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Running head: CRITICAL CARE CASE STUDY
Critical Care Case Study
Jessica Chamberlain
Old Dominion University
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CRITICAL CARE CASE STUDY
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Critical Care Case Study
The purpose of this paper is to present a case of a patient in the intensive care unit and to
show how knowledge, research and theory are used to plan, provide, and evaluate the care
provided. The paper will include a detailed picture of the patient, the medical diagnosis for
requiring intensive care, prioritized nursing diagnoses with outcomes and interventions, and
evaluations of the effectiveness of the interventions.
G.M. is an 88-year-old Caucasian male who presents to the emergency department with
right flank pain. The patient reports his symptoms starting unusual to his previous kidney stones.
The symptoms first presented with constant, general abdominal pain that moved to the right
lower quadrant. He was nauseous and having dry heaves. He self reported a fever and mild pain
of three-out-of-ten on the zero-to-ten pain scale. He also stated having a productive cough.
G.M. has a past medical history of hypertension, paroxysmal atrial fibrillation, peripheral
vascular disease, and experiences sleep apnea. He also has a history of urinary tract infections
and kidney stones. He has a hearing impairment and wears a hearing aid in his right ear. He also
has osteoarthritis and has had bilateral total knee replacements.
G.M. is a retired physician, and was a founding father of one of Riverside’s medical
programs. He lives with his wife, whom has Alzheimer’s dementia, and his grown daughter. He
reports drinking one alcoholic beverage daily and smoked a tobacco pipe for a brief period
recently but has not smoked in over one month. He has no known drug allergies, but reports that
he is not able to take Flomax and Celebrex due to adverse reactions. The patient is 66 inches tall
and weighs 85.98 kilograms. He is a full code.
In the emergency department, G.M. had a computerized tomography (CT) scan of his
abdomen and pelvic area. The scan showed a five-millimeter stone in the right ureter, moderate
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right hydronephrosis, perinephric fat stranding, diverticulosis, and prostatic enlargement. The
stone was causing early pyelonephritis and leukocytosis. They began treatment with the
antibiotic rocephin and scheduled the patient for a right ureteral stent. In surgery, the patient had
a cystoscopy with right retrograde pyelography to place the stent to the right ureter. The
procedure went uncomplicated and the patient was taken to a medical/surgical unit. However,
the patient became hypotensive and began feeling breathless with rigors accompanied by a fever.
Medical Diagnosis
The patient was transferred to the medical intensive care unit (MICU) with signs of septic
shock related to progressing urosepsis that developed from a urinary tract infection he contracted
after his surgery. The septic state led the patient into acute respiratory distress syndrome,
indicated by the presence of increased pulmonary edema and interstitial infiltrates, and
eventually led the patient to acute respiratory failure. The patient was then intubated to maintain
his airway.
Sepsis is the systemic inflammatory response resulting from an infection, as manifested
by at least two of the following: temperature above 38 degrees Celsius or below 36 degrees
Celsius, heart rate greater than 90 beats per minute, respiratory rate greater than 20 breaths per
minute, or a white blood cell count greater than 12,000/mm3 or less than 4,000/mm3. Sepsis
progresses to severe sepsis when the body’s perfusion capabilities and hemodynamic states are
affected, such as in the case with G.M, when he became hypotensive in the medical/surgical unit,
had decreased urine output and labs revealed lactic acidosis. Septic shock ensues when the
hypotensive state is unaffected by a fluid bolus. This was seen in G.M.’s case when he continued
to be hypotensive after a fluid bolus was administered in the MICU, which led to him being
started on a vasopressor drip, neo-synephrine (Urden, 2014).
