CASE STUDY 1 Clinical Case Study: Sigmoid Volvulus with Perforation Amanda Frederick 00791934 Sentara Princess Anne Hospital Submitted in partial fulfillment of the requirements in the course NURS351: Clinical Management – Adult Health Nursing III Old Dominion University NORFOLK, VIRGINIA Spring, 2013 CASE STUDY 2 Clinical Case Study: Sigmoid Volvulus With Perforation C.J is a 76-year-old male who was being evaluated for abdominal distention and constipation. His family made these reports because this patient was nonverbal at baseline due to having Progressive Supranuclear Palsy (PSP). PSP is a “neurologic disorder of unknown cause that is characterized by paralysis of eye muscles, ataxia, neck and truck rigidity, pseudobulbar palsy, and parkinsonian facies” (“Mosby’s dictionary,” 2009, Pg. 1522). Due to the seriousness of this disease, he had a Percutaneous Endoscopic Gastrostomy tube (PEG tube) placed before this admission, which allowed for feeding and medication administration. When the doctors performed a flexible sigmoidoscopy a Sigmoid Volvulus was detected. However, when the doctor advanced the scope it entered into the peritoneal cavity and the procedure was ceased. C.J had a colon resection done; Hartmann’s procedure performed, and then ended up becoming septic. He was unable to be extubated after surgery and was sent to the intensive-care unit (ICU) on a ventilator and with a Jackson-Pratt Drain (JP drain). His past medical history is quite extensive but the most relevant and important ones include: benign prostatic hyperplasia (BPH) with urinary retention, altered mental status, unspecified hypotension, leukocytosis, azotemia, hypernatremia, lactic acid acidosis, acute interstitial pneumonia, bladder neck contracture (BNC), a neurogenic bladder which results in him having a chronic foley, myocardial infarction, and hypercholesterolemia. Scope of Paper The scope of this paper is to discuss the patient’s medical diagnosis, which in turn will allow for relevant nursing diagnoses to be made. Making nursing diagnoses is vital when providing patient care because it also provides an opportunity to make attainable goals and outcomes for that patient. This paper will discuss not only these aspects, but also the appropriate CASE STUDY 3 interventions to be taken with certain nursing diagnoses, which will help attain our goals set forth for this specific patient. Medical Diagnosis C.J’s medical diagnosis, which was noted from the chart, was Sigmoid Volvulus with perforation. However, his main reason for ICU admission was because he became septic from peritonitis and went into respiratory failure and couldn’t be weaned off the ventilator after surgery. Sigmoid Volvulus is a type of mechanical obstruction where the sigmoid colon becomes twisted (Ignatavicius & Workman, 2012). Perforation refers to the fact that the doctor mistakenly pierced a hole through the entire intestinal wall while observing with a scope, which allowed the digestive tract contents to leak into the peritoneal cavity (“Mosby’s dictionary,” 2009). Signs and symptoms of bowel obstruction include abdominal distention and constipation, both of which C.J was experiencing, but also cramping and possible slight pain (Ignatavicius & Workman, 2012). Peritonitis, “a life-threatening, acute inflammation of the visceral/parietal peritoneum and endothelial lining of abdominal cavity” occurs because the peritoneal cavity is usually sterile and when the intestinal contents leak into this space it became contaminated with bacteria, which is what happened in C.J’s case (Ignatavicius & Workman, 2012, pg. 1268). This, in turn, caused an infection, which triggered a whole-body inflammatory response and the bacteria entered into the blood stream and C.J developed sepsis (Ignatavicius & Workman, 2012). To make matters worse, after surgery to try to fix everything discussed thus far, C.J went into respiratory failure and could not be taken off the ventilator. Respiratory failure develops when “the pulmonary system fails to maintain adequate gas exchange” and hypoxemia occurs CASE STUDY 4 (Urden, Stacy, & Lough, 2010, pg. 602). He then was sent to the ICU where he could be discretely watched and cared for. Nursing Diagnoses Impaired Spontaneous Ventilation The priority nursing diagnosis for C.J would be Impaired Spontaneous Ventilation related to acute respiratory failure. Evidence of respiratory failure, such as that of respiratory acidosis and arterial blood gases (ABGs) were not noted