1. Running head: CASE STUDY<br />Mr. RF: A Reflective Case Study<br />Kristen Casey Burritt<br />UIN 00547741<br />ODU On Campus<br />Submitted in partial fulfillment of the requirements in the course<br />NURS 451: Clinical Management of Adult Health Nursing III<br />in the School of Nursing<br />Old Dominion University<br />NORFOLK, VIRGINIA<br />Fall, 2010Mr. RF: A Reflective Case Study<br />Nursing is a holistic practice requiring acknowledgement of many parts of a person’s lifestyle and overall wellbeing. By pulling knowledge from different disciplines together in an academic format, it allows a chance to fully incorporate all aspects of care that a patient may need while hospitalized including what the nurse is responsible for as well as what his or her colleagues’ responsibilities are. When a nurse cares for a patient it must not only be based on the patient’s medical problems, but the patient’s comfort, psychological and social needs as well and should include the needs of the family members if they are active in the patient’s care and life.<br />Patient Overview<br />Mr. RF is a seventy-three year old man who has been in the intensive care unit (ICU) at Sentara Virginia Beach General Hospital (SVBGH) since August 25, 2010. He presented to the Princess Anne Emergency Room (PAER) complaining of feeling sick for two to three weeks but with worsening over the last two or three days. He was experiencing intermittent epigastric pain with dizziness and shortness of breath. He denied having chest pain, fever during his illness, vomiting and swelling. The PAER staff believed he was experiencing dizzy spells because he was also having severe hypotension, and that the malaise feeling was due to a systemic infection, otherwise known as septic shock. Mr. F’s mental status began deteriorating showing signs of decreased oxygen in the brain, as well as worsening acidosis and general instability. His overall oxygen saturation was decreasing, his respirations per minute were getting far too high and he was retaining too much carbon dioxide. Because of these changes, RF required an emergency intubation. <br />Because of his intubation, he required ICU-level care and was automatically admitted to the hospital and transferred to an ICU bed as soon as it became available. Despite his diagnosis of sepsis, no cultures returned positive results for any infective agent. He was treated with the most aggressive antibiotics for treatment but they did not relieve his apparent infection symptoms such as increased respirations, higher than normal heart rate and blood pressures and elevated white blood cell count. He has spent the previous five weeks experiencing multiple organ failures including his respiratory and renal systems and unfortunate, many of the interventions he required to save his life also further injured his already weak organs. <br />Medical Diagnosis<br />Mr. F required ICU-level care most specifically because of his initial orotracheal intubation. However, he also required a close watch while his medications were being titrated to find the best way to treat his septic shock. Septic shock is defined as sepsis with hypotension even if the patient has had sufficient fluid substitutes along with problems with perfusion (Picard, O’Donoghue, Young-Kershaw, Russell, 2006). Input, output, the titration of medication infusions, and mechanical ventilation all required close watch during RF’s attempts are recovery. <br />At the time of care, this patient had also experienced acute renal and respiratory failures, as well as progressed into sepsis with multi-organ system failure. This diagnosis references the dysfunction of two or more organ systems in such a way that homeostasis cannot be maintained in a patient’s body and requires medical interventions to survive (Picard, et al., 2006). <br />Pathophysiology<br />Sepsis begins simply enough with a foreign microorganism entering the body and activating the expected inflammatory and immune response. The response release different cytokines to fight the infection and sometimes the reactions that occur do so incorrectly and create a systemic inflammatory response syndrome. This syndrome affects clotting, how blood flows to organs and tissues and can affect capillary membrane permeability. While the systemic response is trying to fight the foreign organism, it creates a disparity between supply of oxygen and demand for it throughout the body which eventually decreases the amount of oxygen in the tissues (hypoxia), damage to the cells that are functioning without enough oxygen and eventual death. As sepsis progresses and hypoxia begins to harm organs so they can no longer function correctly, it progresses to multiple organ dysfunction syndrome (MODS) in which organ systems cannot maintain their usual function CITATION Urd10 1033 (Urden, Stacy, & Lough, 2010). <br />Mr. F was intubated because of his sepsis-related acute respiratory failure. The cytokines or mediators that are released can cause damage to the inner walls of vessels in the lungs as well as in the alveoli which can increase pressure in the lungs (pulmonary hypertension). This can also increase capillary permeability in the lungs allowing for more fluids to be able to get into the alveoli of the lungs, increasing the