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Grand Rounds Presentation

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Grand Rounds Presentation Caring for Adult Clients II Spring Semester 2008 Linda J. Calderwood Client Demographics Client: MF 77 Year old Caucasian female 5 0 ... – PowerPoint PPT presentation

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Title: Grand Rounds Presentation


1
Grand Rounds Presentation
  • Caring for Adult Clients II
  • Spring Semester 2008

Linda J. Calderwood
2
Client Demographics
  • Client MF
  • 77 Year old Caucasian female
  • 50 tall, 104 lbs.
  • Widowed (lt 1 year)
  • Assisted living
  • One adult child lives locally
  • Religious preference not specified
  • EMS called to client residence for respiratory
    distress.
  • Client was unresponsive with labored breathing
    cyanosis
  • Admitted to CCU 1/20/08 date of care
    1/23/08.

3
History Risk Factors
  • Recent hospitalization
  • for pneumonia - 2 weeks prior
  • COPD
  • Home O2
  • CHF
  • CAD
  • Hyperlipidemia
  • HTN
  • Hx smoking - quit gt 1 year

4
Physical Assessment
  • EENT
  • Oral endotracheal tube
  • Size 7.5
  • 21 at lip
  • Orogastric tube
  • No excess secretions, drooling
  • No ulcerations, swelling
  • Vision intact
  • Hearing intact
  • Vital Signs
  • Apical Pulse 90 - 105
  • Respirations 15 20
  • B/P
  • Systolic 80 118
  • Diastolic 39 50
  • Pulse oximetry 89 - 97
  • Temperature 98.2
  • Pain 0 on 0-10 scale

5
Physical Assessment cont.
  • Cardiovascular
  • Apical pulse regular
  • Cap refill lt 3 sec
  • Radial pulses 3, equal
  • Pedal pulses 2, equal
  • Non-pitting, moderate, weeping edema of hands,
    wrists, arms
  • Cardiac monitoring
  • Bedside monitor
  • SR / ST
  • Respiratory
  • Ventilator support
  • Assist/control mode
  • Vt 450, FiO2 30
  • ETT secured with holder backup airway at
    bedside inline suctioning
  • Cough by suctioning
  • Scant sputum clear, thin
  • Breath sounds diminished both lower lobes
  • Trachea midline

6
Physical Assessment cont.
  • Gastrointestinal
  • Hypoactive bowel sounds
  • Abdomen soft, no tenderness
  • No N/V
  • Last stool 1/22/08
  • Genitourinary
  • Indwelling catheter
  • Urine clear, yellow
  • No foul odor
  • UOP 250 mL/8h
  • No bladder distension
  • Genitals without lesions, edema or discharge

7
Physical Assessment cont.
  • Musculoskeletal
  • Generalized weakness
  • Dependent
  • Joint stiffness
  • Neurological
  • Arousable to stimuli verbal
  • Oriented x 3
  • Follows commands
  • Moves all extremeties
  • Grips equal
  • Calm, cooperative
  • Normal eye contact
  • Pupils 3mm, round, equal, reactive to light
  • RASS score -1 Drowsy

8
Physical Assessment cont.
  • Integumentary
  • Skin warm, dry color appropriate for ethnicity
  • Skin thin, fragile
  • Stage I pressure ulcer, left heel
  • Protective foam boots
  • Psychosocial
  • Without apparent emotional distress
  • Daughter at bedside
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