1. PATHO:
1.1. ARDS: AGGRESSIVE INFLAMMATORY REACTION WITH HYPOXEMIA AND DIFFUSE INFILTRATES, PRECEDED BY COVID 19 PNEUMONIA.
2. DIAGNOSTIC DATA:
2.1. CXR: WORSENING LUNG INFILTRATES, HEMATOLOGY LABS: LOW RBC, LOW H/H, HIGH NEUTRPHILS
3. MEDICATIONS:
3.1. FENTANYL, PRECEDEX, PROPOFOL, LASIX, LOVENOX, METHYLPREDNISOLONE, DOCUSATE SODIUM, ESOMEPRAZOLE, LANTUS
4. PROCEDURES:
4.1. CHEST X-RAY, INTUBATION, TRACHEOSTOMY, CHEST TUBE PLACEMENT
5. ASSESSMENT:
5.1. NEURO: PATIENT SEDATED, PUPILS PERRLA RESPIRATORY: CHEST TUBE PLACED, TRACHEOSTOMY SET TO AC MODE WITH RATE OF 20 BPM, ADDITIONAL PATIENT INITIATED BREATHS OF 7, PEEP 8, FIO2 60%, TV 450, 02 SATS LOW 90'S. SKIN COLOR NORMAL, CHEST RISE/FALL SYMMETRICAL. CHEST X-RAY RESULTS INDICATE WORSENING OF INFILTRATES/PNEUMOTHORAX. CARDIAC: MONITORED BY BP CUFF/ARTERIAL LINE. PB OF 150'S/80'S. APICAL PULSE 75, NORMAL RHYTHM/RATE. PERIPHERAL PULSES PRESENT AND NORMAL ON ALL 4 EXTREMITIES. GI/GU: FOLEY CATHETER PLACEMENT, LASIX GIVEN FOR EDEMA, CONSTIPATION, SMALL BM DAY BEFORE ASSESSMENT. SKIN: CLEAN, DRY DRESSING ON STAGE 2 PRESSURE INJURY ON COCCYX, ABRASION FROM CHEST TUBE ON LOWER RIGHT BACK, CHEST TUBE PLACEMENT UPPER RIGHT BACK, SKIN INTEGRITY AROUND TRACH TUBE INTACT, SKIN AROUND PEG TUBE INTACT, PICC TRI LUMEN PLACEMENT ON UPPER RIGHT ARM, A LINE PLACEMENT ON RIGHT LOWER ARM RADIAL
6. PRIMARY: IMPAIRED GAS EXCHANGE RELATED TO ARDS AS EVIDENCED BY INADEQUATE LUNG FUNCTIONING
6.1. ASSESSMENT:
6.1.1. 02 SAT: 90% ON FIO2 60% CXR: CHEST INFILTRATES PNEUMOTHORAX
6.2. CARE GOAL:
6.2.1. PATIENT WILL REMAIN AT OPTIMAL GAS EXCHANGE AS EVIDENCED BY PULSE OXIMETRY READINGS ABOVE 90% THROUGHOUT THE ENTIRE CLINICAL SHIFT
6.3. INTERVENTIONS 3
6.3.1. 1. CONTINUOUS TRACHEOSTOMY CARE/SUCTIONING
6.3.1.1. RATIONALE: MAINTAIN PATENT AIRWAY
6.3.2. 2. ASSESS CHANGES IN BP/HR/02SAT/TEMP/RR AND RHYTHM.
6.3.2.1. RATIONALE: STATUS CHANGES CAN INDICATE RESPIRATORY COMPROMISE
6.3.3. 3. AUSCULTATE LUNGS, NOTE AREAS OF DECREASED VENTILATION, OR ADVENTITIOUS BREATH SOUNDS.