since I cared for C.J weeks into his admission, where he was then respiratory alkalotic. However, according to Maslow’s Hierarchy of Needs priority must be given to those things that must be met in order to sustain life, in other words physiologic and survival needs (Johnson & Webber, 2010). Maintaining adequate airway is the most vital intervention nurses must implement regardless of the circumstances. This nursing diagnosis coincides with Dorothea E. Orem’s Theory of Self-Care Deficit. Orem explains that when patients are unable to care for themselves, even with the assistance of family members, nurses can meet that self-care demand (Johnson & Webber, 2010). One of the five methods that nurse’s use to help meet self-care needs of a patient is acting for or doing for another, which is what we did when supplying him the ventilation he was unable to provide for himself after coming out of surgery (Johnson & Webber, 2010). Imbalanced Nutrition: Less Than Body Requirements The second most important nursing diagnosis for C.J is imbalanced nutrition: less than body requirements related to an increased metabolic need caused by his disease process. C.J had a PEG tube and was receiving tube feedings. However he was “nothing by mouth” (NPO) status for the two days that I cared for him because he was waiting for an ultrasound to be done. Adequate nutrition is essential for the body to heal, as we have learned in other classes, as well CASE STUDY 5 as an essential part of sustaining life according to Maslow’s Hierarchy of Needs (Johnson & Webber, 2010). Coinciding with interventions for respiratory failure, “the goals of nutrition support are to meet the overall nutritional needs of the patient while avoiding overfeeding, to prevent nutrition delayed-related complications, and to improve patient outcomes” (Urden et al., 2010, pg. 605). As Orem signifies, we must be able to provide this self-care requisite to this patient, as he is unable to make sure he gets proper nutrition on his own (Johnson & Webber, 2010). Infection After airway is maintained and nutrition is adequate, allowing for the healing process to occur, we can then worry about our third nursing diagnosis, which is infection. As previously mentioned, C.J developed peritonitis and went into septic shock, but he also had a urinary tract infection (UTI) containing Klebsiella. This nursing diagnosis is also ranked third because these infections were being well controlled and not as much of a concern as they once were. Health deviation requisites are another universal requisite that Orem discusses in her theory (Johnson & Webber, 2010). C.J is no longer able to assist in fighting off infection and caring for his health, so we must provide that physical support and maintain an environment that supports his personal development (Johnson & Webber, 2010). Ineffective Coping (denial) Another diagnosis that seems fit for this patient is ineffective coping (denial) of his family. The daughters of C.J were very uptight during the days I cared for him. They were very “jumpy” per say about everything that was being done to the patient and asked an abundance of questions. They got very mad and upset when things were changed without their knowing or approval. They did not seem to accept the seriousness and extent of C.J’s illness. They kept CASE STUDY 6 pushing out comfort care measures in hopes that things would miraculously make a turn for the better. Dorothea Orem discusses that we need to be able to provide psychological support, be able to guide and direct, and teach our patients and family when need be (Johnson & Webber, 2010). Though this nursing diagnosis is not directly associated with the patient, it does revolve around him and will have an affect on him in the long run. Impaired Physical Mobility The last diagnosis for C.J is impaired physical mobility. This is not as much of a priority as the others because this is something that we cannot fix due to his debilitating disease state of Progressive Supranuclear Palsy. However, it is something that we need to consider when caring for him. He is unable to provide for himself in any shape or form because his whole body is contracted. Again coinciding with Dorothea Orem’s theory, this is termed a “wholly compensatory system” meaning the patient has no active role in his care and the nurse provides total nursing care to meet self-care needs (Johnson & Webber, 2010). Outcomes and Interventions For Top 2 Diagnoses Impaired Spontaneous Ventilation