loss of blood and anemia (Chabner, 2011, p. 990). The patient has alcohol dependency to the degree that he is suffering from alcohol withdrawal syndrome. When a person like this patient consumes too much alcohol it can cause anemia because blood production is suppressed (Ballard, 1997). Also, the patient is malnourished and has vitamin deficiencies like folic acid that are components that help with red blood cell synthesis.
Hematocrit (Hct)	Hct is the percentage of erythrocytes in a volume of blood (Chabner, 2011, p. 523). The test measures the amount present in the blood.	38.0-54.0 %	27.9 (L)	27.9 (L)	27.9 (L)	Low values indicate loss of blood and anemia (Chabner, 2011, p. 990). The patient has alcohol dependency to the degree that he is suffering from alcohol withdrawal syndrome. When a person like this patient consumes too much alcohol it can cause anemia because blood production is suppressed (Ballard, 1997). Also, the patient is malnourished and has vitamin deficiencies like folic acid that are components that help with red blood cell synthesis.
Platelets	Platelets are located in blood and help with clotting. The test measures the amount present in the blood.	140-440 K/ µl	131 (L)	143	188	Low values indicate possible anemia (Chabner, 2011). Heavy alcohol consumption can lead to production of abnormal blood cell precursors (Ballard, 1997).
Serum Na	The test measures the amount of sodium present in the blood serum (Chabner, 2011, p. 991).	137-145 mmol/L	136 (L)	135 (L)	138	Low values indicate adrenal insufficiency, inadequate sodium intake, and excessive sodium loss (Chabner, 2011). The patient is on enteral nutrition and the lab value should be monitored on the patient to make sure it does not drop any lower, which might indicate adrenal insufficiency that can develop in ventilated patients.
Serum K	The test measures the amount of potassium present in the blood serum (Chabner, 2011, p. 991).	3.5-5.1 mmol/L	4.2	4.6	4.6	Patient lab values within normal limits.
Serum Cl	The test measures the amount of CL present in the blood serum.	98-107 mmol/L	103	100	99	Patient lab values within normal limits.
Serum CO2	The test measures the amount of CO2 present in the blood serum.	22.0-30.0 mmol/L	23.0	25.0	31.0 (H)	An elevated serum CO2 might indicate chronic acidosis and the patient has been diagnosed with metabolic acidosis. The ABG lab values also indicate this.
BUN	BUN stands for blood, urea, and nitrogen. The test measures the amount of each in blood serum (Chabner, 2011, p. 990).	7-20 mg/dL	6 (L)	6 (L)	11	A low BUN could indicate malnutrition or liver disease/damage. The patient is diagnosed with malnutrition and upon admission patient was diagnosed with transaminitis and hepatitis affecting the liver. Also, the CT abdomen showed a fatty liver from the patient’s alcohol dependency.
Creatinine	The test measures the amount of creatinine in the blood serum.	0.66-1.25 mg/dL	0.83	0.82	0.81	Patient’s values are within normal limits.
Glucose	The test measures the amount of glucose present in the blood serum (Chabner, 2011, p. 991).	74-106 mg/dL	146 (H)	139 (H)	136 (H)	The patient is on enteral nutrition, which often can cause high blood glucose because of the high calorie liquid feedings.
Ca	The test measures the amount of calcium present in the blood serum (Chabner, 2011, p. 991).	8.4-10.2 mg/dL	8.4	8.4	8.6	Patient’s values are within normal limits.
Mg	The test measures the amount of MG present in blood serum (Chabner, 2011, p. 991).	1.6 - 2.4 mEq/L	1.8	1.7	1.7	Patient’s values are within normal limits.

