Transcript: Temp. 97.9 F, BP 85/49, HR 60 bpm, RR 18, SPO2 90%, Pain 0/10 Temp. 97.0 F, BP 90/45, HR 65 bpm, RR 17, SPO2 90%, Pain 0/10 Pathophysiology CO2 (22-29): H 33 (up from 31) May be a result of metabolic alkalosis. Creatinine (0.80-1.40): L 0.41 (down from 0.50) May indicate decreased kidney function. All other values WNL CXR, PA AP, Portable Findings: Trach tube hanging below clavicles and 3 cm above carina. Lung volume decreased. Confluent opacities with right-sided veiling opacity. May indicate infection. Nurse should continue to monitor trach, lung sounds, RR, and SPO2. Interpretation and Synthesis Monitor RR and lung sounds Lung sounds clear bilaterally RR 17 Suction when secretions block airway ~30 mL suctioned Patient expressed relief after suction Observe for signs of respiratory distress Pt did not exhibit signs of respiratory distress (use of accessory muscles, etc.) Cluster care to provide rest periods Pt able to rest between interventions Monitor SPO2, contact resp. if necessary SPO2 did not fall below 90% (baseline) Nursing Dx #3 Physical Assessment Cont. Nursing Interventions Assess current level of anxiety Client exhibited written and non-verbal cues to level of anxiety Assess contributing factors Client recently lost ability to communicate verbally Allow client to express feelings Client used written communication to express distress Address client's concerns Client appeared relieved to have answers regarding diagnosis, trach care, and potential hospice 48 year old male presented with complaints of SOB and difficulty swallowing. He has an admitting diagnosis of base of tongue cancer. Patient has a central port with a saline lock (0.9% NaCl), right upper chest and a G-tube, left upper abdomen (Enteral Nutrition Jevity 1.2 350 mL 4x daily) San Francisco Patient had call light within reach, non-skid slippers, HOB elevated to prevent aspiration, pathways were clear, and bed alarm was always on. Patient had a fall risk score of 2, so the importance of asking for assistance was reiterated. Ineffective airway clearance r/t obstructed airway AEB trach, excessive mucous, and retained secretions. Medications Cancer- Base of Tongue Stockholm Supporting Data: Recent tracheostomy Patient appears agitated when trying to communicate Non-verbal cues Supporting Data: Client has recent tracheostomy Client has copious amounts of sputum in trach as well as on clothing and skin Client exhibited incorrect use of external suction Nursing Interventions Assess client's baseline knowledge Client does not have knowledge of how to properly clear secretions Teach client proper use of suction devices to remove sputum. Client listened intently and was receptive Have client demonstrate proper use of equipment Patient was able to demonstrate proper use of external suction in clearing sputum Assess further questions client has Client stated that he understood teaching and had no further questions AM: (cc) photo by jimmyharris on Flickr Lab Tests Nursing Interventions: Pulmonary Services Impaired verbal communication r/t tracheostomy AEB dysphasia Risk for falls r/t muscle weakness Mental Status Oriented x 3 Understands and follows directions Cooperative and calm Nutritional Status G-tube nutrition (4x daily) absorption sometimes impaired AEB aspiration of 200 mL Functional Status Able to ambulate with 1 Unable to complete ADLs independently Hendrich Fall Risk Score 11 Communication Patient able to communicate via written communication only. According to IOM guideines Patient has Hx of reflux disease, ulcer disease, oropharyngeal cancer, anxiety, and depression. Assessment Musculoskeletal Generalized weakness and muscle atrophy Unsteady gait GI/ Abdominal G-tube upper left abdomen Bowel sounds x 4 Renal Dark colored urine with slight odor 300 mL voided during shift Integumentary Braden score 14 Skin warm and dry, fragile Decreased turgor Risk Factors Tobacco use Alcohol Use HPV Hx of caner Alterations in A&P Cells in affected area form mutations in DNA. These mutations allow cancerous cells to grow & eventually form a tumor. These cells may spread to other areas of the mouth & throat. Complications Dry mouth, difficulty swallowing, disfigurement, dysphasia, death Nursing Dx #4 Deep Suctioning/ Trach Care RBC (4.6-6.0): L 3.81 (down from 4.2) Although levels are consistent with advanced cancer, continue to monitor for S/S of hemorrhage. Hgb (14-18): L 9.4 (down from 11.0) Hct (40-54): L 29.8 (down from 30.3) Monitor for S/S of hemorrhage and anemia. If levels drop too low, blood transfusion may be considerend. Na+ (135-145): L 134 (up from 120) Monitor for S/S of hyponatremia. (cc) photo by Metro Centric on Flickr Albuterol treatments ordered PRN for SOB. Patient tolerated treatments well and reported feeling "better" after. After treatment, RR was 17, lung sounds were diminished bilaterally, and SPO2 was 90%. Nursing Dx Developmental Considerations Patient is in Erikson's Ego Integrity vs. Despair stage of development
