Student- Covid-19-Part-III-ICU Skinny Reasoning PDF

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Summary

John is emergently transferred to iccu due to acute respiratory failure....

Description

Novel Coronavirus Disease (COVID-19) Part III: Critical Care Unfolding Reasoning

John Taylor, 68 years old

Primary Concept Immunity/Gas Exchange/Perfusion

Interrelated Concepts (In order of emphasis)    

NCLEX Client Need Categories Safe and Effective Care Environment  Management of Care  Safety and Infection Control Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity  Basic Care and Comfort  Pharmacological and Parenteral Therapies  Reduction of Risk Potential  Physiological Adaptation

Clinical judgment Communication Acid-base balance Patient education

Covered in Case Study   

NCSBN Clinical Judgment Model Step 1: Recognize Cues Step 2: Analyze Cues Step 3: Prioritize Hypotheses Step 4: Generate Solutions Step 5: Take Action Step 6: Evaluate Outcomes

Covered in Case Study      

   

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Part III. Transfer to ICU John is emergently transferred to ICU due to acute respiratory failure. You receive the following SBAR report in preparation to assume care:

Situation: Name/age: John Taylor is a 68-year-old African-American male. BRIEF summary of primary problem: He presented to the emergency department because he felt crummy; complaining of a headache, runny nose, feeling more weak, “achy all over” and hot to the touch and sweaty the past two days. When he woke up this morning, he no longer felt hot but began to develop a persistent “nagging cough” that continued to worsen throughout the day. He has difficulty “catching his breath” when he gets up to go the bathroom. Transferred to MedSurg four hours ago and was clinically stable until he got up to use the bathroom and went into acute respiratory distress with increasing O2 needs and decreasing O2 sat.

Background: Primary problem/diagnosis: positive for COVID-19 RELEVANT past medical history: hypertension and type II diabetes Code Status: Full code

Assessment: Most recent vital signs:  P: 134 (reg)  R: 32 slightly labored  BP: 102/54 MAP: 70  O2 sat: 90% non-rebreather facemask-100% RELEVANT body system nursing assessment data: Pale, diaphoretic, anxious, breath sounds diminished with scattered coarse crackles bilat. Use of accessory muscles, unable to verbalize. RELEVANT lab values: Pending lactate and ABG How have you advanced the plan of care? Initiated rapid response and increased 02 nonrebreather mask. Patient response: O2 sat has increased slightly from 85% on oxymask 6 L to 90% on NRB. Respiratory rate remains elevated at 34 and blood pressure has decreased to 102/54 Isar at the INTERPRETATION of current clinical status (stable/unstable/worsening): Dramatic decline-CRITICAL

Recommendation: Suggestions to advance the plan of care: Emergent transfer to ICU

Transfer to ICU: Five Minutes Later… John arrives to ICU and is transferred to his bed. You place John on the monitor and quickly collect the following assessment data: Cardiac Monitor:

Interpretation/Clinical Significance: Atrial Fibrillation: Rapid firing in the atrium causing pooling of blood same as a hot bath tub in the atrium. Since the atrium not squeezing blood out of the body make the patient have less cardiac output resulting in less oxygen in the body

Current VS:

Last VS before transfer:

T: 102.6 F/39.2 C (oral) P: 118 (irregular) R: 20 (regular) BP: 98/52 MAP: 67 O2 sat: 84% non-rebreather face mask 100%

T: 102.8 F/39.3 C (oral) P: 124 (regular) R: 32 (regular) BP: 102/54 MAP: 70 O2 sat: 90% non-rebreather face mask 100% 15 LPM

Current Head to Toe Nursing Assessment: GENERAL SURVEY: Appears anxious, body tense. NEUROLOGICAL: Unable to assess orientation due to non-rebreather mask and labored resp. Able to follow simple commands. HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. RESPIRATORY: Breath sounds coarse crackles bilat. with diminished aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally. Shallow respiratory effort. CARDIAC: No edema, heart sounds irregular, pulses palpable, equal with palpation at radial/pedal/posttibial landmarks, brisk cap refill. Heart tones audible and irregular, S1 and S2 noted over AP-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. ABDOMEN: Abdomen round, soft, and nontender. BS active in all 4 quadrants. GU: Last void 250 mL 4 hours ago INTEGUMENTARY: Skin hot, dry, intact, normal color for ethnicity. Skin integrity intact, skin turgor elastic, no tenting present. 20 g. peripheral IV/saline lock left forearm. Site intact with no swelling.