Lab Data (per Level)	Description of Lab Test	Normal Value	Result/ Date 2/17/13	Result/ Date 2/18/13	Result/ Date 2/19/13	Pathophysiology: explanation of abnormal lab value, including trends and correlation with disease process
Troponin 1	Measures the troponin levels in the blood. Troponin is released when damage to heart muscle occurs and is part of cardiac markers tested for MI (Chabner, 2011).	0 - 0.1 ng/m	2/13/13: 0.030	Patient’s values within normal limits.
CK	Maker for muscle damage and is used as a cardiac markers tested for MI (Chabner, 2011).	<150 U/L	2/12/13: 202 (H); 2/13/13: 180 (H)	High CK can indicated that there was some muscle damage; possibly to the heart. The doctors thought patient might have alcoholic cardiomyopathy.
CK-MB	MB is both a sensitive and specific marker for myocardial infarction. MB usually becomes abnormal three to four hours after an MI, peaks in 10–24 hours, and returns to normal within 72 hours (Chabner, 2011).	>5% in MI	None available in patient’s chart.	None available in patient’s chart.
Prothrombin Time (PT)	The test measures the amount of time it takes blood to clot (Chabner, 2011, p. 991).	9.4-12.0 seconds	2/12/13: 9.6; 2/13/13: 11.2	Patient’s values within normal limits.
International Normalized Ratio (INR)	This test is for the amount of time it takes blood to clot (Chabner, 2011, p. 991).	0.8-1.0 INR	2/12/13: 0.9; 2/13/13: 1.1 (H)	High INR can indicate an increased clotting time. Elevation not significant.
Activate Partial Thromboplastin time (APTT)	This test for clotting factors in the blood and can be related to see what heparin levels are in a person’s blood (Chabner, 2011, p. 991).	25.6-36.7 s	None available in patient’s chart.	None available in patient’s chart.
ALT	Is an enzyme mainly found in the liver; the best test for detecting hepatitis (Chabner, 2011).	7 to 72 U/L	2/12 123 (H)	2/13 93 (H)	2/16 83 (H)	2/17 66	2/18 64	2/19 68	The patient was diagnosed with transaminitis upon admission. Transaminitis is an increase in liver enzymes (ALT, AST, ALP) that usually indicate liver damage and unspecified hepatitis (Chabner, 2011). The patient also was diagnosed with mild hepatitis and abdominal CT showed patient had a fatty liver.
AST	Is an enzyme found in the liver and a few other places, particularly the heart and other muscles in the body (Chabner, 2011).	8 to 55 U/L	122(H)	93 (H)	97 (H)	59	42	51	The patient was diagnosed with transaminitis upon admission. Transaminitis is an increase in liver enzymes (ALT, AST, ALP) that usually indicate liver damage and unspecified hepatitis (Chabner, 2011). The patient also was diagnosed with mild hepatitis and abdominal CT showed patient had a fatty liver.
ALP	Is an enzyme related to the bile ducts; often increased when they are blocked (Chabner, 2011).	45 to 115 U/L	212 (H)	154 (H)	101 (H)	99	81	98	The patient was diagnosed with transaminitis upon admission. Transaminitis is an increase in liver enzymes (ALT, AST, ALP) that usually indicate liver damage and unspecified hepatitis (Chabner, 2011). The patient also was diagnosed with mild hepatitis and abdominal CT showed patient had a fatty liver.
Amylase/Lipase	This test is used to help diagnose and monitor acute or chronic pancreatitis and other disorders that may involve the pancreas (Chabner, 2011).	50 – 150 U/dL	2/12/13: 150	Patient test was within normal limits.
Urinalysis	This test for issues in the kidneys. Color Pale yellow to amber Turbidity Clear to slightly hazy Specific Gravity 1.015-1.025 pH 4.5-8.0	No urinalysis; toxic screen was negative	The patient did not have a urinalysis on file. The patient’s had a toxicology screen that was negative.
ABGs pH pO2 pCO2 HCO3 BE On RA, % O2, vent settings	This test for the level of oxygen and carbon dioxide in the blood (Chabner, 2011). Arterial Venous 7.35 - 7.45 7.32 - 7.42 35 - 45 38 - 52 70 – 100 28 - 48 19 - 25 19 - 25 90 - 95 40 - 70	7.366 111.5 (H) 41.8 23.4 -1.8 97.9	7.365 85.5 47.6 (H) 26.6 (H) 0.9 96.1	7.369 101.7 (H) 57.8 (H) 32.6 (H) 6.2 97.4	The patient is diagnosed with metabolic alkalosis and his ABG’s have to be monitored. The results suggested compensation or a mixed blood gas results. I asked about the ABG lab values and if they were significant and was told it was not being considered at this time.
TB test	Test for tuberculosis.	None available in patient’s chart.	None available in patient’s chart.
Lactic acid	A lactic acid test is a blood test that measures the level of lactic acid made in the body (Chabner, 2011).	0.4 - 2.3 mEq/L	2/12: 3.8 (H)	2/13: 1.7	2/15: 1.2	High lactic acid can be an indication of liver damage and the patient was diagnosed with hepatitis and transaminitis. His lab values are showing that his alcohol dependency could be starting to damage his live. This is confirmed by the patient’s fatty liver seen on his abdominal CT.
Ammonia	An ammonia test measures the amount of ammonia in the blood (Chabner, 2011).	11 – 35 µmol/L	< 9 (L)	This test was ordered because the doctor’s were concerned about the patient’s hemodynamic issues on his sedation vacation and wanted to rule out possible liver damage causing continued encephalopathy. They thought this because patient has been sedated for awhile and should be beginning to recovery from withdrawal syndrome.
Toxicology Serum Ethanol	This tests the amount of alcohol in the patient’s blood.	0	2/12: 145 (H)	2/13: 32 (H)	2/15: negative	This test showed the amount of alcohol in the patient’s blood stream upon his admission to the hospital.

References:

Chabner, D. (2011). The language of medicine (9th ed.). Saint Louis, MO: Saunders Elsevier.

Ballard, H.S. (1997). The hematological complication of alcoholism. Alcohol Health & Research World 21(1). Retrieved from

http://pubs.niaaa.nih.gov/publications/arh21-1/42.pdf

Diagnostic Testing Worksheet (e.g. x-ray, ECG, colonoscopy, etc.)

Tests	Purpose of Test	Date of Test	Test Results
CT abdomen pelvis w/o IV contrast	Belly pain, vomiting, stone protocol	2/12	CT Abdomen: The scan showed that there was fatty infiltration of the liver as well as a right-sided diaphragmatic hernia containing liver. The patient had extensive evidence of atherosclerotic disease and a left lower pulmonary nodularity. CT Pelvis: There was no obvious free pelvic fluid and bladder was unremarkable.
X-ray abdomen	Duotube placement	2/17	The tip of the duotube is in the 3rd segment of the duodenum.
X-ray chest	Follow up due to aspiration of vomiting	2/17; 2/18; 2/19	Lungs show improvement in each follow up x-ray. The right lower lobe airspace opacities are starting to resolve.
X-ray chest	Line placement of right subclavian CVC	2/15	Line in appropriate place and cleared for use.
X-ray chest	Confirmation of Endotracheal tube placement	2/15	ETT placed correctly.
Echocardiogram	Concern of alcoholic cardiomyopathy	2/17	The patient’s left ventricular systolic function is normal with an ejection fraction of 55-65 %. There is evidence of mild concentric and a diastolic filling pattern that indicates impaired relaxation (Grade 1).

