Term Paper: Critical Care Nursing and Role of the Critical Care Nurse

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Nursing

Critical Care Nursing and the Role of the Critical Care Nurse

Recently, while working in a critical care unit, I had the privilege of attending to the needs of Ms. X, a patient who had recently undergoing open heart surgery. Ms. X had been suffering mitral valve problems before the surgery. Although these problems can be caused by infection or are congenital in nature, in Ms. X's case, it was due to the wear and tear of aging, which is one of the most common reasons patients undergo this type of surgery (Sundt, 2000). This was why surgery had been recommended, even at her relatively advanced age.

The patient was seventy-five years old, and I immediately knew that in dealing with her, I would have to put into practice my knowledge of geriatric as well as Critical Care Nursing. Because of her age, which meant a lesser likelihood of wearing out a biological valve, Ms. X had undergoing a tissue valve or biological rather than mechanical valve replacement, so I would also have to carefully monitor her reception of the new tissue, which would leave her in a fragile state, in terms of her body's adjustment to the new tissue (Sundt, 2000).

In assessing the treatment needs of a patient in a critical care unit, one helpful guideline is that of the Synergy Model of the American Association of Critical Care Nurses, which rates patient needs on different scales of stability, complexity, predictability, resiliency, vulnerability, self-efficacy, and resource availability. For example, a premature infant vs. A healthy adult would be rated as a) unstable (b) highly complex - unpredictable (d) highly resilient (e) vulnerable (f) unable to become involved in decision-making and care, but (g) has adequate resource availability (the AACN Synergy Model for Patient Care, 2005, AACN). I tried to keep this in mind while treating Ms. X personal point-of-view of my nursing experience

When I met Ms. X, she was lying supine under a warming blanket, to keep her warm after her surgery. She was still sedated from her surgery, thus I knew that I would have to make clear what was happening to her, repeating things several times, to avoid confusion, should we be able to engage in a dialogue. In older patients in general, when they are taken out of their familiar surroundings can experience confusion, disorientation, and distress. However, although a patient may not be able to respond to the nurse, the patient may still have some awareness of what is going on around them. It is important for the nurse to remain positive, and to keep communicating with the patient out loud and tactilely, so the patient does not experience a psychological or physical jolt, should the patient regain full consciousness during treatment.

Ms. X was no stranger to surgery -- she had also, I noted from her history, had cataract surgery in the past. However, her vision was still not particularly good, another factor I had to take into consideration with my dealings with Ms. X, as she would likely be more responsive to verbal rather than visual cues.

Comprehensive discussion of critically ill patient and their experience of critical illness

Ms. X was a seventy-five-year-old female although she had a slender, almost frail frame, her past medical history indicated he had non-insulin dependent diabetes mellitus (NIDDM) otherwise known as Type II or adult onset diabetes and hyperlipidemia or elevated cholesterol levels. Thus, Ms. X's heart problems were not her only experience with critical illness, and her general state of physical health had not been well for some time, in several areas of her daily functioning.

In the unit, Ms. X was intubated, so despite her sedated condition I was concerned that she not be in any discomfort. She was intubated with a t-shaped arterial line, a central line, SLX2 in her right forearm, a flow-directed balloon-tipped pulmonary artery catheter (PAC) (also known as the Swan-Ganz or right heart catheter), cordis, chest tubes, a Foley catheter (a thin, sterile tube inserted into the bladder to drain the patient's urine), all of which were situated upon Ms. X's entry into CSICU before I first encountered her in her bed. None of the inserted tubes seemed, upon first glance her any immediate distress, although I prompted her several times, regarding her comfort level, soliciting a personal response, although I did not receive one during the period when I was treating Ms X. Her sedation lessened her apprehension of physical discomfort, and possibly her sense of psychological comfort with being attached to such tubes.

The patient had packed red blood cell (PRBC) transfusions as are routinely administered in the ICU, insulin as indicated by her diabetes, nitroglycerin, Levophed (Norepinephrine) decrease the blood flow to all organs except heart and brain, and the opiate hydromorhone, all of which were infusing at different rates through the different access lines mentioned above.

The patient's heart rhythm was externally paced through an a-V monitor at 78 bpm to address her underlying bradycardia. Bradycardia had been a problem for the patient in the past, I noted.

Despite her sedated condition, I still prompted the patient with yes and no questions that she could answer, if she was able to hear me, to give her a sense of empowerment over her circumstances, which I assumed would be important to a patient, should she wake from post-surgery sedation. I then explained what had happened to her and where she was. I also explained that she was receiving medication to make her feel better, and to relieve her of pain through the tubes inside of her. I reminded her of the type of operation that had occurred to her while in the operating room and why she needed it. I said that her heart had gotten tired, and what the doctors had done would help it beat like it should.

A tried to address my remarks very close to Ms. X because the surrounding environment of the CSICU cardiac surgery ICU was an open area with fifteen other beds, all of which were occupied, often by patients engaged in dialogue with physicians, nurses, or other staff. It was a busy, impersonal environment that could be cold or confusing as Ms. X regained full consciousness. It was noisy, too, as many other people were talking at the same time. There was a rushed feel to the environment, as is inevitable in a CSICU, but which can be uncomfortable to a waking patient and counterproductive to the necessary psychological state to facilitate healing after surgery.

Getting to know Ms. X was difficult, because she had just been through a highly stressful procedure for someone of her age and frailty. However, simply from reading her chart, I realized that she had a number of medical complications to deal with in her past, which made me appreciate her ordeal even more, and the critical nature of her heart condition and other conditions. Also, knowing the side effects of her medications, such as her painkillers, helped me understand how her difficulty gaining orientation, coupled with her age and her recent exit from surgery would be complicated.

Another difficulty was that I did not know Ms. X's immediate family, into whose care she would be discharged. After successful mitral valve replacement patients are usually put on anticoagulations like Coumadin postoperatively. Her family would need to be aware of the side effects and how to administer the Coumadin, as well as to be aware of any postoperative complaints. Patients after surgery also need antibiotics whenever they have procedures done for the rest of their lives, even procedures unrelated to the surgery, and especially given Ms. X's diabetes, it was essential that she always tell her doctor or dentist that she had valve surgery before any surgical procedure, however minor (Sundt, 2000). The risk of infection is always a danger for heart surgery patients who have undergone a tissue replacement.

Knowing the patient's family and social environment would have given me a better idea about her outlook, whether she was optimistic or pessimistic about getting well, how she felt about her state of health in general, and what acts of daily life and independence were most important to her. It would also have helped me assess the family's ability to facilitate the patient's self-care, and their awareness of the seriousness of monitoring her health condition. Also, I would have liked to have known the patient's attitude, and her family's attitude regarding her other ailments, such as her diabetes, her adherence to a special diet, her ability to monitor her blood sugar and cholesterol, as well as her history in observing a medication regime with religiosity and diligence.

According to the AACN synergy model of rating patient needs, I assessed the patient's condition as (a) unstable even in the context of the unit, and even less stable in the long-term when she was not being constantly monitored (b) highly complex because of the number of conditions facing Ms. X -unpredictable although she… [END OF PREVIEW]

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