CC CASE STUDY

Critical Care Case Study Anna Maksimovich 00841057

Submitted in partial fulfillment of the requirements in the course NURS 451: Clinical Management of Adult Health III Old Dominion University NORFOLK, VIRGINIA Fall 2013

CC CASE STUDY Introduction The purpose of this paper is to provide the student nurse an opportunity to integrate knowledge from the humanities and sciences, including nursing research and theory, to plan, provide, and evaluate holistic care given to a specific patient. The author will be reviewing the patients medical diagnosis, prioritizing five nursing diagnoses, and stating specific outcomes, interventions, and evaluations for the top two nursing diagnoses based on critical care-specific

standards of care and clinical pathways. The student nurse will also evaluate personal knowledge that was gained in caring for the patient. S.H., a 70-year-old Caucasian female with a history of chronic obstructive pulmonary disease (COPD), presented to the Sentara Princess Anne Emergency Department on October 28, 3013, via public rescue with increasing shortness of breath, which began after breakfast that morning. The family had also noted bruises all over her extremities with worsened leg swelling bilaterally over the past two days before her admission. The patient has a tracheostomy tube that was placed nine months ago, and is on supplemental oxygen at home. Her airway was suctioned via the tracheostomy tube in the ED, after which the shortness of breath was improved. Ms H had also recently finished an antibiotic regimen for a urinary tract infection, but had urinary frequency and hematuria a day prior to and upon admission. She also complained of mild abdominal pain. The patient was awake and alert upon admission, able to answer questions, but because of her tracheostomy she could not speak, so the history of present illness was obtained mostly from lip reading and family members. Medical Diagnosis Ms. H was admitted from the ED to the intensive care unit with a diagnosis of chronic respiratory failure secondary to COPD. Also among the list of primary medical diagnoses were

CC CASE STUDY congestive heart failure, urinary tract infection, and pulmonary infiltrate. Ms. H was also tracheostomy dependent. Since the primary problem that resulted in hospitalization and is the

likely cause of all her other identified problems is COPD, a closer look at the pathophysiology of this particular disease process is warranted. Based on her symptoms and medical history, Ms. H likely has a form of COPD known as chronic bronchitis. In chronic bronchitis, inspired irritants increase the production of thick, tenacious mucus as well as the number of mucous glands and goblet cells in the airway epithelium. The constant presence of this mucus coating makes it more likely for bacteria to become embedded in the airway secretions and reproduce more rapidly. Ciliary function is also impaired, reducing mucus clearance and thereby compromising the lungs defense mechanisms. This results in increased susceptibility to pulmonary infection and injury, which increases mucus production even further, resulting in inflammation and thickening of the bronchial walls. This constant process of inflammation and infection leads to bronchospasm and subsequent permanent narrowing and constriction of the airways. This initially occurs only in the larger bronchi, eventually spreading to involve all airways. This airway obstruction causes a ventilation-perfusion mismatch with hypoxemia, which can lead to pulmonary hypertension and cor pulmonale if not reversed. The resultant stress that is put on the respiratory muscles leads to decreased tidal volume, hypoventilation, and hypercapnia (McCance, Huether, Brashers, & Rote, 2010). The symptoms that can occur in patients with COPD, causing them to seek medical attention, include activity intolerance, wheezing, and shortness of breath (McCance et al., 2010). Ms. H came to the emergency room after experiencing worsening shortness of breath, which was improved after her trachea was suctioned in the ED. The increased secretions also resulted in a

CC CASE STUDY pulmonary infection and pneumonia, which was later confirmed through a chest x-ray. Her medical history shows that she had been hospitalized multiple times in the past couple of years