MIND MAP (PER LEVEL)

Reason for needing health care/ Medical Diagnosis: Alcohol Withdrawal Syndrome complicated by aspiration pneumonitis, acute respiratory failure, hypokalemia, hypomagnesaemia, hypotension from sedation medication requiring vasopressors, macrocytic anemia, and thrombocytopenia. Anticipated assessments (prep): Neurological, A&O, PERRL, EOM, Intake & Output, respiratory, pancultures, Line assessment (A-Line & Central), Restraints, Labs, Sedation Vacation, medication review patient on Levophed, review vent settings, ECG review & foley catheter Assessment Data (concept map): acute respiratory failure on ventilator, recovering from aspiration pneumonia day 6 antibiotic regime; restraints still needed because patient still agitated, sedated, and ventilated; Patient still needs Levophed because pressures bottom out while on sedation medication and he was not hemodynamically stable enough during sedation vacation at start of shift to stop sedation medication. CV: RRR, no murmurs; Eyes: PERRL, EOM; Head: normocephalic, atraumatic; ENT: MMM, thin clear secretions, 7.5 cm ETT secured at 22 cm at teeth; GI: non-tender, non-distended, not tympanic, no BM for 2 days; GU: foley catheter in place putting out 32 to 175 ml/hr; MS: moves extremities spontaneously patient under sedation; Skin: warm, dry, no rashes; Neuro: RASS score 2+ when put on a sedation vacation; unable to fully assess LOC because patient is sedated and ventilated

Key Problem: Decreased cardiac output R/T altered heart rate and altered heart rhythm AEB patient on Levophed due to cardiogenic shock caused by sedation medication, bradycardia, ECG changes with PVC/PAC, abnormal atrial blood gases values of 7.369, 101.7 (H), 57.8 (H), 32.6 (H), 6.2, & 97.4, BP 118/56 on Levophed, suspected alcoholic cardiomyopathy pending doctor interpretation of echocardiogram. Supporting Data: The patient was placed on the conscious sedation medication Propofol while he was intubated due to acute respiratory failure caused by AWS. The medication put the patient into cardiogenic shock with diastolic below 90, weak pulse, and ECG changes. The patient had to be put on Levophed to manage BP. He is on a continuous drip for as long as he is on the sedation medication. Key Problem: Impaired spontaneous ventilation R/T metabolic factors, 2/2 aspiration, 2/2 encephalopathy and right lower lobe airspace opacities AEB patient ventilated (settings: TV-400, R-14, Mode-PRVC, FIO2-40, & PEEP-5), spike in BP above 200 systolic and 100 diastolic with PVC/PAC ECG changes during sedation vacation, ABG values of 7.369, 101.7 (H), 57.8 (H), 32.6 (H), 6.2, & 97.4 and lactic acid of 3.8, as well as shallow and diminished BS bilaterally in the bases. Supporting Data: Patient sedation vacation trial at the start of shift was not successful the patient was not hemodynamically stable off of sedation medication with spike in BP and ECG changes to tachycardia with PVC/PAC; patient ventilated with above settings; patient has diagnosis of aspiration pneumonia on day 6 antibiotic regime with Zosyn, 2/19 ABG values are: ABG values of 7.369, 101.7 (H), 57.8 (H), 32.6 (H), 6.2, & 97.4.

Key Problem: Risk for impaired skin integrity R/T altered nutritional status, altered circulation, altered metabolic state, mechanical factors, moisture, AEB patient on bedrest, diagnosed with malnutrition, position immobility, use of 2-points restraints, and Braden scale score of 9. Supporting Data: Braden scale score of 9; the patient is on bedrest and mechanically ventilated; patient has been diagnosed with malnutrition and has nutritional deficiencies related to his alcohol dependency; patient has 2 soft mechanical restraints bilaterally on upper extremities because of his AWS agitation where he was pulling out lines.

Key Problem: Risk for infection R/T malnutrition, decreased hemoglobin, decrease in ciliary action, increased environmental exposure to pathogens AEB increased temperature of 100.4, H & H of 9.0 & 27.9, nutritional deficiencies of folic acid & thiamine, ventilated, recovering for pneumonia, and invasive medical lines (A-line, foley catheter, CVP, NG tube). Supporting Data: Fever of 100.4; H & H for 9.0 & 27.9; patient was diagnosed with malnutrition and has nutritional deficiencies related to his alcohol dependency; patient has multiple invasive medical lines including an A-line, foley catheter, CVP, and NG tube which makes him susceptible to nosocomial infections; the doctor ordered pancultures for the patient because of his elevated temperature; and patient is currently on an antibiotic regime for his aspiration pneumonia. Key Problem: Risk for aspiration R/T depressed cough, tube feedings, presence of endotracheal tube, decreased gastrointestinal motility, reduced level of consciousness AEB patient intubated and on ventilator, NG tube placed with tube feeds, previous incident of aspiration, heavy alcohol consumption, decreased LOC while sedated with medication, and RASS of 2+ while on sedation vacation. Supporting Data: the patient has medical diagnoses of GERD, aspiration pneumonia, malnutrition, and alcoholic gastritis; patient had multiple risk factors including depressed cough because intubated, tube feedings, reduced LOC related to AWS, heavy alcohol consumption prior to hospitalization

PROBLEM LIST (PER LEVEL)