Outcomes. Appropriate expected outcomes for this nursing diagnosis that is relevant to C.J include: patient will maintain spontaneous gas exchange resulting in normal arterial blood gases (ABGs) within patient parameters during the two days I am caring for him; Patient will demonstrate no complications from the ventilator, such as ventilator associate pneumonia (VAP), during the two days that I am caring for him; and patient will be able to wean off the ventilator during the two days that I am caring for him. CASE STUDY 7 Interventions. In hopes to meet the outcomes discussed above, certain interventions needed to be implemented along the way. Aseptic suctioning was done, which was “based on a need basis rather than on a preset time interval, which reduced risk for infection and airway trauma” (Gulanick & Myers, 2011, pg. 421). Soft wrist restraints were used to prevent self-extubation, however most likely not needed because this patient was severely contracted in his upper extremities (Gulanick & Myers, 2011). Ventilator alarms were checked whenever they went off, which made sure that problems were taken care of if need be, and made sure that adequate ventilation was being supplied to the patient (Gulanick & Myers, 2011). Ventilator settings were also checked often to ensure that the patient was not fighting the ventilator, meaning receiving more than he needed (Gulanick & Myers, 2011). Spontaneous Breathing Trials (SBTs) were also performed, which tested to see if C.J was able to come off the ventilator and breath on his own. “Ventilator-associated pneumonia (VAP) accounts for the majority of nosocomial pneumonias (90%), which may increase intensive care and prolonged hospital stays” (Speroni et al., 2011, pg 15). So according to the Clinical Practice Guidelines for Mechanical Ventilation and Discontinuation from Mechanical Ventilation, there are many things that can be implemented to prevent VAP that were incorporated in C.J’s care as well. These included: using continuous aspiration of subglottic secretions (CASS tube) and doing oral hygiene with cholhexidine every 4 hours to prevent entry of bacteria into the lower airway; keeping the head of the bed at a 30-40 degree angle at all times to prevent aspiration; and using preventative measures like promoting rest and providing nutrition. Sedwick, M. B., Smith, M. L., Reeder, S. J., & Nardi, J. (2012) also spoke to these same care practices as part of the VAP bundle. CASE STUDY 8 However, they also incorporated peptic ulcer disease (PUD) and deep-vein thrombosis (DVT) prophylaxis and daily interruption of sedation. They monitored nurses incorporating these interventions using a feedback tool and were able to conclude “that strict adherence to a VAP bundle improved morbidity, mortality, and health care costs” (Sedwick, M. B., Smith, M. L., Reeder, S. J., & Nardi, J., 2012, pg. 49). C.J was on DVT and PUD prophylaxis, which included aspirin and prevacid respectively, but was not under any sedation. Teaching is directed toward the family in this situation because the patient is not able to physically learn and incorporate what was taught. However when teaching does occur it should be in front of the patient because he is most likely still able to understand what is going on around him. The nurse needs to make sure the family understands the reasoning for intubation and ventilation and the significance of the alarms (CPG: Mechanical Vent., 2010). For this specific case the family needs more teaching about what to expect when doing spontaneous breathing trials and a better understanding of the severity of his condition. Critically thinking I do not see a good prognosis for C.J and it is going to take a lot to even try to get him weaned off the ventilator. When performing the SBT he failed with a rapid shallow breathing index (RSBI) of 300, which is relatively high. You cannot even be considered for weaning until your RSBI is under 105 (Urden et al., 2010, pg. 659). All of his body systems are working against him right now and his body is overly stressed. Imbalanced Nutrition: Less Than Body Requirements Outcomes. Appropriate expected outcomes for this nursing diagnosis that is relevant to C.J include: Patient will maintain normal hemodynamic state during the two days that I am caring for him; CASE STUDY 9 Patient will have normal electrolyte balances by the end of the two days that I am caring for him; Patient will not lose any weight during the two days that I am caring for him. Interventions. In