Evidence Based Care - Case Study Example

EVIDENCE BASED CARE 04TH September, 2008 TABLE OF CONTENTS 1. ABSTRACT…………………………………………………………………..3.0 2. INTRODUCTION……………………………………………………………3.0 3. AN OVERVIEW OF THE PATIENTS PRESENTING ILLNESS AND MEDICAL HISTORY……………………………………………………….4.0 4. FIVE MAJOR THERAPEUTIC INTERVENTIONS (NURSING/MEDICAL) WHICH HAVE BEEN CARRIED OUT IN THE CARING PRACTICE FOR THE PATIENT………………………………5.0 5. THE BASIS FOR EACH OF THE INTERVENTIONS PROVIDED AND ITS CORRESPONDING IMPACT ON THE PATIENT'S CARE …….. 6.0 6. AREAS WHERE THE RESEARCH DOES NOT SUPPORT THE CURRENT PRACTICE AND CHANGES WHICH COULD BE IMPLEMENTED TO IMPROVE THE CURRENT PRACTICE………11.0 7. CONCLUSION…………………………………………………………… 11.0 ABSTRACT Evidence based care is am imperative tool of the contemporary nursing practices, prevalent in Australia. This paper deals with an elaborative study about a patient who suffered from respiratory problems in the initial stages leading to severe cardiovascular instability in future. The treatment given in the Advanced Intensive Care along with the nursing issues for the patient, are discussed and analyzed to delve deeper into the understanding of the clinical practices. The results of the intervention provided as per the patients condition assisted in prioritizing the nursing practice for similar cases and also helped in analyzing the affectivity of the interventions probed in the current case in comparison with the other possible alternatives which could have been used. INTRODUCTION The current study deals with the case history of a 52 year old female patient who developed signs of ‘sarcoidosis’, which is a granulomatous disorder of unknown etiology. Chest radiographs are seen abnormal in almost 85 percent to 95 percent of patients, showing improper results in pulmonary function tests which reveal symptoms of cough and dyspnoea. The clinical presentation of IFN-induced Sarcoidosis (IIS) is dangerous. (S. Alazemi, 2006). Chronic pulmonary sarcoidosis may result in loss of lung function, where medical intervention in the form of ARPV ventilation becomes necessary, lung transplantation is also an alternative available for patients suffering from severe life-threatening disease failing medical therapy. In case of the patient under study, who developed signs of exacerbation of chest infection and shortness of breath, presence of sarcoidosis is very prominent (. Joseph P. Lynch, Yan Ling Ma, Michael N. Koss, Eric S. White, 2007). The chronic nature of chest infection has resulted in the development of acute lung injury (Joseph P. Lynch, Yan Ling Ma, Michael N. Koss, Eric S. White, 2007) AN OVERVIEW OF THE PATIENTS PRESENTING ILLNESS AND MEDICAL HISTORY: A 52 year old female patient was admitted to the hospital, medical ward, with exacerbation of chest infection. The patient’s medical history revealed no signs of medical or surgical history, and no major genetic disorders. The lady was a fit and healthy. By profession she was a dancer and taught the same to the students, belonging to a well renowned community family exhibiting her role of a mother, wife and a daughter in the best possible manner. The medical negative symptoms included complain of increasing shortness of breath for approximately two months, which was diagnosed by the respiratory specialist as ‘sarcoidosis’. The health deteriorated further two weeks prior to admission into hospital, when the patients reported signs of productive cough and shortness of breath to her general practitioner. Presence of cough also reflects a primary lung injury, such as pneumonia or aspiration. Absence of a cough in a patient with symptoms and signs consistent with ARDS who had a witnessed episode of vomiting suggests that aspiration may have been the primary risk factor for ARDS or ALI (Lennox H Huang, 2006). She was admitted to the hospital for intravenous antibiotic therapy and respiratory management. However her health further worsened on the second day of admission when she suffered a respiratory failure with cardiovascular instability with rapid atrial fibrillation, due to which the patient was transferred to the ICU. FIVE MAJOR THERAPEUTIC INTERVENTIONS (NURSING/MEDICAL) WHICH HAVE BEEN CARRIED OUT IN THE CARING PRACTICE FOR THE PATIENT Patient developed Acute Lung Injury (ALI), high peak respiratory pressures; high carbon dioxide levels, low respiratory volumes during the course of the treatment thus the Intervention carried out in such a case was the use of ARPV ventilation. Acute Lung Injury lead to the development of pulmonary hypertension and right heart failure (right ventricular enlargement), Acute Lung Injury also resulted in the