PROBLEM (Number problems in order of priority)	Nursing Diagnosis with R/T and AEB (Number diagnoses in order of priority)
1) Patient is sedated and ventilated while going through alcohol withdrawal syndrome because of episode of acute respiratory failure caused by aspiration pneumonia and diminished LOC due to encephalopathy that made him unable to protect his airway. The patient is on day 5 of ventilation and the priority nursing action at the start of shift is to initiate a sedation vacation to see if the patient might tolerate weaning and if acute encephalopathy caused by AWS is resolved. 2) The patient was placed on the conscious sedation medication Propofol while he was intubated. The medication put the patient into cardiogenic shock with diastolic below 90, weak pulse, and ECG changes. The patient had to be put on Levophed to manage BP. He is on a continuous drip for as long as he is on the sedation medication. So the second priority problem for this patient is monitoring of the patients Levophed continuous drip and titrating drip so that patient maintains a BP systolic 80-100 or 30-40 mm Hg below previous systolic. 3) The next priority of care for the patient during this shift was risk for infection. The patient had an elevated temperature of 100.4 through the night and into the day shift. The source of the fever could not be determined so we notified the doctors who ordered pancultures be performed on all of patient invasive lines (A-line, foley, and CVP). 4) The patient has multiple risk factors for aspiration including being less alert due to his sedation medications, GERD, drinks large amount of alcohol, and previous incident of aspiration causing pneumonia. The patient also is intubated and on tube feeding. 5) The other priority of care during the shift is skin integrity because the patient is on bedrest and intubated. He has a Braden scale score of 9 placing him at high risk. Also, the patient is diagnosed with malnutrition and has nutritional deficiencies related to his alcohol dependency. Finally, the patient has 2-point soft mechanical restraints on his upper extremities related to the agitation caused by his AWS.	1) Impaired spontaneous ventilation R/T metabolic factors, 2/2 aspiration, 2/2 encephalopathy and right lower lobe airspace opacities AEB patient ventilated (settings: TV-400, R-14, Mode-PRVC, FIO2-40, & PEEP-5), spike in BP above 200 systolic and 100 diastolic with PVC/PAC ECG changes during sedation vacation, ABG values of 7.369, 101.7 (H), 57.8 (H), 32.6 (H), 6.2, & 97.4 and lactic acid of 3.8, as well as shallow and diminished BS bilaterally in the bases. 2) Decreased cardiac output R/T altered heart rate and altered heart rhythm AEB patient on Levophed due to cardiogenic shock caused by sedation medication, bradycardia, ECG changes with PVC/PAC, abnormal atrial blood gases values of 7.369, 101.7 (H), 57.8 (H), 32.6 (H), 6.2, & 97.4, BP 118/56 on Levophed, suspected alcoholic cardiomyopathy pending doctor interpretation of echocardiogram. 3) Risk for infection R/T malnutrition, decreased hemoglobin, decrease in ciliary action, increased environmental exposure to pathogens AEB increased temperature of 100.4, H & H of 9.0 & 27.9, nutritional deficiencies of folic acid & thiamine, ventilated, recovering for pneumonia, and invasive medical lines (A-line, foley catheter, CVP). 4) Risk for aspiration R/T depressed cough, tube feedings, presence of endotracheal tube, decreased gastrointestinal motility, reduced level of consciousness AEB patient intubated and on ventilator, NG tube placed with tube feeds, previous incident of aspiration, heavy alcohol consumption, decreased LOC while sedated with medication, medical diagnosis of GERD and RASS of 2+ while on sedation vacation. 5) Risk for impaired skin integrity R/T altered nutritional status, altered circulation, altered metabolic state, mechanical factors, moisture, AEB patient on bedrest, diagnosed with malnutrition, position immobility, use of 2-points restraints, and Braden scale score of 9.

Nursing Diagnosis and Priority # 1

Impaired spontaneous ventilation R/T metabolic factors, 2/2 aspiration, 2/2 encephalopathy and right lower lobe airspace opacities AEB patient ventilated (settings: TV-400, R-14, Mode-PRVC, FIO2-40, & PEEP-5), spike in BP above 200 systolic and 100 diastolic with PVC/PAC ECG changes during sedation vacation, ABG values of 7.369, 101.7 (H), 57.8 (H), 32.6 (H), 6.2, & 97.4 and lactic acid of 3.8, as well as shallow and diminished BS bilaterally in the bases.

General Goal:

Patient recovers and maintains a normal homeostasis for the remainder of shift after adverse hemodynamic episode that occurred during sedation vacation.

Outcome Objective(s): (use SMART format)

1. The patient will maintain arterial blood gases within the following safe parameters a pH between 7.35 - 7.45, paco2 of 35-45 mm Hg, hco3 of 22 to 26 mEq/liter, pao2 of 80 to 100 mm Hg, sao2 of 95% to 100%, and base excess of -5 to +3 during the nursing shift.

2. The patient’s airway will be effectively maintained during the nursing shift. The patient maintaining an sp02 above 95% will measure an effect airway.

3. The nurse will aid the patient in effectively mobilizing secretions by performing inline suctioning as needed during the nursing shift. The measurement of effective secretion mobilization is that the patient will not have adventitious lung sounds on auscultation.