effort to meet the outcomes discussed above certain interventions needed to be implemented. These included giving medications as needed for low blood pressure such as Midodrine (proamatine), giving replacement therapy fluids to help correct electrolyte imbalances like magnesium sulfate and potassium chloride, doing daily weights, and giving the patient his Jevity at 30ml/hr as directed. Maintaining adequate nutrition can also help with getting the patient off his ventilator because “malnutrition decreases the patients ventilatory drive and muscle strength” (Urden et al., 2010, pg. 605). Other interventions related to Enteral tube feedings include: assessing for patency and free flow of Enteral feeding, which will assure nutrients is delivered; assessing weight every other day or as ordered, which can help determine an improved nutritional status but also fluid retention; and flushing the tube with 20mL of water after medication administration or anytime the flow of solution is interrupted, which will also make sure no disruption of nutrient intake occurs (Gulanick & Myers, 2011). According to the Clinical Practice Guidelines for Enteral nutrition, some indications of malabsorption/maldigestion are: abdominal pain, cramping, loose and frequent stools, electrolyte imbalances, vitamin/mineral deficiencies, unintentional weight loss, and bleeding. So as nurses we can monitor their stool patterns, advocate for diagnostic studies, review medications that may impair absorption and make adjustments, and evaluate the need for total parenteral nutrition (TPN) (CPG: Enteral Nutrition, 2010). Kim et al. (2012) conducted a prospective, cohort study, which evaluated the adequacy of energy and protein intake of patients in an ICU in the first four days after initiation of enteral CASE STUDY 10 feeding and investigated the factors that had impact on adequate intake. This study showed that most of the patients (62%) received insufficient energy and 52% had insufficient protein intake (Kim et al., 2012). They also were able to determine that the reasoning for underfeeding of energy were due to not initiating nutrition early enough, not giving enough nutrition, and because of prolonged interruption of enteral feeding (Kim et al., 2012). Through this study we are able to see that there is a trend of reasons people in the ICU are malnourished. With insight to these results we can look at these factors and make adjustments to the interventions we are doing. For instance, C.J being NPO status for the two days was potentially too long and can hinder our clinical outcomes set forth for him. So we could have waited until we knew exactly when he was going for his ultrasound and stopped his feedings then, while still allowing for accurate results from the ultrasound. Being NPO for over 36 hours was most definitely not needed. Since this patient has had his PEG tube since before his admission, one would hope his family has already learned how to care for it. However assessing for understanding and knowledge should be incorporated. We would want to make sure they know the importance of enteral nutrition and at what rate it should be administered. We would also want to make sure they knew how to maintain good skin integrity, such as applying skin barriers and moisturizers, and being able to detect infection, like the occurrence of swelling, tenderness, or drainage (CPG: Enteral Nutrition., 2010). Critically thinking I think this patient will have a hard time becoming nutritionally sound. With enteral feedings you are always at risk for imbalanced nutrition and with the high demands his body needs right now it will be hard to catch up since he is already behind. However, in order to fix his fluid overload problem, we could give him albumin, which was at a low of 1.7, which will help diuresis to occur more efficiently. CASE STUDY 11 Cultural Considerations Culturally speaking we have to look at the patient’s state of well being and quality of life. C.J has become very ill and his quality of life has decreased dramatically. Though we don’t want to just simply give up on him, we need to look at the overall picture. Having Progressive Supranuclear Palsy has already taken so much from him, that at this state, with all the new health problems, it needs to be considered if were actually prolonging his life or just prolonging his death. C.J is also a DNR/DNI with limits. So this also needs to be taken into consideration. Obviously he didn’t want to live his life the