Transcript: Mr L - 46yrs Background Intracranial haemorrhage Left hemiparesis Post-traumatic epilepsy Presenting complaint: Blocked RIG tube HPC: Feed through pump occluded at 3am Attempts to unblock failed at care home and in A+E Communication Elbow Aid broken Ongoing issues Port site infection Chest infections - saline nebs Manual handling and positioning Extravasation wound O/E Appears relaxed PR 100 (1) RR 22 (1) Problem list Expressive aphasia Unable to medicate Unable to take on fluids/feed Old PEG site infection Immobility Retained secretions Plan Nutrition nurse specialist IV fluids if RIG not unblocked IV meds if RIG not unblocked Inform Gastro Turning chart and manual handling assessment D/C when RIG unblocked and stable Further management Fluid bolus Junior Dr - contact gastro Specialist dietician nurse contact regular dieician and care home staff TTO > GP Transport booked Points for discussion: Communication staff-staff, staff-patient. Confidentiality Medication on time EWS Prevention
Transcript: Madison Young, Pharm.D. Candidate 2020 Oak Park Pharmacy June 4, 2019 Patient Presentation: GH 61 yo WM Admitted xx/xx/xx Readmitted 5/2/19 PMH Acute Chronic T2DM PVD Hx Recurrent diabetic food wounds Diabetic neuropathy ESRD with hemodialysis CAD with hx stenting HTN Hyperlipidemia Afib Hypersomnia with suspected sleep apnea Systolic HF GH Patient Recent right 2nd toe amputation Left 4th and 5th toe amputation Multiple debridements of foot ulcers Right ankle fracture with open reduction internal fixation PCI with stenting Cardioversion for Afib [Failed] Kidney transplant Bilateral cataract surgery AV fistula with multiple procedures for complications Surgical History Surgical History Sister deceased at age 54 of breast cancer Sister deceased at age 50 from complications of rheumatoid arthritis Brother (70) with DM Family History Family History Resides at Oak Park Nursing Home Under care of Dr. Royal No hx of tobacco, alcohol or illicit drug use Social History Social History Subjective HPI Physician's Notes 5/15/19 - Dr. Royal Admitted to EAMC 4/28-5/2 with "hypovolemic shock" Initial concern was sepsis, but no infection found Pt required volume resuscitation and pressure support in ICU symptoms improved quickly Went to dialysis on 5/15 nurses report he was doing well Note: Amiodarone d/c Physician's Notes Objective Objective Labs Click to edit text Subtopic 1 Topic 4 Labs Subtopic 1 Subtopic 1 Medications Assessment Plan
Transcript: 67 year old male weight 170 lbs height 5'5" Reason for Admission (4/02/2012) Resection of Gastro Esophageal junction carcinoma diabetes type II (12/05/2008)-present hyperlipidemia (12/05/2008)-present gout (12/05/2012)-present hypertension (12/05/2008)-present Parkinson's disease (12/05/2008)-present nuclear sclerosis (9/22/2010)-present prostate cancer (10/26/2010)-present GE junction carcinoma-(12/27/2011)-present Radiation started 1/17/2012 and completed 2/15/2012 dysphagia (12/27/2011-3/28/2012)-resolved dehydration (2/07/2012-3/28/2012)-resolved Hypocalcemia (4/03/2012)-present Vitals (4/02/2012) blood pressure 123/21 pulse 69 temperature 98.8 respirations 12 spO2 93% amantadine (parkinson's disease) carbidopa-levodopa (parkinson's disease) epinephrine (adrenaline) injection insulin levalbuterol (xopenex) methylnatrexone (treat constipation) nalbuphine (nubain) (relieves pain) pantoprazole (treat damage to esophagus) pramipexole (parkinson's disease) vancomycin (antibiotic) furosemide (diuretic) cefazolin (treat bacterial infection) Continous infusions during surgery norepinephrine naloxone (reverse effects of narcotic drugs during surgery) bupivacaine (anesthetic) lactated ringers (sterile irrigation of body cavities) dextrose (use when additional fluids are needed) epidural T-6 -7 (pain)-current Procedures during hospitalization Esophagogastrectomy (primary) CT chest (4/04/2012) pneumonia versus atelectasis moderate left pleural effusion two right chest tubes with tiny right anterior pneumothorax Sputum culture collection (04/04/2012) and resulted (04/06/2012) specimen source: Bronchial wash culture report: many Staphylococcus aureus Lab results (4/03/2012) creatine 0.9 BUN 16 NA 138 K 4.1 CO2 26 WBC 10.3 HGB 11.1 PLT 125 ABG ( 4/04/2012) ph 7.39 po2 60.1 pCO2 47.5 HCO3 28.3 Base 2.7 Lab results (4/04/2012) creatinine 0.9 BUN 14 NA 136 K 4.2 CL 101 CO2 30 WBC 8.1 HGB 10.3 PLT 122 CBC 4/05/2012 WBC 8.5 RBC 3.45 Hgb 10.5 PLT 124 Neutrophils 7.61 lymphocites 0.18 monocytes 0.70 basophils 0.01 Rt involvement (4/06/2012) Patient was on 1 l/min NC SpO2 pre 91% post 98% Pulse pre 104 post 94 Levalbuterol (xopenex) nebulizer solution 0.63mg q4h order for chest physioterapy Qid, discontinued that day and started Acapella Diagnosis Cancer of esophagus 2 chest tubes on R lung LLL and RLL collapsed Any questions besides Shawn Medical History Patient Presentation allergies lisinopril (treats high blood pressure) Medications By Karla Arias Admission patient was admitted to ICCU on (04/02/2012) Resection of gastroesophageal carcinoma
Transcript: Life History Born in Manti, UT 3 brothers and 3 sisters Married at one time, currently single Raised 2 sons and a daughter on her own worked multiple jobs low income (Medicaid) Support System Son- working 2 jobs and wife not willing to help with JH Son- house not adaptable to wheelchair Daughter- little contact History of Present Illness Admitted from Mt. View Hospital Having trouble living on her own- wasn't managing diabetes well, having pain with prosthesis, paranoid, poor health (shortness of breath, dysuria, cellulitis of right leg) PCP recommended a short term nursing home stay a couple weeks turned into over a year Tried to discharge twice. 1st time- home overnight, couldn't get up to go to the bathroom, in chair for 12-15 hours 2nd time- got home, could not bear her weight and collapsed getting out of car...son helped her up and she asked if he could take her back to nursing home. Acute & Chronic Conditions Type II Diabetes Hypertension Congestive Heart Failure Liver Cirrhosis Neuropathy Arthritis Umbilical Hernia Sleep apnea Left above knee amputation Glaucoma Insomnia GERD Time with Client Challenging Spent: administering meds, physical assessment, talking with her, the "Dirty Work" Pressure Ulcer Goals- Improved skin integrity and patient more compliant with care plan Interventions- turn q 2 hours, pressure-reducing mattress, monitoring site for any changes in size/color, patient education, assessing why patient is not compliant Outcomes Improved skin integrity Increasing patient compliance Did NOT turn q 2 hrs Uses pressure reducing mattress Able to examine ulcer during brief changes Assessed why patient isn't compliant (doesn't feel ulcer, tiring to turn in bed) Patient Education (importance of turning and keeping site clean/moist) Spiritual Assessment LDS entire life Doesn't get out of bed for church Bring sacrament to her Evidence Based Issue Pressure Ulcers and the Effectiveness of the Pressure- Redistributing Mattresses Knowledge Pressure Ulcer Care Medications (antihypertensives such as Zaroxolyn and Zestril and analgesics such as Methadone and Percocet) Skills Insulin injections Brief changes Bed linen change Heart/Lung Assessment Sample of 60 high-risk patients 65% had existing wounds 5-month period using PRM Although 1.6% developed erythema in sacral area, 69% had improved or healed wounds Journal of Tissue Viability "The Value of Systematic Evaluation in Determining the Effectiveness and Practical Utility of a Pressure- Redistributing Support Surface" Caring/Personal Growth I've learned... Patience Optimism Gratitude Love Knowledge Pressure Ulcer Care Initial Diagnoses Imbalanced Nutrition Impaired Skin Integrity Conclusions Of the 1,959 persons, 83.62% had a Braden scale rating of 6-12 and 43.62% had ulcers 54.62% ulcers improved 7.6% ulcers progressed Compare/Contrast The use of pressure relieving mattresses is a current evidence-based practice and can be seen in the nursin home in the case of JH. Caring Moments Sitting and talking with her about her family (but not in great detail) Watching "Price is Right" with her Demographics 56-year-old Caucasian Female My Care What I Learned Professioni Infermieristiche "Prevention of Pressure Ulcers: Retrospective Study Regarding the Effectiveness of an Alternate Pressure Device" Patient Presentation Evaluated use of APM's in terms of: 1) Risk Factors (Braden Scale) 2) Duration of Mattress usage 3) Description of lesions at beginning 4) Changes in lesions by the end Caring Strategies Keeping her company (talking, watching TV) Bringing her milk and ice Irritated when treated "like a baby" Being gentle (complains that the nurses are rough with her)
