Reflective Journaling #2

Adison Pusateri March 31, 2017

Noticing

Subjective and objective data

o The patient was admitted to the burn ICU for a 16% TBSA
flash burn that occurred while he was smoking a cigarette
while on supplemental oxygen. Pertinent medical history of
the patient includes severe multiple sclerosis, requiring the
patient to have a tracheostomy. His tracheostomy cuff was
deflated, and he was on 10L of oxygen and 40% FiO2. I
cared for this patient on his first day out of the ICU on the
step-down unit.

How did you know there was a problem? Abnormal

patient presentation or your gut feeling?

o From the start of shift until approximately 10:00, the

patient required suctioning of his tracheostomy multiple
times an hour to deal with the copious amount of clear,
thick secretions he was producing. The patient was NPO for
a scheduled procedure to place a peg tube, so instead of
administering medications to help decrease the secretions,
respiratory was called to perform a nebulizer treatment.
The treatment did not greatly improve his condition, and
about an hour after the respiratory therapist left the
patients SpO2 began desatting.

Interpreting

What other information do I need to make a decision? Is

there anyone else I need to involve or notify? What could
be happening and how critical is this situation?

o After the respiratory treatment had failed to alleviate the

problem, my preceptor and I decided it necessary to
contact the department in which the patient was to have
his Peg tube placed in order to get an estimate on when
they would be taking him for the procedure. We were told
there were three patients ahead of him, so we had a
considerable amount of time. Because of this, we decided
 to administer Guafenesin via dobhoff tube in order to help
the patient clear his secretions.

Responding

Should I do something now or wait and watch? How will I

know if I am making the best decision? What
interventions can I delegate to other members of the
healthcare team? Include evidence-based practice (peer
reviewed) to justify why you might make one decision
over another.

o After administering both a nebulizer treatment and a

medication to help thin the patients secretions there was
still no improvement. It was at this time we called for the
respiratory therapist to come up and assess the patient
again, along with the plastics team who was following him.
The plastics team ordered a chest X-ray, which showed
infiltrates in the lower lobe of the patients left lung. It was
with this information that the respiratory therapist and MD
came to the conclusion that, because the patients cuff was
deflated, he was aspirating his own saliva. Therefore, the
respiratory therapist inflated the cuff and bumped the
patients oxygen to 50% FiO2. When inflated, a cuff, or
balloon, in a tracheostomy prevents administered oxygen
from escaping in order to allow it to reach the lower lobes
of the lungs, while simultaneously preventing aspiration
(Weiss & Denman, 2010). The patients condition improved
greatly after this, however, it was concerning because 50%
FiO2 is the highest a patient is allowed to go on oxygen
without being in an ICU (per TGH protocol). Therefore, even
though the patients condition had stabilized, the care team
decided it safest to transfer the patient back to an ICU in
case his oxygen requirement further increased.

Reflecting

Did I make the right decision? Did I achieve the desired

outcome? What did I do really well? What could I have
done better?

o I believe that my preceptor and I did the right thing by

utilizing respiratory therapy and the patients care team in
making a plan for this patient, as the problem fell in their
realm of expertise. I also believe that the care team made
 the right decision by moving the patient back into an ICU,
as he was not in a code bed on the step down unit and,
had he decompensated more later on, there would have
been nothing different that could be done in the
environment he was in. The decision to move him back into
an ICU was by far the safest.

Works Cited

Weiss, M. & Denman, W. (2010). Patent No. US7686019 B2. IFI Claims
Patent

Services.