Running Head: CASE STUDY 1

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1 Running Head: CASE STUDY 1 Critical Care Case Study Ashlan Brown Old Dominion University

2 Critical Care Case Study On October 20, 2014, L.G was brought into the Sentara Leigh's Emergency Room. L.G was diagnosed with a left middle cerebral artery stroke. A Tissue Plasminogen Activator was administered and a computerized tomography scan (CT scan) was completed. The CT scan noted that along with the left middle cerebral artery stroke, she also had a hematoma in the right cerebellar region. She was transported to the Sentara Norfolk General Neurological Intensive Care Unit for further evaluation. The patient's primary medical diagnosis is an intracerebral hemorrhage. An intracerebral hemorrhage is a direct bleed into the cerebral tissue. It is caused by an elevation of blood pressure exerting force against smaller arterial vessels that have been destroyed from arteriosclerotic changes. The arteries will break causing blood to erupt from the vessels into the cerebral tissue, where the hematoma forms. Intracranial pressure rises due to the increase in intracranial volume (Urden, Stacy, & Lough, 2014). The purpose of this case study is to integrate knowledge from the humanities and sciences. This includes nursing research and theory, to plan, provide, and evaluate holistic care provided to a client selected during this clinical rotation. Nursing Diagnosis Upon my arrival to the unit for clinical, I noticed that a few of the nurses were in an uproar. As I listened to their conversation, it become apparent that the root to their frustration was the patient in room 1602, which so happened to be my patient assignment for the week. During the next two days, it become clear that the patient's priority nursing diagnosis would be: Compromised/Disabled Family Coping related to long-term treatment of client; family disorganization/role changes; lack of mutual decision-making, and inadequate understanding of information from the primary care-giver. The patient's daughter was very hostile to the nursing

3 staff and the family couldn t agree on a plan of action for the patient. They believed that the hospital staff didn t have the patient's best interest at heart. They were certain that they were never told that their loved one had a second bleed into the right side of her head, even though they signed the consent for her to have the craniectomy and ventriculostomy. The family even went as far as to ban the palliative care team from coming to see the patient/family. The two days I spent with the patient, I observed the family argue over her code status, tracheostomy placement, peripherally inserted central catheter placement, percutaneous endoscopic gastrostomy placement, and mechanical ventilation days. They told the nurses to stop doing the neurological checks every hour and to stop changing her position every two hours. They were convinced that the patient was not getting enough rest. The daughter shook up the entire nursing staff when she yelled at the patient's granddaughter for being in the patient's room. The patient's daughter stated that the granddaughter caused the patient to have the stroke, and that she was not allowed to be in the room with the patient. There were a lot of family dynamics involved with L.G, and the saddest part about it was that she had no say in anything, because she was unresponsive and there was no advanced directive on file. The second nursing diagnosis is Ineffective Cerebral Tissue Perfusion related to interruption of blood flow. This was evident because of the patient s hypoperfused state. The patient's current CT scans also showed cerebral edema, increased intracranial pressure, and intracranial bleeding. The ventriculostomy also provided accurate measures of intracranial pressure, which were increased. The third nursing diagnosis is Ineffective Airway Clearance related to neurological dysfunction as evidence by abnormal breath sounds, copious secretions, and inability to maintain a patent airway without mechanical ventilation. The fourth nursing diagnosis is Impaired Physical Mobility related to neurological impairment as evidence by the patient being in a state of stupor. The patient was not