deterioration of the kidney function. Judging the condition of the patient, the intervention and the medication treatment suggested was the use of Viagra and renal directed therapy as renal internal feeds (low potassium, low sodium). Acute Lung Injury & ARPV treatment resulted in patient’s discomfort and distress, for which the intervention conducted, was to apply a Neuromuscular blocking infusion (vecuronium) with sedation, along with a Routine nerve stimulator assessment for responsiveness of medication. Nerve Stimulator Assessment is a common practice to monitor the extent of muscular blockade by7 assessing the response to the nerve stimulator. Accurate prediction of the blockade can be predicted, the speed of recovery can be measured, incidence of paralysis can be reduced to a great extent, and hence the intervention provided is absolutely correct in accordance to the patient’s condition (Harper N J N, 1993). Due to the ventilation and sedation the patient was put through, routine mouth care and endotracheal tube movement to prevent pressure area was one of the most important parts of the treatment. To accomplish the objective, regular cleaning of teeth, mouth wash, moving ETT in mouth, providing moisture barrier as paraffin on lips and other required oral care was provided. THE BASIS FOR EACH OF THE INTERVENTIONS PROVIDED AND ITS CORRESPONDING IMPACT ON THE PATIENT'S CARE Whether the use of ‘Airway pressure release ventilation’ or the APRV is appropriate in patients with Acute Lung Injury (ALI) or Adult Respiratory Distress Syndrome (ARDS) has always been an issue of discussion among the medical practitioners. In a research conducted by Kaplan LJ; Bailey H; Formosa V, 2001, use of APRV is absolutely safe in patients suffering from ALI/ARDS. The numerous past researches have stated that the lung is subjected to physical injury during mechanical ventilation. APRV, also named as biphasic ventilation, bi-level ventilation or BIPAP is a pressure targeted form of ventilator support. APRV helps in reduction of the use of sedations as compared with PCV-inverse ventilation and helps in improvement of the cardiac functioning along with decreased pressor use and airway pressure. As in the case of the patient, who developed acute lung injury, use of APRV seemed to be an apt decision. The advantages of using APRV are firstly it facilitates spontaneous breathing, secondly it enhances hemodynamics, thirdly it aids in patients as well as the family’s comfort. APRV is an effective method of oxygenation patients suffering with Acute Lung Injury or Acute Respiratory Distress Syndrome (Lennox H Huang, 2006). In such cases the surface area available for gas exchange is quite less, use of ARPV ventilation supplements immediate ventilation, thereby releasing air pressure to a lower level, what is called as Plow. APRV sets free the traditional requirement of elevating airway pressure and lung volume. With the use of ARPV, the airway pressure is interrupted for a short time; as a result the release volume is driven by gas compression and potential energy. Maintaining lung volume and spontaneous breathing may reduce the need for CPAP recruitment .Moreover the enhanced alveolar surface area helps in the improvement of stress distribution in the lung. During the intervention period, patients are also able to control the frequency and duration of spontaneous breathing. The severely ill patients, as in the case mentioned are able to respond to the changing metabolic needs. Past researches state that the use of APRV improves the splanchnic and renal perfusion with spontaneous breathing. The ARDS Network displayed better gas exchange results and mechanics with aggressive PEEP (Neil R. Maclntyre, 2007). Clinical and experimental studies have proved that APRV results in the improvement of condition related to gas exchange, cardiac output, systematic blood flow and helps in the reduction of patients ventilator dyssynchrony. Hypertension or high blood pressure could lead to kidney failure as observed in the undertaken case. However, Treatment with drugs can improve the function of the damaged kidney.. Kidney could also be affected due to the use of drugs and poor sodium excretion in the body. Past researches conducted reveal that even in the cases where successful drug application for the control of high blood pressure in intervened, their ability to prevent or improve kidney deterioration has not been commendable or convincing. Studies show that dietary protein restriction helps in slowing down the process of constant deterioration of renal function.