Critical Care Nursing: Interdisciplinary Care

Critical Care Nursing: Interdisciplinary Care 

Background Information Summary

Demographics: Patient K.L is a fifty-two-year-old, Caucasian female; of Italian decent. She is married and lives with her spouse and three children ages 25, 21 and 13. K.L. worked as an Elementary school teacher for the past twenty-five years. She is currently on medical leave for the past few years due to health issues. She was a social drinker and never smoked. Denies any history of past alcohol or drug use.

History of present illness: Patient presented to the emergency room in a wheelchair on May 19^th, 2019 with manifestations of shortness of breath, and confusion. Husband stated over the past few days she has become increasingly confused before that patient has been doing well following review of oncology recently started on oral chemotherapy pill Verzenio about three to four weeks ago.

Past Medical History:K.L. was diagnosed with stage 4 breast cancer ten years ago. Recently patient was diagnosed with metastasis to the adrenal, iliac crest, liver and spine. She also has history of gastrointestinal reflux disease. Patient is O2 dependent and uses 2L O2 at home.

Past surgical History: Bilateral pleurX drain. Bilateral mastectomy and Abdominoplasty.

Admitting diagnoses: Patient admitted for sepsis, bilateral pneumonia, hyponatremia and neutropenia.

Course of current hospitalization to date: Patient was admitted to the emergency room for shortness of breath, and acute confusion. Despite confusion patient remains alert and oriented. Patient stated “I have been under a lot of stress this week” says symptoms have been going on for the last few days, but becoming increasingly worse. Patient was placed on Vancomycin 1.25g IVPB, Zosyn 3.375g IVPB and placed on neutropenic precautions due to low white blood cell count. Blood work, blood cultures, were done. A chest x-ray, 12 lead EKG was performed in the ED. Results showed sinus tachycardia and right bundle branch block. Patient had CT Scan of the brain. Order pending for sputum culture. Upon admission to the ICU a deep vein thrombosis (DVT) was found in the patient’s right leg at which time an Intra vena cava filter (IVC filter) was placed.

Significant assessment findings during days of care:

Vital signs

Focused Assessment

Patient is alert and oriented to person, place, and time her speech is clear. Skin is consistent with ethnic background unblemished and is warm and dry. Head is normocephalic with no lumps or lesions present. Hair is evenly distributed thin texture. No signs of infestations. Nail beds pink and capillary refill is brisk less than 3 seconds. Pupils are equal in size and PERRLA round, reactive to light and accommodation. Sclera is white and conjunctiva is pink. Pulses are 3+ and equal bilaterally. Breath sounds throughout crackles, course, diminished. Left upper and lower lobes crackles, coarse. Right upper lobe fine crackles and diminished. Right middle lobe and right lower lobe diminished. Respiratory rate and rhythm excursion symmetrical no use of accessory muscles, no cough, productive sputum or shortness of breath. Abdomen non-tender, upon palpation with no lumps, lesions or masses noted. No rebound tenderness. Bowel sounds are present in all four quadrants. Patient has Pure wick female external catheter.

Monitoring Devices

K.L. was being monitored continuously while in the intensive care unit. She had a five- lead bedside heart monitor. Spo2. blood pressure, temperature, respiratory rate and heart rate were being monitored continuously.

Laboratory and Diagnostic Tests

Diagnostic tests:

Patient had chest x-ray, duplex ultrasound of right leg and CT scan of brain.

Laboratory tests:

Abnormal findings

(Mosby’s Diagnostic and Laboratory Test Reference 2015)

Rationale for diagnostic and laboratory tests

Laboratory and diagnostic testing is done as part of routine checkups as well as looking for changes in the patient’s health, monitor diseases, and help physicians to diagnose medical conditions. K.L. had the following diagnostic and laboratory testing. A CT scan of the brain was done to check for metastasis to the brain from breast cancer. The chest X-ray was done to check lungs for pneumonia. Duplex ultrasound of the leg was done to identify deep vein thrombosis (DVT). Intra Vena Cava filter was placed in groin to filter blood and reduce the risk of pulmonary embolism. Chest x-ray showed bilateral pneumonia. CT scan of brain was negative. The negative CT scan of the brain indicates no metastasis of cancer to the brain.

A complete blood count (CBC) was ordered for the patient to determine and or detect a wide range of disorders pertaining to the patient’s overall health. A comprehensive metabolic panel (CMP) was done to check the patient’s fluid balance. Knowing the levels of electrolytes such as sodium, potassium is crucial in knowing how well the patient’s kidneys and liver are working. An ABG is a blood test to measure the Ph, levels of oxygen, and carbon dioxide coming from an artery. The test was used to check the patient’s lungs and the ability to move oxygen and remove carbon dioxide form the body.

Medications

(Davis Drug Guide 2017)

Nursing Diagnoses

(North American Nursing Diagnosis Association, 2018).

