28 month old vegetative state vent dependant

Oct 22, 2008 08:58 AM

by lulu rn

im having a really hard time finding interventions for my patient this week.
he is in a vegetative state s/p cp arrest after decannulating himself at home. ive got all the typical "diagnoses" but most of my interventions require the patients participation, which there is none from the patient.
1. how do i assess his pain? he doesnt move at all. maybe vitals, does he even feel the pain?
2. his nutrition is more than required because of constant tube feed and no activity but also less than required because of his inability to eat.
how do i make sure he doesnt gain weight?
3 he is at risk for injury obviously but all i can think to do is keep the side rails up, and keep his seat belt on in his kid cart, and supervise during any PT and OT

any suggestions?

*Daytonite* · Oct 22, 2008, 08:18 PM

You can't diagnose a patient without first determining the signs and symptoms that you have to support those diagnoses. To come up with a diagnosis without supporting signs and symptoms is like saying you've got a murder but no body or evidence to prove it. It's irrational. And, the interventions are strategies that target those signs and symptoms. What signs and symptoms? Interventions are of 4 types:

Assess/monitor/evaluate/observe (to evaluate the patient's condition)
Care/perform/provide/assist (performing actual patient care)
Teach/educate/instruct/supervise (educating patient or caregiver)
Manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

Pain is assessed by observing the patient's behavioral and physiological responses which can be sympathetic or parasympathetic.

From Nurse's 5-Minute Clinical Consult: Procedures from Lippincott Williams & Wilkins, page 370
"BEHAVIORAL RESPONSES
Behavioral responses include altered body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, and immobility.

SYMPATHETIC RESPONSES
Sympathetic responses are commonly associated with mild to moderate pain and include pallor, elevated blood pressure, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, and diaphoresis.

PARASYMPATHETIC RESPONSES
Parasympathetic responses are commonly associated with severe, deep pain and include pallor, decreased blood pressure, bradycardia, nausea and vomiting, weakness, dizziness, and loss of consciousness."

Injury to the patient is more than just about what the patient is able to do to himself. What about what we are doing to the patient with all the gizmos we have hooked up to him? What about complications of care or complications of the disease process? Anything invasive puts the patient at risk for injury or infection. Bed rest subjects the patient to a number of complications: pneumonia, DVTs, decubitus, renal stones, contractures, UTIs. Even children.

See http://allnurses.com/forums/f50/help-care-plans-286986.html - Assistance - Help with Care Plans on the General Nursing Student Discussion Forum for information on how to write a care plan.

ttucowgirlnurse · Oct 23, 2008, 10:13 PM

Re: 28 month old vegetative state vent dependant

Quick note about the nutrition portion: Almost all of the vent dependant vegatative state patients I have had experience with have been fat little things. The dietician or the MD or you can calculate the child's caloric needs and then the feeds can be adjusted.

Safety: include turning the patient to prevent a decub. from forming. Someway or another I'm sure you can include oral care and suctioning in there. The oral care and suctioning will prevent VAP.

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28 month old vegetative state vent dependant

28 month old vegetative state vent dependant

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