for pneumonia and sepsis. Her physical exam noted that she had tachypnea and decreased breath sounds in all lobes upon admission. She also had tachycardia and bilateral edema in the lower extremities. The severity of her disease process resulted in a permanent tracheostomy that was placed on 1/22/13, which was noted to be in place upon admission. A history of chronic pulmonary hypertension was also noted. Nursing Diagnosis The Neuman Systems Model is a nursing theory that views the client as an open system that responds to stressors in the environment. The diagram Betty Neuman used to illustrate her theory shows the client system as a central circle that is surrounded by several other circles, representing the various protective lines of resistance and defense. The core consists of physiologic factors that are common to all persons (i.e. blood pressure, temperature, innate/genetic features, system organs). Surrounding this are the lines of resistance, whose function is to protect the client system against stressors and maintain a healthy existence and include various immune system mechanisms, as well as social and psychological supports. These circles are surrounded by two other circles: the normal line of defense representing the baseline wellness level of the client system, which is influenced by variables such as coping patterns, lifestyle factors, as well as developmental, spiritual, and cultural influences; the flexible line of defense representing a protective buffer that prevents or impedes stressors from invading the system. This buffer can be compromised by certain stressors, which in this patients case included fatigue, poor nutrition, and anxiety. When these stressors penetrate the normal line of defense, the lines of resistance become activated to protect the basic core structure. Therefore,

CC CASE STUDY the role of the nurse is to promote stability and balance within this system while implementing the three levels of prevention to protect the client (Ume-Nwagbo, DeWan & Lowry, 2006).

The patients primary nursing diagnosis is ineffective airway clearance related to buildup of secretions in airway and airway constriction and inflammation. This is evidenced by rapid, shallow respirations, productive cough, decreased oxygen saturation, and increased agitation. This diagnosis was identified as primary because it causes the most stress on all other systems and is the primary reason for the patients hospitalization. The thick secretions in the lower portions of both lungs were found to harbor multi drug resistant bacteria. The resultant pneumonia caused isolation protocol to be implemented, and caused further anxiety and restlessness to the already anxious patient because now the even thicker secretions were causing shortness of breath again. As a result, her heart rate went back upputting stress on an already failing heartand blood pressure began to drop to dangerously low levels. The physiological stress caused by the inability to breathe led to the development of a stress ulcer. The second principal nursing diagnosis is altered nutrition: less than body requirements related to dysphagia, NPO diet, no tube feedings, and increased nutritional needs associated with an imbalance in the rate of catabolism and anabolism due to immobility. This was evidenced by albumin levels that were below normal limits (3.2), anemia (hgb of 7.2 & hct of 25.1), fatigue and weakness. The patients skin was already at a very high risk for breakdown, and the lack of nutrition further increased that risk. The decubitus ulcer and wounds that were already present were not able to heal, and the patients diabetic state further prolonged wound healing. This increased the risk for infection, as there were now multiple breaks in the skin barrier and the immune system was impaired by a lack of nutrients. The patient was not able to pass the swallow screen to advance her diet, and was not able to get as much nutrition as needed through tube

CC CASE STUDY feedings because they caused fluid overload that put further stress on the already infected lungs and kidneys. The third nursing diagnosis is impaired gas exchange related to chronic lung disease as evidenced by tachypnea (respirations ranged from 18 to 37), hypercapnea (PaCO2 of 35), restlessness, fatigue, and decreased oxygen saturation. Since the patient required mechanical ventilation to improve gas exchange and decrease the work of breathing, the risk of ventilatoracquired pneumonia was increased and put the patient at risk for infection. She because semidependent on the ventilator and became very anxious when she was taken off of it. The lack of physical mobility due to activity intolerance that was caused by inadequate oxygenation increased the risk for skin breakdown and prevented healing of pre-existing wounds.

The fourth nursing diagnosis is decreased cardiac output related to chronic heart disease, resulting in alteration in preload, afterload, and decreased myocardial contractility. This was evidenced by severe hypotension, tachycardia, decreased ejection fraction (25-30%), dyspnea, fatigue, weakness, and peripheral edema on both of the lower extremities. The fluid overload caused by this affected her respiratory state, as there was fluid in the lungs. Her wounds here not able to heal as quickly, as pulses to the periphery were decreased. She also had constant fatigue and with very limited physical mobility. The fifth nursing diagnosis was identified as anxiety related to disturbed family process, lack of support system, change in environment, changes in treatment, and history of anxiety disorder. This was evidenced by increased respirations and pulse, dyspnea, increased agitation and restlessness. As is seen in the symptoms, anxiety affects many physiological functions and systems. Increased anxiety causes an increase in shortness of breath, respiratory rate, and heart rate, which in turn puts further stress on the heart and lungs. The stress caused by anxiety could

