Nursing 4270: Transition to Professional Practice

November 5, 2014

Jennifer Bauman, RN, BA, PCCNPhD Student

The Ohio State University College of Nursing

Objectives

• Describe the nursing process (ADPIE) in relation to inpatient management of the adult patient in the acute care setting.– Identify five expected assessment findings for the case

study patient. – Identify three nursing diagnoses and accompanying

plan/goals of care. – Identify at least five nursing interventions. – Identify at least two medications used for this patient. – Identify the major tool used for evaluation of this patient.

Case Study• Bob, a 67 year old Caucasian male, was admitted to your unit

four hours before shift change, at approximately 3pm. He was transported to the emergency room via EMS. (His daughter had not heard from him that morning; they usually speak on the phone at 10am every day. Also, they had dinner together yesterday evening, around 6 pm.) Per the EMS transporters, he was found at the bottom of the stairs, on his left side. His left arm appears to be fractured and is immobilized with a sling. He has already gone for full body x-rays and does not have any other fractures. He does have a productive cough, with a moderate amount of yellow-green, thick sputum. Bob has a history of CAD, with DES x2 about four years ago. His EF is maintained at 60%, per a recent echo about 6 months ago. (Remember, DES = anticoagulation necessary, usually with Plavix. Bob is actually on coumadin, because it’s cheaper.)

Assessment findings

• Assessment findings:– Neuro: in C-spine precautions, contusion on L forehead,

A&Ox4, MOEx4 although limited ROM LUE d/t fractured arm, PERRLA intact, no deficits noted at this time

– Cardiac: temp 101.3 oral, ST with PVCs on tele, HR 120’s, BP 95/56 with MAP 69, trace 1+ edema BLE (non-pitting)

– Respiratory: SpO2 87% on RA, RR 28 with mild accessory muscle use, lungs with ronchi t/o and diminished in bases, orthopnea and DOE, yellow-green sputum (moderate amt)

– GI/GU: last BM yesterday, BXx4, no tenderness or pain in abd, foley has been placed but only 50ml dark and tea-colored UOP

– Skin: Large bruise on L chest and flank, poor turgor

What else do you want to assess?

• What time did he fall? How long has been been down? (What condition would you suspect if down for an extended period of time?)

• What medications does Bob take, and when did he last take them? (Cardiac, especially!)

• He fell on his left side – what organ are you concerned about?

Labs• Chemistry

– Na (normal 135-145) = 137 mg/dL– K (normal 3.5-4.5) = 5 mg/dL– Cl (normal 98-106) = 96 mEq/mL– Mag (normal 1.8-2.6) = 1.6 mg/dL– Creat (normal 1-2) = 2.1 mg/dL– BUN (normal 7-20) = 12.6 mg/dL– Calcium (normal 9-11) = 7.5 mg/dL – Phosphorous (normal 3-4.5) = 5mg/dL – Anion gap (normal 8-16) = 22 mmol/L– BUN/Creat ratio (normal 10:1) = 6:1

• Hematology– WBC (normal 4.5-11) = 18 x 103 /L – RBC (normal 4.3-5.7) = 4 x 108 /L– H/H (normal 13.5-17.5 and 39-49) = 12 g/dL and 32%

• Why is the Hct lower than expected, given the Hgb? – Platelets (normal 150-450) = 100 x 103 /L

• Coag panel– INR (normal .9-1.1) = 2.6

• Lactate (not worried if less than 2 mmol/L) = 3.7 mmol/L = increased H+ ions = acidosis (weak correlation)• “Lactate is a marker for cellular hypoxia. A level above 4.0 mmol/L is associated with a 27% mortality rate, compared with a

mortality rate of 7% for patients with a lactate level of 2.5-4.0 mmol/L and a death rate below 5% for those with a lactate level below 2.5 mmol/L, said Dr Strehlow of the university” (Boschert, 2007).

• CK (normal 36-137) = 10,000 U/L – “CK is consisted of three isoenzyme which are: CK-MM mostly found in muscles, CK-MB mostly found in heart and

CK-BB mostly found in the brain and kidneys” (E et al., 2007).

What other diagnostics do you want?