4 on any barbiturates, anesthetics, or pain medications. She could only be aroused with vigorous and repeated stimulation. All of her extremities were flaccid upon arousal. Her eyes would open, but she was unable to track the nurse's fingers. After the stimulation had ceased she would become unresponsive. The last nursing diagnosis was Risk for Infection related to intubation, ventriculostomy, open brain flap, indwelling catheter, intravenous devices, inadequate primary defenses (skin tears, open wounds, ulcers), and chronic disease (Gulanick & Myers, 2011). All of the stated nursing diagnoses are interrelated with one another. The patient had an intracerebral hemorrhage that caused her to have decreased cerebral blood flow leading to a lack of oxygen supply to her brain (Decreased Cerebral Tissue Perfusion). This event caused her to go into a stupor-like state where she is unable to maintain a patent airway (Ineffective Airway Clearance). Therefore she was intubated and placed on a mechanical vent. The patient was immobile, unless the health care team re-positioned her. No purposeful movement was present (Impaired Physical Mobility). Immobility can lead to a number of complications, including infections. The patient had a current diagnosis of hospital-acquired pneumonia that was being treated with antibiotics. Under these circumstances, she is now placed at an even higher risk for acquiring further infections due to all of her lines, wounds, surgical openings, and elevated white blood cell count (At Risk for further Infections). Compromised/Disabled Family Coping encompassed all of the nursing diagnosis. Her series of unfortunate events have placed her family members in an uncontrollable panic. It is understandable, and people deal with stress in different ways. Her family would really benefit from an intervention to relieve stress, and promote an understanding of their loved one's situation. Lydia Hall s Care, Cure, and Core theory fits the patient's situation and primary nursing diagnosis. The theory states, the core is the person or patient to whom nursing care is directed

5 and needed. The core would be L.G, and she will remain the focal point during her stay at Sentara Norfolk General. Nursing diagnosis/goals were based off her current health status. The nurse physically cares for the patient and develops a nurturing relationship with the patient. The nurse spends the most time with the patient, and has been taught to advocate for the patient at all times. Nurse Cheryl provided wonderful care towards the patient, and included the family in her care as well. The family took notice of this, and respected her for doing so. I found this phenomenal, and watched how the family became more open towards Nurse Cheryl and actually listened to what she had to say. This placed Nurse Cheryl in the perfect position to gain the family's trust and build a rapport with them. She was able to educate the family about certain situations. The cure is the attention given to patients by the health professionals. The model explains that the nurse shares the cure circle with other health professionals (physicians, surgeons, care partners, respiratory therapist, etc ). The cure includes interventions or doctor orders geared on treating or curing the patient from her illness or disease. The component of this model is the motherly care provided by nurses. The circle shows that the nurse acts as a professional in helping the patient meet his/her needs and attain a sense of balance, which I observed during my two days working with L.G. ("Care, Cure, Core and," 2012). Outcomes From the physician s point of view the patient was medically stable. L.G was in the recovery process of her stroke, when I provided care for her. At the end of my first day working with L.G it was clear that the family/psychosocial box would become the priority for her on my care plan. Therefore her primary nursing diagnosis would be Compromised/Disabled Family Coping. There are several outcomes that would be great for the family to accomplish for the well being of the patient. The family will be able express more realistic goals and expectations of

6 their loved one. They will be able to verbalize understanding of the patient's disability, disease process, and treatment options. They will be able to develop improved methods of communicating and coping. They will be able to develop a trusting relationship with the nursing staff and other health care workers (Gulanick & Myers, 2011). These outcomes should be obtained a week after the interventions are implemented. The second nursing diagnosis is Decreased Cerebral Tissue Perfusion, a common nursing diagnosis for stroke patients that are deprived of oxygen to their brain. The patient will have improved cerebral tissue perfusion, as evidence by a National Institute of Health Stroke Scale score of less than 15, Glasgow Coma scale greater than 10, absence of new, neurological deficits, and, warm extremities, palpable peripheral pulses, absence of edema, and a stable blood pressure within the next two weeks of her hospital stay (Gulanick & Myers, 2011). Although these outcomes aren t ideal, they are realistic for the patient's current health status. Interventions With Compromised/Disabled Family Coping a psychosocial mindset must be used when planning interventions for the patient/family. Due to the unseen circumstances that followed the patient's stroke, the family has been under a lot of pressure to make important medical decisions that will affect the patient for a lifetime. Family member's lived experience in the intensive care unit: A phemenological study is a nursing research article that discussed families' experiences of their interactions with staff in an intensive care unit (qualitative study). This particular article is interesting and applicable to L.G because of all the family dynamics that were involved with her care. By understanding the families' experiences, nurses are able to implement interventions to minimize the families distress, while providing more holistic, person- and family-centered care. The patient's family can either improve their care, or hinder their care, so it is important for the

