beleanor

Thank you so much Calivianya!!! This is exactly what I was looking for. May I ask what hospital you work for? I'm at Mercy St. Louis is the BURN ICU, so we also give massive amounts of fent/versed (though most of us nurses prefer propofol). The most I've ever had on a gtt was 1200mcg fent and 18mg versed, so it can get crazy. I really like the CPOT, but I think there are some practical things to consider. My shared governance committee is meeting with our head physician and pharmacist in a day or so. Again, thanks, this is great!

Hey everyone, My hospital has decided to adopt the CPOT pain scale for our non verbal/vented patients. I am researching for our critical care shared governance committee how a CPOT score might be turned into a medication order so that we can develop a protocol for pain management. THe CPOT scale has been widely validated, but there is little to no scholarly research on this. I consider this to be the case for 2 reasons: the CPOT scale is fairly new and secondly, the author herself maintains that the scale is not a measure of severity of pain but a measure of presence of pain. Therefore, any treatment protocol could only be individualized based on assessment, treatment and reassessment (a reduction in CPOT score by 2 points is considered a "working" treatment; pain management can then be tailored based on specific assessment, dosing and goals). I'm bringing this to y'all because I know there are ICU's out there that use the CPOT scale and I need to know, if you use this in your institution, how your physicians translate CPOT scores into medication orders. ANY HELP IS APPRECIATED... I've been going round and round on this one... Thanks! Eleanor

Hey everyone, My hospital has decided to adopt the CPOT pain scale for our non verbal/vented patients. I am researching for our critical care shared governance committee how a CPOT score might be turned into a medication order so that we can develop a protocol for pain management. THe CPOT scale has been widely validated, but there is little to no scholarly research on this. I consider this to be the case for 2 reasons: the CPOT scale is fairly new and secondly, the author herself maintains that the scale is not a measure of severity of pain but a measure of presence of pain. Therefore, any treatment protocol could only be individualized based on assessment, treatment and reassessment (a reduction in CPOT score by 2 points is considered a "working" treatment; pain management can then be tailored based on specific assessment, dosing and goals). I'm bringing this to y'all because I know there are ICU's out there that use the CPOT scale and I need to know, if you use this in your institution, how your physicians translate CPOT scores into medication orders. ANY HELP IS APPRECIATED... I've been going round and round on this one... Thanks! Eleanor

Thanks for feedback everyone - to answer questions/clarify: sun0408: I was typing/thinking fast when I wrote and I agree - "high" is the wrong description for 4.6. I will be more accurate. The patient has not had the experience before of numbness, tingling around the mouth, or the eye twitch. GrnTea: Yes, Diflucan, Zosyn, Colace, Lovenox are scheduled, Oxycontin is prn. Diflucan and Seroquel do interact -> Diflucan reduces clearance of Seroquel. I believe this is the strongest case for EPS - I've also read that EPS can be an early sign of neuroleptic malignant syndrome (as de2013 implies) De2013: He's 54, liver enzymes are WDL, BUN is 8 and creatinine is 0.81. There is perhaps no clear answer as to whether or not the twitch is: 1. mild TD from anesthetic overdose (patient has no other signs pointing to neuroleptic malignant syndrome) 2. or muscle spasm r/t phosphorus of 4.6 THanks for confirming Seroquel for anxiety - I have come to the conclusion that this is the use for my patient. He was actually moved to a step down unit yesterday. His WBC has decreased from 26.7 to 16.1 and the C&S from an intr-aabdominal abscess came back positive for candida. He will likely be discharged in a couple days with home healthcare and IV antibiotics.

Hey all, I had a patient on tuesday who, with no axis I psych Dx, was prescribed 100mg of Seroquel daily. While seroquel is a weak neuroleptic and EPS are rare, he developed a new eye twitch during the course of the day tuesday after receiving his first dose the previous night. The twitch looked like it involved the entire right orbicularis oculi. My response: I called the physician, who ordered a stat CMB, and all electrolytes came back WNL except phosphorus, which was 4.6 (WNL = 2.5-4.5). His calcium was normal, 9.1 and the physician ended up calling it a response to a local anesthetic use earlier that day (though the patient denied circumoral parethesia or tingling/numbness of any kind). He also complained of a left calf muscle cramp for most of the day. So, of the three possibilities: high phosphorus, response to anesthesia, or Seroquel, what do people think is most likely? On a related note, has anyone heard of Seroquel being prescribed for anxiety? I can't figure why he's even on this drug to begin with... Thanks for any help!

thanks Esme12 for your feedback. I often find the most frustrating part of any formal training is knowing how best to enact your ideals in the real world. I'll keep the ABC prioritization and include my rationale...

I'm in a one year, accelerated program - started in May and graduate May 2013. Re: prioritization - makes sense according to ABC's/Maslow, but my hesitancy is that no one seems to be paying attention to the med dx "aspiration/chemical pneumonitis." This patient is still allowed oral intake and there've been no mentions of nursing interventions regarding aspiration prevention in any care plan. It seems to me that his care team is prioritizing his "not progressing" nutritional status above this airway problem - which could be possible, I suppose, even though it flies in the face of ABC, he does have a BMI of 15, "non progressing status," and a granulating stage IV ulcer. He is on diflucan, vanc and ertepenem. Is it possible that his care team is assuming the aspiration is "minimal"? Is it possible that they are assuming he's prophylactically covered by his antibiotics against the development of pneumonia? Is it possible they're calling it "aspiraiton pneumonitis," but really it's not (the CXR showed LLL infiltrate, not RML infiltrate as is commonly seen with aspiration pneumonia)? I guess I just find it hard to believe that me, of all people/nursing students, could find something wrong with the care/prioritization of care for my patient... Thanks for your help!!