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In this case, acute respiratory distress syndrome (ARDS) developed from sepsis, an
indirect injury, when the infection spread to the lungs via the bloodstream, which then activated
the humoral response, damaging the alveolar-capillary membrane (Urden, 2014). There are three
phases to ARDS, exudative, fibroproliferative, and resolution, respectively. During the first
phase, the capillaries are injured which causes increased permeability that leads to fluid leaking
into the alveoli. This stage is characterized by interstitial and alveolar edema. The edema causes
compression and swelling of the alveoli that interrupts ventilation/perfusion matching
[ventilation/perfusion mismatching: areas where oxygen perfusion is inadequate due to under
ventilated alveoli] and permits intrapulmonary shunting [occurs when there is no gas exchange
at the arterial level due to absence of ventilation in that area]. This causes hypoxemia, which
then leads to alveolar hypoventilation [inadequate oxygen supply to alveoli]. G.M. presented
pulmonary edema and suspected pulmonary hypertension, signs of the first stage of ARDS, but
did not progress to the following two stages. The second stage is referred to as disordered
healing, where cellular granulation and collagen deposition takes place in the alveolar-capillary
membrane causing the lungs to stiffen. The final stage is when the restructuring of the alveolarcapillary membrane occurs (Urden, 2014).
Acute respiratory failure, or acute lung failure, is when the respiratory system cannot
maintain proper gas exchange; often resulting after damage to respiratory function has already
begun from another disorder; in this case, ARDS. The type of acute respiratory failure presented
with this patient was type two, hypoxemic hypercapnic respiratory failure. This failure occurs
due to alveolar hypoventilation and/or ventilation/perfusion mismatching and intrapulmonary
shunting (described above); all three were present with this patient (Urden, 2014).
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Patient Scenario During Clinical Rotation
By the time of the clinical rotation, the patient had significantly improved since his
admission to the unit. G.M. was intubated and on mechanical ventilation, with a goal of
extubation within the next day or two, related to improved x-ray images of the chest over the
course of a few days. His vent settings are shown on the concept map in Appendix A. He had a
triple lumen peripherally inserted central catheter in his right arm. He was on a sedation drip of
propofol, but alert and able to follow commands during sedation-vacation; the drip was
discontinued early on the first day after titrating down, and then started on a fentanyl drip later in
the day to replace the sedation medication. He was in atrial fibrillation rhythm and on a neosynephrine drip with a mean-arterial-pressure (MAP) goal between 55-60; this drip was also
titrated down according to MAP goal and eventually discontinued by end of the clinical day. He
also had a med line running of normal saline at 3mL/hour. The patient had an orogastric tube
that provided a continuous feeding, set at goal of 45mL/hour. His kidney function was stable,
indicated by a balanced 24-hour intake and output (2423/2300). G.M.’s lab values can be seen in
Appendix A. The patient appeared agitated about having the endotracheal tube and the inability
to effectively communicate with staff and family.
Nursing Diagnoses
The priority nursing diagnosis for G.M. is ineffective airway clearance related to
endotracheal intubation and abnormal secretions as evidenced by episodes of excessive
secretions and occasional blood tinged secretions, anxiety, restlessness, abnormal breath sounds,
and an ineffective cough. This is the first nursing priority due to the end goal of getting the
patient extubated and out of the hospital. Before extubation can proceed, the patient needs to
show signs of ability to maintain his airway after the tube is removed. Virginia Henderson’s
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theory, Nature of Nursing, focuses on assisting the patient to achieve independence (Craven,
2013). This theory is used in care of this patient because the ability to breathe effectively and
clear the airway independently is a factor for getting taken off of mechanical ventilation.
The second nursing diagnosis with priority for this patient is anxiety related to the
inability to communicate effectively and the inability to breathe adequately without support as
evidenced by restlessness, facial tension, tachypnea, and perspiration. Communication with the
patient was one-way; staff and family speaking to him, but he was unable to effectively
communicate back, which easily agitated the patient and made him anxious. Anxiety was chosen
as a high priority diagnosis for this patient considering his background in medicine. He likely
understood all that we were telling him, but could not relay his own questions or concerns due to
the inability to speak with the endotracheal tube in place. His anxiety also could have stemmed
from the inability to hear people speaking to him due to his history of hearing impairment.
Anxiety can hinder improvement and self-confidence, affecting the end goal of achieving
independence to get him extubated and returned to home.