7 nurse to incorporate the family into the patient's care. Researchers interviewed twelve different families of patients admitted to the ICU with the average length of stay of 19 days. Families appreciated when the nurses used "lay" terms that were easy to understand about their family member's care. It s important for staff to be honest and upfront about their family member, even with bad news. The families experienced supportive and unsupportive communication as well. When staff members provided the families with reassurance and paid attention to the families' non-verbal cues and acted on them, the family viewed that as exceptional communication. Unsupportive communication included inconsistent information and staff speaking rudely to the family members (McKiernan & McCarthy, 2010). Lay terminology, honest, effective communication, and positive reassurance were found to be adequate interventions in this study; therefore can be applied to the care provided for L.G. Standard one in the Standards of Care for Acute and Critical Care Nursing Practice (SCACCN) is Assessment (Bell, 2008). Assessing each family member's understanding and beliefs about the patient's condition and the family's normal coping patterns including strengths, limitations and available resources would be a great place to start for interventions. L.G's family had a lot of misconceptions about her prognosis and treatments that needed to be clarified. For example, her daughter believed that the patient should remain on the vent for ninety days before a weaning attempt (she read this on Google). The nurse should provide education to the family on how the mechanical vent/intubation works, benefits (deliver oxygen, eliminate oxygenation, keeps airway open), and risks (infection, lung damage). The family would also benefit from written material to refer back to in regards to the stroke disease process and treatment measures. The nurse should encourage the family to ask questions and to voice their concerns regarding the patient. To build trust with the patient, nursing staff should try to assign the same nurse to the

8 patient for consistency. L.G's family members were upset that they always missed their opportunity to talk to the doctor. Scheduling care appointments for the family to meet with the patient's health care providers would ease their anxiety and allow them the opportunity to place a face with everyone who is taking care of their loved one (Doenges, Moorhouse, & Murr, 2014). A qualitative study was conducted to describe the critical care (CC) nurses' experience of relatives in the critical care setting. Semi-structured personal interviews were held with Eight CC nurses. Results showed that nurses appreciated when the relatives participated in the care of their sick loved one, so they would encourage them to visit. More importantly this study describe the challenges faced when working with difficult visitors/relatives. The nurse had discussed the setbacks involved when relatives were too overbearing and demanding, and they described how they felt when relatives chose not to be involved in the patients care. To avoid the negative energy, the CC nurse stated that in order to resolve some of the difficult situations that may arise, the nurse need to have an open and honest conversation with the patient's family to improve the relationship between the two. The CC nurses were understanding when it came to not only the patient's life but their relatives lives too, which has changed dramatically due to their loved ones health decline. Feelings of anger, frustration, and sadness are common, and professional support may be needed. In conclusion, the CC nurses suggested the following interventions while working with relatives in the CC setting. To reduce anxiety, educate the family on the technical equipment in the room, explain treatments/procedures, encourage the family to ask questions, be honest with the family in regards to the patients care, and supply them with daily information and updates about their loved one (Engström, Uusitalo, & Engström, 2010). In the African American culture many individuals take their religion seriously. L.G's family was praying continuously during their time with her in the intensive care unit. The family

9 had a hard time with trusting the hospital staff, which is common amongst the African-American population. New health-care providers are seen as strangers, therefore suspicions may arise due to the high frequency of misdiagnosis in the black community. "Physicians are recognized as the head of the health-care team, with nurses having lesser importance. However, as nurses become more educated, African Americans are holding them with higher regard (Purnell, 2009, p. 46)". A critical care nurse is highly skilled in their area of expertise, and should be able to answer a majority of the questions that the family members may have in regards to the patient's care. Incorporating their beliefs into different interventions could also help the family cope, gain trust, and relieve stress. Praying for the sick and having faith in GOD are associated with positive outcomes in the African-American culture. The nurse may not have the same religious background, but praying with the family and including the patient's spiritual leader into health care practice would be great (Purnell, 2009). All of these interventions will require the nurse to step out of her comfort zone, but the family would really appreciate and respect his/her effort in doing so. L.G was treated with tissue plasminogen activator, which caused her to have an intracranial bleed. The University Health System (2009) prepared a diagram that describes the clinical pathway to treat patients with post IV t-pa and intracranial hemorrhage. Key points to stopping TPA are consulting the neurosurgeon, administering blood, and multiple CT scans. The diagram is listed in the Appendix. In L.G's situation, her physicians most likely followed a similar protocol. Her intracranial bleed/hemorrhage caused her to have decreased cerebral tissue perfusion. Ineffective Cerebral Tissue Perfusion is a state where the brain is receiving inadequate blood flow to maintain brain function. There are a multitude of interventions to promote blood flow to the brain and stimulate tissue perfusion. Standard 4 is planning; the nurse should develop an individualized plan with intervention to help the patient attain the outcomes associated with

