STUDENT NURSE

Preclinical Work-up
Student: STUDENT NUSE_

Unit: ICU

Day of Care: 5FEB2015

I. BASELINE INFORMATION
A. Demographics
Pt. Initials C.G Room #5 Gender/Age F/63 Code Status FULL A.D. YES
Ht 1.6 m (53)

Wt : 48 Kg (105 lb 13.1 oz)

ALLERGIES (and response to if known) Lanolin, PCN, Silicone, Sulfa, Vicodin (Unknown Response)
Admitting Diagnosis: RESPIRATORY FAILURE ACUTE/ HCC
Actual (Current) Diagnosis RESPIRATORY FAILURE ACUTE/ HCC

Date of Admission 02/01/2015

Current Surgery(s) flexible and rigid bronchoscopy for removal of airway foreign body (02/01/2015)
Isolation Precautions NONE
Fall Risk Precautions YES
Eriksons Developmental Level Generative vs. Stagnation
Culture/Ethnicity/Religious Preference: Caucasian/Jewish
II. INFORMATION FROM CHART
1. Chief Complaint (Reason for Hospitalization):
Acute Respiratory Arrest
2. History of Present Illness (HPI) Tell the patients story about this illness; provide a brief summary from the chart):
2/1/15 Pt. was having lunch when all of a sudden she started having difficulty breathing, chocking and coughing x10
min before collapsing. The paramedics were called and the pt. was brought to the ED intubated. She arrived with VS
T:95.8, HR:100, BP:101/77, RR:21. The EKG showed ST (124), cXray showed bilateral alveolar infiltrates, left greater
than right. A bronchoscopy revealed that the pt. was on acute respiratory failure secondary to foreign object (chicken) in
the left main bronchus. The pt. was on severe metabolic acidosis. The foreign object was Sx. removed.
2/2/15 Patient is stable. Foreign body removed. Right vocal cord appeared to have a lesion at DL. The plan is to wean
vent as tolerated. Consider outpatient or elective ENT consult. Trach to be considered and conversion of PEG (placed
2003) to be used for feedings. Pt. is on SR but converts to ST when agitated. There is moderate amount of blood tinged
pulmonary secretions. Feedings via PEG started and NGT clamped. Adequate UO via indwelling catheter. Intact skin.
PICC line inserted.
2/3/15 Lungs are diminished bilaterally. SR. BS WNL. No edema, no s/s of DVT. Tracheostomy
2/4/15 cXR continues to show significant L sided infiltrate and small on R. Rhonchi on L. SR. BS WNL.
3. Past Medical History (Bullet-points)

Migraine
Stroke (HCC)
Hypothyroidism
Aspiration pna
Sepsis
TB
Chronic back pain Baclofen pump
Pt. Deaf in both eats

Cerebral palsy
Anxiety disorder
Degenerative disc disease
Frozen should on the left side secondary to
fracture
Hx. of car accident resulting in neck surgery and
PEG placement
Hx. of dysphagia

I. Baseline Information II. Information from Chart III. Focus of Care IV. Considerations for Care

STUDENT NURSE

III. FOCUS CARE (Think like a nurse, bullet-points)

1. Based on your preclinical research, what do you expect this patient to look like in terms of their diagnosis and
condition when you walk into the room at the start of the shift?
Based on the Dx., I expect to find a pt. that continues to be sedated and restrained due to her need for a ventilator. During the
sedation vacation, the pt. becomes agitated and requires to be restrained to prevent her from pulling lines. Additionally, when the pt.
becomes agitated, she presents with ST. I predict that this pt. will not be ready to be weaned from the ventilator. The pt. continues to
show no s/s of pulmonary improvement, thus I expect to find that she is still on FiO2 40%. I expect the pt.s lungs will continue to
show s/s of L infiltrate and will continue to present with diminished bilateral breaths sounds.

2. What are the important assessment to make, including labs and diagnostics?

The focus of this pt.s assessment is RESPIRATORY

o Lung sounds
o RR
o ABGs
o O2 sat
o Monitor HR tachycardia can be an indication of respiratory failure
o Monitor cXR for s/s infiltrates
o Skin color and capillary refill
o Monitor CBC
It is important to assess VS for s/s of infection as the pt. is on a ventilator and at risk for VAP

3. What will tell you if the patient is improving?

cXR with decreased infiltrates

Clear lung sounds
ABGs pH WNL
No agitation during sedation vacation
Pt. shows signs of spontaneous effort
Pt. meets weaning criteria
Pt. tolerates ventilation weaning IMPORTANT FOR DISCHARGE FROM ICU!

4. What complications may occur & how would you recognize it; who would you notify if it did?

Inadvertent extubation pt. has a tracheostomy call for help (another nurse) if the pt. is agitated and requires
holding during reintubation - all the equipment the RN needs is at the beside. Document and let the charge nurse
know? Would you need to call the MD after or would it be something you shared when s/he came for rounds?
VAP contact MD and RT
DVT contact MD
Acid/Base imbalances contact MD
ARDS contact MD

5. What interventions will prevent the complications?

Use of restrains
ABCDE Bundle to promote early extubation
HOB at 30 to prevent aspiration
Monitor BS to determine motility, check residuals to prevent aspiration.
Intermittent sequential pneumatic compression
Suctioning
Oral care

I. Baseline Information II. Information from Chart III. Focus of Care IV. Considerations for Care

STUDENT NURSE

IV. CONSIDERATIONS FOR CARE

1. Diet and rationale (include reference):
Tube feeding tube feeding formulas contain vitamin k to meet the daily recommended intake of 80 mcg/day in 1000 to
1500 ml of formula. Consideration should be given when dosing anticoagulation medications for patient who have
recently and extremely limited their intake of dietary vitamin k.
Product: Replete (1 cal/ml, high protein, replaces promote). Rate: 40 ml. Increase 10 ml q6hr until goal rate (60 ml) is
met.
PEG
Additional water volume: 20 ml q2h
Rationale: Nutritional depletion can lead to loss of muscle mass, which can impair respiratory muscles and prolong
recovery. Enteral feedings provide the calories needed to meet the hypermetabolic state of the pt. and prevent nutritional
depletion. The pt. is on tube enteral feeding because during acute respiratory failure there is a risk for aspiration;
additionally the pt. is sedated and on a ventilator. (Lewis et al., 2011, p. 1755).
2. Activity order (per MD order (if no order, expected activity ability): BEDREST WITH HOB AT 30 AT ALL TIMES
3. Discharge (on MAP only, teaching, referrals, etc...):
4. Culture/Ethnicity (on MAP only, nursing considerations R/T )

I. Baseline Information II. Information from Chart III. Focus of Care IV. Considerations for Care