Care Nursing of Critically Ill Patients - Case Study Example

Critical Care Nursing Name Institution Date Table of Contents Table of Contents 2 Abstract 3 Critical Care Nursing 4 Introduction 4 Assessment and care needs for Margaret 4 Collaborative care needs of the client and the use of diagnostic procedures and therapeutic interventions 5 Prioritizing client’s care needs 7 Conclusion 15 Bibliography 15 Abstract The paper presents a number of issues in the management of patients in the critical care unit with respect to Mrs. Margaret. Mrs. Margaret presents will a number of clinical presentations hence effective care at the ED is important. Margaret is then transferred to the HDU where continuous care needs to proceed. Understanding the pathophysiology of a disease is vital for establishing patient’s care needs. For instance, Margaret has a heart failure hence understanding the pathophysiology in heart failure improves proper identification of Margaret’s care needs. The paper has also discussed the significance of collaborative care during the management of a patient in the critical care unit. The major principle outlined behind care collaboration is to enhance patient’s safety and outcome. Medical errors can occur during patient care, and early prevention can help in protecting the patient. Lastly, the context has outlined how priority is given according to collaborative care needs of the patient. Critical Care Nursing Introduction Individuals with the HDU require continuous medical support and other relevant support so as to maintain the functioning of their body. For instance, they might not manage to breathe properly within their own means and might have numerous organ failures. At this point, medical equipment replaces what the patient’s body cannot be able to do while the patient recovers. With this respect, Mrs. Margaret Cronin has been admitted to HDU following assessment in DEM. She has an irregular heart rate, history of hypertension and pneumonia and appears anxious on admission to the unit. She has been ordered drug therapy, blood transfusion hence proper preparation in the HDU by the registered nurse prior to receiving a patient (in this case Margaret) from the emergency department (ED) is very crucial. Some of these preparations include and not limited to: bed side preparation, having enough supplies within the room to avoid any unnecessary distress. Assessment and care needs for Margaret Understanding the pathophysiology of the Margaret’s condition will facilitate understanding the care needs of the heart failure that Margaret is suffering from. Cardiac failure is a medical syndrome that occurs in case the heart is not able to offer enough flow of blood to fulfil metabolic needs or accommodate venous return in systemic. Mrs. Margaret has a heart failure meaning that her heart is not sufficiently carrying out its functions like blood pumping, her work of breath is increased, fluid retention, and is put on frusemide which is a diuretic drug to ease fluid retention as well as control high blood pressure. Diuretics are greatly used in management of hypertension (Liamis et al, 2008). The principal care needs for Mrs. Margaret should relate to relieving the symptoms she presents due to heart failure in addition to making her comfortable. Additionally, it is vital to monitor urine output on an hourly basis to establish the function of kidney since kidney failure worsens the condition that the patient is in already. At this point it is imperative that collaborative care be established so as to enhance patient outcome. Reassuring the patient about the need for treatment since she seems disoriented as evidenced by her statement about being left to die. Collaborative care needs of the client and the use of diagnostic procedures and therapeutic interventions A crucial role of nurses in the critical care unit is to offer non-stop observation of patients who are critically ill (Wyckoff et al, 2009). Effective observation for Margaret will help the RN to establish the care needs of the patients hence reduce the abrupt deterioration of risks of the patient, monitor their overall dependence on equipment of support and avoid their confusion or agitation resulting to harm. Observation entails integration, interpretation and valuation of information which include the patient’s psychological and physical response to whichever interventions, condition’s changes, the importance of observed physiological parameters as well as the safe operation of equipment. So far a lot of practice involve multi-disciplinary whereby every practitioner independently assess and plan for patient care. Nurses are able to become members of the collaborative team through understanding and communicating nurse role, skills and knowledge to others; learning from other health providers; identifying where mutual roles, skills and knowledge present; and being ready to work within collaborative teams (Orchard, 2010). Nurses ought to address a number of fundamental matters regarding practice that counteract collaboration as well as patient-centred management. According to Despins (2009), promoting safety of patient via ICU interdisciplinary teamwork calls for understanding of the ICU squad’s constituency, interdisciplinary collaboration’s attributes, hindrances to this teamwork, and interventions and behaviours that are able to facilitate collaboration. According to Mrs. Margaret’s case, she requires a collaborative care due to her condition. For instance, she sends me for a bed pan and on and off and I discover the need for an IDC will be very relevant to avoid stressful moment for both the patient and myself. Other collaborative needs that Mrs. Margaret requires include getting a CVC line for