So, I've reworked my prioritized list, but I'd still be interested in feedback! Imbalanced nutrition: less than body requirements r/t increased caloric and protein needs 2° to wound healing AEB low hemoglobin and low hematocrit, chronic anemia, very low albumin, low total protein, edema, low BMI, patient statement, "It's hard to make yourself eat if you don't feel like it. I'm trying to here - but I fill up quickly." Ineffective airway clearance r/t immobility, stasis of secretions, absent cough 2° aspiration pneumonitis AEB chest xray showing bilateral infiltrate, tachypnea (respiratory rate between 24-28). Impaired tissue integrity r/t the effects of pressure and immobility 2° to sensory and motor deficits AEB 3 decubitus ulcers. Risk for falls r/t fatigue 2° infection, malnutrition, r/t impaired mobility 2° paraplegia. [*]Risk for infection r/t anti-ulcer medication therapy 2° aspiration of neutralized gastric contents. [*]Risk for complications of decreased cardiac output r/t septic shock. collaborative. [*]Risk for complications of cardiac arrhythmias r/t sepsis or septic shock. collaborative [*]Risk for complications of deep vein thrombosis r/t immobility, recent pelvic surgical history, advanced age and indwelling catheter, and thrombocytosis. collaborative. [*]Activity intolerance r/t compromised oxygen transport 2° to anemia AEB tachypnea, verbal report of "weakness." r/t increased metabolic demands 2° sepsis and fever AEB tachypnea, verbal report of "weakness." [*]Risk for bleeding r/t anticoagulation medication therapy. [*]Adult failure to thrive r/t limited ability to adapt to effects of aging and loss of social relatedness AEB declining physical functioning, social withdrawal, weight loss, self-care deficit, apathy, and anorexia. Patient statements: "I don't want to wake up to take a pill if I feel fine," "it's hard to make yourself eat if you don't fee like it," "it's just me, so I don't worry about eating." [*]Ineffective self health management r/t complexity of therapeutic regimen, mistrust of home healthcare personnel, and questions about benefits of regimen AEB verbalized desire to manage treatment and sequelae, verbalized difficulty with integration of regimens, acceleration of illness symptoms, verbalization that client specifically did not take action to include treatment regimens into daily life. Thanks everyone and anyone!

Hi All, I'm a brand new member here after months of reading others' posts! I'd greatly appreciate any help with this mess! Here's the situation: I'm in the middle of writing a monster care plan - in my program we only have to fully develop 2 diagnoses per plan, but I do need to list, completely, all relevant nursing Dx, etiologies and defining characteristics. My patient is 73, septic, in isolation for MRSA, with a stage IV decubitus ulcer on the sacrum (w/ bilateral femoral osteomyelitis). He's severely protein malnourished, has co-morbid cardiovascular problems and is paraplegic from a much older occupational accident. He's TPN + oral intake and consumes a minimum of 2445 calories/day and 144 g protein/day - these figures represent only TPN and Ensure, not what he orders from the cafeteria, which is protein heavy. He eats small amounts, all day long and has moderate colostomy output and well functioning kidneys. His HOB is rarely above 30 degrees to reduce shearing forces and so he now also has bilateral lung infiltrate, and a med Dx of aspiration pneumonitis. I have at least 15 nursing diagnoses for him (though half are pulled out of "disuse syndrome.") I'm fairly comfortable with my prioritization and PES formatting, except for... Can I use risk for aspiration? I feel this needs to be high priority (ABC's, maslow), especially considering that he's aspirating right now, not risk for, but actual. Even though he is asymptomatic right now, this situation could become so much worse - even more so because he's on IV pantoprazole, so while the aspirated contents would normally burn his bronchial tree, it's now neutralized and could allow for bacterial organisms. I can't figure out how to build this into my nursing care without making it a medical diagnosis - there is no "aspiration" dx for nursing. While it's probable that he does have impaired gas exchange, I did not hear crackles upon auscultation and his respiratory rate (24-28), could be the result of fever, sepsis, etc. Also, I think part of my problem is that this man is dealing with paraplegia - something I can't do anything about, but that impacts his safety and care... As I look at the list below, I feel like impaired mobility, impaired tissue perfusion are glaring holes, but I can't seem to figure out where to put them in.... this is quick look at my prioritized list: 1. Imbalanced Nutrition: less than body requirements r/t increased protein and vitamin requirements for wound healing secondary to stage IV decubitus ulcer 2. Impaired skin integrity r/t necrotic tissue secondary to peripheral vascular alterations and venous stasis 3. Risk for aspiration r/t prolonged recumbency secondary to pressure ulcer treatment OR 4. Impaired respiratory function r/t bronchial inflammatory response secondary to aspiration pneumonitis AEB tachypnea, CXR shows bilateral infiltrates 5. risk for falls 6. risk for shock 7. risk for PE/DVT 8. risk for bleeding 9. disturbed sensory perception r/t loss of proprio/extero/cortical sensory loss secondary to paraplegia 10. activity intolerance r/t fatigue and increased oxygenation demands 11. bathing/toileting self care deficits 12. adult failure to thrive 13. ineffective self health management 14. readiness for enhanced self health management 15. social isolation any ideas for tidying, elegant solutions, dove-tailing, better prioritizing and puzzle solving would be awesome!!!