Interventions with time frames/frequency	Rationale (for each intervention)	Patient Responses (subjective/objective data)
1) Monitor the patient q2hrs for signs of increased respiratory rate, use of accessory muscles, intercostal muscles retraction, flaring of nostrils, and decreased 02 saturation (Ackley & Ladwig, 2011). 2) Administer analgesics and sedatives as needed to keep the patient comfortable while recovering from AWS (Ackley & Ladwig, 2011). Titrate up and down within protocols to maintain hemodynamics at stated parameters. 3) Place the patient on a sedation vacation to see if he has recovered sufficiently from alcoholic encephalopathy, to perform neurological assessment, and to see if the patient can hemodynamically handle it so he can go off of the Levophed (Per MIHS MICU nursing protocol). 4) Analyze and respond to ABG’s, etCO2, and pulse ox value changes (Ackley and Ladwig, 2011). 5) Prevent unplanned extubation of patient by making sure ETT is secured with tape and that it stays at correct centimeter (22) at the teeth.	1) All of these assessment factors are signs that the patient might not be tolerating the current ventilation settings and he could be experiencing respiratory failure (Burns, 2005). 2) Studies have shown that when nurses have a sedation protocol that allows them to manage the patient’s analgesics and sedatives there is a decrease in the days of intubation and hospital stay (Brook et al., 1999). 3) Use of continuous IV sedation infusions is associated with a longer duration of mechanical ventilation (Kress et al., 2000). Also, a sedation vacation is needed daily when a patient is on a continuous IV sedation infusing to assess clients agitation and need for the medication (Kress et al., 2000). 4) Patients on ventilatory support should be continuously monitored to make sure that they are receiving adequate oxygenation and acceptable acid base balances (Ackley and Ladwig, 2011). 5) Secure taping can prevent inadvertent extubation and checking the tube cm at the teeth confirms that tubes placement in the lungs (Takeda et al, 2003).	1) During the nursing shift the patients respiratory status was monitored for these signs q2hrs. The patient did not experience any of this signs so his ventilation settings are adequate and he is tolerating the ventilator. 2) During the nursing shift (outside of the patient’s adverse hemodynamic reaction to his sedation vacation) the patient maintained his hemodynamic status within stated parameters-systolic between 80-120 mm Hg; sp02 >95%; pulse <110 while on sedation. Sedation medication was titrated to maintain patient at a comfortable sedation level. 3) It was determined that the sedation vacation was not successful the patient became hemodynamically unstable with increased BP and ECG changes PVC/PAC and a RASS of 2+. The previous level of sedation was resumed. 4) Patients pulse ox and etC02 remained within safe parameters the whole nursing shift. The patient ABGs showed mixed results with metabolic and respiratory acidosis. 5) The patient’s tube remained at 22 cm at the teeth during the entire nursing shift and the nurse made sure the tape was present securing placement of ETT.

Evaluation of outcome(s):

1. The outcome was not met the ABG result from the morning of 2/19 was pH: 7.369, paO2: 101.7 (H), paco2: 57.8 (H), hco3: 32.6 (H), BE: 6.2, & sa02: 97.4.

2. The outcome was met the patients spO2 did not desaturation below 95% during the nursing shift.

3. The outcome was met during the nursing shift the patient tolerated inline suctioning when performed and there was only a thin small amount of white secretions. There was no adventitious lung sounds upon auscultation.

Reference for rationales

Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis, MO: Mosby Elsevier.

Burns, S.M. (2005). AACN Procedure Manual for Critical Care (4th ed.). Philadelphia, PA: Saunders.

Brook, et al. (1999). Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Critical Care Medicine 27(12): 2609. Retrieved on February 23, 2013 from http://journals.lww.com/ccmjournal/pages/default.aspx.

Kress, et al. (2000). Daily interpretations of sedative infusions in critically ill patients undergoing mechanical ventilation. New England Journal of Medicine 342: 1471. Retrieved on February 23, 2013 from http://www.nejm.org.

Takeda, et al. (2003). The assessment of three methods to verify tracheal tube placement in the emergency setting. Resuscitation 56(2): 153-157. Retrieved on February 23, 2013 from http://www.resuscitationjournal.com.

Nursing Diagnosis and Priority # 2:

Decreased cardiac output R/T altered heart rate and altered heart rhythm AEB patient on Levophed due to cardiogenic shock caused by sedation medication, bradycardia, ECG changes with PVC/PAC, abnormal atrial blood gases values of 7.369, 101.7 (H), 57.8 (H), 32.6 (H), 6.2, & 97.4, BP 118/56 on Levophed, suspected alcoholic cardiomyopathy pending doctor interpretation of echocardiogram.

General Goal:

The patient will maintain a systolic blood pressure of 80-120 or 30-40 mm Hg below previous systolic.

Outcome Objective(s): (use SMART format)

1. During the nursing shift, the patient will demonstrate adequate cardiac output by maintaining a systolic BP between 80-120 mm Hg, a pulse less than 110, and strong peripheral pluses while on Levophed.

2. The patient will remain free the following Levophed side effects during the nursing shift: Arrhythmias, decreased urine output, hypertension, metabolic acidosis, and fever.

3. The patient will tolerate his sedation vacation trial this nursing shift so that he can be titrated off of the Levophed.

