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Stenberg College NURS 201-3 Weekly Case Study and Care Plan Clinical group Members: Andrea Geib, Lorna Muenz, Kristina Day, Sasha Yunick, Jill Shaw, & Michelle Couper Date: June 2th -8th 2014 Case Study Critical thinking questions NURSING MANAGEMENT: Lower Respiratory Problems Aspiration Pneumonia Client Profile Sam, a 27-year-old man, was admitted to the hospital because of an uncontrollable fever. He was transferred from a long-term care facility. He has a history of a gunshot wound to his left chest. Following a cardiac arrest after the accident, he developed hypoxic encephalopathy. He has a tracheostomy and gastrostomy tube. He has a history of methicillin-resistant Staphylococcus aureus (MRSA) in his sputum. Subjective Data ·Family says that they visit him regularly and are very devoted to him. Objective Data Physical Examination ·Thin, cachectic man in moderate respiratory distress ·Unresponsive to voice, touch, or painful stimuli ·Vital signs: temperature 40°C (104°F), heart rate 120, respiratory rate 30, O2 saturation 90% ·Chest auscultation revealed crackles and scattered wheezes in the left upper lobe Diagnostic Studies ·Serum albumin 28 g/L (2.8 g/dL) ·White blood cell (WBC) count 18 × 109/L (18,000/μL) ·Sputum specimen: thick, green-coloured, foul smelling; cultures pending ·Arterial blood gases: pH 7.29, PaO2 80 mm Hg, PaCO2 40 mm Hg, bicarbonate 16 mEq/L ·Stool culture positive for Clostridium difficile ·Chest x-ray: infiltrate in left upper lobe; no pleural effusions noted Critical Thinking Questions 1.What types of infectious disease precautions should be taken related to Sam’s hospitalization? Sam’s stool culture tested positive for Clostridium difficile and his sputum tests are still pending but since he has had a history of methicillin-resistant Staphylococcus aureus (MRSA) and his sputum was observed to be thick, green, and foul smelling, there is strong indication that an infection exists and he could test positive for MRSA. Two levels of infectious disease precautions should be taken due to his positive test for C Diff and suspected MRSA infection (Kwong & Springer, 2014). These two levels of precaution include standard precautions and transmission based precautions (Kwong & Springer, 2014). The standard precautions system applies to blood, all body fluids, non-intact skin, and mucous membranes (Kwong & Springer, 2014, p. 321). Transmission based precautions are designed for patients suspected of or known to be infected with highly transmissible pathogens in which additional precautions need to be implemented to interrupt transmission (Kwong & Springer, 2014). Three types of transmission based precautions include airborne, droplet and contact (Kwong & Springer, 2014, p. 321). In Sam’s case standard precautions would apply as well as contact (transmission based) precautions as MRSA and C Diff can be transmitted through direct contact with infected individual or environmental surfaces (Kwong & Springer, 2014). These precautions would include hand hygiene, gloves, mask, eye protection, face shield, gown, linen, and patient transport (pp. 320-321). Hand Hygiene procedure: wash hands using either soap or alcohol-based hand rubs. This should be done before initial contact with patient or his environment, before aseptic procedures, after body fluid exposure risk, and after contact with patient or environment (Kwong & Springer, 2014, p. 320). Gloves: wear nonsterile gloves when touching blood, body fluid, secretions, excretions, and contaminated items. Remove promptly after use. In Sam’s case contact precautions would be implemented as well which would include wear gloves when entering the rom and whenever providing direct care or having hand contact with contaminated surfaces (Kwong & Springer, 2014, p. 320). Mask, Eye Protection, Face Shield: wear to protect mucous membranes when administering direct care and more specifically in situations when dealing with blood, body fluids, secretions and excretions. Wear within 1 m of coughing patient. Gown: since Sam has diarrhea it is especially important to wear gown especially if substantial contact is required. Remove and discard properly immediately after use (Kwong & Springer, 2014, p. 320). Linen: handle, transport, and process used linen in a manner that prevents sin exposure and contamination (Kwong & Springer, 2014, p. 320). Patient Transport: limit movement of patient unless absolutely essential; if transport is necessary minimize contamination of environmental surfaces or environment (Kwong & Springer, 2014, p. 320). In addition to the above precautions, best practice guidelines suggest that individuals infected with C Diff should be isolated and have a private room and bathroom and signage indicating the precautions that should be used (p. 1165). Kwong, J. & Springer, L. (2014). Medical Surgery Nursing in Canada. Toronto, ON: Elsevier Mosby 2/2 2. What clinical manifestations of aspiration pneumonia did Sam exhibit? Explain their pathophysiological bases. Signs and symptoms of aspiration pneumonia that Sam exhibits is a fever, respiratory distress, crackles and wheezes in left upper lobe, increased heart rate, and O2 saturation of 90%. All elevated vital signs are due to the underlying infection while the low o2 sat and crackles and wheezes are due to the aspirated materials in his lungs. Crackles sounds in the chest, can either be fine or coarse sounding. If the crackle sounds are fine, this indicates fast equalization of gas pressure when the alveoli are distorted, or the terminal bronchioles open up abruptly. If the crackles are coarse, this is caused by mucosa blocking the airway intermittently; resulting in air not being able to pass through, or the bronchial wall is unstable. The aspirated material that entered Sam’s lung is the reason for Sam developing this type of pneumonia; also with Sam not responding to voice, touch or painful stimuli, this suggests that he may be unconscious. With Sam potentially being unconscious, his cough and gag reflexes are depressed, and the chances of him aspirating are even higher. White blood cell count is high (18, 000/uL) showing signs of infection because normal white blood cell count is approximately 3,500-10,500/uL. With Sam having such high white blood cell count, his body is working very hard to fight off the infection by itself. 2/2 Crimlisk, J. & Bolan, C. (2010). Nursing Management: Lower respiratory problems. In Lewis, S., Heitkemper, M., Dirksen, S. R., O' Brien, P. G., Barry, M., Goldsworthy, S., & Goodridge, D. (Eds.), Medical-surgical nursing in Canada (2nd ed.) (pp. 626-669). Toronto, ON: Mosby Elsevier. 3. What antibiotic medication is likely to be prescribed? The patient has MRSA which means standard antibiotics will not work in treating his pneumonia. The most recommended medication that would be prescribed for him is Vancomycin (Table 17-6 pg 318). According to WebMD Vancomycin, an antibiotic is prescribed for treating serious bacterial infections by stopping the bacterial growth. It is most commonly given intravenously however when used to treat C-Diff it is taken orally where it remains in the intestines to stop bacteria growth and is not absorbed into the rest of the body. 1/1 The above patient would be prescribed oral to treat his C-Diff and IV to treat his pneumonia. WebMD. (n.d.) Drugs & medications – vancomycin. WebMD. Retrieved from: http://www.webmd.com/drugs/drug-939-Vancomycin+IV.aspx?drugid=939 4. What is his oxygenation status and metabolic state? 4. What is his oxygenation status and metabolic state? His O2 saturation is 90% while arterial blood gasses show: pH 7.29, paO2 80 mmHg, PaCO2 40 mm Hg, and a Bicarbonate 16 mEq/L. The blood gas readings show the patient is at risk for metabolic acidosis. This means that in order for his body to compensate, his CO2 levels increases to compensate and thus his breathing increases, and is not getting enough O2, thus giving him a deficit in bicarbonate (16mEq/L). The fact that his “Chest auscultation revealed crackles and scattered wheezes in the left upper lobe” and is in “moderate respiratory distress” explains that he is having trouble breathing, thus heart rate is up and is having problems with O2, he will need O2 therapy to get his breathing and heart rate back to normal and less distressed. This is called hypoxia. 1/1 Malone, M. (2014) Nursing Management: Lower Respiratory Problems. In M. Barry, S. Goldsworthy & D. Goodridge (Ed.) Medical-Surgical Nursing in Canada: Assessment and management of clinical problems (3rd Canadian ed.) (pp. 658-708) Toronto, ON: Elsevier Canada. 