Transcript: Patient Portal Utilization Meaningful use is using certified electronic health record (EHR) technology to: Improve quality, safety, efficiency, and reduce health disparities Engage patients and family Improve care coordination, and population and public health Maintain privacy and security of patient health information Meaningful use sets specific objectives that eligible professionals (EPs) and hospitals must achieve to qualify for Centers for Medicare & Medicaid Services (CMS) Incentive Programs. Two metrics: Patient Electronic Access 1: 50% target Measure 1: More than 50 percent of all unique patients seen by the EP during the EHR reporting period are provided timely access to view online, download, and transmit to a third party their health information subject to the EP's discretion to withhold certain information. Patient Electronic Access 2: 5% target For an EHR reporting period in 2017, more than 5 percent of unique patients seen by the EP during the EHR reporting period (or his or her authorized representatives) view, download or transmit to a third party their health information during the EHR reporting period. “When patients interact with their test results, they need to know the purpose of the test, the interpretation of the result, and next steps. Addressing these issues may help improve patient-centered care” (Baldwin, Singh, Sittig, & Giardina, 2016). References 2016 Program Requirements. Retrieved September 25, 2016, from https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/2016ProgramRequirements.html Baldwin, J. L., Singh, H., Sittig, D. F., & Giardina, T. D. (2016, October). Patient portals and health apps: Pitfalls, promises, and what one might learn from the other. In Healthcare. Elsevier. Eschler, J., Liu, L. S., Vizer, L. M., McClure, J. B., Lozano, P., Pratt, W., & Ralston, J. D. (2015). Designing Asynchronous Communication Tools for Optimization of Patient-Clinician Coordination. In AMIA Annual Symposium Proceedings (Vol. 2015, p. 543). American Medical Informatics Association. Heyworth, L., Paquin, A. M., Clark, J., Kamenker, V., Stewart, M., Martin, T., & Simon, S. R. (2014). Engaging patients in medication reconciliation via a patient portal following hospital discharge. Journal of the American Medical Informatics Association, 21(e1), e157-e162. Snyder, E., & Oliver, J. (2014). Evidence based strategies for attesting to Meaningful Use of electronic health records: An integrative review. Available in the. Online Journal of Nursing Informatics (OJNI), 18(3). Wade-Vuturo, A. E., Mayberry, L. S., & Osborn, C. Y. (2013). Secure messaging and diabetes management: experiences and perspectives of patient portal users. Journal of the American Medical Informatics Association, 20(3), 519-525. Wilcox, L., Patel, R., Back, A., Czerwinski, M., Gorman, P., Horvitz, E., & Pratt, W. (2013, April). Patient-clinician communication: the roadmap for HCI. In CHI'13 Extended Abstracts on Human Factors in Computing Systems (pp. 3291-3294). ACM. Stage 3 and MACRA Meaningful Use and the Patient Portal Literature “regular internet use and having a personal computer partially accounted for differences in use of the portal to send messages to health care providers by age, race, and income, whereas education and sex-related differences remained statistically significant even after controlling for internet access and care preference” (Graetz, Gordon, Fung, Hamity, & Reed, 2016). Meaningful Use Usability and Functionality Wanjiku Kariuki Viola B. Leal Mohammad Tabatabai Ana Ibarra Noriega MyUofMHealth.org Secure Messaging “over two-thirds had at least one medication discrepancy at discharge, and nearly one-third had at least one potential ADE” (Heyworth et al., 2014). The authors found that “virtual medication reconciliation following hospital discharge has the potential to improve medication safety in the transition from inpatient to outpatient care” “more effort on the part of the provider is needed to encourage patients to use a portal system. If providers take a more active role in educating patients as to the benefit of the portal, provide a positive view of the system, provide consistent standardized information, and remind the patients in multiple ways and times, patients are more likely to enroll in the portal system” (Snyder & Oliver, 2014). Objective 8: Patient Electronic Access (VDT) Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP. Patient Portal Metric Provider Buy-in Portal on Newer Internet Browser Lab Test Results DMC Patient Portal “patient and provider attitudes toward patient portal use found that the most negatively-perceived feature was user-friendliness, making the portal difficult to navigate” (Baldwin, Singh, Sittig, & Giardina, 2016). “When patients interact with their test results, they need to know the purpose of the test, the interpretation of the