CC CASE STUDY also impact gastrointestinal function and absorption and further suppress the immune system, causing an increased risk for infection. Outcomes

The expected outcome for the diagnosis of ineffective airway clearance is that the patient will maintain clear, open airways throughout each shift as evidenced by normal breath sounds, normal rate and depth of respirations, and absence of dyspnea. This would also be seen by an oxygen saturation that stays above 95 percent, with adjustments made as necessary (Haugen & Galura, 2011). The expected outcome for the diagnosis of altered nutrition: less than body requirements is that the patient will maintain an adequate nutritional status over the course of 48 hours as evidenced by weight within normal range for the patient, normal BUN and increased serum albumin, hematocrit, hemoglobin, and lymphocyte levels. The patient will also show no further decline in strength and activity tolerance and maintain healthy oral mucous membranes (Haugen & Galura, 2011). Interventions The priority nursing diagnosis, ineffective airway clearance, can be treated with various independent and collaborative interventions, utilizing established standards of practice and clinical pathways. Since the patient is being mechanically ventilated with occasional breaks on blow-by oxygen via the tracheostomy cuff, she is at significant risk of acquiring ventilator associated pneumonia (VAP) or other lung infection every time the nurse goes to suction out secretions. This risk is reduced by implementing the VAP bundle, which includes providing oral care using chlorhexidine to reduce the amount of bacteria in the oral cavity, as well as elevating the head of the bed 30 to 45 degrees to prevent aspiration. In support of the interventions used to

CC CASE STUDY prevent further lung infections an adverse effects associated with regular suctioning of

secretions, a Danish study found that for best practice the patient should be suctioned only when necessary. Other recommendations made by the researchers include using a suction catheter occluding less than half the lumen of the endotracheal tube, using the lowest possible suction pressure, inserting the catheter no further than carina, suctioning no longer than 15 seconds, performing continuous rather than intermittent suctioning, avoiding saline lavage, providing hyperoxygenation before and after the suction procedure, providing hyperinflation combined with hyperoxygenation on a non-routine basis, always using aseptic technique, and using either closed or open suction systems (Pedersen, Rosendahl-Nielsen, Hjermind, & Egerod, 2009, p. 30). An important intervention identified in the clinical practice guideline: Mechanical Ventilation and Discontinuation of Mechanical Ventilation is physiological monitoring, both cardiorespiratory and pulse oximetry, and regular assessment of respiratory status. Promoting rest and minimizing oxygen consumption while adjusting supplemental oxygen as necessary was another intervention listed in the guideline and utilized by nursing and respiratory staff (2012). Albuterol, budesonide (Pulmicort), and ipratropium (Atrovent) were inhalation treatments used to prevent further airway inflammation and irritation. Prednosine (20 mg) was also administered daily via the patients feeding tube to decrease inflammation. The diuretics Lasix and Diamox were also administered to reduce fluid overload, which helped in reducing the amount of fluid in the lungs. Patient teaching included demonstrating an effective cough technique to better clear secretions from the airway. Another important teaching point would be discussing smoking cessation with the patient, and perhaps even involving family members to encourage the patient to pursue a healthier lifestyle. Other teaching points include educating the patient and family

CC CASE STUDY about medication side effects. For example, albuterol is known to cause restlessness and nervousness in some people, and the inhalation medications are associated with headache and dizziness (Hodgson & Kizior, 2011). The second nursing diagnosis of altered nutrition: less than body requirements requires interventions that focus on ensuring adequate nutrition and hydration while maintaining a reduced risk of aspiration. In the process of being weaned off the ventilator, Ms. H was on a strict NPO diet. She was receiving Jevity 1.5 kcal/min at a continuous rate of 35 ml/hr, which was her goal. However, the feeding was stopped and the feeding tube removed in hopes of advancing her diet; however, her swallowing was impaired, as proven by a failed swallow screen, and her only option was to be placed back on enteral nutrition. Nursing interventions, supported by the clinical practice guideline Feeding Dysfunction with/without Swallowing Impairment, included raising the head of the bed at least 30 to 45 degrees to promote safe