patient’s work of breathing CITATION Urd10 1033 (Urden, Stacy, & Lough, 2010). <br />The kidneys are one of the most important organs in the body and a lack of blood flow, and therefore oxygenation, can severely harm them. As the body shunts the blood flow to more vital organs such as the heart, lungs, and brain, the kidneys are left less perfused and without fluid to filter. This can cause hypoxia and injury to the kidneys which decreases the amount of urinary output CITATION Urd10 1033 (Urden, Stacy, & Lough, 2010). <br />Related Signs and Symptoms<br />Septic shock diagnosis includes the definition of sepsis as well as hypotension with fluid resuscitation and perfusion abnormalities or acute mental status changes. Before being diagnosed with this, at least two conditions must be met including a temperature less than or equal to 36 degrees Celsius, a heart rate of over ninety beats a minute, more than twenty respirations a minute or carbon dioxide level from an aterial blood gas sample of less than 32 millimeters of mercury and a white blood cell count of either more than 12,000 or less than 4,000 per cubic millimeters. While in the PAER, RF had an axillary temperature of 95.6 degress Fahrenheit or 36 degrees Celsius, a heart rate of 82 beats per minute but a respiratory rate of 36 breaths per minute. His blood pressure while in the ER ranged from eighty to 96 systolic blood pressure and fourteen to sixty diastolic blood pressure which is severely below the acceptable normal blood pressure of 120 systolic, and eighty diastolic. He also experienced acute mental status changes, so the ER staff chose to intubate him to help ensure adequate oxygenation was getting through his body. Mr. F was experiencing tachypnea, signs of hypoxia and pulmonary hypertension. He blood work also showed signs of elevated creatinine (2.6) and blood urea nitrogren (BUN) levels (97). The ER also reported that he had very little urinary output while in their custody CITATION Urd10 1033 (Urden, Stacy, & Lough, 2010). <br />Nursing Diagnoses <br />There are many nursing diagnoses that can go along with Mr. F’s conditions while in the hospital. The mental status alterations witnessed shortly after he arrived in the emergency room were likely a result of a lack of respiration, exchange of gases between the alveoli and blood, a nursing diagnosis for Mr. F should be impaired gas exchange related to ventilation/perfusion mismatching. Decreased cardiac output related to increased afterload also fits for this patient as he is experiencing higher pressures in the vessels of his lungs which is what the heart must pump against. Ineffective renal tissue perfusion related to a decrease in renal blood flow would also be appropriate for Mr. F because his oliguria (little urinary output) and elevated creatinine and BUN levels indicate worsening kidney perfusion CITATION Urd10 1033 (Urden, Stacy, & Lough, 2010). <br />Between his intubation, medication titrations, and medical diagnosis of septic shock, Mr. RF required admittance to the ICU. At this point, it would be valid to say that a psychosocial concern for both the patient and his family is compromised family coping related to having a critically ill family member CITATION Urd10 1033 (Urden, Stacy, & Lough, 2010). A study by Plakas, Cant and Taket (2009) shows that having a relative in an ICU setting is stressful on the family as well as on the patient. Findings of this study showed that many strong emotions such as anticipatory grief for a dying loved one and finding sources of strength to hope for miracles were felt. Family members also felt better about the situation if they were within close proximity to the ICU. Religion was found to be a strong resource for those members coping with the burden they felt and the idea that the patient’s identity has changed. Plakas, Cant and Taket (2009) also discovered that the families needed information and would ask for it every chance they would get. The family also worried about the care the patient was receiving and whether they were being treated with dignity CITATION Pla09 1033 (Plakas, Cant, & Taket, 2009). <br />Overall, because of the many problems facing Mr. F, he is unable to properly eat in any way that a healthy person would and at the time of care, he was not receiving any nutrition. Because of these facts and that if he does not receive proper nutrition he will have a harder time fighting his infection, a nursing diagnosis of imbalanced nutrition: less than bodily requirements related to both an increase in demands from his body and no external means of nutrition, would fit his case appropriately CITATION Urd10 1033 (Urden, Stacy, & Lough, 2010). <br />Setting Priorities<br />Abraham Maslow set for the most basic of nursing theories, the Theory of Human Motivation and Hierachy of Basic Human Needs. Maslow’s theory was welcomed to the nursing profession as it helped practicing nurses to prioritize between their each of the patients and between each of their patients’ needs. Following this theory, the most basic of needs must be met first and these needs include air, food and water. This distinction groups together the first four priorities of the previously stated diagnoses CITATION Joh05 1033 (Johnson & Webber, 2005). <br />The need for