• Lower respiratory culture• Strep/pnemo urine (Legionella pneumophila and Streptococcus

pneumoniae)• Blood cultures• Urine culture• Differential added on to hematology labs • Chest Xray• Uric acid • CT of head and abdomen – use contrast? Why/why not? • Toxicity panel (urine and blood) • If indicated due to severity of symptoms, can also assess CVP with CVC … • ABG?

Diagnoses

• Risk for falls related to recent fall.• Risk for hemorrhage related to chronic

anticoagulation.• Decreased fluid volume related to rhabdo aeb

dark urine, low urine output, poor skin turgor. • More ???

Plan/Goals of Care

• Bob will be free from falls while in the hospital.

• Bob will remain free from signs/symptoms of hemorrhage while in the hospital.

• Bob will experience adequate fluid volume, as evidenced by increased UOP, less concentrated urine, and improved skin turgor.

• More ???

Rhabdomylosis

• Muscle breakdown causes cell lysis, which releases the intracellular components.

• “When reperfusion starts, leukocytes migrate into the damaged area, cytokines and prostaglandins increase whereas free radicals are produced in the presence of oxygen.”

• Myoglobin clogs the renal tubules + vasoconstriction + hypovolemia acute renal failure

• Metabolic acidosis

Pneumonia

• Community Acquired Pneumonia (CAP)• Healthcare Associated Pneumonia (HCAP)

• What are the differences?• Which of these do you think Bob has?

SIRS/Sepsis

• SIRS: systemic inflammatory response syndrome – from an infectious or non-infectious insult

• Sepsis: a complication of severe infection, characterized by dysregulated inflammation; from SIRS sepsis severe sepsis septic shock – Increased capillary permeability– Vasodilation– Leukocyte accumulation

Risk Factors

• Bacteremia • Advanced age (over 65 yo)• Immunosuppression• Community acquired PNA• Genetic factors

• Temperature >38.3 or <36ºC• Heart rate >90 beats/min or more than two standard deviations above the normal value for

age• Tachypnea, respiratory rate >20 breaths/min• Altered mental status• Significant edema or positive fluid balance (>20 mL/kg over 24 hours)• Hyperglycemia (plasma glucose >140 mg/dL or 7.7 mmol/L) in the absence of diabetes• Inflammatory variables

– Leukocytosis (WBC count >12,000 microL–1) or leukopenia (WBC count <4000 microL–1)– Normal WBC count with greater than 10 percent immature forms– Plasma C-reactive protein more than two standard deviations above the normal value– Plasma procalcitonin more than two standard deviations above the normal value

• Hemodynamic variables– Arterial hypotension (systolic blood pressure SBP <90 mmHg, MAP <70 mmHg, or an SBP decrease >40

mmHg in adults or less than two standard deviations below normal for age)• Organ dysfunction variables

– Arterial hypoxemia (arterial oxygen tension [PaO2]/fraction of inspired oxygen [FiO2] <300)– Acute oliguria (urine output <0.5 mL/kg/hr for at least two hours despite adequate fluid resuscitation)– Creatinine increase >0.5 mg/dL or 44.2 micromol/L– Coagulation abnormalities (international normalized ratio [INR] >1.5 or activated partial thromboplastin

time [aPTT] >60 seconds)– Ileus (absent bowel sounds)– Thrombocytopenia (platelet count <100,000 microL–1)– Hyperbilirubinemia (plasma total bilirubin >4 mg/dL or 70 micromol/L)

• Tissue perfusion variables– Hyperlactatemia (>1 mmol/L)– Decreased capillary refill or mottling

Early goal-directed therapy targets — Although evidence is conflicting regarding the routine measurement of early goal-directed therapy targets, we suggest measuring the following targets for fluid management in patients with sepsis:●Mean arterial pressure (MAP) ≥65 mmHg (MAP = [(2 x diastolic) + systolic]/3)●Urine output ≥0.5 mL/kg/hour●Static or dynamic predictors of fluid responsiveness, eg, central venous pressure (CVP) 8 to 12 mmHg when central access is available (static measurement) or respiratory changes in the radial artery pulse pressure (dynamic measurement).●Central venous (superior vena cava) oxyhemoglobin saturation (ScvO2) ≥70 percent (when central access is available) or mixed venous oxyhemoglobin saturation (SvO2) ≥65 percent (if a pulmonary artery catheter is being used).