The third nursing diagnosis is risk for aspiration related to a depressed cough/gag reflex
due to intubation, tube feeding, and possible impaired swallowing. This is prioritized as the third
nursing diagnosis because of the relatedness to maintaining the airway. Aspirating can impair
the airway, worsen the patient’s anxiety and increase the risk for further infection.
The fourth nursing diagnosis is imbalanced nutrition: less than body requirements related
to inadequate nutrition before hospitalization, nothing-by-mouth (NPO) status, and increased
metabolic needs as evidenced by low albumin and protein levels, weakness, and supplementation
of electrolytes. Adequate nutrition is essential for healing and fighting off infections.
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The fifth nursing diagnosis is infection related to a compromised immune system from
the septic episode that occurred during early hospitalization and use of protonix as evidenced by
positive stool culture for clostridium difficile (C. diff). The patient’s lab values indicate that his
original infection was treated effectively with the antibiotic he was taking, zosyn. However, the
stool came back positive for C. diff on the second clinical day. The presence of another infection
compromises the patient’s ability to improve efficiently.
Outcomes, Interventions, and Evaluation of Priority Diagnosis
The expected outcomes for the first nursing diagnosis, ineffective airway clearance, are:
G.M. will maintain a patent airway during intubation as evidenced by adequate secretions and
clear breath sounds after suctioning, and G.M. will maintain a patent airway after extubation as
evidenced by ability to cough up and suction out secretions, clear breaths sounds, and a
respiratory rate and rhythm at his baseline.
In order to reach these expected outcomes, independent and collaborative interventions,
and patient teaching need to be implemented. Assessment of lung sounds frequently for any
adventitious breath sounds is important in order to notice when changes occur. Perform
endotracheal suctioning as needed based on how the lungs sound. Only suctioning when
indicated will help to prevent over suctioning which can cause hypoxia and tissue damage.
When suctioning, give the patient extra oxygen before and after, to prevent hypoxia and
dysrhythmias. Turning the immobile patient every two hours, per practice guidelines, not only
prevents skin breakdown and venous stasis, but also facilitates the loosening up of secretions
allowing patients to cough or have the secretions suctioned out feasibly. Ensure the patient is
receiving adequate fluid intake to keep the secretions from thickening (Gulanick, 2011).
Perform effective oral care frequently to improve the comfort of the patient and prevent
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swallowing of oral secretions that can cause an impaired airway or infection (Lin, 2011).
Researchers implemented a study to gain insight on nurses’ knowledge, attitudes and practices in
oral care of intubated patients. There was a positive correlation between the nurses’ knowledge
and frequency of practice regarding oral care. The nurses’ attitude pertaining to oral care in
intubated patients is shown by their classification differences: ranked as third priority on the list
of physical care activities and eighth on the list of nursing treatment activities (Lin, 2011). In a
study comparing three different strategies of oral hygiene and their effect on bacterial growth and
incidence of ventilator associated pneumonia, prevention of infections that can cause impaired
airway clearance is best when oral care uses mechanical brushing (tooth brush) along with the
mouth rinse and suction (Berry, 2010). Discuss with a respiratory therapist whether chest
physiotherapy will benefit the patient in removing secretions (Urden, 2014). Orders to promote a
patent airway include DuoNeb, an inhalant that is administered with the respiratory team. Teach
the patient the importance of coughing up secretions once extubated, to prevent accumulation
that can lead to pneumonia (Gulanick, 2011). The patient can also be taught how to do selfsuctioning of oral secretions in order to maintain an effective airway independently.
The patient successfully met the expected outcome indicated for ineffective airway
clearance by the end of the clinical rotation. The first day, the patient was turned every two
hours and assessed for suctioning needs. His lung sounds were clear. Oral care was provided
more frequently with this patient because he expressed having dry mouth, by mouthing the word
“water”, which was alleviated with oral maintenance. Chlorhexidine was ordered and
administered every four hours to prevent mouth sores. The patient did not receive chest
physiotherapy but did receive his DuoNeb treatment. The patient’s secretions began to decrease
and he was indicated to be extubated on day two. After extubation, the patient was educated on
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the importance of coughing up secretions and having them suctioned out. He was also taught
how to use the suction to be able to do this independently. Before extubation, the patient was put
on a weaning trial to test ability to maintain airway independently. Interestingly, a research
study by Wang, Ma, and Fang, compared the results of extubation with and without the use of
spontaneous breathing trials, and found that there was not a significant difference in outcomes,
indicating that extubation can occur without having a breathing trial (2013).
