Background Information Summary
My clinical patient that I chose ,MS, a 66-year-old Female with Increased swollen extremities and altered mental status. MS had increased medical problems over the last year despite all the new medical problems, she lived alone , and was still Employed. MS has past medical history of Hypertension and a CVA in February of 2018, Electrolyte abnormality in 08/18, Paroxysmal Atrial Flutter diagnosed in 06/18, Anemia starting to progress in April of 2018, and Mixed Hyperlipidemia in December of 2016. Her problem began when family noticed she was swollen all over her body and then her her mental status began to change over several days.
MS family then called an ambulance and had her sent to Hospital #1. At the first hospital they were trying to figure out what the underlying cause for her altered mental status was. Hospital #1 treated her A Flutter in the process of figuring out what else was going on. After 2 or 3 days with no answer from hospital number one family requested she be transferred to another hospital, as Hospital number 1 was not able to treat her effectively, so she was transferred to Hospital #2,which is where I came in contact with MS.
By this time, MS had been at this current hospital for 30 days with an admitting diagnosis of Altered mental status due to swelling of all extremities, Within 24 hours diagnosis was changed to Intravascular lymphoma. MS then received an arterial line for accurate measures of blood pressure. She also got a PICC line placed for long term use of medication, Because of the lymphoma placing and IV was very difficult. She also had a feeding tube placed to help with nutritional needs. In MS case her lymphoma is intravascular causing liver and kidney dysfunction on top of her Atrial Fibrillation with RVR acting up. MS was then placed on dialysis within the first week of being at Hospital #2, three times a week. The hospital came to the conclusion that MS was now in kidney failure do to the intravascular lymphoma, cutting of blood supply to the kidneys. MS mental status would constantly change day to day and even sometimes within hours. her medical team then decided the day that i was there that it would be in her best interest to get a permanent dialysis catheter placed. The patient is on medication for her heart rate and medications to help with her stomach.
Significant assessment findings for the patient at the time of care included alert and oriented to place and situation with minimal response when speaking to her. Pulses found in upper extremities with fingers but found with a doppler for lower extremities. MS has 3+ edema in arms, legs, feet and ankles. She is weak in all extremities. Eye assessment demonstrated PERRLA. MS heart rate staying steady in the 120’s with a continuous Amnio Drip, oxygen saturation between 95-100 % on two liters via nasal cannula, and blood pressures in the rage of 140’s / 80’s . Respiration at a normal rate. When asked if in pain she would sometimes respond to the question and other times, she wouldn’t respond. Temperatures stayed in the 99 to low 100 range during the duration of my shift.
Laboratory and Diagnostic Tests
One of the first labs MS got when he arrived at current hospital was a draw of blood cultures to indicate if there is any bacteria or fungi present in the blood. We then began to draw labs daily to monitor kidney and liver function. Another laboratory test that was performed was the lactate level. This is done on patients who are critically ill or who could become more severe at any point. This lab test can indicate whether the patient is becoming septic or developing other conditions.According to MS’s nurse, blood cultures are routine in the admission process with an ICU patient, to rule out and bacterial growth that would be causing any further complications. During my clinical day we tested patients stool to see if C. diff was present, patient had loose stools and was going several times a day.
As for the arising kidney problems, a ultrasound was performed to get a better look. This was to help get a better look at the blood flow to the kidneys that has been decreased by the intravascular lymphoma . This ultrasound came with some more concerns, causing them to order a renal biopsy. Renal biopsy can help identify what type of kidney disease that MS may have developed.
Another diagnostic test that was performed on MS was a swallow study test. This test was done to see if the patient was able to eat by mouth without problems of aspiration. she was eating by feeding tube, when mental status changed MS pulled the tub out causing problem with being able to place another dobhoff. MS went almost 30 days without eating solid foods by mouth, causing the need for the study.
A CBC was also done daily to monitor liver, kidney, and HGB levels. The BUN and Creatinine are closely monitored in this this patient due to the dysfunction of the kidneys and liver. Her labs came back during my clinical day indicating that her BUN and Creatinine where both elevated. Also another alarming lab that came back was here HGB levels, MS HGB was at a 6.9, requiring a unit of blood be transfused. Due to MS mental status we have to ask her first for permission to transfuse the blood, which at that time she denied the transfusion.
