Case Study: Critical Care Nursing

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¶ … care needs, concerns and treatment strategies for Mrs. Margaret Cronin, an elderly patient admitted to HDU following assessment in DEM. This paper will first examine her necessities of care while determining the impact of all biopsychosocial and pathophysiological responses of the client. Given the melee of Margaret's symptoms, along with her medical history -- hypertension, pneumonia, and extreme anxiety -- much of her care will have to be collaborative. This paper will examine the details of her collaborative care, including all diagnostic procedures and therapeutic interventions. With a patient suffering from these conditions including the immediate treatments she's been prescribed -- drug therapy, blood transfusion, and rigorous cardiorespiratory monitoring, and a saline IV -- the nursing care priorities will have to be extremely detailed and well structured.

Preparing the bed area prior to the patient arrival was crucial, ensuring that all the proper supplies were ready for the patient's entrance. For instance the indwelling catheter had to be prepared, the CVC so that CVP could be measured, all monitoring equipment had to be established and the tools needed to create the arterial line.

Assessment of the Client/Care Needs/Analysis of the impact of Biopsychosocial and Pathophysiological responses of the client

Margaret has heart failure: her body is retaining fluid, breathing is more laborious and her heart is not pumping as it should. The first assessment that needs to be done on Margaret is an airway assessment. One needs to determine if there are any obstructions or if her labored breathing is just a byproduct of her hypertension and coronary artery disease (Elliott, 2007). The assessment of Margaret's airways are that they are patent, meaning open and unblocked.

The assessment of Margaret's breathing is what needs to occur next and it was precisely what led to the usage of the Hudson mask. What also needs to occur is an assessment of whether or not Margaret is experiencing any abnormal breath sounds that are indicative of heart failure and/or pneumonia. Her breathing is at 26 per minute and she suffers from coughing episodes which she coughs up green phlegm and has difficulty catching her breath afterwards. Margaret's circulation assessment is pink in colour and warm to the touch and with her blood pressure at 168/100 she's at a high risk for hypertension. Her disability assessment demonstrates an altered level of consciousness, demonstrated by the way that Margaret keeps asking where she is. In regards to the environmental and exposure assessment, Margaret's ECG demonstrates that an abnormality is present, based on the nonstandard reading (Guerrero, 2011). Margaret's temperature is also raised (37.8) and is another manifestation of Margaret's environment and exposure assessment. Checking Margaret's skin for swelling or bruises or bloating would also be useful.

However, the assessment becomes deeper upon the arrival of Margaret's daughter who explains both the fall and the bruises on Margaret's back, which the head to toe assessment unveiled.

There needs to be a clear understanding of the biopsychosocial responses of the client and how they relate to the intimidating and confusing complications with her health. As one professional describes, clinicians need to understand that their relationship to the patient is also a form of medical treatment (Adler, 2007). The nurse needs to recognize that they are engaged in moment to moment mutual recognition of one another's biopsychosocial states (Adler, 2007). Furthermore, "the introduction by either patient or physician of even small changes in their interactive process can lead to large changes in their biopsychosocial outcomes" (Adler, 2007). Finally allowing empathy to emerge can be viewed as a biospsychosocial relational process and is something which can also act as a guide toward ideal outcomes (Adler, 2007). Thus, in this case, it's important to bear in mind the extreme emotional pain that Margaret must be enduring. She lost her husband of fifty years four months ago. This was a man that she spent almost her entire life with. The loss of her husband had to have been a devastating experience and one which is probably waging a negative impact on her mental and emotional health and no doubt negatively influencing her physical health.