1. EVALUATE your patient by INTERPRETING relevant clinical data to determine if your patient is improving, declining, or reflects no change. (NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care) RELEVANT Data: Clinical Significance: Improving-Declining No Change: -John Taylor is a 68-year-old African American male

-Elderly over 65-year-old are more susceptible for covid-19.

-Type 2 diabetes & Hypertension

-Underlying factors increase risk of covid-19

-Patient is anxious, weak, having headache, hot to touch, sweaty and a nagging cough with SOB.

-he is anxious because he feels ill -These are the signs and symptoms of COVID.

-Temperature: 102.6 F -Pulse 118 (irregular) -BP: 98/52 -O2 SAT: 84% non-rebreather mask 100% -Skin: Patients skin is hot and he is sweaty -IV’s: Patient has a an IV placed on his left forearm.

-the older the age, the more the risk of COVID19 & complications -type 2 diabetes can increase risk of complications with covid -anxiety comes from all the stress patient is in. headache, weak, sweaty

-Elevating temperature is associated with COVID-19. Sign & Symptoms come from COVID-19symptoms -Pulse is irregular due to tachycardia temp has not changed -BP is due to hypotension -pulse decreasing -bp= declining -O2 is low -Elevating temperature is the sign of his immune system are fighting with infection.

2. Has the overall status of your patient improved, declined, or remain unchanged? What is the current nursing PRIORITY? If your patient has not improved, what nursing interventions need to be implemented? (NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care)

Overall Status: Still remain unstable.

Current Nursing Priority:

Nursing Interventions:

impaired gas exchange -Make sure to monitor for signs and symptoms of respiratory distress. -Making sure to give patient oxygen in order increase his oxygen level -Raising head of the bed can help him improve his respiratory problem

The primary care provider just arrives on the unit and you provide the following concise SBAR to update her on his status:

Situation: Name/age: A 68-year-old African American male name is John Taylor BRIEF summary of primary problem: Patient was transferred from the emergency room because he was declining his vital signs when he came in, blood pressure was 98/52, he also had an elevated temperature of 102.6 F/39.2 C (oral), pulse 118(irregular), the respirations was 20, and O2 sat: 84% non-rebreather face mask 100. He came in complaining of a headache, runny nose, feeling weaker, “achy all over” and hot to the touch and sweaty the past two days. He has difficulty “catching his breath”. As of right now he is stable

Background: RELEVANT past medical history: Code Status: Positive for covid-19

Assessment: Most recent vital signs: BP= 98/52 P=118 Temp=102.6F(39.2 oral) RR= 20 O2sat= 84% non-rebreather RELEVANT body system nursing assessment data: Breath sounds coarse crackles bilat. with diminished aeration on

inspiration and expiration in all lobes anteriorly, posteriorly, and laterally. Shallow respiratory effort. RELEVANT lab values: Patient has atrial fibrillation and respiratory scidosis Patient response: He presented to the emergency department on room air and was 90% non-rebreather facemask100%, but his O2 sat dropped slightly in the last hour to 84%. He is placed on non-rebreather and his O2 sat has been consistently 84% with no shortness of breath at rest INTERPRETATION of current clinical status (stable/unstable/worsening): unstable

Recommendation: Suggestions to advance the plan of care: the nurse need to keep checking on his vital sign and also heart monitoring and also trying to help pt relieve his anxiety.

The following labs just resulted in the electronic health record: Arterial Blood Gas (ABG) pCO2 pO2

pH Norms: Current:

HCO3

O2 sat

(7.35-7.45)

(35-45 mmHg)

(80-100 mmHg)

(18-26 mEq/L)

(94-100%)

7.28

52

58

20

82 on 100% NRB

Misc.

Current: 6 Hours ago:

Mg

COVID-19

`Ion Ca

Lipase

Lactate (Ven)

(1.6-2.0 mEq/L)

Neg

(1.05-1.46 mmol/L)

(3-73 units/L)

(0.5-2.2 mmol/L)

---

---

4.2 2.2

---Pos

3. What lab results are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s): -O2 SAT: 82% -pCO2:52 -pO2: 58 -pH: 7.28 -Lactate

Clinical Significance:

TREND: Improve/Worsening/Stable:

Patient is going toward respiratory acidosis which happens when Patient’s conditions are the oxygen saturation is decreased. This is resulting in hypoxemia, worsening. since PCO2 is high. pH is low due to blood being acidic from decreasing oxygen. -elevating of lactate indicating of organ failure.

The intensivist agrees with your recommendation for emergent intubation. The nurse anesthetist, respiratory therapist and additional critical care nurses are present to proceed with intubation.

Fifteen Minutes Later… John is successfully intubated and has a 7.0 mm endotracheal tube (ET) that is well secured, 24 cm at the lips. Current vent settings are: CMV/AC rate 12, TV 550 mL, PEEP +5, FiO2 100%. He has an arterial line placed in the right radial artery and a central line was placed in the right internal jugular (RIJ) vein. Correct placement of the ETT and central line was confirmed by chest x-ray. After John is intubated his breath sounds have coarse crackles scattered bilat and aeration remains diminished. He is sedated and not moving. You collect the following set of VS:

Current VS:

Most Recent:

T: 102.8 F/39.3 C (oral) P: 106 (regular) R: 12 BP: 82/50 MAP: 60 O2 sat: 92% vent: FiO2 100%

T: 102.6 F/39.2 C (oral) P: 128 (irregular) R: 20 (regular) BP: 98/52 MAP: 67 O2 sat: 87% bi-pap FiO2 100%

4. What clinical data collected is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Health Promotion & Maintenance) RELEVANT Data:

Clinical Significance:

Trend:

-Temp: 102.8 F

-Elevating of temperature is indicating of immune system are combating with the infection

-BP: 82/50

-this mean pt can go to orthostatic hypotension leading to SOB and -BP is declining fatigue due to covid-19. -O2 Sat is improving -Patients O2 Sat increased since we last checked with the vent. his vitals.

-O2 Sat: 92%

-still increasing

Cardiac Telemetry Strip:

Interpretation/Clinical Significance: Sinus Tachycardia: this can happen from stress ex. fear, pain, anxiety --- treat the underline cause of physiological stress

Put it All Together to Think Like a Nurse 1. What is the pathophysiology of the priority problem? (NCLEX Management of Care/Physiologic Adaptation) Priority Problem: Pathophysiology of Problem in OWN Words: Impaired gas exchange There is a much higher risk when a patient has Type 2 diabetes & hypertension and gets diagnosed with and patient also has HTNCOVID-19. This increases the risk of worsening symptoms of COVID-19.Based on studies show that 24% of Type 2 diabetes, headache,people who went to the hospital with severe COVID-19 had diabetes type 2. Patients with diabetes are at most risk and are more likely to pass from the virus. fever, chills, These are all signs and symptoms of COVID-19. People ages 65 and higher are at more risk, especially sweating & impaired gas if they have underlying health conditions. COVID-19 especially targets the respiratory system. It starts from exchange. the upper body and travels to the lungs. This process of infection then destroys the production of healthy alveolar cells, which then result to decreased oxygen levels entering the patients’ bloodstream.

Collaborative Care: Medical Management 2. State the rationale and expected outcomes for the medical plan of care. (NCLEX Pharm. and Parenteral Therapies) Care Provider Orders: Ventilator settings: CMV/AC rate 12, TV 550 mL, PEEP +5, Fi O2 100%.

-Pt’s breathes are transferred through the ventilator.