Interventions with time frames/frequency	Rationale (for each intervention)	Patient Responses (subjective/objective data)
1) Observe the patient for signs of cardiogenic shock throughout the nursing shift. Cardiogenic shock signs are impaired mental status, hypotension with blood pressure lower than 90 mm Hg, decreased peripheral pulses, cold clammy skin, signs of pulmonary congestion, and decreased organ function. Notify physician is signs on present (Ackley & Ladwig, 2011). 2) The nurse will titrate the patients Levophed within the define parameters to maintain contractility, preload, and afterload per physicians orders (Ackley & Ladwig, 2011). 3) Strict monitoring of the patients urine output throughout the shift to ensure remains above 30 ml/hr. 4) Assess patients pulse oximetry regularly to make sure remains above 95%. 5) Apply continuous gradual compression stockings below the knee, removing twice a shift to assess the extremity (Ackley & Ladwig, 2011).	1) The patient is at risk for cardiogenic shock as long as he is on sedation medications that require vasoactive medication management. Cardiogenic shock is a state of circulatory failure and needs to be recognized early and studies show these signs are good indications for it (Oliva & Monteiro da Cruz, 2003). 2) By following the doctor’s parameters for the Levophed the nurse ensures there is a good balance of the medication for stimulating the heart to increase contractility, while maintaining adequate perfusion of the body (Ackley & Ladwig, 2011). 3) One of the side effects of Levophed is a decrease in urinary output (Deglin, Vallerand, & Sanoski, 2013). 4) Patients with low cardiac output need to have their pulse ox assessed regularly to ensure that their body is receiving adequate oxygenation. Especially, in the peripheries (McCance & Huether, 2010). 5) Research shows knee-length gradual compression stockings are as effective as thigh length and they help to promote venous return and prevent DVT (Amarigiri & Lees, 2005).	1) The patient did not experience any signs of cardiogenic shock during the day of care and maintained a systolic BP greater than 90. 2) The nurse was able to titrate the patient’s Levophed dosage throughout the nursing shift to maintain the systolic BP between 80-120 and pulse lower than 110 ; except for sedation vacation. 3) The patient maintained a urinary output between 32 -175 ml/hr on the day of care. 4) The patient’s pulse ox reading remained above 95% for the entire day of care. 5) The patient’s knee-length gradual compression stockings were kept on continuously and removed twice for limb assessment the day of care. The patient responded to intervention and systolic BP remained between 80-120 mm Hg.

Evaluation of outcome(s):

1. The outcome was partially met the patient maintained a systolic BP between 80-120 and a pulse less than 110 during most of the shift. However, during the patient’s sedation vacation he had a spike in systolic BP above 200 and pulse above 110.

2. The outcome was partially met because the patient did not experience the side effects of decreased urinary output b/c output was above 32 ml/hr whole shift. The patient experience arrhythmias, hypertension, metabolic acidosis, and fever during the shift as shown by temp, ABG, and arrhythmias/hypertension experienced during sedation vacation.

3. The outcome was not met. The patient did not tolerate sedation vacation with spike in systolic BP above 200, pulse above 110, and arrhythmias on ECG. Previous sedation level resumed.

Reference for rationales:

Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis, MO: Mosby Elsevier.

Amarigiri, S.V., & Lees, T.A. (2005). Elastic compression stockings for prevention of deep vein thrombosis, Cochrane Database Syst Rev (3): CD001484, 2005.

Deglin, J. H., Vallerand, A. H., & Sanoski, C. A. (2013). Davis’s drug guide for nurses 13th edition (13th ed.). Philadelphia, PA: E.A. Davis Company.

McCance, K. L., & Huether, S. E. (2010). Pathophysiology: The Biological Basis for Disease in Adults and Children (6th ed., pp. 745-751). Missouri: Elsevier Health Sciences.

Oliva. A.P., & Monteiro da Cruz, A. (2003). Decreased cardiac output: validation with postoperative heart surgery patients, Dimensions Critical Care Nursing 22(1): 39-44. Retrieved on February 23, 2013, from http://journals.lww.com/dccnjournal/pages/default.aspx.

Nursing Diagnosis and Priority # 3:

Risk for infection R/T malnutrition, decreased hemoglobin, decrease in ciliary action, increased environmental exposure to pathogens AEB increased temperature of 100.4, H & H of 9.0 & 27.9, nutritional deficiencies of folic acid & thiamine, ventilated, recovering for pneumonia, and invasive medical lines (A-line, foley catheter, CVP).

General Goal:

The patient will not develop Ventilator Assisted Pneumonia (VAP) while intubated under my nursing care.

Outcome Objective(s): (use SMART format)

1. The patient will not develop signs of infection such as a temperature above 100 F, warmth, redness, or discharge during the nursing shift.

2. The nurse will perform appropriate hand hygiene and where gloves when administering patient care during the nursing shift to help prevent the development of infection.

3. The nurse will perform the patients oral care q2hrs during the shift and daily care routines (bathing, pericare, hair, and nail) qshift to help prevent infection by decrease bacteria on patient skin and in oral cavity.

Interventions with time frames/frequency	Rationale (for each intervention)	Patient Responses (subjective/objective data)
1) The patient was position with the head of bed at 30-45 degrees during the nursing shift to prevent gastric reflux of organisms into the lung (Ackley & Ladwig, 2011). 2) Drain collected fluid from condensation out of ventilation tubing qShift (Ackley & Ladwig, 2011). 3) Auscultate patient’s lungs for adventitious sounds q4hrs. 4) The nurse will preform appropriate hand hygiene and ensure all people coming into contact with the patient are as well. 5) Observe the patient for signs of infection during the nursing shift such as fever, warmth, redness, or discharge (Ackley & Ladwig, 2011).	1) Elevation of the patient’s head of bed at 30-45 degrees is one of the strategies implemented to prevent VAP (Hunter, 2006). 2) This intervention lowers the risk for infection because it decreases the inhalation of potentially contaminated water droplets (Burns, 2005). 3) Assessing for adventitious lung sounds associated with VAP is one of strategies to prevent healthcare acquired infections (Hunter, 2006). 4) Hand hygiene is one of the best strategies a healthcare worker can use to prevent the development of a nosocomial infection (Hunter, 2006). 5) Studies show that a fever of unknown origin is the single most common and clinically important entity in the assessment for a hospital acquired infection (Engelhart et al, 2002).	1) The patient tolerated the head of bed elevated at 30 degrees during the nursing shift. He had no adverse physiological changes to the position while being on the ventilator. 2) The patient tolerated the intervention and experienced no desaturation below 95% while touching and draining the ventilator tubing. 3) The patient’s lung sounds were assessed q4hrs and not adventitious lung sounds were auscultated. 4) The patient was not exposed to unnecessary infection due to poor hand hygiene during the shift. 5) The patient did experience a fever of 100.4 F during the shift that was reported to the doctor and pancultures of invasive medical lines were taken to try and determine origin.

