Carly Hickey Medical-Surgical Neurovascular 7T Clinical

CRITICAL THINKING-PRIORITIZING

Admit Dx: Acute hypoxic respiratory failure with hypercapnia, bilateral lower lobe pneumonia, COPD
exacerbation.
Past Medical Hx: Tobacco use, squamous cell carcinoma of the throat, COPD, HTN, carotid stenosis,
TIA, depression.

1. Read the H & P. What are the presenting symptoms?

Presenting symptoms: Patient woke in the night with violent productive cough with passage of blood clots
and frank blood. Right sided inspiratory chest pain, and sore throat, tachypnea, rhonchi and wheezing.
Pneumonia exacerbation. Last week patient had green sputum, SOB, and cough. Negative for fever,
current SOB, epistaxis, melena, or hematuria
2. From the H & P. What is the plan of care? What are the consultations? Were the consults
made?
Plan: Prescribed Rocephin 2g IV once daily, Doxycycline ABX, con’t med regimen. Supplemental O2 as
necessary, currently at 6L. Patient states he is on 2L via nasal cannula at home. Hold Aspirin and Plavix.
Urgent bronchoscopy with immobilization of clots and platelet perfusion if large vol hemoptysis occurs.
Currently hemoptysis improving.
3. Read the consultation reports. What conclusions or plans did the specialist make? Was it
initiated?
Pulmonary: NPO after midnight, hold antiplatelets. Continue home meds, add bronchodilators, Albuterol
PRN. Monitor closely, wean oxygen as tolerated. Repeat chest CT in 4-6 weeks. Platelet transfusion if
large vol hemoptysis occurs, no further hemoptysis since yesterday. CT negative for PE.
Speech: Mildly thicken liquids, history silent aspiration. NPO r/t airway compromise. Objective imagine
videofluroscopic swallow study (VFSS) recommended to determine LRD (least restrictive diet).
PRIORITY POTENTIAL & ACTUAL COMPLICATIONS (3 – 4)
o Increased risk of stroke r/t D/C of Aspirin and Plavix
o Sepsis r/t pneumonia (currently on ABX)
o ARDS (Acute Respiratory Distress Syndrome)
o Flash pulmonary edema

PRIORITY ASSESSMENT OR CUES (3 - 4)

WOB, lung sounds, cough, clots? Pulse ox monitoring. Accessory muscle use, abdominal muscle use to
facilitate breathing
PRIORITY INTERVENTION or ACTIONS (3-4)
o Supplemental O2 to keep SpO2 at or above 92%
o Repositioning, high fowler’s
o Breathing treatments
o RT consult
o Telemetry to monitor HR due to increased risk stroke and MI
Carly Hickey Medical-Surgical Neurovascular 7T Clinical

PRIORITY EDUCATION/DISCARGE ISSUES include issues with health care disparities (3-4)
o Smoking cessation, nicotine patch. No smoking around O2 at home.
o Incesntive spirometer use
o Educate on s/s stroke – FAST
o Monitor for other s/s bleeding
o Nebulizer and inhaler: ensure script up to date, and patient understands proper use