Transcript: Thinking points Decreased albumin production Increased a-1-AGP Possible p-450 reduction Increased liver/renal flow 49 yo female admitted with 86% TBSA burn (80% 3rd degree). > 5 month ICU stay. Multiple infections and antibiotic courses PMH Hypothyroidism Adrenal insufficiency SH 1/2 pack/d smoker FH Negative Allergies None Phases of Thermal Injury Phases of Thermal Injury Clinical Presentation Blood culture results 10/30 P. aeruginosa Tobramycin 400 mg Iv q24h Antibiotics in burn patients : Pharmacokinetic considerations Clinical Presentation Clinical Presentation Phases of Burn Injuries Increased blood flow Antibiotics (11/9) Fluconazole 800 mg IV q24h Tobramycin 400 mg Iv q24h Phase 2 cont. Increased blood flow and reduced albumin production results in an increase is elimination of highly protein bound antibiotics. Ertapenem Daptomycin Ceftriaxone Nafcillin Phase 1 (<48-72 hr) Hypovolemia Vascular Hyperpermeability Negative interstitial pressure Low CO/GFR Phase 2 (>48-72 hr) Hypermetabolic Increased contractility/CO Low vascular resistance Increased liver/renal flow Clinical Presentation Phase 2 (>48-72 hr) Hypermetabolic Increased contractility/CO Low vascular resistance Increased liver/renal flow
Transcript: Expose Findings/Interventions Disability/Dextrose/Doctor/Discomfort Findings/Interventions Due to patients presentation so far: No need to call doctor at present States pain currently 6/10, but able to tolerate assessment at this time No evidence of hyper/hypoglycemia, so blood sugar not checked at this time Patient remains alert and interactive with assessment Clinical Case Presentation Airway Findings Interventions Patient alert and interactive. No complaints of c-spine trauma or tenderness Feel Listen Look Ensure safety equipment available at bedside including appropriately sized: Suction equipment BVM OPA Oxyegn delivery devices Able to speak full sentences No stridor No hoarse voice Equal rise and fall of chest Sitting upright and maintaining own airway No drooling, edema, or FB in mouth If required, could have felt for air movement Had enough evidence from look and listen to avoid this step Primary Assessment While the PAT for this patient demonstrated no major red flags, the patient was calm, and cooperative with the assessment, so I continued with a quick primary assessment before starting my secondary Pediatric Assessment Triangle Appearance Circulation Alert Walking independently Talking with dad Maintaining own airway Skin pink, warm and dry Mucus membranes moist Interventions? Patient walked to room independently Writer proceeded to primary assessment Breathing No WOB Resps regular and easy No tripoding or drooling Chief Complaint c/o 5/7 hx of left sided chest pain/pressure with intermittent SOB and sharp "stabbing" pain to left chest c/o intermittent pain radiating to L and R shoulder/arm Circulation Interventions Findings Consider IV access Due to stability at this point in assessment, no IV initiated at this time Cardiac monitoring initiated NSR demonstrated ECG ordered Unsure of what is causing CP, ECG can provide evidence of cardiac changes/damage Demonstrated NRS Cap refill: Brisk (<3 sec) Equal centrally and peripherally Skin: Warm Pink, no cyanosis Dry No mottling to peripheries Heart rate/rhythm: Peripheral pulses strong and regular No murmur on auscultation S1S2 audible Rate age appropriate at 80 bpm Breathing Findings Interventions Lung Auscultation Breath sounds decreased to left side, but A/E still audible to base A/E clear to right side No adventitious lung sounds bilaterally Apply pulse oximetery Apply to index finger on right hand SpO2 100% No indication for oxygen supplementation at this time, but nasal prongs, face mask, and NRB available if needed. No WOB No accessory muscle use No nasal flaring No prolonged expiration Breathing appears effective Chest rise and fall symmetrical No tracheal tug Respiratory rate adequate for patients age 16-24 resps/min
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