measuring preload of right ventricle and CVP, need IA line to measure ABGs and blood collection, IDC will be required for hourly urine measures. In accordance to increasing patient safety through collaborative practice, the RN should inform the medical officer (MO) about the need for the above requirements for Margaret, which he would help me fix. Effective communication involving health providers is vital for an operational team. Negative factors impeding collaborative practice include poor communication, conflict involving providers of health care and failure to devise emergency plan in the occurrence of possible complications (Despins, 2009). Improved practice in patient safety results in reduced infection and better outcomes of the patient as well as reducing costs (Bolz, et al, 2008). HDU is considered an excellent unit to provide care to patients who are too complex for the general ward, although not requiring critical care of high intensity. There are important benefits in offering a place where professional teams are able to continue with caring for the patients who are very ill, with the help of specialists in intensive care, without causing unnecessary risk to the patient (Marcucci, 2007). Prioritizing client’s care needs One major conventional nurses’ role entails surveillance. Surveillance may encompass watching the patient for any changes within their situation, identifying early health deterioration, in addition to harm or mistakes’ protection (Elliott & Coventry, 2012). For more than 100 years, it has been a routine for nurses to carry out this surveillance with respect to similar vital signs: pulse, temperature, respiratory rate, blood pressure, and in present years, saturation of oxygen. According to Elliott & Coventry (2012), timely detection as well as reporting any changes within the fundamental signs is critical because delays in commencing the right management can affect the outcome of the patient in a detrimental manner. Every medical/nursing intervention need to be grounded on a rational clinical review of a patient (Urden, et al, 2010). For patients who are critically ill, airway assessment is of fundamental importance. Protocols of advanced support of life necessitate that the initial assessment’s aims of patients that are critically ill are to: to make the patient stable; and to identify and manage conditions that are life-threatening (Higginson & Jones, 2009). There exist various triage, evaluation and survey frameworks that can be used in the assessment of patients that are critically ill, although they all follow the related ABCDE pattern (Foreman, et al, 2010). According to the case study, this is what the RN should consider as the top priority for Mrs. Margaret’s care needs. The rationale behind assessing the patient’s airway helps the nurse to identify if the airway is clear as well as identifying any obstruction sign brought about by foreign bodies, tongue, or vomit. It is important to begin with this primary assessment because without a patent airway, every other intervention does not matter. The rapid assessment of confirming if the patient’s airway is patent or not is by asking him or her any question. A standard verbal answer from Margaret directly informs the RN that the airway of the patient is patent, she is breathing properly as well a perfusing her brain. The rationale for breathing assessment is to establish whether there is proper chest fall and rise and whether there is adequate breathing with regards to chest wall, lungs, and diaphragm (Sole, et al, 2009). The initial step in breathing assessment is to monitor Margaret and actually watch how she breathes. This assessment aspect is referred to as inspection. It is necessary that when the respiratory system of the patient who is being assessed, the RN observes among other things: the color of mucus membranes and skin of the patient since this is considered a helpful haemoglobin saturation’s indicator; and patient’s capacity to speak. In circulation assessment, the nurse should establish if the circulation is enough to fulfill the patient’s needs and this is checked through blood pressure assessment, any loss of blood and heart rate (Higginson & Jones, 2009). Vital signs like temperature should also be assessed. With this respect, Margaret’s temperature is 37.6. The rationale is that elevated temperature is an indication for pneumonia, and rise in breathing work. Mrs. Margaret’s blood pressure is considered high blood pressure (145/90 mmHg) since it is above the normal parameters by her age which is (120/60). The heart rate is also high hence affecting the normal circulation. Normal parameters of HR for adults should be 50-100 beats in every minute. Margaret’s HR is 150 which imply her heart is not pumping in the proper manner. With regards to medication, the case study indicates that 450mg in 50mls of Amiodarone maintenance dose. This means 9mg per 1ml. The Australian Injectable Drugs Hand book stipulates that up to 1200mg should be diluted in 500ml which is up to 2.2mg per 1ml. Margaret is to be infused with 4 times the dose that is recommended. This needs prompt addressing with the MO; hence this becomes a collaborative care strategy. The rationale is to enhance patient safety. The RN should inform the MO that the medication is rejected since the order is not correct. The issue of medical mistakes, and specifically medication mistakes, has activated a powerful reaction by the industry of health care, governments, and purchasers (Pearlman & Reddy, 2010). Medical errors are accountable for more than 1 million severe injuries and fatalities in the United States. Medication errors entail prescribing mistakes (like in the case study), dispensing mistakes, medication