Interventions for Bob • Establish IV access• Fluids

– What should be added to your IVF? • Measure intake/output (probably every 2h)• VS q1h• Continue tele and pulse ox• Trend labs • Oxygen therapy • Neuro checks q4h (for now…) • Cooling measures

– Antipyretic– Cooling blanket, if tolerated

• Electrolyte replacements– What do you do about the high K? – Tell me about the Phos/Calcium relationship

• Antbx• Safety measures• What am I missing?!?!

Bob’s Condition Worsens

You have been caring for Bob for six hours (10 hours post admission). On your hourly rounds, you walk into Bob’s room and notice that he is sitting at the edge of the bed, picking at his skin and pulling at his foley and monitor wires. He does not know the year or where he is, and you notice that his hands are shaking. Bob is also diaphoretic and anxious. His HR and BP are elevated, and he has taken off his oxygen, so his SpO2 has dropped to 85%. What do you do?

Your shift continues … You put Bob back in bed, replace his oxygen (his SpO2 is now 94% on 2L NC). You assess Bob’s CIWA score; it is 16, indicating moderate etoh withdrawal. You contact the LIP, who enters the CIWA order set but also requests that you contact Bob’s daughter, to rule out other types of withdrawal. You call Bob’s daughter, and she states that Bob drinks a fifth of whiskey per day, which he has been doing since his wife died two years ago. He has never been admitted for withdrawal in the past and does not take any other medications from which withdrawal would be considered. She said that Bob ran out of whiskey two days ago, but he drank two beers at dinner last night. What else do you want to do???

(Ethyl) Alcohol = Ethanol

• Ethyl alcohol is the only type of consumable ethanol.• Central nervous system (CNS) depressant• Simultaneously enhances inhibitory tone via modulation

of gamma-aminobutyric acid (GABA) activity and dampens excitatory tone via modulation of excitatory amino acid activity

• To keep the inhibitory and excitatory tones balanced (i.e., homeostasis), must have constant presence of ethanol.

• Abrupt cessation of ethanol creates an imbalance (i.e., interrupts homeostasis) = overactivity of CNS

Long term effects of Alcohol Misuse

• Liver disease– Cirrhosis

• “Among all cirrhosis deaths in 2009, 48.2 percent were alcohol related. The proportion of alcohol-related cirrhosis was highest (70.6 percent) among decedents ages 35–44”(NIAAA, 2014).

• However, only 5-10% of alcoholics develop cirrhosis

– Fatty liver disease – Hepatitis – 1 in 3 liver transplants in 2009 were due to alcohol-related disease (NIAAA, 2014)

• Increased risk for cancer of mouth, esophagus, pharynx, larynx, liver, and breast

• Pancreatitis• Malnutrition • Wernicke’s Encephalopathy• Higher risk for injury, especially falls• Impaired judgement = high risk behavior = increased risk for STIs, sexual

assault, etc.

Alcohol Withdrawal(If it doesn’t work, use this link: http://www.youtube.com/watch?v=bAEcA4mCMfc)

Symptoms of Withdrawal • Insomnia• Anxiety and/or Fear• Restlessness• Nausea and/or Vomiting• Headache• Seizures – may need CT scan, lumbar puncture• Altered Sensory Perceptions, including visual (common), tactile

(common), auditory• Tremors• Diaphoresis• Tachycardia, which may/may not be accompanied by palpitations

(why??)

Delirium Tremens (DT)

• “… hallucinations, disorientation, tachycardia, hypertension, fever, agitation, and diaphoresis in the setting of acute reduction or abstinence from alcohol.”

• Last up to 7 days, mortality rate of 5% • Increased cardiac indices, oxygen delivery, and oxygen consumption • Arterial pH rises due to hyperventilation (respiratory alkalosis) = decrease in

cerebral blood flow • Fluid and electrolyte status:

• Hypovolemic r/t diaphoresis, hyperthermia, vomiting, and tachypnea• Hypokalemia r/t renal and extrarenal losses, alterations in aldosterone

levels, and changes in potassium distribution across the cell membrane• Hypomagnesemia r/t malnutrition; may predispose to dysrhythmia

(torsades des pointes) and seizures• Hypophosphatemia r/t malnutrition; may contribute to cardiac failure and

rhabdomyolysis.

Who is at risk for DT?