10 ineffective tissue perfusion (Bell, 2008). To start the head of her bed should be no higher than 30 degrees. This will decrease intracranial pressure (ICP) by increasing cerebral venous flow. The patient's neck should stay aligned in a central position to stimulate venous drainage from the brain. Mannitol can be given to decrease ICP by reducing cerebral edema; this drug is an osmotic diuretic. In a cultural perspective, the pathophysiology of hypertension in African American is often related to volume expansion, decreased rennin, and increased intracellular concentration of sodium and calcium, making African American more genetically prone than Caucasians to absorb sodium (Purnell, 2009). Antihypertensive will be given to stabilize her blood pressure and maintain cerebral perfusion. Nicardipine and labetalol are both used to control high blood pressure in critically ill patients. Malesker and Hilleman (2012) conducted a retrospective analysis on patients receiving intravenous labetalol or intravenous nicardipine in a critical care setting. The purpose of their study was to assess the short-term clinical outcomes and costs of intravenous labetaol and nicardipine to control hypertension. In the study 189 patients received labetalol and 193 received nicardipine. The continuation of therapy was shorter for labetalol but the number of titrations was greater. There were more patients who achieved their ideal blood pressure goal with nicardipine. Labetalol has a significantly higher association with side effects (bradycardia, hypotension, atrioventricular block) and more patients required an alternate antihypertensive medication with this drug. The costs between labetalol and nicardipine were approximately the same. In conclusion, nicardipine was found to be the more effective antihypertensive medications, with the major advantage being that it had less adverse effects (Malesker & Hilleman, 2012).

11 0.9% sodium chloride can be used to maintain volume status. It is given to treat lower extracellular fluid, commonly seen with hemorrhaging. The fluid remains in the extracellular compartment and is disbursed between the intravascular and interstitial spaces (Crawford & Harris, 2011). Along with giving fluids the patients intake and output should be measured and documented. Another intervention would be to assess the patient's neurological status using the Glasgow Coma scale every hour, monitor progress, and document any signs of deterioration. The Glasgow scale measures changes based off verbal, papillary, and motor responses. Vital signs should be recorded every hour. Frequent blood pressure measures are imperative, because a normotensive state is desired to promote efficient cerebral perfusion. An arterial line would be essential. The patient's family repeatedly referred to her arterial line as a PICC (peripherally inserted central catheter) line. Family education on the differences, the uses, and functions of a PICC line and arterial line was needed, because the patient had both. The electrocardiogram should be monitored frequently, especially in L.G's situation because she has a history of atrial fibrillation (Gulanick & Myers, 2011). Evaluation It's amazing how the simple interventions for Compromised/Disabled Family Coping can turn an entire clinical experience around. Although I was not able to witness all of the interventions, I can say at the end of my clinical rotation with the patient, the family was less anxious, less aggressive, and more attentive to the patient's real-life situation. I believe all it took was a patient and positive nurse. I was fortunate enough to observe just that. Nurse Cheryl answered all of their questions, made sure that the doctors made it a point to speak directly to the family, prayed with them, educated them on a number of items (medications, procedures, treatments, CT scans), and explained each aspect of the patients condition in a simple/concise

12 way. From the beginning, Nurse Cheryl was open and honest about the patient, giving the family a realistic viewpoint on the patient's health status. Most importantly she remained calm. She saw the hurt and pain in their eyes, and knew exactly how to handle it. She didn t get frustrated when they yelled; she just listened and provided them with comforting words and compassion. Although the patient was in a stupor-like state, she talked to her and hugged her as if L.G was alert and aware of the situation. The family commended Nurse Cheryl for that. They praised her, and on my second day they were happy to have her as a nurse again. In just one day there was a lot of progress made within this family. I am positive that within a week they will fully achieve all of their outcomes. One added intervention that Nurse Cheryl suggested for this family was to purchase a journal and write down the names and conversations of each person that came in contact with the patient. The family went and purchased journals that evening. They trusted Nurse Cheryl, and respected her for the care she provided to their mother. After my second day with L.G, she was still in critical condition. Each intervention was used, but it takes time for cerebral edema to decrease. The head of her bed was 30 degrees, osmotic diuretic was administered, neck alignment remained centered, stool softeners were administered, and her urine output was within normal limits. Her blood pressure was maintained with Nicardipine. There was only one situation where her blood pressure was elevated, and would not return to baseline. Nurse Cheryl quickly acted on it and gave her labetalol to stabilize her blood pressure, which worked perfectly. She also received cardene at 60 ml/hour as a maintenance drug to treat her atrial fibrillation. The patient had an arterial line placed for accurate blood pressure monitoring, which was great. From a neurological standpoint her Glasgow Coma Scale reading was four. I noticed after vigorous stimulation she would keep her eyes open for a longer time period on day two. She wasn t able to track with her eyes, and she still wasn t able to make any

