Nursing 4270 Transition to Professional Practice November 5

Nursing 4270: Transition to Professional Practice November 5, 2014 Jennifer Bauman, RN, BA, PCCN Ph. D 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 3 pm. 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 10 am 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 xrays 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 x 2 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&Ox 4, MOEx 4 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: Sp. O 2 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, BXx 4, no tenderness or pain in abd, foley has been placed but only 50 ml dark and teacolored 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 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?

• Chemistry – – – – – • Labs Na (normal 135 -145) = 137 mg/d. L K (normal 3. 5 -4. 5) = 5 mg/d. L Cl (normal 98 -106) = 96 m. Eq/m. L Mag (normal 1. 8 -2. 6) = 1. 6 mg/d. L Creat (normal 1 -2) = 2. 1 mg/d. L BUN (normal 7 -20) = 12. 6 mg/d. L Calcium (normal 9 -11) = 7. 5 mg/d. L Phosphorous (normal 3 -4. 5) = 5 mg/d. L 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/d. L 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 m. L/kg over 24 hours) Hyperglycemia (plasma glucose >140 mg/d. L or 7. 7 mmol/L) in the absence of diabetes Inflammatory variables – – • Leukocytosis (WBC count >12, 000 micro. L– 1) or leukopenia (WBC count <4000 micro. L– 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 mm. Hg, MAP <70 mm. Hg, or an SBP decrease >40 mm. Hg in adults or less than two standard deviations below normal for age) • Organ dysfunction variables Arterial hypoxemia (arterial oxygen tension [Pa. O 2]/fraction of inspired oxygen [Fi. O 2] <300) Acute oliguria (urine output <0. 5 m. L/kg/hr for at least two hours despite adequate fluid resuscitation) Creatinine increase >0. 5 mg/d. L or 44. 2 micromol/L Coagulation abnormalities (international normalized ratio [INR] >1. 5 or activated partial thromboplastin time [a. PTT] >60 seconds) – Ileus (absent bowel sounds) – Thrombocytopenia (platelet count <100, 000 micro. L– 1) – Hyperbilirubinemia (plasma total bilirubin >4 mg/d. L 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 mm. Hg (MAP = [(2 x diastolic) + systolic]/3) ●Urine output ≥ 0. 5 m. L/kg/hour ●Static or dynamic predictors of fluid responsiveness, eg, central venous pressure (CVP) 8 to 12 mm. Hg 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 (Scv. O 2) ≥ 70 percent (when central access is available) or mixed venous oxyhemoglobin saturation (Sv. O 2) ≥ 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 2 h) VS q 1 h Continue tele and pulse ox Trend labs Oxygen therapy Neuro checks q 4 h (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 Sp. O 2 has dropped to 85%. What do you do?

Your shift continues … You put Bob back in bed, replace his oxygen (his Sp. O 2 is now 94% on 2 L 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=b. AEc. A 4 m. CMfc)

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 p. H 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 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-alcoholwithdrawal/

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 2 mg of IVP Ativan every hour during your shift. His head CT was completed, and he has small, 2 mm 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-abouthow-prepared-i-feel-to-handle-ebola And http: //whatshouldwecallnursingschool. tumblr. com/post/74607297818/my-high-falls-riskpatient-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 (5 th 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. ), Up. To. Date. 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, S 27 -72. MDCalc. (2014). CIWA-Ar for Alcohol Withdrawal. Retrieved September 20, 2014, from http: //www. mdcalc. com/ciwa-ar-foralcohol-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. ), Up. To. Date. 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. Girls. Health. 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. ), Up. To. Date. Retrieved from http: //www. uptodate. com/. Weed, H. G. (2011). Clinician’s Guide to Alcohol Withdrawal as a Secondary Diagnosis. 2 nd Edition. From The Ohio State University Medical Center Evidence Based Practice Clinical Resources. Retrieved September 20, 2014, from http: //www. osumc. edu.