Critical Care Nursing: Interdisciplinary Care

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18th Jun 2020 Nursing Case Study Reference this

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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 19th, 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

Time Temperature HR RR BP SaO2
0730 36.4C 108 23 118/81 87% on 2L O2
0930 98 22 93/67 97% on 5L O2
1000 97 23 93/67 86% on 2L O2
1030 36.5 C 105 20 97/72 93% on 4L
1100 88 22 100/72 94% on 4L O2
1130 96 22 95/74 98% on 4L O2
1230 36.5 C 100 23 101/79 99% on 4L O2

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

Lab test Results Normal Reference Range Reasoning
Sodium 120 (L) 134-142 mEq/L Due to hyponatremia. Administering new chemotherapy drug Verzenio
Calcium 7.5 (L) 8.5-10.5 mg/dL Due to cancer diagnosis
Total Protein 6.0 (L) 6.4-8.2 g/dL Due to cancer diagnosis
Albumin 1.9 (L) 3.4-5.0 g/dL  Due to cancer diagnosis
Alk. Phos. Total 220 (H) 40-150 u/L Due to chemotherapy medication/treatment
WBC 4.0 (L) 4.5-11.0 Due to chemotherapy medication or infection
RBC 3.4 (L) 4.2-5.4mcL Due to chemotherapy medication
Hgb 11.1 (L) 12- 16g/dL Due to chemotherapy medication
Hematocrit 32.2 (L) 37-47% Due to chemotherapy medication
Platelet 51 (L) 150-450 uL Due to sepsis
Glucose 148 (H) 70-110 May be pre-diabetic
Phosphorus 1.6 (L) 2.5-4.9 Possibly from malnutrition
PCO2 64 (H) 35-45 mEq/L Possibly due to respiratory acidosis
HCO3 31 (H) 24-26 mEq/L Possibly due to metabolic alkalosis