13 noises or move any of her extremities. Her intracranial pressure on day one averaged to be five, and on day two it was one, so her cerebral tissue perfusion may have increased just a fraction of what it had been. The intervention stated previously will be beneficial in improving cerebral tissue perfusion; the patient just needs more time to heal. Summary L.G was my first critical care patient, and I feel as though I learned a great deal of information working with her. She sustained a massive left middle cerebral artery stroke with a right hemorrhagic transformation after intravenous thrombolytic were administered. A craniectomy with the bone flap removed was performed and a ventriculostomy was placed to reduce swelling and intracranial pressure, also placing her at a higher risk for infection. I learned that with stroke patients, it s a "waiting game" against time, to see if they will regain any of their neurological deficits back. Although she only improved a little bit, there was still progress. My top two nursing diagnoses were Compromised/Disabled Family Coping and Impaired Cerebral Tissue Perfusion. I am very knowledgeable about interventions for both nursing diagnosis, and I was fortunate enough to observe a majority of them during L.G s care. I learned how all the systems in the body are intertwined, and if one shuts down, they all will begin to shut down. Blood pressure also plays in important role in intracranial hemorrhages. It must be maintained so that the patient will not sustain another insult to the brain. Overall her family dynamics were overwhelming to the point where it became her priority nursing diagnosis. The interventions that were used during my clinical rotation will forever be embedded in me. I'm aware that the ICU is a scary place not only for the patient but the family as well. I've never seen a family so overbearing and aggressive as L.G s family. The interventions Nurse Cheryl used with this family will be embedded in my brain for a lifetime.

14 References Bell, L. (2008). Standards of care for acute and critical care nursing practice. Retrieved from rsing.pdf Crawford, A., & Harris, H. (2011). I.V. fluids: What nurses need to know. Nursing 2014,41(5), Retrieved from Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2014). Nursing care plans: Guidelines for individualizing client care across the life span. Engström, B., Uusitalo, A., & Engström, Å. (2010). Relatives involvement in nursing care: A qualitative study describing critical care nurses experiences. Intensive and Critical Care Nursing, 2011(7), 1-9. doi: /j.iccn Gulanick, M., & Myers, J. L. (2011). Nursing care plans: Diagnoses, interventions, and outcomes. St. Louis, MO: Elsevier Mosby. Ignatavicius, D. D., & Workman, M. L. (2013). Medical-surgical nursing: Patient-centered collaborative care. St. Louis: Elsevier Saunders. Malesker, M., & Hilleman, D. (2012). Intravenous labetalol compared with intravenous nicardipine in the management of hypertension in critically Ill patients. Journal of Critical Care, 27(5), 528.e7 528.e14. doi: /j.jcrc McKiernan, M., & McCarthy, G. (2010). Family members lived experience in the intensive care unit: A phemenological study. Intensive and Critical Care Nursing,26(5), doi: /j.iccn Purnell, L. D. (2009). Guide to culturally competent health care. Philadelphia: F.A. Davis Co.

15 Urden, L. D., Stacy, K. M., & Lough, M. E. (2014). Critical care nursing: Diagnosis and management. St. Louis, MO: Elsevier/Mosby.

16 Appendix

17 Honor Code We, the students of Old Dominion University, aspire to be honest and forthright in our academic endeavors. Therefore, we will practice honesty and integrity and be guided by the tenets of the Monarch Creed. We will meet the challenges to be beyond reproach in our actions and our words. We will conduct ourselves in a manner that commands the dignity and respect that we also give to others. Ashlan Brown

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