Interventions: Routine Nursing Management

Interdisciplinary Care

Interdisciplinary Care- Collaborative Management:

A critically-ill patient in the intensive care unit of the hospital requires in depth care from various health team members. The health care team who participate in the ill patient’s care can include the primary care provider, nurse, respiratory therapist, nutritionist, pharmacists, social worker as well as many other specialty physicians. The primary care provider oversees all aspects of the patients care while inside and outside of the hospital. The nurse plays a huge role in the care of the critically ill patient. A patient admitted to the intensive care unit can not only be a crisis to them but to their family as well. Nurses are there meet patient and family needs in all aspects of care from psychological to physiological (Stayt, 2017). The respiratory therapist plays a large role in helping to aid in the recovery of the critically ill patient. They provide comfort by initiating respiratory care such as breathing treatments, ventilators, bi-pap machines, chest physiotherapy and the titration of oxygen therapy as well as monitoring the patients blood gases. The pharmacist’s role in caring for the patient is to provide the proper medication for the patient ensuring the dose is correct as well as educating the patient and health care providers on the adverse reactions to the drugs. The dietician/nutritionist is there for the patient to provide the proper nutritional goals as they pertain to the patient. The social worker provides multitude of things to the patient and the family from help with insurance to providing support while in the hospital as well as after discharge. They are trained to help patients with community and home-based services addressing both medical and psychological needs (Barber, Kogan, Riffenburgh & Enguidanos 2017). Depending on what is wrong with the patient there could be many other disciplinary team members involved in a critically ill patients care.

Interdisciplinary Care- Therapeutic Modalities: The patient was initially on 2L of oxygen via nasal cannula. However, after giving a bed bath and trying to move patient to chair her O2 saturation became critically low at 77 and oxygen was increased to 5L. Nurse noted that whenever patient moved around in bed or tried to get out of bed patients oxygen level continually desaturated. It is important for the nurse to continuously monitor the patients SaO2 levels to make sure the patient is receiving adequate oxygenation as well as maintaining a normal oxygen level. The nurse must always notify the provider when changes in patients O2 levels become critically low and may require further intervention from the physician.

Nursing Role Reflection

The intensive care unit in this facility had morning meeting or a “huddle” as they called it as a mean of communication amongst hospital staff. The meeting was run by the nurse manager and included the nursing staff, patient care technicians and unit secretary. They discussed many aspects of what was going on within the unit. After the morning huddle the night nurses gave report to the on coming day nurses. They updated them on the patient’s labs/diagnostics and any impending tests. During this time, they were able to ask each other questions pertaining to the patient and provided each other with further treatment plans for the patient. Throughout the day many different physicians would come and go and they would discuss the course of treatment for the patient with the nurse and the patient’s family.

The student nurses on the unit for the day were able to observe during the morning huddle and morning report. It is crucial to have ongoing communication between interdisciplinary teams. It is important for that communication to be well organized and each input precise to each other. During the time I was there the nurse held the primary role for communication and provided therapeutic communication for the patient and the family. During patient care, I used my therapeutic communication skills to speak with the patient and her husband who was by her bedside. I spoke in a empathetic manner and made simple gestures like holding the patients hand to let her know that I was there for her. Using therapeutic communication helps to build a solid rapport and foundation with your patient allowing them to trust me to care for them. Luckily the patient was very pleasant and open with me and we had an open dialect about her breast cancer diagnosis.

A system barrier that alters the quality of care and outcome of the critically-ill individual is the lack of awareness. This is the most common barrier, the lack of awareness and understanding of exactly what patient safety is. In a survey done in the United States the term “patient safety” was viewed less important than “medical errors” (McGinley, 2010). This suggested that patients do not fully understand that medical errors and patient safety actually refer to the same topic. In the critically ill setting the nature of illness can prevent a patient from engaging in patient safety and error prevention strategies. A review conducted by Davis et al. (2007) found that patients feel more comfortable communicating with their family physician then they do with the hospital staff (Scobie & Persaud, 2010). In addition to feeling uncomfortable with communicating with hospital staff the hospital setting itself presents a number of difficulties particularly to critically ill patients. Patients who are critically ill lack the capacity to be able to fully engage themselves in error prevention (Scobie & Persaud, 2010).

One recommendation for this facility would be for the doctors

and nurses to communicate better. Interdisciplinary communication is crucial in effective collaboration and can avoid serious medical error (Institute of medicine 2014). Key problems in communication between doctors and nurses include when nurses communicate important patient information in regards to the diagnosis and treatment of the patient and it is ignored by the physician. On the flip side nurses sometimes fail to communicate relevant information to the physicians. In the ICU, patients were confined to their beds instead of sitting in a chair or ambulating with assistance. Another recommendation for this facility would be hourly rounding. Nurses would enter patient’s rooms greet them check on their comfort assess their pain offer any toileting assistance and just do an all around environmental check making sure call bell is with in reach. Evidence based practice shows that hourly rounding can impact patient fall rates, patient call light usage and overall patient satisfaction (Orich, Kalman, Nigolian, 2012).

Professional self-development is a crucial part of being a valuable team member in the hospital setting. Collaborating with team members on plans of care for patients will enable me to become an effective nurse and be able to fully understand my patients and their illnesses. It is equally important to develop communication skills with the patient and their families. Daily interaction with patients and family will allow me to enhance not only my therapeutic nursing skill but also my bedside skills allowing me to care for my patient’s medical issues and needs.

References

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