( Rostand, Stephen G., Brown, Grace, Kirk, Katharine A., Rutsky, Edwin A., Dustan, Harriet P, 1989) The decision to treat a patient in the Intensive care with unit neuromuscular blocking infusion is a bit difficult and tedious in nature; however where the use of neuromuscular blocking is used for the placement of an endotracheal tube, the decision of applying NMBAs is a common one. Such an intervention is more dependent on an individual practitioner’s preference rather than the standards of evidence based medical practice. In the current case the patient was intervened with neuromuscular blocking infusion (vecuronium) with sedation, along with a routine nerve stimulator assessment for responsiveness of medication. Sedation becomes essential for severely ill patients suffering from respiratory problems. However, the negative impact of sedation and NMBAs relates to the depression of reflex cough. In this case with the use of APRV cough and secretion clearance could be facilitated (Habashi N M, 2005). Use of NMBAs in the ICU is basically to aid mechanical ventilation or to manage patients with traumatic conditions (American Journal of Health-System Pharmacy, 2002). Neuromuscular Blocking Drugs are frequently used for muscle relaxation and to facilitate ventilation control (George H Meakin, 2007). Pressure support ventilation (PSV) is also one of the commonly used systems to decrease work of breathing (WOB) in patients requiring ventilatory assistance (Dirk Varelmann, Hermann Wrigge, Jörg Zinserling, Thomas Muders, Rudolf Hering, Christian Putensen, 2005) Neuromuscular blocking agents are routinely used for critically ill patients. One of such agents is, vecuronium which does not cause significant histamine release consequence being development of bronchoconstriction in patients. Another negative occurrence of its use can be seen as prolonged ventilatory dependence due to increased span of neuromuscular blockade, however due to a short duration of action and limited accumulation, vecuronium is widely accepted as an intervention for treatment of such cases. Sedation is a general term used to calm a severely ill patient. An ICU patient generally bears unpleasant feelings, anxiety, frustration, pain, irritation etc, supportive care such as mechanical ventilation could also lead to patient’s distress and discomfort, where sedation becomes essential. Local anesthesia with sedation offers anesthetist a higher flexibility in customizing the quantity needed of anesthesia as per the condition and requirement of the patient (Michael Mercandetti, 2008). However Excessive sedation has increases the duration of mechanical ventilation in patients with acute respiratory failure Procedures that were taxing and time consuming are now performed safely in office and outpatient surgical suites. However, sedation has its own negative consequences as well; decreased blood pressure and reduced breathing are few of them. NMBAs should be added only when sedation fails and not along with it. Vecuronium NMBA is an effective agent taking just 3 to 5 minutes and lasting for about 35 minutes, but persistent use may accumulate in a renal failure and it also does not enhance the neuromuscular block (Keiichi Nitahara, , Shinjiro Shono, Takamitsu Hamada, , Hideyuki Higuchi, , Tadakazu Sakuragi, , and Kazuo Higa, 2005) In the current case, the severity of the patients condition may also be due to the intervention applied, thus the use of Vecuronium should be avoided as far as possible. (Kumar P, 2003). Heart failure is the pathophysiologic state in which the heart is unable to pump blood at a rate required by the metabolizing tissues of the body or pumps only from an abnormally elevated diastolic filling pressure (Michael E Zevitz, 2006). The risk and the absence of supportive clinical data, makes it important to justify the use of APRV for its widespread application. The patient suffered from a right sided heart failure. Pulmonary hypertension may be one of the reasons to generate high blood pressure in arteries connecting the right-side of the heart to lung, resulting in a right side heart failure. Chest pain, acute shortness of breath, discomfort and anxiety are few of the symptoms of the failure which were also exhibited in the patient. Patients with severe RV pressure overload are one of the major reasons for critical condition of the patient. ECG parameters result in worsened condition of patients with chronic RV pressure overload, irrespective of the nature of the congenital heart disease. In all patients, a positive correlation was found between QRS duration and RVEDV. As per the past researched done, the strongest correlation was found in the group of patients with subpulmonary RV functioning under chronic