• A history of sustained drinking• A history of previous DT• Over age 30 • The presence of a concurrent illness• The presence of significant alcohol withdrawal in the

presence of an elevated alcohol level• A longer period since the last drink (ie, patients who

present with alcohol withdrawal more than two days after their last drink are more likely to experience DT than those who present within two days)

Other diagnoses to consider

• “A premature diagnosis of alcohol withdrawal can lead to inappropriate use of sedatives, which can further delay accurate diagnosis.”

• Infection (e.g., meningitis) • Trauma (e.g., intracranial hemorrhage)• Metabolic derangements• Drug overdose• Hepatic failure• Gastrointestinal bleeding

Assessment: Clinical Institute Withdrawal Assessment (CIWA)

Assessment: CIWA Calculation

• http://www.mdcalc.com/ciwa-ar-for-alcohol-withdrawal/

Assessment – beyond CIWA

• Questions to ask: – CAGE questions (Kosten et al, 2003)

• Can you cut down on your drinking?• Are you annoyed when asked to stop drinking?• Do you feel guilty about your drinking? • Do you need an eye opener drink in the morning when you wake up?

– How long have you gone without alcohol in the past six months? – Has anyone ever advised that you cut down on your drinking?– When was the last drink (i.e., the most recent alcohol consumption)?– How much alcohol per day?– How long has the patient been dependent on alcohol? – Has he/she ever experienced withdrawal or delirium tremens

before? • If so, how many times has this occurred, and did he/she ever have seizures?

Continued assessment …• Vital signs – what would you expect to find, and why?• See “Symptoms” slide for signs/symptoms of withdrawal • Risk for elopement, falls, aspiration • Smoking status• Blood sugar – Accucheck• Urine drug/toxicity screen • Blood work to collect:

– Chemistry– Complete Blood Count (CBC) with differential and platelet– Coagulation panel (PT, INR, PTT)– Liver Function Tests (LFT)– Uric acid – Alcohol, whole blood – Drug/toxicity screen – should be collected at the same time as the urine, if possible

Diagnoses (examples)

• Risk for Injury (especially falls!) • Risk for Elopement• Risk for Sensory-Perceptual Alterations • Anxiety and/or Fear r/t alcohol withdrawal

aeb restlessness, tachycardia, hypertension• Risk for Aspiration (Ineffective Breathing

Pattern) • Risk for Seizures

Plan and Goals of Care (examples)

• The patient will remain free from falls during the hospital stay by using bed exit alarm and frequent monitoring by staff.

• The patient will not elope from the hospital during his/her stay through frequent monitoring, purple gown, security alert.

• The patient will not aspirate during his/her stay by keeping HOB > 30 degrees, monitoring during PO intake, staff evaluation for safe swallow.

Interventions• IV access • Administer medications (as ordered by LIP)• Possible sitter/safety coach and/or to be closer to nurses’ station• If at risk for elopement, place in special gown (at OSUWMC, it is bright purple), notify

security of increased risk, and keep close to nurses’ station, away from elevators. • Going off the unit is contraindicated, both due to risk for elopement and medication

administration • Avoid the use of restraints, especially LBB• Bed exit alarm • Seizure pads on bedrails• HOB at 30 degrees or greater, if no contraindications • Quiet, dark, calm environment• Fan or cool washcloths• Nurse should present calm demeanor• Limit setting• Nicotine replacement • Consults: social work, nutrition, psychiatry, nicotine dependence

Interventions: Medications • Chlordiazepoxide (Librium) – long-acting benzodiazepine• Diazepam (Valium) – long-acting benzo• Lorazepam (Ativan) – short-acting benzo• Flumazenil (Romazicon) – reversal agent for benzo• Clonidine (Catapres) - centrally acting alpha-2 agonist, for

severe DT, but may mask symptoms of worsening status• Phenobarital – anticonvulsant, if severe DT or status

epilecticus • AVOID the routine use of anticonvulsants, beta blockers (mask

symptoms) and antipsychotics (lower the seizure threshold) • Vitamins, especially folic acid and thiamine• Electrolytes, especially glucose, magnesium, phosphate, and

potassium • Intravenous fluids, if not contraindicated

Interventions: Medications used at OSUWMC

Evaluation

• Back to assessment – check CIWA score per the protocol

• Re-assess

Back to Bob … • Your shift is coming to an end. Bob is resting

peacefully after receiving 2mg of IVP Ativan every hour during your shift. His head CT was completed, and he has small, 2mm hematoma on the right frontal lobe. You continue to perform neuro checks every hour, and you’re reversing his warfarin (Coumadin) with vitamin K and FFP. He continues to receive IVF (with sod. Bicarb.), antbx, and oxygen therapy. His urine output is improving in amount and color. What do you want to pass onto the oncoming shift? (You can give me a sample shift report, if you want!)

