Critical Care Clinical Case Study

NURS 451- Clinical Management of Adult Health Nursing III

Purpose of Assignment
The purpose of this case study is to integrate knowledge from the humanities and
sciences, including nursing research and theory, to plan, provide, and evaluate holistic care
provided to a client selected during this clinical rotation.

Student Approach to Assignment

The patient who I chose for my case study was a 75 year old man admitted to the
Emergency Department for shortness of breath, altered mental status, and generalized weakness.
The Emergency doctor diagnosed him with sepsis and aspiration pneumonia which he was
quickly sedated and intubated and transferred to the Medical Intensive Care Unit. He would
intubated for several days before I took care of him but they decided to extubate him on the day I
arrived and he was not doing very well. It gave me a unique insight on how the progression of
care that patients go through during their time in the ICU. The focus of the paper was the
progression of the patients in the ICU.

Reason for Inclusion of the Assignment in the Portfolio

This assignment is included in the portfolio because it highlights the care that I gave to a
complex patient and demonstrates integration of a wide variety of end of program behaviors.
Critical Thinking
Uses nursing and other appropriate theories and models to guide professional practice.
Example: In this case study I used Ida Jean Orlandos theory of The Dynamic Nurse-
Patient Relationship. This theory states that nurses must be able to provide immediate
care for patients who are in need of help. This is particularly important in an ICU
setting because on certain occasions these needs that the nurses must meet are ones of
life and death. This patient in particular needed assistance immediately because he
was just extubated and placed on CPAP but could not clear his secretions 100%.
When this occurred myself or the nurse would have to suction his mouth but without
this the patient would not be able to get sufficient oxygen to his lungs due to his
secretions. So immediate nursing intervention is needed for patient.
Uses decision-making skills in making clinical or professional judgments.
Example: In this paper I discussed my ability to make decisions by talking to the
patient about end of life support or a DNR. The patient had stated that he wanted to
become a DNR but still had an IV with fentanyl and a sedative running which means
he cant make any medical decisions while still on these drugs. I made the decision to
go back with the nurse some time later when the IV medication was complete
whether he would like to sign the DNR and if so to discuss it with his wife first.
 Evaluates nursing care outcomes through the acquisition of data and the questioning of
inconsistencies.
Example: When a patient is taken off of the ventilator they must be able to cough up
their own secretions and when this is done they are generally extubated if they can
tolerate breathing on their own as well. My patient supposedly passed the cough test
but once he was able to be extubated he did not show any signs of being able to cough
up his secretions. So we had to go back and teach him multiple times to cough and
how to cough.
Revise action and goals based on evidence rather than conjecture
Example: The patient went from a ventilator to CPAP to high flow nasal cannula.
While on the high flow nasal cannula his oxygen saturation would steadily drop
below 85% then come back and hover around 90%. The nurse and I made the
decision to switch the patient from high flow back to CPAP because he was not being
adequately profused based on evidence such as an elevated heart rate, blood pressure,
and a low oxygen saturation percentage
Engages in creative problem solving
Example: In this specific example the nurse was proving care for a patient with a sore
on the bottom of his heel. While she was doing a dressing change she was having to
hold the foot up. I thought it would be better to place a pillow underneath the patient
leg to prop it up while the nurse changed the dressing of the patient.
Nursing Practice
Implements traditional nursing care practices as appropriate to provide holistic health
care to diverse populations across the life span.
Example: The traditional nursing practices provided for this patient were care for the
patient were administration of medication, talking to the family, discussing plan of
care, and counseling the patient.
Demonstrates an awareness of complementary modalities and their usefulness in
promoting health.
Example: Some complementary modalities that are useful in promoting care was
providing oral care for the patient. The oral care provided multiple health benefits
such as reducing the amount of secretions allow the patient to breathe better.
Performs therapeutic interventions that incorporate principles of quality management
and proper safety techniques based upon assessment findings
Example: The patient had been feeling like he could not breathe even though he was
on high flow nasal cannula. The nurse and I went to listen to his lungs and found that
he was wheezing during inspiration and expiration. The only safe intervention was to
call respiratory to come and give him a nebulizing treatment to allow him to breathe
better.