pressure overload. A link has been found between ventricular enlargement and a prolonged QRS duration on surface ECG resulting in ventricular arrhythmias. The electrocardiography results have also revealed the fact that a speed of 25 mm/s and 1 mV/cm standardization resting 12 lead ECG is obtained while observing the patients (A standard (speed of 25 mm/s and 1 mV/cm standardization) resting 12 lead ECG was obtained during the patient’s last visit to the outpatient clinic and compared with ECGs from a visit five years previously (Neffke J G J, Tulevski I I, E E van der Wall, Wilde A A M, D J van Veldhuisen, A Dodge-Khatami, B J M Mulder, , 2002). Oral hygiene is proposed as a key intervention for reducing ventilator associated problems. Mouth care is a vital aspect of patient care especially for the seriously ill patient as they are usually wholly dependant on others for their oral and other care provides it. The intervention requires regular brushing of teeth twice daily, for this foam sticks soaked in Corsodyl can also be used for reducing plague and debris (Berry AM; Davidson PM; Masters J; Rolls K, 2007). Sore mouth is rated high among the ICU patients. In addition to the unpleasant odor associated with halitosis there is also another aspect of not having a clean mouth. ICU patients may require oral intubations to create an airway. The use of an endotracheal tube can cause potential complications for a patient such as lung infection severely ill patients develop impaired immunological deficiencies, thereby unable to combat the bacterial incursion of the lungs. For the ICU patients, it becomes essential to keep them dehydrated in order to improve respiratory and cardiac function; however this could lead to xerostomia and increase the potential for oral infections. It is well stated fact that use of an endotracheal tube allows the direct entry of bacteria into the pulmonary tract which leads to the impairment of the cough reflex and enhances mucus secretion. Risk of developing nosocomial pneumonia, eternal nutrition therapy and dental plague is increased. In such conditions excessive oral health care needs to be entertained. To deal with the problem of dry mouth cold water or soda water could be offered at regular intervals, use of paraffin for avoiding lip moisture are an effective way to prevent dry mouth. Education and focus on good oral care strategies are required to impart the best oral care procedure for the intensive care unit patients. The intervention in the case could be further improved by having a continuous and regular oral assessment with increased health care activities. Evidence-based cares for oral care of critically patients are not adequate, and oral hygiene measures are emphasizing from on patients’ comfort rather than removal of microbes. AREAS WHERE THE RESEARCH DOES NOT SUPPORT THE CURRENT PRACTICE AND CHANGES WHICH COULD BE IMPLEMENTED TO IMPROVE THE CURRENT PRACTICE The research does not support the intervention of Vecuronium due to its negative consequences leading to a heart failure and renal failure which are visible in the patients deteriorating health condition. Any other agent could have been used, depending upon its positive and side effects on the patient’s current condition and past history. The oral health care must be undertaken more profusely, monitored through a proper assessment chart CONCLUSION It can be concluded that interventions applied in the case are appropriate. Airway pressure–release ventilation (APRV) is a relatively new mode of ventilation that allows for ventilation with mean airway pressures however, data are insufficient to compare it its efficiency with the traditional methods. Oral hygiene is taken to be as a standard nursing care, but is generally neglected in severely ill patients or done in a hasty manner; there is a dire need to published protocols for oral care in ventilated patients. Results also reveal that Ventilator induced diaphragmatic dysfunction (VIDD), a ventilatory muscle abnormality could be induced by mechanical ventilatory support strategies provided to a critically ill patient, which results in elimination of the spontaneous ventilatory muscle activity, thus it should be taken care of in all aspects (Neil MacIntyre, 2007). The ICU patient requires additional care and support to cope up with the stress, anxiety, discomfort along with the natural pain inflicted by the disease he is suffering. The case projected involved the right interventions as per the patient’s condition and requirement. Word count: 2511 REFERENCES 1. Joseph P. Lynch, Yan Ling Ma, Michael N. Koss, Eric S. 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