GRAND ROUNDS

Shelaina LewisApril 17, 2008

CLIENT DEMOGRAPHICS-R.C.

69 year old, DOB 7/12/38 Caucasian Male Single – lives alone No children No Form of Religion English Speaking Height: 177.80 cm (70 in) — Weight: 145 lb (65.91kg) BMI: 18.8 No known allergies DNR

RISK FACTORS Recurrent bilateral

pneumonia c pleural effusions

Severe malnutrition Smoker – 2ppd, 30 years Chronic alcohol abuser Gastroesophageal reflux

disease (GERD) Left lung abscess in 2003

Patient history of: COPD Diabetes Mellitus

Type II Atrial Fibrillation Gastrointestinal

Bleed Coronary Artery

Disease Anemia Hypertension Alcoholic Hepatitis Right-sided heart

failure (RHF)

PHYSICAL ASSESSMENT:

Blood pressure: 98-132/61-98 Map: 71 Pulse: 78-92 Respirations: 30-52 Temperature (axillary): 97.5o-

98oF CVP: 8-10 Oxygen Saturation: 90-94%

Head – bitemporal wasting, dry and brittle hair, some hair loss

Neck – tracheotomy with mechanical ventilation midline, neck ties dry and intact

Vital Signs Head and Neck

PHYSICAL ASSESSMENT:

Eyes – closed, brisk reactive to light, conjunctivae pink and moist

Ears – equal size bilaterally, able to hear when spoken to close to ear

Nose – symmetric and midline

Mouth – poor dental health, several teeth missing, six caries, mucous membranes pink and moist EENT

Skin cool, dry, pale Reddened abrasion on right hip Stage III pressure ulcer on coccyx Stage II pressure ulcer on upper back-

right Stage I pressure ulcers on left and

right heel Mild (2+) peripheral edema in upper

extremities and lower extremities Triple lumen central line in right

subclavian Peripheral IV in left forearm All IV sites: dressing dry and intact

EENT Integumentary

PHYSICAL ASSESSMENT:

Telemetry: 6 second strip indicate

Normal Sinus Rhythm borderline tachycardia

PR interval: 0.16 QRS: 0.08 QT interval: 0.32

Normal rate and rhythm with no abnormal heart sounds noted

Capillary refill < 3 seconds All pulses palpable and equal

bilaterally

Continuous Mandatory Ventilation AC: 12 TV: 450 FiO2: 70

PEEP: 7.5 Abnormal coarse rhonchi on right

side Diminished or absent breath

sounds on left side Copious, thick, foul smelling

secretions with yellowish-tan color

Cardiovascular Respiratory

PHYSICAL ASSESSMENT:

Active bowel sounds in all four quadrants

Abdomen softly distended

Two large, loose, non-odiferous stools

Percutaneous endoscopic gastrostomy tube (PEG tube) in upper left quadrant, patent, residual 20 cc

Foley catheter draining to gravity

Urine yellow and clear

Output 175 ml at A.M. assessment

Gastrointestinal Genitourinary

PHYSICAL ASSESSMENT:

Eyes open to pain, pupil size 2 mm, brisk reaction bilateral

Unable to respond due to tracheotomy

Responds to localized pain Briefly awakens to voice

(eye opening and contact < 10 seconds)

Mild weakness in all extremities

Passive range of motion to prevent contractures

Neurological Musculoskeletal

PHYSICAL ASSESSMENT:

Family present at bedside for several hours

Decision made to terminally wean

No request for clergy

Psychosocial