5. What other clinical issues need to be addressed in his plan of care? Looking at the predisposing factors for pneumonia, Sam has a few, the first one identified is his altered state of consciousness, the next factor would be bed rest and prolonged immobility, as well as intestinal and gastric feedings and lastly tracheal intubation (Malone, 2014, Table 30-1, p. 660). Other clinical issues would be in connection to these factors. Because of his clinical situation, he is at risk for aspiration because of his neurological status. This patient has a complex care plan to deal with, because he is in a compromised position, with being in a coma, it is the nurse’s responsibility to follow all precautions for the care of Sam. Starting with universal precautions for MRSA, they would include hand hygiene; gloves, mask, eye shield; gown and linen care (Malone, 2014,) as well as documenting on the patients chart so the healthcare team is well informed. Utilizing a cart outside the patient’s room and having all the supplies needed on hand will help to remind the team of the patients needs. Therapeutic positioning for a patient with pneumonia, would generally be with the patient’s head slightly elevated and positioned on his side with the good lung down, for the lung “to achieve maximum lung expansion” Malone, 2014, p.666). Although with the tracheostomy and the feeing tube the patient would be monitored easier on his back. Turning of this patient would need to be addressed every two hours ”to facilitate adequate lung expansion and to discourage pooling of secretions” (Malone, 2014,). Aseptic technique for the care of his tracheostomy and gastric tubes is very important to reduce the chance of hospital-associated infection, hand hygiene and sterile suctioning techniques are important for reduction of these infections. “Respiratory devices can harbor microorganisms and have been associated outbreaks of pneumonia”(Malone, 2014, p.666). The treatment of clostridium difficile also know as C. difficile is for the most part prevention of the spread of the disease. C. diff is caused in “patients who are taking certain antibiotics in high doses over a prolonged period of time”( phac.gc.ca, 2014). The bacteria causes abdominal cramping and watery diarrhea. Transmission of this disease is through people not washing their hands after contact with feces. “People can get infected if they touch surfaces contaminated with feces, and then touch their mouth” (phac.gc.ca, 2014). In mild cases treatment is not always needed, in severe cases medication and surgery could be warranted (phac.gc.ca, 2014). For Sam medication and universal precautions for the transmission of the bacteria would be the best treatment. 1.25/2 Nursing measures should be directed toward prevention of aspiration. He is malnourished as evidenced by hypoalbuminemia and cachectic condition, and the reasons for this need to be investigated. phac.gc.ca (2014)Fact Sheet - Clostridium difficile (C. difficile) Public Health Agency of Canada. Retrieved from http://www.phac-aspc.gc.ca/id-mi/cdiff-eng.php Malone, M. (2014) Nursing Management: Lower Respiratory Problems. In M. Barry, S. Goldsworthy & D. Goodridge (Ed.) Medical-Surgical Nursing in Canada: Assessment and management of clinical problems (3rd Canadian ed.) (pp. 658-708) Toronto, ON: Elsevier Canada. 6.What family interventions would you initiate? We would discuss with the family how Sam’s previous and present diagnosis’s when all combined are having very negative effects on his health. Explaining to the family about what pneumonia is, how it is affecting Sam, and how it is usually treated would be important. We would also have to explain to the family that because of Sam’s MRSA, unfortunately antibiotics will not be effective in treating his pneumonia. At this time it would be important to speak to the family about a DNR and the patient’s quality of life, especially with his current status. Discussing comfort measures and palliative care options, as well as looking at family support systems and recommending grief counselling is also crucial. We would provide the family with as many resources possible regarding Sam’s health issues, and also any supportive resources. 1/1 7. Based on the assessment data presented, write one or more appropriate nursing diagnoses. Are there any collaborative problems? 