swallow and aspiration precautions, promoting oral hygiene, monitoring for signs and symptoms of respiratory distress, and determining the amount of feeding the patient could handle without going back into fluid overload. Nutrition goals were set using a collaborative approach between nursing, physician, and dietary staff. An Egyptian study that evaluated the implementation of nursing guidelines for tube feedings found that the majority of nurses do not check NG tube position, endotracheal cuff pressure, or place patients heads in a neutral position before starting a tube feeding. The study noted that these interventions are very important in preventing aspiration and should be done on a regular basis (Seliman, El-Soussi, Sultan, & Othman, 2011). These interventions were especially important for Ms. H, as she was at a very high risk for aspiration that could have easily caused more respiratory problems. In patient teaching, an emphasis should be placed on eating a healthy diet, as it is

CC CASE STUDY important to help reduce further progression of the disease. Based on the patients history and home environment, it is highly unlikely that she regularly consumed a balanced and nutritious diet before hospitalization. There is evidence that suggests that high levels of antioxidants in vitamins C and E have a protective effect on lung tissue and can reduce or preventing COPD

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symptoms (Barnett, 2011). Barnett also states that patients with COPD should be encouraged to eat a daily protein intake of at least 1.5g per kg of body weight to allow optimal protein synthesis along with a high-carbohydrate, calorie-dense diet, but to avoid eating too much salt and foods high in fat and sugar (p. 6). Even though the patients BMI is 27.06 kg/m 2, which is considered overweight, she could still be malnourished from consuming foods that lack essential vitamins and nutrients. The nurse must acknowledge this and address the knowledge deficit of both the patient and her caregivers. Cultural Considerations Ms. H is widowed, and it is evident that her children do not foster a healthy home environment or provide any social support. They rarely visit her in the acute care setting, and when they do come, the patient experiences an acute increase in anxiety. Everyone at home smokes, which is does not foster any sort of initiative for smoking cessation. The patient has been to multiple acute care facilities over the past few years, and her health problems seem to only be getting worse. Since the patient is mostly dependent of the care provided by her children, it is almost fruitless to provide patient teaching without the other family members present. Evaluation Ms. H is making progress towards meeting the outcomes for her primary nursing diagnosis. Her respiration rate still remains above normal limits when she is off the ventilator and on supplemental oxygen. However, she is coughing better and loosening up secretions that

CC CASE STUDY can then be suctioned by either the nurse or the respiratory therapist. Lung sounds are still diminished, but they sound significantly clearer. Ms. H still experiences episodes of dyspnea when she becomes anxious, and keeps indicating that she is having trouble breathing. This usually resolves by raising the head of the bed further up and suctioning. Though this

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intervention was not performed, a study found that nature-based sounds can significantly lower systolic blood pressure, diastolic blood pressure, anxiety and agitation levels of patients on mechanical ventilation support (Saadatmand et al., 2013). Playing a channel with soft nature sounds could be potentially very useful in reducing Ms. Hs anxiety levels, thereby reducing the physiological stress on her body. For the second nursing diagnosis, the outcomes were partially met. Ms. H did not lose any additional wait during the observation period, and her overall nutritional status for the most part did not decrease. However, there was no increase in nutritional status either, as albumin levels failed to rise, and hematocrit and hemoglobin levels continued to fall. Her BUN levels decreased from 36 to 31. Her energy levels and strength went unchanged, which was expected. An additional intervention, as suggested by the clinical practice guideline Feeding Dysfunction with Swallowing Impairment, would be to implement oral motor therapies by changing the thickness and texture of food, or changing the bolus size (2012). Additional vitamin and mineral supplementation could also be added via feeding tube. Conclusion The student nurse has gained much knowledge from the care of the patient and from further exploration of the patients health problems in this case study. Caring for a tracheostomy and ventilator were new skills that were learned, and the sterile procedure of suctioning the trachea via the tracheostomy was also a first experience in the clinical setting. Since Ms. H had

CC CASE STUDY so many systems involved in her disease process, the student was able to see the full extent of system interrelatedness and apply critical thinking skills that are similar to that of critical care nurses. The nursing process was applied on a far greater and more in-depth level than any experience prior to this one, and the author has gained a greater appreciation for the field of nursing as a result.