The last medication that MS Receives is daily heparin Injection , given subcutaneously. Heparin is an anticoagulant drug, given to patients as a precaution, especially those that are in the hospital long term, with little to no movement. Some adverse effects that may occur while taking this drug are easy bleeding and bruising, redness or skin changes at the injection site, heparin induced thrombocytopenia, and increased liver function test results . Nursing implications: Assess and monitor for signs of bleeding or hemorrhage, Monitor APTT levels, ALT and AST. Nurse should make sure that protamine sulfate is available (Vallerand,2015). This medication was given to MS to help the reduce the risk of clot, due to muscle weakness in all extremities and non movement.
The first nursing diagnosis for MS is ineffective peripheral tissue perfusion related to impaired blood flow, as evidence by renal dysfunction (Sole,Moseley,Klein,2017). The three nursing outcomes for this nursing diagnosis are: the patient will show improvement in peripheral circulation in arms and legs, the patient renal dysfunction will improve with circulation, and the patient will respond with better mental status. Three nursing interventions related to this diagnosis are : checking capillary refill and measuring edema in each extremity every four hours, monitor renal dysfunction daily , and monitor all pulses on each extremity without having to use doppler. Collaborative interventions would include keeping the primary team updated on any changes to the patient, help with communication between different teams involved in her care, and act as the patient advocate when family isn’t available.
The second nursing intervention in MS’s plan of care is excess fluid volume related to compromised regulatory mechanism( renal failure), as evidence by peripheral edema and changes in mental status (Sole,Moseley,Klein,2017). The three nursing outcomes for this nursing diagnosis include: the patient will display stable weight, the patient will display appropriate urinary output with laboratory studies near normal, and absence of edema. The three nursing interventions for excess fluid are: the nurse will accurately record intake and output including hidden fluids ( gastrointestinal losses, wound drainage, and nasogastric) and do daily weights at the same time on the same scale. The nurse will assess areas for increased or decreased edema every 4 hours. The nurse will monitor for changes in mental status every Two hours. Collaborative interventions for excess fluid with compromised regulatory mechanism: include management of fluid volume , using the laboratory to test renal function, and each team collaborate together to monitor the health status of patient (Sole,Moseley,Klein,2017).
The last nursing diagnosis for MS is a potential risk for diagnosis. MS is at risk for infection related to immunosuppression, as evidence by vital signs (Sole,Moseley,Klein,2017). The three nursing outcomes for risk of infection : patient will remain absence of fever, redness, swelling, pain and heat. MS’s WBC, Urinalysis and cultures will remain within normal limits. Patient will be to show proper hygiene by the time of discharge. Nursing interventions for risk of infection are: monitor vital signs and temperature at least every 4 hours, Nurse will monitor lab results, and the nurse will encourage incentive spirometry and change of position every 1-2 hours. Collaborative interventions would include having protocols in place for infection, having goals established between at interdisciplinary teams and monitoring patients status frequently, and act as an advocate for patient .
Interventions – Routine Nursing Management
Since the patient’s are in ICU, we as student nurses don’t care for them independently, but with the assistant of the primary nurse and doctors. The primary concern for this patient at the time I was present, was the collaboration between teams as to what treatments they were going to tackle first, with maintaining her A-Fib at a manageable rate.
Another important nursing intervention that I helped with was the positioning of the patient since MS was weak in all extremities. MS was unable to move herself, we placed wedges under her to reduce the risk of skin breakdown and to promote some movement of blood. pressure ulcers related to skin break down are very common but are easily preventable in patients who are bed bound, as long as we are turning our patients frequently.
The most difficult nursing I encountered thus far was informing the patient of her health status, with her frequent changes in mental status. This was a very difficult because at times she was understanding what was going on and able to make her own decisions and then her status would change to where she was unable to make decisions. Another part of the agreements on treatment that was difficult was that MS son was her decision maker if she was unable, but he was not present at bedside; her sister were present most of the time and wanted to make decisions for her. During this difficult time we had to explain to the sisters that if MS was unable to make these decisions on her own, that her son was the only other one to make them. In regards to MS being able to make decisions during certain times, we gave clear instructions and reasons for interventions related to her health.