way he is, stuck on a ventilator, so it really is a matter of getting the family to accept what all is going on and getting them to understand what is morally right for the patient. Evaluation C.J did not progress in the two days that I was with him in the ICU. If anything, things may have taken a turn for the worse. Although he did not develop ventilator associated pneumonia, his ABGs did not remain within normal parameters: pH – 7.506 (high), PCO2 – 30.0 (low), PO2 – 77 (low), HCO3 – 23.8, which is indicative of respiratory alkalosis, and he was unable to be extubated after failing two spontaneous breathing trials. Alternatively, the next time that an SBT is done, maybe we could make sure the family is present. This might give C.J some encouragement and he may try harder. We could also ensure that he is sleeping at night that way he has enough energy to perform better on the SBT. Also, as previously mentioned, maintaining adequate nutrition could also be of benefit to him, while trying to wean off the ventilator (CPG: Mechanical Vent., 2010). His nutritional status did not improve either in the two days that I was there. As mentioned, he was placed NPO status for a pending ultrasound, in which they held his tube CASE STUDY 12 feedings, and he was not fed anything for over 36 hours. His blood pressure remained low: 95/46, and electrolytes were still out of normal limits: Phosphorus - 1.5 (low), calcium - 7.2 (low), potassium – 3.4 (low). He was +18 liters and his albumin level was low: 1.7. Alternatively, as spoken to before, we could give him some albumin to help with the diuresis process, which in turn would help with his electrolyte imbalances, which are low from dilution. Conclusion During this two-day assignment with C.J I learned a lot. His health status allowed me to connect the different body systems and understand how they all affect each other. For instance, since he was 18 liters positive in fluid, this affected his respiratory status as well as his cardiovascular system, making his electrolytes low from dilution. I also saw how important the quality of life of a patient is and how much it really does matter when speaking to life or death issues. It made me realize what “being alive” actually means. Sadly, C.J was not progressing. He was having a hard time trying to compensate for all the bullets he was struck by. Going from a simple bowel obstruction, to developing an infection and becoming septic, to going into respiratory failure and being stuck on a ventilator is a lot of stress on the body at one time, especially for a 76 year old. Comfort measures would be highly considered if it were my decision but its not. But, it is my obligation as a soon to be nurse, to advocate for C.J and make sure the right decisions are made, while respecting what he would have wanted. CASE STUDY 13 References (2009). Mosby’s dictionary of medicine, nursing & health professions. (8th ed., p. 1522). St. Louis, MO: Mosby Elsevier. (2010). Clinical practice guidelines: Enteral nutrition. CPM Resource Center: an Elsevier Business (2010). Clinical practice guidelines: Mechanical ventilation and discontinuation from mechanical ventilation. CPM Resource Center: an Elsevier Business Gulanick, M., & Myers, J. L. (2011). Nursing care plans: Diagnoses, interventions, and outcomes. (7 ed.,). St. Louis, MO: ELSEVIER. Ignatavicius, D. D., & Workman, M. L. (2012). Medical-surgical nursing: Patient-centered collaborative care. (7 ed., Vol. 1, p. 1254). St Louis, MO: ELSEVIER. Johnson, B. M., & Webber, P. B. (2010). An introduction to theory and reasoning in nursing. (3rd ed.). Lippinocott Williams & Wilkins Kim, H., Stotts, N., Froelicher, E., Engler, M., Porter, C., & Kwak, H. (2012). Adequacy of early enteral nutrition in adult patients in the intensive care unit. Journal Of Clinical Nursing, 21(19/20), 2860-2869. doi:10.1111/j.1365-2702.2012.04218.x Sedwick, M., Lance-Smith, M., Reeder, S. J., & Nardi, J. (2012). Using Evidence-Based Practice to Prevent Ventilator-Associated Pneumonia. Critical Care Nurse, 32(4), 41-51. doi:10.4037/ccn2012964 Speroni, K., Lucas, J., Dugan, L., O'Meara-Lett, M., Putman, M., Daniel, M., & Atherton, M. (2011). Comparative Effectiveness of Standard Endotracheal Tubes vs. Endotracheal Tubes With Continuous Subglottic Suctioning On Ventilator-Associated Pneumonia Rates. Nursing Economic$, 29(1), 15-37. CASE STUDY 14 Urden, L. D., & Stacy, K. M., & Lough, M. E. (2010). Critical care nursing: Diagnosis and management. (6th ed.).