administration mistakes, and errors of patient compliance. A potential mistake is an error in prescribing, delivering, or intended administration of medication that is discovered and rectified via intervention (by a patient or another provider of healthcare, in this case the RN) prior to actual administration of medication (Marcucci, 2007). It is important that potential mistakes be reviewed and charted as separate occurrences from mistakes of events (errors that essentially reach the patient) to establish opportunities to correct issues in the system of medication use even prior to their occurrence. Discovery of potential mistakes ought to be an element of the routine of the hospital in terms of quality improvement procedure. Documentation of occasions in which the prevention of medication error occurrence has taken place will facilitate identification of system weakness as well as reinforcing the significance of several checks within the system of medication use. In case an individual suffers injury when being taken care of by a medical professional, whether as a result of error, negligence, or other malpractice act, the hospital where the individual is receiving or received the management might be held accountable for whichever losses or injuries that the patient endured (Pearlman & Reddy, 2010). Hospitals are designed to meet their patients’ needs and protect them; however, occasionally, the safety of the patient is compromised due to hospital’s failure to act promptly to prevent negligence and medical errors. With respect to claims in medical malpractice, the system of civil justice offers two important benefits to citizens. The first is that citizens are given constitutional right in order to follow up for damages for suffering and losses they have gone through due to negligence and medical errors. The second benefit is that it supports hospitals in taking greater actions to protect the sick; hence, potentially avoiding medical malpractice and mistakes prior to their happening. Additional to assisting families and individuals who are hurt, lawsuits in medical malpractice work to defend every individual who seek healthcare. A lot of studies have depicted that when medical professionals are more accountable, healthcare quality and safety of the patient becomes greater. When assessing disability of the patient, neurological status is considered. This is done in terms of consciousness level of the patient using AVPU scale or the Glasgow Coma Scale. The scale of AVPU is based on patient’s Alertness, Voice, the degree of Pain, and Unresponsive (Rosdahl & Kowalski, 2012). According to the case study, Margaret appears anxious when admitted to the HDU hence the RN should make the patient calm and comfortable. The rationale is that calm patients have a greater capacity for compliance. Margaret only has peripheral IVs insitu when admitted to HDU. Collaboration with the MO is required for the insertion of a CVC. The rationale is that CVC allows CVP measurement and can have more than one lumen for administration of fluid and drug. Additionally, the CVC is positioned in the superior vena cava or right atrium hence large volumes of fluids can be administered quickly. Care of CVC is very important so as to avoid any irritation and infection to the patient. The triple lumen CVC is preferable for Margaret’s case because a triple lumen means that the RN will have 3 separate lines that come out in 3 different places along with the CVC catheter, thus 3 extra lines in one cannula. Normal practice for a triple CVC is to have one line for continuous monitoring of CVP, another for drugs and the third for fluids. CVCs are universal in critical and acute care units. Due to the complication of the management for critically ill patients, a lot of CVC have multiple lumens (Peterson, 2012). Preventive measures such as aseptic techniques and good hand washing ought to be considered when fixing a CVC. The rationale behind this is because of the serious complications linked to CVCs (Cole, 2007). Intravascular volume is the quantity of blood within circulation and is an essential CVP component. According Scales & Pilsworth (2008), through controlling the fluid balance in the body, primarily, the intravascular volume will be maintained. Imbalances in fluid can lead to either volume depletion or volume overload. Overload in volume is majorly observed in patients like Margaret who have cardiac or renal failure and leads to CVP increase (Scales, 2010). Taking care of patients with an IDC is a very common aspect of clinical practice in nursing in the environment of acute care, which for a number of patients is necessary for their clinical management (Foxley, 2011). Margaret is given frusemidewhich is a fast IV injection and would require to be administered in a different port or following flushing of the port and then administration of the medication, then flushing again (Liamis et al, 2008). The rationale is to prevent pain at the administration site. Enoxaparin comes in a syringe that is pre-packed that is marked with doses on the syringe’s side. Clexane is the trade name and the unwanted amount can be discarded. The MO can be informed about this intention so as to avoid any unnecessary mistake. It is very vital to consider how medications work in order to avoid administering drugs that counteract. Aspirin is anti-platelet; this means it stops plates sticking together and to plaque. Enoxaparin is low molecular weight heparin (LMWH) which makes it an anti-thrombin medication. Therefore both medications play a role in the care of Margaret. Margaret would benefit from CPAP or BiPaP. This needs to be ordered by the MO who will also order the required setting. The RN sets up the machine and applies