Case Study On Clinical Deterioration Of A 72-Year-Old Male

Principle Reason of Admission

Case study on clinical deterioration of 72-year-old male Mr Harry.
 

Demographic Information

This case study is based on clinical deterioration of 72-year-old male Mr Harry. The patient was from African background weighing 65kg and height of 165cm. The patient was an ex- smoker and is married with three children. He lived with his wife and is currently unemployed.

Principle reason of admission

The patient was presentedwith type 1 respiratory failure with septic shock secondary to whole lung right sided pneumonia and was admitted to the Intensive Care Unit.

The main issues were 1) septic shock- right lobe consolidation and hypotension

Respiratory failure- hypoxia

The patient was seen in the local clinic accompanied by his wife. Moreover, the general practitioner noted respiratory failure in the  patient. He had visited the general practitioner yesterday who ordered CXR. However, the patient called ambulance today and presented in the hospital as he wasn’t feeling well to get up of its own and have the CXR done. He was then admitted to the Emergency Department at 7 am this morning based on his referral from the local clinic. The patient was then further transferred to the ICU at 9 am this morning from the Emergency Department.

Morbidities

The patient had co-morbidities including asthma and Hypertension. 

History of present illness

The patient has been feeling unwell for the past 3 days and was unable to perform any daily activities as he was feeling extremely lethargic. The patient denied any chest pain, rhinorrhoea, and had no sick contacts.

The patient’s past social history revealed that he was an ex-smoker. However, he is non- alcoholic. He had a past medical history of polycythemia, asthma, neuropathic pain, and pancreatic cancer. Moreover, the patient is allergic to tramadol.

His physical examination findings showed that he was febrile (temperature of 38.8), had rigors, dry cough, myalgia, and exertional dyspnoea.

Current Treatment Option & Problem Resolution -

The patient’s current treatment includes the combination therapy of antibiotics of Ceftriaxone and Azithromycin (Dickinson & Kollef, 2011). The patient was also put on endotracheal intubation.

Episode of Deterioration

The condition of Mr Harry had been rapidly deteriorated after being transferred to the Intensive Care Unit from the Emergency Department.  Later in the afternoon, his vital signs were showing him hypoxic, which makes him febrile and agitated. Despite 65% FiO2 – Oxygen Saturation dropped to 84%, ABG, PaO2- 44 Normal values, and PCO2-29, which are clear signs that he is hypoxic and requires additional supplemental oxygen. He has increased use of accessory muscles and low level of consciousness (Glasgow Coma Scale 10/15).  Mr Harry’s blood pressure monitoring revealed that he was hypotensive with blood pressure of 91/55 mmhg and was below the normal range of 120/80. BP drops as condition deteriorates. The patient had mild hypothermia of 38.4 degree which is an indicator of infection .His respiratory rate of 26 breaths per minute sits him in tachypnoeic state as the normal range lies between 12-18 bpm. The patient had sinus rhythm with pulse of 128 beats per minute which showed the evidence of tachycardia. Higher heart rate and respiratory rate was clear indication of initial hypoxia. His hypoxic condition was sign of further deterioration, which may cause respiratory failure.  

Morbidities

Physical Examination diagnostic Studies 

Examination has been conducted as per Hospital protocol and noted accordingly. Upon Intensive Care Unit (ICU) admission, the patient was awake, orientated and afebrile. His vital signs included pulse rate of 76bpm, blood pressure 131/62 mmHg, and respiratory rate 24 bpm with dyspnoea. On auscultation, crackles were heard in the right lung, and oxygen saturation was 94% on Continuous Positive Air Pressure.

Abdominal examination showed no abnormalities in his abdomen.

As per doctor’s direction, Stool and urine sample has been taken and sent for testing.

Stool lose and yellowish in appearance.

Various reports based on the patient’s profile  showed signs of respiratory failure and infection as given below :-

Chest X-ray: His chest x-ray showed focal consolidation in the right lower lobe, suggestive of pneumonia.

Blood cultures: Sent for further evaluation.

Blood Test: Blood tests were obtained, which showed the increase in blood platelet count, WCC=17.4.  

His infection can be the underlying cause of fever associated with pneumonia.

Arterial Blood Gases: Showed pH of 7.2 and Pco2 of 55, which is suggestive of respiratory acidosis.

Urinalysis- 

Nursing Management

In the best interest of the patient, the patient was intubated and the endo tracheal tube was inserted into the patient. Moreover, the intubation process was being discussed, as well as, explained to his family. 

Suction will be provided twice to clear the secretion in case the patient is unable to clear his airway effectively. Endotracheal intubation was done to protect his airways as the patient was unable to maintain an open airway (Brown, 2012). Oxygen therapy was indicated and has been given to the patient as per prescription. Increased oxygen tension in the alveoli may result in more oxygen diffusion into the capillaries. Mr Harry’s body alignment has been done for the optimal respiratory excursion to promote lung expansion, as well as, to improve the air exchange. He has been re-positioned every 2 hours to facilitate secretions, movement, as well as, the drainage.

For his infection, the patient was given a combination therapy of antibiotics i.e., Ceftriaxone and Azithromycin. Moreover, Pregabalin was given to the patient for his neuropathic pain.