Evaluation of outcome(s):

1. The outcome was not met the patient had a temperature of 100.4 F during the shift requiring the taking of pancultures to determine source of fever.

2. The outcome was met the nurse practiced appropriate hand hygiene and wore gloves for patient care during the shift.

3. The outcome was met. Oral care was performed q2hrs with toothette and suctioning. The patients daily cares were also accomplished during the shift.

Reference for rationales:

Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis, MO: Mosby Elsevier.

Burns, S.M. (2005). AACN Procedure Manual for Critical Care (4th ed.). Philadelphia, PA: Saunders.

Engelhart, S., Glasmacher, A., & Exner, M. et al (2002). Surveillance for health care acquired infections and fever of unknown origin among adult hematology-oncology patients, Infection Control Hospital Epidemiolgy 23(5): 244. Retrieved on February 23, 2013, from http://www.jstor.org/page/journal/infeconthospepid/about.html.

Hunter, J.D. (2006) Ventilator associated pneumonia, Postgrad Medical Journal 82(965): 172-178. Retrieved on February 23, 2013, from http://pmj.bmj.com.

Nursing Diagnosis and Priority # 4:

Risk for aspiration R/T depressed cough, tube feedings, presence of endotracheal tube, decreased gastrointestinal motility, reduced level of consciousness AEB patient intubated and on ventilator, NG tube placed with tube feeds, previous incident of aspiration, heavy alcohol consumption, decreased LOC while sedated with medication, medical diagnosis of GERD and RASS of 2+ while on sedation vacation.

General Goal:

The patient will not aspirate any secretions or gastric contents during the day of care.

Outcome Objective(s): (use SMART format)

1. The patient will maintain clear lung sounds upon auscultation q4hrs during the nursing shift.

2. The patient will digest tube feedings and will have less than 200 ml in stomach upon aspiration of NG tube q8hrs during the nursing shift.

3. The nurse will perform oral care q2hrs and suctioning PRN to prevent aspiration of secretions in the oral cavity during the nursing shift.

Interventions with time frames/frequency	Rationale (for each intervention)	Patient Responses (subjective/objective data)
1) Monitor the patient’s respiratory rate, depth, and effort. The nurse should not any signs of aspiration such as dyspnea, cough, cyanosis, wheezing, hoarseness, or fever (Ackley & Ladwig, 2011). 2) The nurse should auscultate the patients lung sounds q4hrs for new onset adventitious sounds indication aspiration (Ackley & Ladwig, 2011). 3) While the patient is receiving a continuous tube feed his he of bed should be elevated 30-45 degrees to decrease the risk of aspirating gastric contents. 4) Provide meticulous oral care including brushing of teeth q2hrs. Good oral care can prevent contamination of the mouth, which can be aspirated (Ackley & Ladwig, 2011, p. 872). 5) Listen to bowel sound q6hrs to determine if they are decreased, absent, or hyperactive (Ackley & Ladwig, 2011).	1) Signs of aspiration should be assessed as soon as possible so that lifesaving treatment is not delayed (Guy & Smith, 2009). 2) Bronchial auscultation is a specific intervention that has been proven to identify client at risk for or who have aspirated (Shaw et al, 2004). 3) Studies have shown that the elevation of the HOB at 30-45 degrees decreases aspiration pneumonia and the onset of fevers (Guy & Smith, 2009). 4) There is a multitude of research data that shows that good oral care can reduce risk of aspiration pneumonia (Arpin, 2009). 5) Decreased of absent BS indicate possible ileus with possible vomiting and aspiration. High-pitched bowel sounds indicate mechanical obstruction with possible vomiting and aspiration (Ackley & Ladwig, 2011).	1) The patient did not experience any signs of aspiration during the nursing shift. RR was set at 14 by the ventilator and depth was steady. 2) The patient lung sounds were auscultated q4hrs and not adventitious sounds were present. 3) The patients HOB was maintained at 30 degrees throughout shift because patient is on a continuous tube feed at 55 ml/hr. 4) The nurse performed oral care on the patient q2hrs during the nursing shift. 5) The patient’s BS were auscultated q6hrs and were normal.

Evaluation of outcome(s):

1. The outcome was met the patients lung sounds remained clear upon auscultation q4hrs during the nursing shift.

2. The outcome was met the patient had less than 200ml of gastric contents aspirated q8hrs from NG tube.

3. The outcome was met the nurse performed oral care q2hrs with toothbrush and chlorohexidine mouthwash, as well as performing suctioning PRN when patient had secretions built up.

Reference for rationales:

Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis, MO: Mosby Elsevier.

