mlauren

"More likely she failed exutbation as a result of the aspiration PNA and what ever caused her to aspirate in the beginning . They were afraid, or she couldn't, protect her airway." Can you explain what you mean by aspiration PNA and trouble extubating because of what caused her to aspirate?

Not sure what all they tried because I didn't find that in the report and the nurses didn't know. I don't know how she aspirated, but I was told when she was extubated she developed strider and was reintubated. The nurse said doc thought et tube was too large and that sometimes very small patients have this reaction to intubation. She is dialysis 3X per week.

I had a patient the other day who was admitted with aspiration pneumonia and had to be intubated. After several days on the vent she was weaned and that is when it became evident that her airway was swollen from the intubation. She was reintubated and put back on SIMV w/CPAP. Her x-rays now show that the infiltrates have cleared, breath sounds good, O2sat good. BP and C. diff infection being treated. ESRD. She got a trach after having the ET tube for 2 wks. I'm basically wondering if anyone has an idea of what the plan for this patient would be (recovery time, d/c planning, etc). Obviously her airway has to heal, but I'm just learning about mech. ventilation and trying to get an idea of what the care for this patient would consist of until then. I know RT does a lot. Thanks for any comments/opinions.

Hey guys. It has been a while since I've needed some help, but I'm having a little bit of a problem deciding what i should be focusing on with my patient. He has a UTI and kidney stones (staghorn) and also has COPD. So on my care plan I know for sure his main problems are acute pain, impaired urinary elimination, and ineffective airway clearance. There are others as well, but those are my top 3 that I think I need to focus on. I think that impaired urinary elimination should come before pain because if his UTI and kidney stones are taken care of then he won't be in pain. But when ti comes to deciding where to put ineffective airway clearance I'm just not sure. He quit smoking in 2008. He is very compliant with treatment for COPD. He has a wheeze in the early morning, but it clears with cough. His respiratory rate and O2sats are fine. I know that airway comes before anything so that's why I'm having a hard time deciding if this should come first even though he's not currently having any respiratory problems. What do you guys think? Should this come before the other two? In my opinion pain and urinary elimination are the focus because that's what he is in the hospital for, but like i said airway is so important. I'm confused. Also, I'm really struggling with an outcome for impaired urinary elimination. This patient had bladder cancer in 2008 and had a radical cystectomy with urinary diversion and ileal conduit. He has had problems with staghorn kidney stones ever since the urostomy. So now he has a bilateral nephrostomy. Urostomy drained about 175 in 4 hrs, Rt nephrostomy drained 750 and left drained 400. The urine was pale, clear, yellow with brown sediment. So I think the UTI is resolving, but still he has to have a lithotripsy in a few days for the kidney stones. Anyway, I'm not sure what my outcome should be or how to make it measurable. If you guys have any hints I would greatly appreciate it. THe only thing I've thought of is > patient will have no sediment in urine one week after lithotripsy procedure and will have negative urine cultures. I don't know how realistic that is. I'm researching the procedure now to find out what's expected afterwards and how long antibiotics take to eradicate bacteria with UTIs. I guess after the full course of antibiotics. He was getting meropenen IVPB for that. ANyways, hopefully someone can help me to reach a conclusion here. Thanks for any help!

Well I just finished GI lecture and man do I wish we had went over this last week. It definitely explained a lot and could have saved me a lot of time. But I'm just happy I can understand most of wht was going on with this patient. Also pretty devastated for her. Thanks again for all the opinions.

Thanks for sharing your thoughts. All of you have been very helpful in helping me understand this patient better

Thanks for the post

Like when a transfusion would be ordered.

Ok so I had all of these and some others, but didn't know about the cap refill not being good indicator with this. Also didn't have orthostatic hypotension. Thanks for sharing what u know about transfusions. I also had to monitor for fluid overload if fluids were infused, because of her condition.

Well I have included interventions for ineffective breathing pattern, ineffective airway clearance, acute pain, fluid volume deficit, ineffective renal perfusion, an decreased cardiac output. When I first started researching about ckd I was thinking anemia was part of it, but couldn't be the whole problem. I did look up the surgeries and my initial thinking is that yes, she had to have lost a lot of blood. But I always doubt myself when I see how the nurses are approaching it. They always seem so calm about things that I think are really important. So I kind of thought maybe she was just anemic and BP was low because of the meds. Now I'm thinking differently. To be completely honest my interventions for fluid volume deficit are very generic because i really am not sure what all I should do other than assess, monitor, and report it to the physician. I would think she needs fluids running and blood though. Thank you for explaining the benazepril. That was throwing me off.

Something else I thought of...her Calcium was 7.4. Wouldn't this contribute to blood loss? Is this level not low enough to be treated? She was on electrolyte protocol, but the nurse didn't pull any of her PRN vitamins. She might have been holding them until another time I guess, but not sure. She also had a history of vit. D, B12, and folic acid deficiency.

I did look loculated pleural effusion up and found that it was fluid build up in pleura divided into compartments. In the chart I read something about the thoracotomy involving scraping of something, but couldn't understand exactly what it was saying. I have looked up some info about all of the procedures. Her H&H and RBCs make me think low volume and I figured it was due to blood loss from the surgeries, but wasn't sure how much she lost and if it would still be a problem weeks later. I couldn't find anything about blood loss during/after surgery in the chart or anything about blood transfusions. That would be helpful to know. She wasn't receiving any fluids or transfusion while I was there with her. No antibiotics were ordered that I seen unless I missed it on the list. Stage 3 CKD...I'm just learning about this, but I know that they usually have high blood pressure as a complication. So no, usually hypotension isn't the issue. Since it is for this patient though, it could lead to more kidney damage, because they aren't getting the blood supply they need. I don't understand why benazepril was still given. But the RN pulled it and my instructor agreed that we should give it. ??? Shouldn't this patient be getting fluids? Do you think she wasn't getting any b/c of CKD and fluid restrictions? What about blood transfusions? At what point is the BP so critical that there needs to be something done about it??? I wish I could go back and see what is going on with this patient today. I really would like to know if her BP went back up and if so, what was done to correct it.

I did look loculated pleural effusion up and found that it was fluid build up in pleura divided into compartments. In the chart I read something about the thoracotomy involving scraping of something, but couldn't understand exactly what it was saying. I have looked up some info about all of the procedures. Her H&H and RBCs make me think low volume and I figured it was due to blood loss from the surgeries, but wasn't sure how much she lost and if it would still be a problem weeks later. I couldn't find anything about blood loss during/after surgery in the chart or anything about blood transfusions. That would be helpful to know. She wasn't receiving any fluids or transfusion while I was there with her. No antibiotics were ordered that I seen unless I missed it on the list. Stage 3 CKD...I'm just learning about this, but I know that they usually have high blood pressure as a complication. So no, usually hypotension isn't the issue. Since it is for this patient though, it could lead to more kidney damage, because they aren't getting the blood supply they need. I don't understand why benazepril was still given. But the RN pulled it and my instructor agreed that we should give it. ??? Shouldn't this patient be getting fluids? Do you think she wasn't getting any b/c of CKD and fluid restrictions? What about blood transfusions? At what point is the BP so critical that there needs to be something done about it??? I wish I could go back and see what is going on with this patient today. I really would like to know if her BP went back up and if so, what was done to correct it.