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” tall, 104 lbs. • Widowed (< 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.
History & Risk Factors • Recent hospitalization for pneumonia - 2 weeks prior • COPD • Home O2 • CHF • CAD • Hyperlipidemia • HTN • Hx smoking - quit > 1 year
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 Physical Assessment
Cardiovascular Apical pulse regular Cap refill < 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 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 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 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 Physical Assessment cont.