0.5/1 Nursing Focus of Care / Nursing Diagnosis Collaborative problems Domain 11: Safety/Protection Infection, respiratory distress, prolonged bed rest, increased secretions and impaired swallowing due to tracheostomy. Risk for Aspiration Domain 11: Safety/Protection Risk for Contamination Domain 9: Coping/Stress tolerance Compromised family coping Patient is positive for MRSA and C-Diff isolation precautions must be taken to prevent the spread of diseases to nurse or other patients; aseptic technique, gloves, gown, mask, eyewear, hand washing, isolation room, linens and equipment sterilization. Family at risk for denial, fear, grieving, depression, helplessness, and guilt. 5/5 Malone, M. (2014) Nursing Management: Lower Respiratory Problems. In M. Barry, S. Goldsworthy & D. Goodridge (Ed.) Medical-Surgical Nursing in Canada: Assessment and management of clinical problems (3rd Canadian ed.) (pp. 658-708) Toronto, ON: Elsevier Canada. Stenberg College RDPN Program Nursing Care Plan Nursing Diagnosis Desired Outcomes Interventions (I)Independent (C) - Collaborative Rationale & APA Reference Evaluation of Interventions NDX: (Problem) Goal (Reversal of Problem) N1-(I) (C) R1-Single most important thing you can do to prevent an infection E1-Ensure hand sanitizer or access to soap and running water are available outside patient’s room and nurses are aware of isolation precautions. Risk for Contamination R/T: (etiology/factor): MRSA Treat and protect against spread of infectious disease Hand hygiene (author, Pg. 319) Author Pg. 319 Nursing Diagnosis Desired Outcomes Interventions (I)Independent (C) - Collaborative Rationale & APA Reference Evaluation of Interventions C-Difficile Patient in coma N2-(I) (C) R2-Non-sterile gloves should be used when touching bodily fluids and changed frequently in between tasks. E2-Ensure clean gloves are available, accessible and fully stocked in different sizes. Author, Pg. 320 Pg. 320 R3-Protect against splashes or spray from bodily fluids E3-Nurse must wear these within 1 meter of coughing patient Pg. 320 Pg. 320 R4-Protect skin and prevent clothing soil during patient care. E4-Assessment of specific risk determines the type of gown to be worn. eg, fluid resistant. AEB: (s/sx; defining characteristics) 1. sputum text positive for MRSA 2. Stool positive for C-Difficile *If ‘risk for’ would exhibit: Gloves Nurse will (list measurable outcomes; reverse signs and symptoms) 1. use of proper isolation measures 2. prevent the spread of contaminable diseases to staff, patients and public N3-(I) (C) Mask, eye protection and face shield N4-(I) (C) Gown Pg. 320 Pg. 322 N5- (I) (C) 3. proper documentation Linen Evaluation of Outcomes (address each outcome) 1. contain and prevents the spread of infectious contaminants. 2. use of isolation and protective measures with all people accessing the patient 3.Make sure R5- prevents skin and mucous membrane exposure. Pg. 321 R5- make sure pts room has accessible laundry bins, and supplies readily available Pg. 321 N6- (I) (C) R6- limit movement and transport to prevent spread of disease. E6- transport for essential services and place mask on pt. Pg. 321 Pg. 321 N7- (I) (C) R7- E7- Treatment of C-Diff with ? ? Limit Patient Transport Nursing Diagnosis Desired Outcomes Interventions (I)Independent (C) - Collaborative Rationale & APA Reference Evaluation of Interventions chart is labelled and isolation precautions are posted on pts room Evaluation of Goal: Goal met – if all isolation precautions and protection measures are taken and followed by staff and visitors. (If goal not met, describe outcomes not met) Continuation of plan: (circle one) Continue plan of care until patient discharged. All of your interventions should be under one umbrella of isolation precautions. There are some important measures that you missed in your care plan to deal with infection – ie medications, blood work, mobilization –even if it is in bed and chest physiotherapy. These are all important aspects of monitoring the body to treat and prevent infection. 2.5/5 Kwong, J. & Springer, L. (2014) Infection and Human Immunodeficiency Virus infection. In M. Barry, S. Goldsworthy & D. Goodridge (Ed.) Medical-Surgical Nursing in Canada: Assessment and management of clinical problems (3rd Canadian ed.) (pp. 314-343) Toronto, ON: Elsevier Canada. 16.25/20 Some work needs to be done on your care plan. See my comments. Your critical thinking questions were very well done. Don’t forget about the collaborative nursing diagnoses – these can just be listed.