(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

Trade name Xanax
Generic name Alprazolam
Classification Benzodiazepine
Therapeutic use Treatment of anxiety
Major adverse effects CNS: Dizziness, drowsiness, lethargy, confusion, hangover, headache, mental depression, paradoxical excitation. EENT: blurred vision. GI: constipation, diarrhea, nausea, vomiting. DERM: rashes. MISC: physical dependence, psychological dependence, tolerance.
Nursing implications Teach client to take medication exactly as prescribed. May cause drowsiness or dizziness. Older clients may have increased “hangover effect” in the morning and are at increased risk for falls. Avoid drinking grapefruit juice during therapy. Avoid the use of alcohol or other CNS depressants con-currently with these drugs. Kava, valerian, and chamomile can increase CNS depression. Assess degree and manifestations of anxiety during therapy. Monitor CBC with differential and liver and renal function. Showing no
Route/Dosage/Reason given 0.5 mg tablet oral, PRN every 6 hours/anxiety
Trade name Zosyn
Generic name Piperacillin
Classification Anti-infective/extended-spectrum penicillins
Therapeutic use Treatment of infection
Major adverse effects CNS: seizures at higher doses, confusion, dizziness, headache, insomnia, lethargy. GI: diarrhea, constipation, drug-induced hepatitis, nausea, vomiting. GU: interstitial nephritis. Derm: rashes Hemat: bleeding, leukopenia, neutropenia, thrombocytopenia. Local: pain, phlebitis at IV site. Misc: hypersensitivity reactions including anaphylaxis and serum sickness, fever and superinfection.
Nursing implications Teach client to report rash/itching immediately. Notify HCP if fever and diarrhea occue, especially if stool contains blood, pus or mucus. Obtain specimens for culture prior to beginning medication. Assess for improvement of infection. Obtain a history before initiating therapy to determine previous use of and reactions to penicillin’s or cephalosporin’s Observe patient for signs and symptoms of anaphylaxis. Evaluate CBC, serum K+, BUN, serum bilirubin, alkaline phosphatase, and PT/aPTT.
Route/Dosage/Reason 3.375 gm IVPB/ sepsis
Trade name Xarelto
Generic name Rivaroxaban
Classification Anticoagulant
Therapeutic use Prevention and treatment of DVT and PE.
Major adverse effects CNS: confusion, dizziness, headache, insomnia. CV: edema, hypotension. GI: constipation, diarrhea, dyspepsia, increased liver enzymes, nausea, vomiting. GU: urinary retention. Derm: bullous eruption, hematoma purpura, rash. Hemat: bleeding, thrombocytopenia. F and E: hypokalemia. Misc.: fever, increased wound drainage.
Nursing implications Teach client to report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever, swelling or difficulty breathing. Assess for signs of bleeding and hemorrhage from any orifice. Assess for evidence of additional or increased thrombosis. Monitor for neurologic changes. Monitor platelet count closely. Monitor CBC, serum creatinine levels and stool for occult blood during therapy.
Route/Dosage/Reason 20 mg orally daily for DVT
Trade name Solu-MEDROL
Generic name Methylprednisolone
Classification Anti-inflammatory (steroidal) agent, immunosuppressant/glucocorticosteroids.
Therapeutic use Systemic and local treatment of a wide variety of inflammatory diseases and conditions. Suppresses inflammation and the normal immune response.
Major adverse effects CNS: depression, euphoria, headache., personality changes, psychoses, restlessness. EENT: cataracts, increased intraocular pressure. CV: HTN. GI: peptic ulceration. Derm: acne, hirsutism, petechiae. Endo: adrenal suppression, hyperglycemia. F and E: fluid retention, hypokalemia. Hemat: thromboembolism, thrombophlebitis. Metab: weight gain, hyperglycemia. MS: muscle wasting, osteoporosis, aseptic necrosis of joints, muscle pain. Misc: cushingoid appearance, increased susceptibility to infection.
Nursing implications Teach client not to stop medication suddenly. Avoid grapefruit juice and limit caffeine when taking oral forms. Monitor I & O, daily weights, edema, lung sounds, serum electrolytes and glucose level. Give with food in the AM to decrease gastric upset.
Route/Dosage/Reason 125 mg IV push daily / pneumonia
Trade name Vancomycin
Generic name Proamatine
Classification Anti-infective
Therapeutic use Treatment of life threatening infections.
Major adverse effects EENT: ototoxicity. CV: hypotension, massive histamine release called “red man syndrome” with rapid IV infusion. GI: nausea, vomiting. GU: nephrotoxicity. Derm: rashes. Hemat: eosinophilia, leukopenia. Local: phlebitis. MS: back and neck pain. Misc: anaphylaxis, superinfection.
Nursing implications Teach client that oral forms are to be taken exactly as prescribed. Report tinnitus, rash, vertigo, hearing loss, flushing, of the skin or dizziness. Perform culture and sensitivity tests prior to initiating therapy. Monitor the IV site closely to avoid extravasation. Monitor blood pressure and presence of skin flushing throughout IV infusion. Monitor I&O and daily weight. Cloudy or pink urine may be a sign of nephrotoxicity. Assess bowel status. Monitor CBC with differential and liver and renal function. Monitor peak and trough drug levels. Report toxic levels immediately. Administer IV over at least 60-90 minutes to prevent “red man syndrome”.
Route/Dosage/Reason 1 gm IV push, for sepsis
Trade name Diflucan
Generic name Fluconazole
Classification Antifungal
Therapeutic use Treatment of fungal infections caused by susceptible organisms.
Major adverse effects CNS: headache, dizziness, tremor, seizures. GI: hepatoxicity, abdominal discomfort, diarrhea, nausea, vomiting. Derm: skin disorders. Endo: hypokalemia, hypocalcemia, hypomagnesemia, hypertriglyceridemia. Misc.: allergic reactions, including dyspnea, hypoxia, wheezing CV: hypotension, arrhythmias. GU: nephrotoxicity, hematuria, MS: arthralgia, myalgia. Neuro: peripheral neuropathy.
Nursing implications Teach client to take medication as prescribed. Notify health care provider if skin rash, abdominal pain, fever, diarrhea, unusual fatigue, anorexia, nausea, vomiting, jaundice, unusual bruising, bleeding, palpitations, dark urine, or pale stools occur. Report any development of a rash immediately. Obtain specimens for culture before therapy starts. Monitor LFT, RFT, and CBC with differential. Monitor vital signs every 15-30 minutes during test dose and every 30 minutes for 2-4 hours after administration of amphotericin. Assess respiratory status daily after administration of amphotericin.
Route/Dosage/Reason 20 mg tablet, by mouth daily for neutropenia.
Trade name Lovenox
Generic name Enoxaparin
Classification Anticoagulant
Therapeutic use Prevention of DVT and PE
Major side effects CNS: dizziness, headache, insomnia. CV: edema. GI: constipation, nausea, vomiting, Derm: ecchymosis, pruritus, rash. Hemat: bleeding, anemia, thrombocytopenia. Local: pain in the injection site, hematoma. Misc.: fever, hypersensitivity. Neuro: epidural or spinal hematoma with use during spinal procedures.
Nursing implications Teach client to report any symptoms of unusual bleeding or bruising to health care provider immediately. Do not take concurrently with antiplatelet agents. Use soft toothbrush and an electric razor. Follow instructions for proper method of injecting the drug. Assess client for signs of bleeding and hemorrhage. Monitor for hypersensitivity reactions. Monitor CBC with platelets and D-dimer studies. Monitor LFT. Antidote is protamine sulfate.
Route/Dosage/Reason 40mg sub-q injection daily for DVT