6.3.3.1. RATIONALE: DECREASED/ABSENT BREATH SOUNDS INDICATE AIRWAY OBSTRUCTION, WHEEZING/CRACKLES/RHONCHI INIDICATE PRESENCE OF SECRETIONS
6.4. EVALUATION:
6.4.1. PATIENT MAINTAINED ADEQUATE GAS EXCHANGE AS EVIDENCED BY 02 SATS REMAINING ABOVE 92% THROUGHOUT THE ENIRE CLINICAL SHIFT
7. ALTERATION IN ELIMINATION RELATED TO SEDATIVE MEDICATION AND PATIENTS INABILITY TO CONTROL URINATION AS EVIDENCED BY PLACEMENT OF FOLEY CATH
7.1. ASSESSMENT:
7.1.1. FOLEY CATHETER PLACEMENT DUE TO INABILITY TO COMPLETELY EMPTY OR CONTROL VOIDING RELATED TO SEDATION
7.2. CARE GOAL:
7.2.1. PATIENT MAINTAINS ADEQUATE URINARY OUTPUT VIA FOLEY CATHETER AS EVIDENCED BY URINARY OUT PUT GREATER THAN OR EUAL TO 30 ML/HR THROUGHOUT THE ENTIRE CLINICAL SHIFT.
7.3. INTERVENTIONS 3
7.3.1. 1. KEEP URINE COLLECTION BAG BELOW LEVEL OF BLADDER.
7.3.1.1. RATIONALE: PREVENT THE BACK FLOW OF URINE INTO THE BLADDER WHICH CAN INCREASE THE RISK OF BACTERIA GROWTH
7.3.2. 2. OBSERVE FOR CLOUDY, BLOODY, FOUL ODOR OF URINE.
7.3.2.1. RATIONALE: SIGNS OF UTI OR KIDNEY INFECTION THAT CAN POTENTIATE SEPSIS
7.3.3. 3. MEASURE AND DOCUMENT INPUT AND URINE OUTPUT.
7.3.3.1. RATIONALE: I/O'S HELP DETERMINE ADEQUACY OF URINARY TRACT/KIDNEY FUNCTION
7.4. EVALUATION:
7.4.1. PATIENT MAINTAINED ADEQUATE URINARY OUTPUT EVIDENCED BY URINARY OUTPUT OF 1100ML/8HR CLINICAL SHIFT.
8. IMPAIRED SKIN INTEGRITY RELATED TO IMMOBILIZATION AS EVIDENCED BY PRESSURE INJURY ON COCCYX AND LOWER BACK
8.1. ASSESSMENT:
8.1.1. STAGE 2 PRESSURE INJURY ON COCCYX ABRASION ON BACK FROM CHEST TUBE SKIN BREAKDOWN ON PERI AREA
8.2. CARE GOAL:
8.2.1. PATIENT WILL MAINTAIN SKIN INTEGRITY EVIDENCED BY NO ADDITIONAL SKIN BREAKDOWN THROUGHOUT THE ENTIRE CLINICAL SHIFT.
8.3. INTERVENTIONS 3
8.3.1. 1. REPOSITION PATIENT EVERY TWO HOURS
8.3.1.1. RATIONALE: REPOSITIONING PATIENTS ALLOW FOR ADEQUATE BLOOD FLOW TO AREAS UNDER PRESSURE, OR ON BONY PROMINENCES, DECREASING CHANCE FOR PRESSURE INJURY
8.3.2. 2. ASSESS FOR FECAL INCONTINENCE FREQUENTLY, KEEP PERINEAL AREA CLEAN AND DRY.
8.3.2.1. RATIONALE: STOOL MAY CONTAIN ENZYMES THAT CAUSE SKIN BREAKDOWN
8.3.3. 3. ENSURE DIET THAT MEETS NUTRITIONAL NEEDS (PROMOTE INTERNAL FEEDING)
8.3.3.1. RATIONALE: HIGH-PROTEIN AND HIGH-CALORIE DIET TO PROMOTE WOUND HEALING
8.4. EVALUATION:
8.4.1. PATIENT MAINTAINED SKIN INTEGRITY THROUGH THE ENTIRE CLINICAL SHIFT EVIDENCED BY NO ADDITIONAL SKIN BREAKDOWN