Norepinephrine IV infusion (0.5-30 mcg/min) to maintain MAP >65.

-Norepinephrine IV infusion will stimulate sympathetic nvs which make blood pressure increased which can prevent septic shock.

Vasopressin 0.04 IV infusion

-treat pt with septic shock from viral infection

0.9% NS IV infusion 100 mL hour

-IV: for replenishing fluid & electrolyte in patient who having -Patient will maintain septic shock hydrated and electrolytes -Rx via IV to sedate pt& used to measure sedation.

Fentanyl IV infusion 10-125 mcg/hour. RASS goal -3 (Mod. Sedation)

Rationale:

Expected Outcome: This protects the pt w/ hypoxemia complication. -Patients HR is stable

-Restoring normal levels

-will stay balanced.

Dexmedetomidine IV infusion 0.2-1 mcg/kg/hour. RASS goal -3 (Mod. Sedation)

-Used in controlled IV device.

Chlorhexidine 15 mL oral/swab every 12 hours

-Mouthwash is given to pt to decrease the bacteria in the intubated pt.

Famotidine 20 mg IV every 12 hours

-act as stress ulcer prophylaxis

Heparin 5000 units SQ every 8 hours

-This is used for patients with unstable angina

Insert urinary catheter

-urinary cath is to drain the patient’s bladder

-Patient will have decreased stress ulcers. -Patient won’t have urinary retention which very discomfortable and also clear from UTI.

3. What nursing priority(ies) and goal will guide how the nurse RESPONDS to formulate a plan of care? (NCSBN: Step 4 Generate solutions/Step 5: Take action/NCLEX Management of Care) Impaired gas exchange related to covid-19

Nursing PRIORITY: GOAL of Care:

Nursing Interventions: Monitor respiratory (ABC’s) Monitor vital signs Help pt change positions Provide patient comfort measures Keep patient well hydrated

Maintain adequate O2 saturation > 92%

Rationale: -To make sure SOB does not increase & pt doesn’t have a difficulty breathing elevated temp and bp is a concern & needs attention & evaluation -Changing positions will help pt breathe better & elevating bed will help open up airway. -Help patient to relieve stress. Talk to patient, provide massage, light music/different scenery to alleviate anxiety -keeping pt hydrated can assist to decrease body temp

Expected Outcome: -patient is experiencing adequate breathing & o2 intake. -decrease temp indicates decreased fever. -Pt will perform better o2 -Patient will show decreased s/s of anxiety

4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient and spouse? (Psychosocial Integrity/Basic Care and Comfort) Alleviated patient stress and anxiety.

Psychosocial PRIORITIES:

PRIORITY Nursing Interventions:

Rationale:

Expected Outcome:

-Make patient feel more relaxed and at ease.

-To decrease patients signs of anxiety from all that he is Patient will show no going through in the hospital from his illness. signs of anxiety and will -Provide comfort measures to ease anxiety from -Be there with the patient, use therapeutic nursing measures demonstrate a good and sickness. to talk to him and make him feel like we care as a nurse. -Make patient less lonely

relaxed state of mind. Patient expresses -Therapeutic conversation can help patient forget about loneliness since covid-19 pt need to be alone at all time in confidence and more social behavior after the hospital. talking to him.

Reflect on Your Thinking to Develop Clinical Judgment 5. To develop clinical judgment, reflect on your thinking that was used to complete this case study by answering the following questions: What did you do well in this case study? Make sure that I focus on ABC; airway, breathing and circulation. I provided optimal nursing care for the patient while he was here. I unveiled all the signs and symptoms of COVID-19 during his stay

What is your plan to make any weakness a strength?

What weaknesses did this case study identify? My weakness is EKG reading.

How will you apply what was learned to future patients?

I learned that, in any situation, I have to be confident and get We as nurses have to have empathy, make sure we are knowledgeable myself ready for anything that happen. Because the patient will and are doing everything in a orderly to prevent any problems. feel that from the nurse also and make patient more stressful and get worsening....