Outcomes, Interventions, and Evaluation of Second Priority Diagnosis
The expected outcomes for the second nursing diagnosis, anxiety, are: during intubation,
G.M. will be able to communicate understanding of situation and interventions to be
implemented and have reduced anxiety as evidenced by using nonverbal communication
techniques, have a relaxed face, have a heart rate less than 100 beats per minute, and have
respirations less than 20 breaths per minute, and after extubation, G.M. will be able to
communicate verbally, report a reduced level of anxiety, and have vitals signs that are at his
baseline.
Through therapeutic and collaborative interventions, the patient is expected to meet the
outcomes identified for anxiety. Assessment of the patient for signs of anxiety is done
continuously in order to know when and what type of intervention is needed based on findings.
For example, if the patient is found to be experiencing moderate to severe anxiety and exhibiting
physical symptoms, then an anxiolytic may be necessary, but if the patient only appears agitated,
then reassuring them about their situation can likely help. Maintaining a calm and understanding
demeanor while interacting with the patient will help facilitate trust and reduce the patient’s
anxiety towards staff (Gulanick, 2011). Speak to the patient’s good ear (ear with the hearing aid)
when explaining any task, such as a turning, assessment, suction, or medication administration,
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to reduce barriers to understanding. Ask simple questions one at a time to allow patient to
answer, with patient declaring understanding by answering with a head nod/shake or squeezing
of hand (Grossbach, 2011). The family was shown to write messages on paper and hold them up
for the patient to read. This intervention is similar to the use of illustrations to help broaden the
communication between staff or family and patients that cannot communicate verbally
(Otuzoglu, 2014). A research study examined the effectiveness of using illustrated materials for
communication with intubated patients. The study concluded that illustrations were an effective
tool for communication about 78% of the time (Otuzoglu, 2014). Family members were present
to help reduce patient anxiety (Gulanick, 2011). A medication order for Haldol is indicated as
needed for agitation in the patient’s orders. Haldol is an antipsychotic drug that can be used to
treat agitation (Hodgson, 2013). The patient also had a fentanyl drip ordered as a form of
sedation. This medication reduces the emotional response to pain and therefore can reduce pain
related anxieties (Hodgson, 2013).
The expected outcomes for anxiety were partially met during the clinical rotation.
During intubation, the patient continued to show signs of anxiety and agitation, regardless of the
fentanyl drip that was initiated, but not to the point of needing a pharmacological intervention.
He alternated between periods of what appeared to be understanding, marked by head nods and
hand squeezing when spoken to, and periods of frustration and restlessness, marked with facial
tension, eye bulging and increased respirations. The daughter was helped explain his condition
to him and that the tube was going to be removed by using hand gestures and writing on paper.
After extubation on the second day, the patient was successful in communicating verbally his
reduced anxieties and he maintained stable vital signs for the rest of clinical day.
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Conclusion
G.M. was an 88-year-old “VIP” patient that came in for probable kidney stones. After
surgery to treat the diagnosed kidney stone, he became septic and was sent to the intensive care
unit. He then went into uroseptic shock and acute respiratory failure all in a matter of five days.
He was intubated and sedated, and started on a vasopressor drip to improve his hemodynamic
stability. He was weaned off his drips and remained stabile; which permitted extubation after
three days of intubation. After care of this patient and getting an in-depth look at his clinical
picture, the realization of how quickly a patient can deteriorate and also be brought back to
baseline, or near baseline, was fascinating. Understanding of the importance of knowing the
bodily systems and how they interrelate to one another was apparent in this clinical case study.
This review of a clinical patient helped understand how nursing interventions were chosen and
implemented to care for the priority problems of the patient.