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CC CASE STUDY References Barnett, M. (2011). Providing nutritional support for patients with COPD. Journal Of Community Nursing, 25(6), 4, 6, 8 passim. Feeding Dysfunction with/without Swallowing Impairment. (2012). CPM Resource Center/ Elsevier. Haugen, N. & Galura, S. (2011). Ulrich & Canales Nursing Care Planning Guides. St. Louis, MO: Saunders. McCance, L. K., Huether, E. S., Brashers, L. V., & Rote, S. N. (2010). Pathophysiology: The biologic basis for disease in adults and children. (6th ed.). Maryland Heights, MO: Mosby Elsevier.

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Mechanical Ventilation and Discontinuation of Mechanical Ventilation. (2012). CPM Resource Center/Elsevier. Pedersen, C., Rosendahl-Nielsen, M., Hjermind, J., & Egerod, I. (2009). Endotracheal suctioning of the adult intubated patient--what is the evidence?. Intensive & Critical Care Nursing, 25(1), 21-30. doi:10.1016/j.iccn.2008.05.004 Saadatmand, V., Rejeh, N., Heravi-Karimooi, M., Tadrisi, S., Zayeri, F., Vaismoradi, M., & Jasper, M. (2013). Effect of nature-based sounds' intervention on agitation, anxiety, and stress in patients under mechanical ventilator support: A randomised controlled trial. International Journal Of Nursing Studies, 50(7), 895-904. doi:10.1016/j.ijnurstu.2012.11.018 Seliman, A. A., El-Soussi, A. H., Sultan, M. A., & Othman, S. Y. (2011). Effect of Implementing Nursing Guidelines for Tube Feeding on the Occurrence of Aspiration among Critically Ill Patients. Nature & Science, 9(11), 164-175.

CC CASE STUDY Ume-Nwagbo, P., DeWan, S., & Lowry, L. (2006). Using the Neuman systems model for best practices. Nursing Science Quarterly, 19(1), 31-35.

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HONOR CODE I pledge to support the Honor System of Old Dominion University. I will refrain from any form of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a member of the academic community it is my responsibility to turn in all suspected violators of the Honor Code. I will report to hearing if summoned. Signature: Anna Maksimovich Date: 11/25/13

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NURS 451 Client Case Study Grading Criteria Student: __________________________ Score: __________ Grading Criteria Points Faculty Comments
Introduction Pt. Overview Scope of paper Medical Diagnosis Dx for ICU adm. Patho Related S/S Nursing Diagnosis 5 NANDA (1+ psych/soc) Priority with theorist support Outcomes for top 2 NDX Appropriate for NDX Attainable within timeframe Interventions for top 2 NDX Interventions with rationale SOP /Clinical Path Patient/family teaching Critical Thinking Cultural Considerations Evaluation Progress toward outcomes Additional/alternative plan Conclusion Review of learning 2 1 2 4 4 5 10 #1 #2 2.5 2.5 2.5 2.5 #1 6 2 2 2 #2 6 2 2 2

Points Awarded

#1 #2 5 5 1 1

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Grading Criteria
Sources 5+ sources 3+ primary nursing research Study results reviewed/applied Study poorly reviewed/applied Research omitted APA Format (Cover page, headings, margins, type size) Format conforms to APA Format Format includes 1-3 APA errors Format includes 4-6 APA errors Format includes >6 errors APA- References/Reference Page Conform to APA Format Include 1-3 APA errors Include 4-6 APA errors Include >6 APA errors Do not conform to APA format Writing Style (Grammar, spelling, punctuation, language) Logical, organized, without errors Logical, organized minor errors (<5) Lacks logic/organization OR major spelling/grammar/errors (>5) Lacks logic / organization AND major spelling / grammar / errors (>5)

Points
1 3 3 3 1 1 1 0 0 0

Faculty Comments

Points Awarded

3 2 1 0

4 3 2 1 0

3 2 1 0

Comments: