An Intensive Care Unit - Assignment Example

Introduction: The Patient Mr. X was admitted to the hospital after a motorcycle accident. The 58-year-old man had been hit by a truck. The initial CT scan revealed multiple lesions including bilateral fracture of the occipital condyles at the skull base, unstable fracture of the cervical spine at level C4, double left-sided upper arm fracture, bilateral contusions in the lower lung lobes, left-sided fracture in the sacral bone, dislocation of the right hip, and right-sided tibial fracture. Mr. X underwent neurosurgery for fixation of the unstable C4-fracture. He also underwent orthopedic surgery to stabilize his upper arm and tibial fractures and reduced hip dislocation. Traction was applied for occipital condylar fractures and hip dislocation. Mr. X was being cared in the intensive care unit (ICU) of an urban hospital. One week after admission, the ICU nurse in-charge of Mr. X’s care noticed respiratory distress and fever of unknown origin. The nurse reported it to the attending physician and to the intensive care specialists. The intensive care specialists ordered a new CT scan to re-evaluate the status of the brain, the occipital skull base fracture, the post-operative cervical spine, the condition of the lungs, the abdomen for possible source of infection and a pelvis examination locating the sacral fracture and the right hip. Mr. X was chosen as the case study subject primarily because the alarming incidence of motorcycle accident worldwide caught the interest of the author and wanted to delineate the multisystem effect of motorcycle accident to the individual. Clarke, Ward, Bartle and Truman (2004) stated that motorcyclists are at the highest risk for accidents due to poor safety record and the estimated killed and serious injury rate in UK per million vehicle kilometers is twice than a pedal cyclist and 16 times than car drivers and passengers (p. 6). Introduction to the Intensive Care Unit An intensive care unit (ICU) refers to a hospital area that uses state-of-the-art technology and aggressive therapy both in invasive and noninvasive monitoring of critically-ill and high risk patients (Varon and Acosta, 2010, p. 1). Continuous monitoring is necessary and physiological factors affecting the health status of the patient must be reported promptly and on a continuous basis to the attending physician in order to adjust and meet the patient’s health needs. Patients older than 50 years old who suffered from cervical fracture have 26% mortality rate (Browner, Jupiter, Levine, Trafton, 2003, p. 868). Critical care is offered for patients in the intensive care units in providing advanced life support through modern technology.One of the newest areas in the intensive care unit is the neurointensive care area, where Mr. X was confined for close monitoring and receiving of necessary interventions for multiple traumas. Neurointensive care risks are high and interventions must be based on evidenced-based practice as well as on the six most important areas for neurointensive care such as cerebral perfusion pressure and intracranial pressure management, fluid and electrolyte management, ventilator management, sedation/pain control, diagnosis and treatment of seizures, and emotional support of the patient and family (Siddiqi, 2008, p. 2). For instance, fluid resuscitation should be adequately titrated in order to avoid hemorrhagic shock from massive fluid administration or multiple organ failure from restricting fluid administration (Fink, Suter and Sibbald, 2006, p. 12). With the high risks involved in employing critical care, health care professionals must have an extensive network of support staff and specialized equipment to assist them in providing advanced life support. Death while under critical care is possible. Health care professionals should have an open line of communication between patient’s family members in terms of possible end-of-life decisions. Roper, Logan and Tierney’sModel of Nursing Care Pathway Used in Intensive Care Unit Roper-Logan-Tierney Model of Nursing originated in Britain to guide nursing care and practice. In this model, Roper, Logan, and Tierney presented five concepts such as activities of daily living (ALs), lifespan, dependence/independence, factors influencing the ALs, and individuality in living (Holland, Jenkins, Solomon, and Whittam, 2008, p. 2). The model presented 12 activities that are essential for survival and referred to as the 12 elements of the model of living. These activities involve maintaining a safe environment, communicating, breathing, eating and drinking, eliminating, personal cleansing and dressing, controlling body temperature, mobilizing, working and playing, expressing sexuality, sleeping, and dying (Holland, Jenkins, Solomon, and Whittam, 2008, p. 2). The assessment of Mr. X will focus on these 12 activities of living (ALs) in order to formulate a plan of care in lieu with the Roper-Logan-Tierney Model. Nursing Assessment on Mr. X A. Nature The nature of the nursing assessment will focus on the health status of Mr. X and the related conditions or complications from present health status. B. Purpose The nursing assessment aims to identify health problems in the assessment areas of Roper-Logan-Tierney Model. Furthermore, it also aims to prevent, control, resolve or eliminate identified health problems. C. Methodologies The nursing assessment will utilize the Roper-Logan-Tierney Model in the assessment process. Likewise, observation, physical examination, and review of Mr. X’s records and diagnostic and laboratory tests will be used as methods of assessment. D. Process A comprehensive and systematic approach used to perform nursing interventions, called nursing process will be used in identifying the health needs of Mr. X. It includes assessment, nursing analysis (nursing diagnosis is used in US), planning, implementation, and evaluation (Long, Phipps and Cassmeyer, 1995, p. 8). Assessment Using the Roper-Logan-Tierney Model 1. Maintaining a Safe Environment. Physical observations revealed that Mr. X was unable to move his arms and shoulders. One week also after admission, respiratory distress was noted. Vital signs monitoring include a temperature of 38.5° C, pulse rate of 100 bpm, respiratory rate of 30 cpm, and blood pressure of 90/70 mmHg. Mr. X has difficulty in speaking. His wife verbalized that Mr. X cannot walk at the moment due to his condition but is able to see, hear, and respond through facial expressions. Mr. X is also unable to move by himself due to the fixators and tractions. 1.1. Implications:Traumatic injury is an unpredictable event in an individual’s life. A lot of information is not known to the patient including the extent of injury, the change in environment, and functional outcome. These changes made them at risk for further injury (Bayley and Turcke, 1992, p. 174) 2. Communication.Mr. X has difficulty in speaking. His wife only interprets the facial expression of his husband when communicating his needs. Mr. X’s wife is a Filipino- American and can speak English fluently with the nurse. 2.1. Implications:Filipino Americans often agree with the health care provider without clarifying the information given. Filipino Americans respect and value authority figures. Use of open-ended questions is necessary to elicit accurate assessment (Fujii, 2011, p. 60). 3. Breathing.One week upon admission, the nurse noticed that Mr. X was gasping for shallow breaths with respiratory rate of 30 cpm. Upon auscultation, the nurse notes wheezing sound. A non-rebreather mask with flow rate of 12-15 lpm was administered to Mr. X. 3.1. Implications:The normal respiratory rate for adult is 12-20 cpm. Multiple traumas may result to adult respiratory distress syndrome characterized by severe dyspnea, hypoxemia, and diffuse pulmonary edema. Provision of mechanical ventilator support is necessary as well as monitoring of oxygen (White, 2005, p. 873). 4. Eating and Drinking.After the operation, Mr. X was put in NPO. Hydration and nutrition is maintained through the administration of intravenous solutions. 4.1. Implications:Multiple trauma patients should be fed aggressively with enteral or parenteral feedings soon after the injury. Patients with injury severity score of 15 needs to have intensive nutritional support(Way and Jones, 2004, p. 121). 5. Elimination.Mr. X’s urination and bowel pattern changes after the operation. The limitation of movements makes it hard for him to initiate normal elimination. The attending physician ordered a laxative for his elimination problems and put him under catheterization. The urine is straw-colored and smells aromatic. The stool is brown in color, smooth, soft, and like a sausage or snake in appearance. 5.1. Implications:Elimination can be a major problem after a multiple trauma. It is essential to view the patient holistically and view all the factors that affect elimination such as pain, anxiety, and limited mobility (Langstaff and Christie, 2000, p. 224). 6. Personal Cleansing and Dressing.Mr. X requires complete assistance with personal hygiene and availability of personal objects such as the rosary.Mr. X has good grooming and his wife always give him a sponge bath. 6.1. Implications:The information and assistance aid by the occupational therapist is needed in order to assist the individual and family in adapting to the present conditions. Information on the usual mode of cleansing and dressing must be obtained to adjust nursing care to patient’s identified needs (Alexander, Fawcettand Runciman, 2006, p. 476). 7. Controlling Body Temperature.Upon vital signs assessment, Mr. X’s temperature is 38.5 ° C. Skin is warm to touch and shivering was observed. 7.1. Implications: Multiple trauma patients have difficulty in regulating body temperature. They can develop hyperpyrexia, a very high body temperature that can worsen the condition of the brain (Panté, 2010, p. 116). 8. Mobility.Mr. X requires assistance from his wife when turning and moving from his bed due to post-operative conditions. The lesion in the C4 area permanently paralyzed Mr. X’s shoulder and arms. Mr. X preferred to be assisted by his wife in performing range-of-motion exercises with some restrictions ordered by the physician. 8.1. Implications:Family members play a vital role in assisting the patient in mobilization. Instructing the family members in performing range-of-motion exercises enable family members to express their love, support, and care to the patient. In this way, patient may feel motivated in rehabilitation therapy after a traumatic injury (Robinson, 2006, p. 52). 9. Working and Playing. Mrs. X stated that her husband had worked as a teacher in an urban university. Mr. X’s hobbies are reading fictional books and playing chess with their children. 9.1. Implications:Recovering from a traumatic injury takes about 3 months to 2 years, depending on the severity of injury. Returning to work depends on the individual case and usual leisure activities need to be adjusted. The effects of multiple traumas to work and play may be stressful to the client and the continuous support of the family is essential in full recovery (Broek, M.D., Schady, W.J. and Coyne, M. J., 1995, p. 27). 10. Expressing sexuality.To preserve the dignity of the patient, consent about discussing sexuality and maintenance of privacy were assured. Although this was explain to the patient, Mr. X refuses to discuss this matter. His wife verbalized to understand his husband’s resentment as the doctor implied to them of possible sterility. 10.1. Implications:Some Filipino people feel embarrassed in discussing personal topics such as sexuality. Sex issues are very sensitive that they do not discuss it openly with other individuals ( Gigerand Davidhizar, 2004, p. 434). 11. Sleeping.Mr. X’s wife verbalized that Mr. X’s usual sleeping pattern starts at around 12 midnight. Upon admission, sleeping patterns had changed at nine to ten o’clock. Mr. X sleeps for almost 6-8 hours per day in the hospital. Visiting hours is restricted in the neurosurgical unit and this enable Mr. X to get enough rest hours. 11.1. Implications:Sleeping posture has to be adapted to accommodate the infusion lines. The comfortable position of the patient must be preferred except when it is not permitted by the attending physician due to medical conditions. Multiple trauma patients who will receive long-term care may adjust parenteral support to match the sleeping needs of the patient and resume a normal sleeping pattern (Jamieson, McCall and Whyte, 2004, p. 269). 12. Dying.Mr. X’s wife was very grateful that despite the severity of the accident, Mr. X still managed to live and survived. She stated that death is a fearful thing that could ever happen to their family and they are not prepared for this. Mrs. X added, “As a Catholic, it is a miracle and a blessing from God. I’m sure he’s sad about the possible complications but I think he’s also thankful that God gave him a second chance in life.” 12.1. Implications:Catholic Filipino Americans believe in the power of God. They believe that diseases and accidents are God’s will. These cultural beliefs affect the interaction of the health care provider with the patient in that they manifest indirect communication in order to avoid stressful events (Braun, Pietschand Blanchette, 2000, p. 112). Key Problem/Need Based on Patient Assessment Based on the assessment, there are several problems or patient’s needs that need to be addressed. However, identified problems or patient’s needs are prioritized. The first priority is airway, followed by breathing, circulation, disability, and exposure or environment control (Dang, Schultz and Keenan, 2011, n.p.). Therefore, the key problem or need is based on airway and breathing which is, impaired gas exchange related to traumatic injury as evidenced by gasping of breath and respiratory rate of 30 cpm. Goal of Care References: Read More