oxygenation and circulation go hand in hand in importance, but because the inspiration and expansion of the lungs can help the heart to contract, the impaired gas exchange problem will be Mr. F’s number one priority. This is followed by a close second of decreased cardiac output. Ineffective renal perfusion is the obvious third priority because it goes along with the blood circulation but because it is reliant on blood circulation as opposed to a causative reason for circulation it will go after output. The fourth priority is nutrition. Because the body can survive for days without nutrients and only a couple of minutes without oxygen and blood flow, this is the obvious last in this category of Maslow’s CITATION Joh05 1033 (Johnson & Webber, 2005). <br />The third and fourth levels of basic human needs are love, which includes acceptance and affection, and esteem needs, which include a patient’s self-worth and –image. Because of Mr. F’s hospitalization with a critical illness, both he and his family need to be able to cope with this information. The family, who loves this patient, must be able to cope with his illness and all possible outcomes in the same way that Mr. F must cope with his illness and deal with possible low self-esteem because he is no longer the man his family knows him as. <br />Priority One: Impaired Gas Exchange<br />Outcomes<br />The first two priorities, impaired gas exchange and decreased cardiac output will be focused on for elaboration of outcome identification and interventions. <br />Impaired gas exchange for Mr. F is related to ventilation/perfusion mismatching in which in oxygen supply does not adequately match his oxygen demands; his alveolar-capillary membranes are no longer working as faultlessly as they should and because his blood flow is altered because of pulmonary hypertension. These manifestations are evident through his confusion and mental status alterations, hypercapnia (too much carbon dixoxide) and hypoxia. An appropriate outcome for this problem would be that before extubation, Mr. F should be able to spontaneously breathe, maintain gas exchange levels within his usual range with no reduction of mental status. He should also have no signs or symptoms of respiratory distress. According to ICU guidelines, it is a goal to have patients weaned off of the ventilator as soon as possible and preference is within approximately 7 days. However, this period had long since passed and they hoped that within two weeks of this date, this patient would be stable enough to extubate CITATION Gul07 1033 (Gulanick & Myers, 2007). <br />Interventions<br />In order to properly care for patients wherever they may be, collaboration between different members of the health care team including doctors, nurses, nutritionists, respiratory therapists and so on, is absolutely crucial. When initially beginning evaluations for any patient, especially Mr. F, assessment is the first step. When the head-to-toe physical assessment is beginning, lungs are the first things to assess. Assessing the patient for quality, rate, rhythm, depth and effort of breathing can help determine effective gas exchange. Either excessively high or low rates or deep or shallow depths may indicate a problem. Assessing sounds throughout the lungs can also show possible areas of concern involving gas exchange issues CITATION Gul07 1033 (Gulanick & Myers, 2007). <br />Vital signs can sometimes be some of the fastest indicators of respiration issues. Hypoxia and hypercapnia initially increase blood pressure, heart rate and respirations per minute. Skin color changes especially around the mouth and on mucous membranes can be indicative of decreased oxygenation to tissues. Doctors may order that arterial blood gases (ABGs) be drawn periodically as well as hemoglobin levels CITATION Gul07 1033 (Gulanick & Myers, 2007). Changes in ABG levels can be indicative of respiratory failure and are one of the critical signs of impaired gas exchange according to Zeitoun, Leite de Barros, Michel, and Cassia de Bettencourt (2007). These researchers also showed the two most differential signs of impaired gas exchange are the altered ABG levels and hypoxic evidence such as decreased or crackle breath sounds and even confusion (Zeitoun, et al., 2007). <br />Maintenance of oxygen delivery is important so that Mr. F’s saturation level does not drop below ninety percent to help provide for adequate tissue oxygenation. When rotating the patient, a side-lying position should be done if tolerable. By putting the good or uninjured lung down, blood flow can more adequately perfuse the tissue and react better with the oxygen it receives through the respirations. All of Mr. F’s physical activities were spaced throughout the day as to not over-tire him and increase his oxygen demand CITATION Gul07 1033 (Gulanick & Myers, 2007). <br />Needed Patient and Family Teaching<br />As Mr. F begins to recover, he should not be overly stimulated in a way that will cause him to tire quickly or deprive him of enough oxygen. He should be taught appropriate methods of breathing and coughing so as to aid air exchange and secretion clearance through the respiratory system. If Mr. F still requires nursing care after his recovery and discharge from the hospital, he should be given a referral to a home health agency and possibly a pulmonary rehabilitation program CITATION Gul07 1033 (Gulanick & Myers, 2007). <br />Standards of Practice<br />Standard 1: Assessment. Upon first taking care of RF, I received report from the off-going nurse and learned of his most recent problems and lab results. A full head-to-toe assessment was done that determined his status had not yet changed much. His oxygen saturation levels were at 95 percent and remained within 2 percentages of this all shift. His ABG results showed that his pH level was much closer to a normal level although slightly basic (7.458), that his oxygen levels were higher than normal and the carbon dioxide in his system was lower than expected (American Association of Critical Care Nursing [AACN], 2008). <br />Standard 2: Diagnosis. Mr. F’s medical diagnoses were discussed during daily rounds and found to be consistent with his assessment information as well as his laboratory data. When his wife came to visit, his status and expected care and procedures were discussed with her. As stated above, RF’s nursing diagnoses were prioritized to allow for the most effective nursing care to be implemented (AACN, 2008). <br />Standard 3: Outcome Identification. The ICU team discussed on rounds the intended outcomes for RF. While the 7 day period for extubation had been exceeded, the team still hoped that this patient would remain and grow more stable so that extubation and a return to spontaneous breathing would be a reasonable goal for him and a new date of 14 days later was established. The team felt that 14 days would be more than enough time to stabilize this patient and give him the chance to breathe spontaneously with only minimal help from the ventilator (AACN, 2008). <br />Standard 4: Planning. Mr. F’s respiratory status was determined to be of the highest priority. It was determined that this patient’s ABGs would be closely monitored so that his ventilator settings could be adjusted to his needs. Once these results were normalized, the spontaneous settings should be tried to determine if he is able to adequately ventilate himself and perform gas exchange. If he was able to do this setting, he would be closely monitored for signs of respiratory distress and declining mental status (AACN, 2008). <br />Decreased Cardiac Output<br />Outcomes<br />Decreased cardiac output is related to decreased afterload, likely decreased preload (ventricular filling) because of an increase in heart rate and decreasing oxygenation. As Mr. F’s body gets less oxygen sent to it, his heart tries to compensate by increasing its rate so as to pump oxygen quicker since it can’t pump more, however as it beats faster, its ability to fill the ventricles decreases and the heart itself requires more oxygen. Within approximately 2 hours of being on medication drips to decrease his arrhythmias that increased his heart rate and highly oxygenated ventilation, Mr. F should maintain his blood pressure within normal limits, have warm dry skin and a regular cardiac rhythm CITATION Gul07 1033 (Gulanick & Myers, 2007). <br />Interventions<br />Assessing heart rate and blood pressure should be the first assessment for this patient. An elevated heart rate and increased blood pressure are the first signs of a decreased output as the heart is trying to compensate for the small volume it is able to put out by pumping it out quicker. As output continues to drop, the patient’s blood pressure will decrease. Skin color and temperature are also easily checked markers of cardiac output. According to the study done by Schey, Williams and Bucknall (2009), subjective skin temperature measurements in the form of a one to three rating scale with one being the entire foot is cold, two means that the feet are warm but the toes are cold, and three meaning that the whole foot is warm, are an accurate and noninvasive marker of cardiac output and the heart’s ability to perfuse the body. Because pulmonary hypertension can frequently increase the afterload or force that the heart must pump against, listening to the lung sounds to determine locations of possible fluid accumulation CITATION Gul07 1033 (Gulanick & Myers, 2007) <br />All health care team members must help Mr. F maintain optimal fluid balance because by increasing extracellular fluid, cardiac output can be raised because there is more fluid for the heart to pump through the body. Maintaining ample ventilation and perfusion by elevating the head of the bed to at least a thirty to 45 degree angle, putting the patient in supine position and giving humidified oxygen as ordered can help by reducing preload, increasing return of blood to the heart and decreasing the oxygen demands of the heart CITATION Gul07 1033 (Gulanick & Myers, 2007). <br />Needed Patient and Family Teaching<br />As his recovery comes along, Mr. F and his wife need to have the symptoms of as well as the interventions for decreased cardiac output explained to them so that they will follow the treatment plan set forth for them. Any medications that are prescribed to the patient should have satisfactory teaching about them including the reason for taking it, what the dose is and possible side effects including what is expected and what needs to be reported so that the patient may take an active role in his self-care later in his recovery. As he begins to perform more activities, the signs of overexertion should be explained so that he can monitor his own responses and reduce his risk CITATION Gul07 1033 (Gulanick & Myers, 2007). <br />Standards of Practice<br />Standard 1: Assessment. Mr. F’s renal status was slowly progressing upwards and he put out a relatively consistent amount of urine each hour of the shift, between 45 and seventy milliliters an hour. As previously stated, his neurological assessment was difficult to truly obtain which did not allow for exploration of his mental status as a sign or symptom of adequate blood supply to his brain. However, he was unable to withdrawal his extremities from painful stimuli, although on the first day of care he was able to grimace. He was also unable to follow simple commands (AACN, 2008). <br />Standard 2: Diagnosis. While his decreased cardiac output is of concern the entire ICU team, it was made a secondary priority. Measures of increasing his output were discussed with Mrs. F when she came to visit this day and all of her questions about new medications and different doses were answered during this conversation (AACN, 2008). <br />Standard 3: Outcome Identification. It is expected that Mr. F’s heart rate and blood pressure be maintained within normal limits by his medications once the correct titrations are discovered. By maintaining his heart rate and blood pressure, his oxygenation should increase allowing his heart to pump appropriately oxygenated blood to not only the most vital organs, but also to all of the tissues that need it (AACN, 2008). <br />Standard 4: Planning. Once again, the decreased cardiac output was decided to be a secondary problem. Once adequate oxygenation through respiration is achieved, and the blood pressure and heart rates remain stable, the perfusion issues should be corrected (AACN, 2008). <br />Cultural Considerations<br />One of the most surprising things that occurred in Mr. F’s room was the presence, or lack thereof, of his wife. In my family, when someone is sick and in the hospital, one family member is there at almost all times of day. For example, the last time my grandmother was in the hospital, my grandfather was there constantly with the exception of overnight when he would go home to sleep and for breakfast. At these times other family members would take over keeping her company such as her children stopping by on their way to work in the morning and evening visitations by various grandchildren. <br />Mrs. F, while visiting every day, only stayed for about an hour each day. It also threw me off that when she was there she did not obviously try to communicate with her husband but watched the television in his room and worked on puzzles. It could be that this is her method of coping with his illness, but it seemed strange that she did not try to speak with him. <br />Evaluation<br />Standard of Practice 5: Progress Toward Outcomes<br />Mr. F’s lung sounds were equal with expiratory wheezing with some diminishment at the bases of the lungs. His ventilator was set to deliver 12 breaths a minute but he was able to take eight spontaneous breaths a minute. His rhythm was relatively regular but would vary over periods of time. Respirations were deep and equal with no accessory muscle usage, however he did move his mouth when breathing on his own. <br />His blood pressure and heart rate remained stable throughout the day while his respirations varied more when he was more spontaneous. These stable values within normal limits help to ensure that his lungs are being adequately oxygenated and his cardiac output is stable. His skin color was pink with no cyanosis. All of his extremities were warm and dry which indicates adequate cardiac output and oxygenation in the blood. His oxygen saturation levels remained above ninety percent and all activities were spaced out thoroughly to help keep this appropriate. <br />Alternative Plans<br />A change in care for Mr. F could include a sedation vacation so as to more adequately assess his neurological status and to determine whether or not he is a candidate for ventilatory weaning. Because he is more than able to take breaths on his own, this may be a possibility. On the other hand, it is possible that Mr. F may need longer term, skilled nursing care that this hospital cannot provide for him so his family and the discharge planner should discuss the possibility of being transferred to a skilled nursing facility. <br />Conclusion<br />Care for all patients must be not only holistic, but collaborative as well between all staff including the ER team, the ICU team, the nutritionists, pharmacists, and respiratory therapists. This is an overview of the nursing care this patient received while I was caring for him as well as the relevant medical diagnoses and collaborative interventions he received. <br />Sources<br /> BIBLIOGRAPHY 1033 American Association of Critical Care Nursing. (2008). Standards for acute and critical care nursing practice. Retrieved October 5, 2010, from American Association of Critical Care Nursing: http://classic.aacn.org/aacn/practice.nsf/vwdoc/scp<br />Gulanick, M., & Myers, J. L. (2007). 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