the settings and face mask. The CPAP or BiPaP treatment would replace the non-breathing mask and as such is a collaborative care strategy. Sputum specimen needs to be collected prior to antibiotic recommendation. Hence it is important to document this for the next shift. Another collaborative strategy will involve discussing with MO about having a FBC. Testing for Hb would be done after blood transfusion, which will be done the following day. However, other tests can be routinely collected during the afternoon shift. Blood sample to be collected for non-urgent tests which can wait and fasting blood test should also be collected. Therefore a pathology form should be written and night staff be advised of need for patient to have blood fasting test in the morning. Red cells and whole blood ought to be infused in the first 30 minutes after taken away from temperature controlled blood refrigeration. The rationale is to give fresh blood to the patient. The patient should be informed about the reason behind blood transfusion. The checks should be witnessed by the RN and the MO hence collaborative practice. Margaret’s identification should be done, patient’s identity as well as gender should be done and the compatibility label’s details should be confirmed. Any discrepancies should be noted, and date of expiry on the pack of blood should be checked too. These checks are very important because any incompatible transfusion can be fatal (Wright, 2010). The blood observations should be taken before the start of transfusion, at the start of transfusion, 15 minutes when transfusion is started, at least each hour in the course of transfusion, when transfusion is completed and 4 hours when transfusion is complete. A collaborative strategy would involve talking to a radiologist about reading the CxR and the report taken to the unit for review by the MO. During the 8hour shift, the RN should make sure that the patient is stabilized so as to enhance health outcomes. This is because Margaret is still disoriented to time and place and any referral to associated health or mental health would not take place until the patient is stable. Therefore it is the responsibility of the RN to write relevant referrals in her shift. Social workers also may be helpful but they are not specialist in assessing the mental health of the client. The wound has been assessed and redressed in ED. The RN in the HDU is happy hence no need to redo redressing. However, it is important that the RN observe the dressing for ooze and Margaret’s levels associated with the wound. If ooze or pain increases, then review is highly recommended because pain management enhances patient’s outcome. Taking care of a patient with enlarged heart involves administration of diuretics such frusemide, which is indicated for Margaret. It is the role of the RN to monitor the response of Margaret in terms of the indicated medication and assess the complications that might arise due to cardiomegaly. Safety of the patient should always be considered when dealing with patients (Sole, et al, 2009). For instance, safety should be considered when choosing which line to run the blood through. For instance, if blood is infused through a CVC inserted in the subclavian vein, the first indication of a transfusion reaction will be central symptoms and signs, such as increased temperature and sweating. In case blood is infused through peripheral IVC, there will be local signs of reaction of transfusion prior to the central reaction such as redness within the site, IV site that is painful, inflammation at cannula site. Margaret will require continuous cardiorespiratory monitoring of SpO2, CVP and BP through intra-arterial line so as to observe her progress. Referral to the dietician concerning Margaret’s diet, particularly on the issue of high potassium food is necessary. Healthcare providers taking care of patients who are critically ill should develop relationships that are collaborative with family members of their patients, grounded on clear exchange of information, aimed at assisting members of the family deal with their grief as well as permitting them to advocate for the client in necessary (Urden, et al, 2010). Meeting Margaret’s and her family members’ needs is a significant element of the roles of critical care unit nurses and other health providers, who are dedicated to lessening the suffering and pain of the people who have critically sick relative. Margaret and her family need to be involved in decision making. A key responsibility of HDU nurses and physicians is to offer members of the family with the correct, precise, and considerate information they required to take part in decision making concerning patients who cannot make decisions. Assessments of the needs of the family provide helpful information for getting better the understanding, satisfaction, as well as decision making ability of families. The RN has a holistic role in the care of a patient. This is because the RN often is the key supplier of information to family members and the patient, as well as the interdisciplinary team. A proper handover will enhance overall patient outcome (Foreman, et al, 2010). Conclusion In conclusion, the paper has presented the care of critically ill patients in the HDU with respect to Mrs. Margaret. Indeed priority of care is very important so as to enhance patient’s outcome as well as survival. Additionally, the paper has presented how collaborative practice is very important in the care of patients. The key consideration during care of patients is safety. This can be achieved when proper care is delivered to the patient. Medical errors greatly occur in the setting of healthcare. 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