Arpin, S. (2009). Oral hygiene in elderly people in hospitals and nursing homes. Evidence Based Dentistry 10(2): 46. Retrieved on February 23, 2013, from http://www.nature.com/ebd/archive/index.html.

Guy, J.L., & Smith, L.H. (2009). Preventing aspiration: a common and dangerous problem for patients with cancer. Clinical Journal

Oncology Nursing 13(1):105-108. Retrieved on February 23, 2013, from http://www.medscape.com/viewarticle/588931

Shaw, J.L., Sharpe, S., & Dyson, S.E., et al. (2004). Bronchial auscultation: an effective adjunct to speech and language therapy

bedside assessment when detecting dysphagia and aspiration? Dysphagia 19(4): 211. Retrieved on February 23, 2013, from

http://www.springer.com/medicine/otorhinolaryngology/journal/455

Nursing Diagnosis and Priority # 5:

Risk for impaired skin integrity R/T altered nutritional status, altered circulation, altered metabolic state, mechanical factors, moisture, AEB patient on bedrest, diagnosed with malnutrition, position immobility, use of 2-points restraints, and Braden scale score of 9.

General Goal:

The patient will maintain his skin integrity and not breakdown during my nursing shift.

Outcome Objective(s): (use SMART format)

1. The nurse will turn the patient q2hrs to help preserve skin integrity and prevent development of pressure ulcers during the nursing shift.

2. The nurse will evaluate the necessity of restraints q2hrs to help prevent altered circulation and preserve skin integrity during the nursing shift.

3. The nurse will perform daily care qshift and PRN to prevent the build up of moisture in skin folds and perianal area during the nursing shift.

Interventions with time frames/frequency	Rationale (for each intervention)	Patient Responses (subjective/objective data)
1) Monitor necessity and site of patient’s 2-point soft restraints q2hrs because there friction of the skin can lead to skin breakdown. 2) The patient is on bedrest and sedated so he has limited mobility. The condition of his skin was assessed throughout the shift and special attention was paid to the skin covering his bony prominences (Ackley & Ladwig, 2011). 3) The nurse will complete the Braden scale assessment on the patient qshift. 4) Turn the patient q2hrs or elevate bony prominences with cushions/specialty devices to prevent skin breakdown (Ackley & Ladwig, 2011). 5) The nurse will administer the patient’s prescribed nutritional supplements folic acid, thiamine, and multivitamin. Also the nurse, will minimize the time that the patient’s continuous tube feed is put on hold.	1) Mechanical forces such as friction, pressure, and shearing can cause/accelerate skin breakdown (Ackley & Ladwig, 2011). 2) Pressure ulcers are more likely to develop over bony prominences in patients with limited mobility (Magnan & Maklebust, 2009). 3) A risk assessment tool like the Braden scale can be used to assess immobility-related risk factors the patient has and rate the patient’s level of risk (Magnan & Maklebust, 2009). 4) Turning the patient and using specialty devices like foam wedges are all pressure-reducing interventions that help to preserve skin integrity (Magnan & Maklebust, 2009). 5) The patient is diagnosed with malnutrition and poor nutritional status, which can increase the risk for and impair the recovery of skin breakdown/pressure ulcers (NPUAP, 2009).	1) The patient was restraints were assessed q2hrs and were determined necessary due to sedation agitation and pulling at lines. Sites of restraints were inspected q2hrs for signs of decreased circulation or skin breakdown. No signs of skin breakdown or altered circulation were noted during the shift. 2) The patient’s skin on his bony prominences was assessed throughout the shift and there were no signs of skin breakdown noted during the shift. 3) The nurse completed the Braden scale on the patient during the shift and the score was 9 placing the patient in the high-risk category for skin breakdown. 4) The patient was turned q2hrs and foam wedges were used under ankles during shift to prevent skin breakdown. No skin breakdown was noted during the nursing shift. 5) The patient was administered his prescribed nutritional supplements and the nurse avoid excessive pauses on the patient’s tube feeding.

Evaluation of outcome(s):

1. The outcome was met the nurse turned the patient q2hrs during the nursing shift and the patient did not develop any new areas of skin breakdown during the shift.

2. The outcome was met the nurse elevated the necessity of the 2-point soft restraints on the UE q2hrs. The restraints were deemed necessary because of patient’s sedation agitation and pulling of lines. Nurse documented on restraints q2hrs on whether or not affecting circulation or causing skin breakdown. No new issues related to skin were noted due to the restraints.

3. The outcome was met the nurse performed the daily cares qshift and cleaned up moisture PRN and there was no new areas of skin breakdown during the shift.

Reference for rationales:

Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis, MO: Mosby Elsevier.

Magnan, M.A., & Maklebust, J. (2009). The nursing process and pressure ulcer prevention: making the connection. Advanced Skin

Wound Care 22(2):83-91. Retrieved on February 23, 2013, from http://www.nursingcenter.com/prodev/cearticle.asp?tid=

844646.

National Pressure Ulcer Advisory Panel (NPUAP). (2009). The new international guideline consensus on implementation, 11th

Annual Biennial Conference. Washington, DC: NPUAP. Retrieved on February 23, 2013, from

http://onlinelibrary.wiley.com/doi/10.1111/j.1742-481X.2009.00618.x/abstract.

Adapted from:

McHugh Shuster, P. (2002). Concept mapping a critical thinking approach to care planning. Philadelphia, PA.: F.A.Davis Co.

Reference:

Gordon, M. (2008). Assess notes: Nursing assessment and diagnostic reasoning. Philadelphia, PA.: F.A.Davis Co.