Care of the Critically-Ill Patient: Interdisciplinary Care
Chamberlain College of Nursing
NR 341: Complex Adult Health
Care of the Critically-Ill
... [Show More] Patient: Interdisciplinary Care
73-year-old, Caucasian, widowed, retired male was admitted to the hospital on May 11, 2017 from his home. He does not have a resuscitation status, and no known allergies. Admitting diagnosis is mitral valve disease secondary to bacterial endocarditis, and acute kidney injury. Past medical history includes obstructive sleep apnea, hypertension, hemothorax, gout, GERD, diabetes mellitus, atrophy of the left kidney, and alcohol abuse. Recent surgery on May 12, 2017 includes mitral valve replacement with a cardiopulmonary bypass. Significant assessment findings are as follows: temperature 37o C, pulse 84, respiratory rate 17, blood pressure 140/61, O2 saturation 94 on room air, and 0 pain reported on a scale from 0 to 10. Foley catheter is in place, and output measurement is 100 mL at 0900. A peripherally inserted central catheter is located on his left arm. Student was unable to obtain amount from pleur-evac. Patient was semi-lucid; therefore, unable to obtain a review of systems. Focused assessment includes as follows:
Integumentary: Skin is warm, dry, and no skin turgor noted.
Head and neck: Normocephalic, and jugular vein distension is absent.
Respiratory: Chest expansion is symmetric, and lung sounds are clear on the right side yet
Diminished on the left side.
Cardiovascular: S1 and S2 are noted on auscultation, and S3 and S4 are absent.
Gastrointestinal: Abdomen is rounded and symmetric, skin is smooth, bowel sounds are present
in all four quadrants, and last bowel movement was the morning of May 14, 2017.
Neurological: Patient is oriented to person, place, and time.
Eyes: Pupils are 3 mm, and equal, round, reactive to light and accommodation.
Laboratory and Diagnostic Tests
Lab Test Result Normal range Comment
Sodium 141 135 – 145
Potassium 4.2 3.5 – 5.3
Chloride 103 98 – 106
CO2 24 23 – 30
BUN 22 10 – 20 High; this is related to his acute kidney injury, and may be related to previous administration of gentamicin, which is an aminoglycoside
Creatinine 1.94 0.6 – 1.2 High; this is related to his acute kidney injury, and may be related to use of lisinopril
Glucose 182 70 – 130 High; this is related to his diabetes mellitus, and may be related to use of atorvastatin
Calcium 8.3 8.8 – 10.2 Low; this is related to his acute kidney injury, as well as alcohol abuse
eGFR 34 >90 mL Low; this is related to his acute kidney injury, and is inversely related to creatinine
WBC 9.70 5,000 – 10,000
RBC 3.14 4.7 – 6.1 Low; this may be related to his acute kidney injury, blood loss secondary to recent surgery, or anemia
Hemoglobin 9.0 14 – 18 Low; this is directly related to his red blood cell count
Hematocrit 27 42% – 52% Low; this is directly related to his red blood cell count
Platelets 125 150,000 – 400,000 Low; this may be related to administration of heparin, or bacterial endocarditis (i.e., infections may lower platelet counts)
Medications
Ampicillin Medication class: Antiinfective – broad spectrum; aminopenicillin
Therapeutic use: Treatment for bacterial endocarditis
Major adverse effects: Acute liver failure, nephrocalcinosis, thrombocytopenia, Stevens-Johnson syndrome, and anaphylaxis
Dosage: 2 g in NaCl 0.9 100 mL
Route and frequency: IV every 4 hours
Nursing implications: Monitor vital signs every 15 – 30 minutes during first infusion, watch for decreasing urinary output, increasing BUN, monitor liver function tests, and dermatitis/rash
Aspirin (Bayer Aspirin) Medication class: Nonopioid analgesic, nonsteroidal antiinflammatory, antipyretic, and antiplatelet
Therapeutic use: Stroke prophylaxis
Major adverse effects: Seizures, GI bleeding, hepatitis, thrombocytopenia, and bronchospasm
Dosage: 81 mg
Route and frequency: Oral; one every day
Nursing implications: Assess for pain, fever, and if patient is receiving long-term therapy, monitor liver function tests, creatinine and BUN
Lipitor (Atorvastatin) Medication class: Antilipemic; HMG-CoA reductase inhibitor
Therapeutic use: Hypercholesterolemia
Major adverse effects: Liver dysfunction, pancreatitis, rash, myalgia, and rhabdomyolysis
Dosage: 40 mg
Route and frequency: Oral; one at bedtime
Nursing implications: Monitor hepatic and renal lab results, assess for constipation, and signs of rhabdomyolysis (i.e., muscle tenderness or weakness)
Colace (Docusate sodium) Medication class: Laxative
Therapeutic use: Stool softener
Major adverse effects: Throat irritation, nausea, anorexia, cramps, and diarrhea
Dosage: 100 mg
Route and frequency: Oral; two times a day
Nursing implications: Assess for constipation, cramping, rectal bleeding, nausea, and vomiting
Lasix (Furosemide) Medication class: Loop diuretic
Therapeutic use: Pulmonary edema
Major adverse effects: Circulatory collapse, renal failure, thrombocytopenia, Stevens-Johnson syndrome, and toxic epidermal necrolysis
Dosage: 20 mg
Route and frequency: IV; daily
Nursing implications: Monitor weight, I&O, blood pressure, signs of metabolic alkalosis, hypokalemia and tinnitus
Heparin Medication class: Anticoagulant and antithrombotic
Therapeutic use: DVT prophylaxis
Major adverse effects: Hematuria, hemorrhage, thrombocytopenia, anemia, and anaphylaxis
Dosage: 5000 u
Route and frequency: Subcutaneous; every 12 hours
Nursing implications: Assess for bleeding, hemorrhage, black tarry stools, petechiae, ecchymosis, hematuria, epistaxis, decrease in Hct, blood pressure, and labs