Questions?

http://whatshouldwecallnursing.tumblr.com/post/100024997786/when-i-think-about-how-prepared-i-feel-to-handle-ebola

And

http://whatshouldwecallnursingschool.tumblr.com/post/74607297818/my-high-falls-risk-patient-going-to-the-bathroom

Thank you for having me, and enjoy the rest of your semester!

References• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American

Psychiatric Publishing. Retrieved September 30, 2014, from http://dsm.psychiatryonline.org/book.aspx?bookid=556. • Boschert, S. (2007). Is it septic shock? Check a lactate level. American College of Emergency Physicians. Retrieved November 4,

2014, from http://www.acep.org/Clinical---Practice-Management/Is-It-Septic-Shock--Check-Lactate-Level/• Criddle, L.M. (2003). Rhabdomylosis: Pathophysiology, recognition, and management. Critical Care Nurse, 23(6), 14-30. • Efstratiadis, G., Voulgaridou, A., Nikiforou, D., Kyventidis, A., Kourkouni, E., & Vergoulas, G. (2007). Rhabdomylosis updated.

Hippokratia, 11(3), 129-137. • Hoffman, R.S., & Weinhouse, G.L. (2013). Management of moderate and severe alcohol withdrawal syndromes. In S.J. Traub & J.

Grayzel (Eds.), UpToDate. Retrieved from http://www.uptodate.com/.• Kosten, T.R., & O’Connor, P.G. (2003). Management of drug and alcohol withdrawal. New England Journal of Medicine, 348(18),

1786-95. • Mandell, L.A., Wunderink, R.G., Anzueto, A., Bartlett, J.G., Campbell, G.D., Dean, N.C., Dowell, S.F., File, T.M., Musher, D.M.,

Niederman, M.S., Torres, A., & Whitney, C.G. (2007). Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases, 44, S27-72.

• MDCalc. (2014). CIWA-Ar for Alcohol Withdrawal. Retrieved September 20, 2014, from http://www.mdcalc.com/ciwa-ar-for-alcohol-withdrawal.

• National Institute on Alcohol Abuse and Alcoholism (NIAAA). (2014). Alcohol facts and statistics. Alcohol and Your Health. Retrieved September 30, 2014, from http://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-facts-and-statistics.

• National Institute on Alcohol Abuse and Alcoholism. (n.d.). What is a standard drink?. Alcohol and Your Health. Retrieved September 30, 2014, from http://www.niaaa.nih.gov/alcohol-your-health/overview-alcohol-consumption/standard-drink.

• Neviere, R. (2014). Sepsis and the systemic inflammatory response syndrome: Definitions, epidemiology, and prognosis. In P.E. Parsons & G. Finlay (Eds.), UpToDate. Retrieved from http://www.uptodate.com/.

• Nurselabs.com (n.d.). 5 Alcohol Withdrawal Nursing Care Plans. Retrieved September 30, 2014, from http://nurseslabs.com/5-alcohol-withdrawal-nursing-care-plans/.

• Office of Women’s Health at the U.S. Department of Health and Human Services. (2013). Straight talk about alcohol. GirlsHealth.gov. Retrieved September 30, 2014, from www.girlshealth.gov.

• Schmidt, G.A., & Mandel, J. (2014). Evaluation and management of severe sepsis and septic shock in adults. In P.E. Parsons , D.J. Sexton, R.S. Hockberger, & G. Finlay (Eds.), UpToDate. Retrieved from http://www.uptodate.com/.

• Weed, H.G. (2011). Clinician’s Guide to Alcohol Withdrawal as a Secondary Diagnosis. 2nd Edition. From The Ohio State University Medical Center Evidence Based Practice Clinical Resources. Retrieved September 20, 2014, from http://www.osumc.edu.