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References
Berry, A.M., Davidson, P.M., Masters, J., Rolls, K., & Ollerton, R. (2010). Effects of three
approaches to standardized oral hygiene to reduce bacterial colonization and ventilator
associated pneumonia in mechanically ventilated patients: A randomised control trial.
International Journal of Nursing Studies, 48. 681-688. doi:
10.1016/j.ijnurstu.2010.11.004
Craven, R., Hirnle, C., & Jensen, S. (2013). Fundamentals of Nursing: Human Health and
Function. (7th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams &
Wilkins.
Grossbach, I., Stranberg, S., & Chlan, L. (2011). Promoting effective communication for patients
receiving mechanical ventilation. Critical Care Nurse, 31(3), 46-60. doi:
10.4037/ccn2010728
Gulanick, M. & Myers, J.L. (2011). Nursing Care Plans: Diagnoses, Interventions, and
Outcomes. (7th ed.). St Louis, MO: Elsevier.
Hodgson, B. & Kizior, R. (2013). Nursing Drug Handbook 2013. St. Louis, MO: Elsevier.
Lin, Y.S., Chang, J.C., Chang, T.H., & Lou, M.F. (2011). Critical care nurses’ knowledge,
attitudes and practices of oral care for patients with oral endotracheal intubation: A
questionnaire survey. Journal of Clinical Nursing, 20. 3204-3214. doi: 10.1111/j.13652702.2011.03819.x
Otuzoglu, M. & Karahan, A. (2014). Determining the effectiveness of illustrated communication
material for communication with intubated patients at an intensive care unit.
International Journal of Nursing Practice, 20(5), 490-498. doi: 10.1111/ijn.12190
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Urden, L.D., Stacy, K.M., & Lough, M.E. (2014). Critical Care Nursing. (7th ed.). St. Louis,
MO: Elsevier.
Wang, J., Ma, Y., & Fang, Q. (2013). Extubation with or without spontaneous breathing trial.
Critical Care Nurse, 33(6), 50-56. doi: http://dx.org/10.4037/con2013580
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Appendix A
Concept Maps
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Honor Code Statement
I pledge to support the Honor System of Old Dominion University. I will refrain from any form
of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a
member of the academic community, it is my responsibility to turn in all suspected violators of
the Honor Code. I will report to a hearing if summoned.
Jessica Chamberlain
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NURS 451 Client Case Study Grading Criteria
Student: __________________________ Score: __________ Grading Criteria Points Faculty Comments Points Awarded Introduction Pt. Overview Scope of paper Medical Diagnosis Dx for ICU adm. Patho Related S/S Nursing Diagnosis 5 NANDA (1+ psych/soc) Priority with theorist support Outcomes for top 2 NDX Appropriate for NDX Attainable within timeframe Interventions for top 2 NDX Interventions with rationale SOP /Clinical Path Patient/family teaching Critical Thinking Cultural Considerations Evaluation Progress toward outcomes Additional/alternative plan Conclusion Review of learning 2 1 2 4 4 5 10 #1 #2 2.5 2.5 2.5 2.5 #1 #2 6 6 2 2 2 2 2 2 3 #1 #2 5 5 1 1 3 CRITICAL CARE CASE STUDY
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Grading Criteria Points Faculty Comments Points Awarded Sources 5+ sources 3+ primary nursing research Study results reviewed/applied Study poorly reviewed/applied Research omitted APA Format (Cover page, headings, margins, type size) Format conforms to APA Format Format includes 1-­‐3 APA errors Format includes 4-­‐6 APA errors Format includes >6 errors APA-­‐ References/Reference Page Conform to APA Format Include 1-­‐3 APA errors Include 4-­‐6 APA errors Include >6 APA errors Do not conform to APA format Writing Style (Grammar, spelling, punctuation, language) Logical, organized, without errors Logical, organized minor errors (<5) Lacks logic/organization OR major spelling/grammar/errors (>5) Lacks logic / organization AND major spelling / grammar / errors (>5) 1 3 3 3 1 1 1 0 0 0 3 2 1 0 4 3 2 1 0 3 2 1 0 CRITICAL CARE CASE STUDY
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