Lantus (Insulin glargine) Medication class: Antidiabetic and pancreatic hormone
Therapeutic use: Management of diabetes
Major adverse effects: Blurred vision, dry mouth, rash, hypoglycemia, and peripheral edema
Dosage: 5 u
Route and frequency: Subcutaneous; bedtime
Nursing implications: Monitor fasting blood glucose, urine ketones, and hypoglycemic reaction that can occur during peak time
HumaLOG (Insulin lispro) Medication class: Antidiabetic and pancreatic hormone
Therapeutic use: Management of diabetes
Major adverse effects: Blurred vision, dry mouth, rash, hypoglycemia, and peripheral edema
Dosage: Sliding scale protocol
Route and frequency: Subcutaneous; sliding scale protocol
Nursing implications: Monitor fasting blood glucose, urine ketones, and hypoglycemic reaction that can occur during peak time
Prinivil (Lisinopril) Medication class: Antihypertensive and angiotensin-converting enzyme 1 (ACE) inhibitor
Therapeutic use: Management of hypertension
Major adverse effects: Stroke, hepatic failure, pancreatitis, neutropenia, and angioedema
Dosage: 10 mg
Route and frequency: Oral; one every day
Nursing implications: Monitor platelet counts, renal and hepatic blood tests, assess for signs of angioedema, and peripheral edema
Lopressor (Metoprolol tartrate) Medication class: Antihypertensive and antianginal; beta-blocker
Therapeutic use: Management of hypertension, and to reduce myocardial contractility post-surgery
Major adverse effects: Bradycardia, cardiac arrest, pulmonary/peripheral edema, thrombocytopenia, and bronchospasm
Dosage: 12.5
Route and frequency: Oral; every 12 hours
Nursing implications: Monitor weight, I&O, blood pressure, glucose levels, and renal and hepatic labs
Protonix (Pantoprazole) Medication class: Proton pump inhibitor
Therapeutic use: Management of GERD
Major adverse effects: Pancreatitis, rhabdomyolysis, myalgia, pneumonia, and Stevens-Johnson syndrome
Dosage: 40 mg
Route and frequency: IV; once daily
Nursing implications: Monitor hepatic labs, vitamin B12 deficiency in long-term therapy, serious skin reaction, electrolyte imbalances, rhabdomyolysis, and myalgia
Nursing Diagnoses
Nursing diagnoses in order of priority are as follows:
Ineffective airway clearance related to stasis of secretions secondary to immobility from surgery as evidenced by diminished lung sounds.
Activity intolerance related to increased metabolic demand secondary to surgery as evidenced by patient report of dyspnea upon exertion.
Risk for electrolyte imbalance related to acute kidney injury.
Interventions and Management
Intervention and management of the critically-ill patient includes as follows:
• Review echocardiogram results to ensure that mitral valve, as well as overall heart, is functioning properly.
• Ensure that ejection fracture is greater than 55%.
• Discuss with healthcare provider (HCP) the cause and treatment of diminished lung sound in left lung, and when chest tubes will be removed in order to assess patient before, during, and after procedure.
• Discuss the treatment plan to be administered by the respiratory therapist.
• Discuss with HCP the acute kidney injury of the patient, and other treatment measures that can be taken to correct the renal labs of the patient.
• Discuss with physical therapist how patient is responding to therapy (i.e., getting out of bed and ambulation).
• Continue to monitor the laboratory results, and make sure they are within range.
• Continue to administer medications in a timely manner, and if needed, administer pain medication.
• Assess patient on an hourly basis.
• Provide therapeutic communication about condition and prognosis (Sole, Klein, & Moseley, 2017).
References
Sole, M. L., Klein, D. G., Moseley, M. J. (2017). Introduction to critical care nursing. Retrieved from https://bookshelf.vitalsource.com/books/9780323377034
GRADING CRITERIA Assignment Criteria Points % Description
Background Information 20 17 chest tubes important part of assessment?location? how many? Drainage? Suction? Chest xray? 10% Includes all the elements as described in the assignment guidelines.
•Demographics
•History of present illness
•Relevant past medical and surgical history
•Admitting diagnosis(diagnoses)
•Course of current hospitalization to date
•Significant assessment findings during day(s) of care. Include vital signs,focused assessment, and data from monitoring devices.
Laboratory and Diagnostic Tests/
20 20 10%
•Identifies and lists relevant and significant lab values and diagnostic tests andprocedures performed.
•Includes the rationales for performing the tests and for any abnormal results.
•Provides an analysis of the relationships between and among the diagnostictests and lab results with the critically ill individual’s current condition(s).
Nursing Dx 20 20 3 nursing diagnoses in order of priority
Meds
20 20
10%
•Identifies and lists relevant and significant medications.
•Indicates the trade name and generic name, the medication classification, thetherapeutic use, major adverse effects, and nursing implications.
•Includes the rationale as to why the medication is prescribed for treatment.
Interventions/Management/Modalities. 20 20 10%
•Describes independent nursing care provided in the care of the critically illindividual.
•The rationales are included for each intervention/modality
TOTAL 100points 97 points
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