When it comes to the patient's pathophysiological responses, it's absolutely vital to understand how Margaret's altered physiology impacts her clinical presentation. it's important to keep in mind that this is a disease of cellular pathophysiology and not simply a hemodynamic disorder (Pratt, 1995). "The progression of compensated ventricular dysfunction to symptomatic heart failure is marked by the activation of vasoconstrictor hormones. Norepinephrine, renin-angiotensin-aldosterone, and arginine vasopressin are secreted in response to inadequate systemic perfusion" (Pratt, 1995). This can be so damaging because the heart is already failing and doesn't need this added stress and burden. When the heart is under such stress and is experiencing a failure in functioning, the body makes up for it in the following ways: via a maintenance of systemic pressure by vasoconstriction, which leads to a redistribution of blood flow to vital organs as well as a re-establishment of cardiac output by bolstering the myocardial contractility and the heart rate by expanding the extracellular fluid volume (Colucci, 2012). Unfortunately when the human body makes these adaptations it creates an overwhelmed state of "the vasodilatory and natriuretic effects of natriuretic peptides, nitric oxide, prostaglandins, and bradykinin. Volume expansion is often effective because the heart can respond to an increase in venous return with an elevation in end -- diastolic volume that results in a rise in stroke volume" (Colucci, 2012). Furthermore, a number of maladaptive consequences generally result because of this neurohumoral activation.

Collaborative Needs of the Patient: Diagnostic Procedures and Therapeutic Interventions

"The ICU team is a self-organizing, complex entity, that expands and contracts based on the needs of the moment" (Despins, 2009). While the degree of collaboration is going to fluctuate, the team in this case will consist of a bedside nurse, respiratory therapist and a physician (Despins, 2009). Thus, there needs to be a strong degree of communication, zero conflict between the care providers and a development of a contingency plan in case the patient in non-responsive. Nurses can be members of collaborative teams by their ability to re-socialize, being able to comprehend and articulate their roles as nurses, the knowledge and skills they can bestow on others, and their willingness to work on collaborative teams (Orchard, 2010). Fundamentally, Margaret needs a highly communicative team of clinicians who all work well together.

The diagnostic procedures and therapeutic interventions were described reasonably well in the case study. For example, blood pathology testing was ordered by the medical officer, as was a sputum sample. A CRX is also ordered as is a loading and maintenance dose of amiodarone. Based on the blood test results, the medical officer ordered dosages of resonium, frusemide, the patient's standard medications, repeat ABGs, liver and thyroid exams, blood transfusion, oxygen. With a patient like Margaret, there needs to be a greater sense of collaborative care between all clinicians who are treating her and engaging with her in therapeutic interventions. For example, there needs to be a great level of cohesion and correspondence between Margaret's general practitioner, her cardiologist, the medical officer, and the nurse practitioner. There needs to be a stronger and more cohesive identification of the management of reversible cardiac causes of heart failure (wa.gov.au, 2008). "Medication and symptom review, aiming to achieve target doses of heart failure Medication such as ACE/ARB Inhibitors and Beta-Blockers in line with evidence-based guidelines and changing requirements for diuretic medication" (wa.gov.au, 2008). This needs to occur with a referral for investigation and a more comprehensive care management plan along with rehabilitation services (wa.gov.au, 2008).

Furthermore, there needs to be a stronger recognition of the comorbidities that are occurring with Margaret, such as the viral pneumonia and her issues with hypertension. "Comorbidities and baseline health status are therefore important when applying and establishing appropriate medications and dosages and choosing treatment for an older person" (Kraschnewski et al., 2006). The therapeutic interventions selected for Margaret do indicate that the collaborative care team was aware and at least trying to address her range of symptoms and the various co-existing conditions. Comorbidities are serious and can often be what lead to readmission or mortality rates for HF or CAD patients (Muzzarelli et al., 2010).

It's also important to note that many of the therapeutic interventions appear to point to the physical and emotional frailty of Margaret, something that is common in elderly adults who are experiencing coronary artery disease (Kraschnewski et al., 2006). "Because frailty is a syndrome of impaired resistance to stressors, it is well suited to predict the elderly patient's response to cardiovascular stress. One of the most promising clinical applications lies in using frailty to predict the elderly patient's risk of mortality and morbidity in the setting of invasive cardiovascular procedures" (Afilalo, 2011). Margaret's frailty is no doubt aggravated by her emotional state and is something which needs to be addressed by a strong collaboration of therapeutic strategies to reverse that development and to prevent adverse outcomes (Afilalo, 2011).… [END OF PREVIEW]

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