Communication
 Uses therapeutic communication within the nurse-patient relationship.
Example: In the case study I discussed being able to communicate with the patient
regardless of his raspy voice. His voice was extremely horse due to ventilation and
due to the CPAP. But I was still able to communicate with him and ask him about his
DNR status and how he wanted to continue with that.
Adapts communication methods to patients with special needs
Example: My patient could not talk properly so sometimes we had to communicate
with a simple yes or no response. He was just extubated but unable to communicate
due to his voice being so hoarse.
Teaching
Providing teaching to patients and/or professionals about health care procedures and
technologies in preparation for and following nursing or medical interventions
Example: Before administering any medication or when performing a procedure the
nurse and myself would explain what the medication was, explain the procedure
before it was performed. In this specific example the nurse and I had to place a salem
sump on a patient who was lightly sedated. Before starting with the placement the
nurse and I explained what the procedure was, what it was for, how it was going to
get placed.

Research
Differentiates between descriptive nursing literature and published reports of nursing
research.
Example: In this case study I used an article called that discussed which technique of
suctioning was most appropriate for patients with an endotracheal tube. It used a
quasi-experimental method to determine which method was safest and most effective
with patients. There were several nursing literature that stated that one was better than
the other but this research proved that this particular technique was the best.
Evaluates research that focuses on the efficacy and effectiveness of nursing interventions.
Example: In this paper I discussed research on the effects of oral care and the ability
to cough. The research proved that with proper oral care the patient could have a
better outcome when coming off the ventilator and having the ability to cough as
well. This directly effects nursing interventions because oral care needs to be done
more often and more efficiently.
Leadership
Articulates the values of the profession and the role of the nurse as member of the
interdisciplinary health care team.
Example: I described throughout the case study that the use of doctors, respiratory
therapists, and other nurses were vital in taking care of the patient and supporting
him.
 Professionalism
Differentiates between general, institutional, and specialty-specific standards of practice
to guide nursing care.
Example: Nursing care provided to the patient by the nurse and myself were directed
by the hospital policy. We used resources such as respiratory therapy, the doctors, and
other nurses for resources. We were able to utilize medication to reduce the
discomfort of the patient and we were able to use ethics in telling the patient to wait
and discuss his DNR status with his family.

Understands the effect of legal and regulatory processes on nursing practice and health
care delivery, as well as limits to ones own scope of practice.
Example: Understanding that the patient was on a IV with fentanyl and a sedative
when asking for a DNR form to fill out. The patient had not talked with his family,
was not able to make medical decisions for himself and there for the nurse and I did
not give him the consent form to sign. We went back later to discuss the topic again
after the IV was stopped and asked the question again and told him to talk it over with
his family who was on their way.

Applies ethical decision-making framework and legal guidelines to clinical situations

that incorporate moral concepts, professional ethics, and advocacy for patient well-being
preferences.
Example: The only way a patient can signs a consent form for a DNR is in the
presence of a MD. The doctor initially asked the question of the patient because of his
previous medical history of multiple ventilation. Even though the doctor knew that he
was still on the IV drip and could not make decisions for himself the doctor wanted to
know where the patient was at in terms of level of care able to provide. The doctor
would have to come back later to talk to the patient and see if he was still willing to
sign the DNR after the IV was discontinued.

Culture
Demonstrates sensitivity to personal and cultural definitions of health, and how these
beliefs influence an individuals reactions to the illness experience and end of life.
Example: The patients medical history is a pretty long one with him being
hospitalized several times for his COPD and then having to be intubated due to his
inability to breath. He had been intubated not 6 months prior to this one. He told the
nurse and myself that he does not want any extenuating circumstances. Even though
we explained to him that he was looking like he was going the right direction to
recovery but that he would have restrictions. He stated that he did not want to be
ventilated again.