MS’s interdisciplinary team consisted of nephrology, radiology, cardiology, general ICU physician , a pharmacist, dialysis, nurses, social worker, Occupational therapy, physical therapy, speech therapy, dietician and the laboratory specialists.
Nurse’s are the main caregivers of patient, as nurses we spend the most time with them and monitor their care. The physicians involved in MS care specialize in a certain area of the body including cardiac, nephrology and radiology. Pharmacy is involved with every patient care, they verify and bring up all medications for each patient. Radiology took care of MS’s diagnostic testing of the renal biopsy and detection of the intravascular lymphoma. A dialysis nurse came to MS’s room to set up dialysis 3 time per a week, draw labs during the process and stayed with her until the dialysis was finished. Laboratory is in charge of running tests after being collected and sent down, as well as getting the results back as quick as possible. OT and PT where set up for 5x a week to work with her on regaining strength. Speech Therapy was consulted to do a swallow test periodically to see if in when she will be able to begin eating and drinking by mouth. Lastly, the social worker was consulted, in the management of care to help with the family and maintaining healthy environment to the best of abilities.
The first, therapeutic modality used in MS care was a nasal cannula for oxygen assistance. Nasal cannula don’t need much training or have special care for them. It’s a cannula that is plugged in the oxygen station on the wall and can be increased or decreased with MS oxygen stats. This product ensures that MS is maintaining adequate oxygenation.
Another therapeutic modality used in MS’s care was dialysis. she had a dialysis nurse that would come and set up the machine and continually monitor while patient was receiving dialysis treatment. Having a nurse in there at all times during therapy is very important. Traditional dialysis helps keeps the body in balance by removing waste and extra water to prevent them from building up in the body, as the kidney function can not do this on its own. Dialysis can cause a number of effect on the body, so ensuring that someone is there for immediate attention is a priority.
Lastly, the continuous vital machine is used in all ICU settings. This therapeutic modality monitors the patient’s vital signs based on the setting that you select on the screen, this is vital in the care on MS because not only does she have renal dysfunction, and lymphoma causing her blood to not be able to get to vital organs, she also has chronic A-fib which can change at any given moment. Having this machine will alarm the nurse of anything that is out of any normal range set on the machine by the nurse.
Nursing Role Reflection
The nurse is the biggest role in the communication and interaction of the patient and making sure that each part of their care teams knows everything that is going on. This is a big thing across the bored in the health care setting, especially those that are critically ill and may not be able to speak and tell them what is going on or how they are feeling at any given moment. Any change with the patient should be reports so that there is no oversight in the plan of care. The nurse is with the patient more than anyone and is usually the first one to notice changes, so its is so important to have excellent communication amongst all members.
While on the critical care unit I noticed that all physicians involved with everyday care and the nurse where all together. They were all very direct and to the point on making decisions together that best fit MS. They each communicated and put ideas together to come up with a plan each day to try and improve the health of MS. The physicians were very respectful with listening to the nurses concern and ideas that might help get her better faster. This helped me as a student nurse figure out what type of communication I want for myself and my patients when I become a nurse. This type of communication helps make things run more smooth especially during critical situations.
Each different team involved in the care of MS was great and communicated well together to come up with a treatment plan, One thing that did stand out to me as i explained before was the communication difference with her family when she was unable to make decisions on her own. This was a great learning experience on how to communicate to the family that only one person can be in charge and make decisions. When the family begins to act up it can cause a lot of problems for the interdisciplinary team and the direct impact on the care of the patient. I learned a lot from the different ways each person dealt with this communication error, but the nurse who I was working alongside with contacted the right people and handle this situation in a well manner.
My suggestion in this overall experience would be to help with identifying family needs. Identifying different way families deal with situation and who is the point of care could be very beneficial in the out come of the care that the patient is receiving. If talking to the family and getting their outlook is towards the top of the list I feel that the care can go even more smooth. As stated in the article by Schub “ The desired outcome of communicating to establish a nurse- patient relationship is improved quality of care”(Schub,2017). Communicating improves the overall care for the patient.