(Davis Drug Guide 2017)

Nursing Diagnoses

1: Risk for fluid and electrolyte imbalance related to side effects of treatment-related medication Interventions: Monitor I & O’s and weigh client daily. Monitor lab values.
Nursing outcomes: Patient’s will display a heart rate, blood pressure and laboratory results within normal limits. Patient will have absence of muscle weakness. Patient will show no neurological irritability. Collaborative interventions: Refer patient to nephrology consult in order to monitor renal function. Refer patient for neurology an PT consult.
2: Impaired gas exchange related to inflammation of airways and alveoli secondary to pneumonia as evidence by tachypnea. Interventions: Assess respiratory rate, rhythm, depth and use of accessory muscles Assess patient’s mental status and any changes in level of consciousness.
Nursing outcomes: Patient will demonstrate improved ventilation and oxygenation of tissues. Patients ABG’S will be within acceptable range. Patient will show no signs of respiratory distress. Collaborative interventions: Refer patient for pulmonology consult. Refer to respiratory therapy for treatments.
3: Imbalanced nutrition: Less than body requirements related to hypermetabolic state due to cancer as evidenced by inadequate food intake, altered taste sensation and loss of interest in food. and generalized edema. Interventions: Monitor patient’s daily food intake. Encourage patient to eat high-calorie, nutrient rich foods and have adequate fluid intake. Encourage the use of supplements.
Nursing outcomes: Patient will participate in specific interventions to stimulate appetite and increase dietary intake. Collaborative interventions: Collaborate with dietary to have proper nutritional

foods/supplements on hand for the patient. Refer Refer patient for nutritional consult in order to promote consult to promote adequate nutritional intake.

(North American Nursing Diagnosis Association, 2018).

Interventions: Routine Nursing Management

Nursing Intervention Rationale
Reposition the patient every two hours (Woodhouse, Worsley, Voegell, Schoonhoven & Bader, 2015). Patients who have limited mobility are at higher risk for developing pressure ulcers. To reduce the risk it is important to reposition the patient at least every 2 hours.
Administer oxygen therapy via nasal cannula (Azoulay, Lemiale, Mokart, Nseir, Argaud, Pène, & Girault 2018). When treating hypoxemic patients oxygen therapy is the first line of defense.
Monitor for signs and symptoms of deep vein thrombosis (DVT) (Gordon & Schreiber 2016). Patient diagnosed with DVT in left leg currently being treated. It is important to monitor the patient closely for any signs and symptoms of another DVT or for signs and symptoms of dislodgement of DVT.
Monitor patients fluid and electrolytes (Berardi, Rinaldi, Caramanti, Grohe, Santoni, Morgese, Cascinu, 2016). Hyponatremia is common in patients with a cancer diagnosis. It can be related to medications for the treatment of the cancer. Monitoring and managing the patient’s fluid and electrolytes can improve patient’s overall outcome.
Monitor patient’s daily weights and I & O’S

(Makic, Ladwig, & Ackley 2017)

Patient does not have adequate nutrition and fluid intake; therefore, it is important to monitor for any weight loss.
Monitor patient’s vital signs continuously (Trinier, Ruth, Liske, Lori Nenadovic & Vera 2016). Critically ill patients require specialized nursing care. Vital signs of a critically ill patient should be monitored closely and continuously to assess for changes in the patient’s condition. This allows for further identification if the patients status is deteriorating.
Provide frequent perineal care (Conely, McKinsey, Ross, Ramsey & Feeback 2017). It is important to provide frequent perineal care to the critically ill. Patient has Purewick female catheter placed and it should be assessed and changed when needed.

 

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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