Pulse oximetry has been used continuously for the regular monitoring of oxygen saturation  and pulse rate. Pulse oximetry is the test used to measure the oxygen level present in the blood. Pneumonia can prevent the lungs from transferring enough of oxygen supply into the bloodstream (Swischuk, 2007). Hence, the patient will be assessed for lung sounds periodically and will listen closely for the presence of any crackles or wheezing sounds.

Special nursing care intervention is required in case of patients having chronic illnesses and in the nursing care of the patients that are admitted in the Intesive care unit. The patient must not be left without the nurse in attendance at any time during the admittance. Each member of the multidisciplinary team is responsible for monitoring the patient’s condition, as well as, the for provision of the care. Close monitoring of the symptoms should be done regularly to avoid occurring of any fatality. The provision of precise supportive care is very important and essential part in the management of the critically ill patient. Hence, the protocol of FAST HUGS was being followed in the intensive care unit, which includes the following:

Discussion

F- Feeding/fluids

A- Analgesia

S - Sedation

T- Thromboembolic Prophylaxis

H- Head of Bed elevation/Head up position. In case of intubation Head up position should be 30 degrees.

U – Ulcer prevention

G – Glycemic control

S – Spontaneous Breathing Trial or other ventilator separating strategy.

Further, in addition to the FAST HUGS, following parameters were considered in the patient. These are:

Indwelling catheter

Nasogastric tube

Bowel cares

Environment (like maintenance of temperature control, as well as, appropriate surroundings maintenance)

De-escalation (For e.g. treatments that are no longer required)

Psychosocial support (for patient, family, as well as, the staff) (Vincent & Hatton, 2009).

Holistic care: It is an integrated approach to one’s health care and focus on treating the "whole" person, and not only the symptoms, as well as, the disease. Moreover, the patients are not the passive recipients of the health care. Hence, Mr Harry was encouraged to become responsible for the daily care of his health through maintaining his diet, exercise, attitudes, as well as, his lifestyle contributing towards his wellness. During the patient’s health care following interventions was followed:

CNS:  Propofol was used as a sedative to make the patient comfortable, reduce oxygen demand, as well as, to ensure patient safety (Ruokonen et al., 2009).

Fentanyl was also administered to the patient as an analgesic to alleviate the patient’s pain (Minami et al., 2009).

For Sepsis antibiotics was given.

CVS: Noradrenaline was given to the patient to treat his low blood pressure.

Propofol is used to lower the blood pressure as it is the related side-effect of Propofol (Marik, 2004).

Respiratory: Endotracheal tube was intubated.

Skin: Clexane was given as a prophylactic agent.

Non- invasive CPAP: The benefits of non-invasive ventilation appears to be the consequence of avoiding tracheal intubation and the associated morbidity and mortality. Morbidity includes an increased risk for ventilator-associated pneumonia (VAP), ventilator-induced lung injury, increased needs of sedation that contribute to prolonged ventilation, and complications of the upper airway related with prolonged translaryngeal intubation (Ferrer, Cosentini, & Nava, 2012).

Our protocol of intermittent noninvasive ventilation resulted in significan higher rates of improvement in the abnormalities of gas exchange as compared to the standard treatment. Mechanisms of improvement may include the beneficial effects of PEEP on the redistribution of extravascular fluid, on alveolar recruitment, and in treating atelectasis at an early stage and the ability of pressure support to reduce the work of breathing (Ferrer et al., 2012). It may also help in maintaining the tidal volume, which is compatible with the adequate alveolar ventilation. Reducing the work of breathing during noninvasive-ventilation sessions may also allow respiratory muscles to regain efficiency. Moreover, High Flow Nasal Prongs was also used to give patient the break from the treatment. Further, ventilation delivered through a face mask can improve the pathophysiological manifestations of hypoxemic respiratory failure (Keenan et al., 2011).

The nursing plan’s main objective was to monitor the presence of shortness of breath if any, respiratory rate, blood pressure, as well as, heart rate in the patient based on the evidence discussed above. The patient’s respiratory rate was 37bpm, heart rate was 140, and blood pressure was 90/30 mmHg. The plan of care was followed in an appropriate way to provide the best and effective care to the patient. The regular report of the patient was obtained and maintained from the registered nurse. Medication administration record, as well as, chart was regularly reviewed. The patient’s daily care plan was always updated on the daily basis. In assistance with other team members involved in the provision of health care to the patient, proper adminsteration of the medications, as well as, its associated side-effects were evaluated periodically. 

History of Present Illness

Conclusion:

The need of effective communication within the multidisciplinary team is very important for providing benefits to the patient’s care. Relevant information was clearly communicated amongst all the members of the teams. The clear and relevant information regarding the problem and the intervention was being discussed with the patient and his family for better understanding of the treatment (Featherstone & Krist, 2016). Moreover, all the necessary, as well as, timely information related to his vital signs was provided to the senior practitioners for better and effective management of the patient. Any abnormality observed in the patient’s vital signs whether it is blood pressure or respiratory rate was immediately informed to the higher authrorities and necessary steps were taken to bring them back to the normal range. We used the multidisciplinary team approach to implement the medical care protocol to its maximum, including adjustment of various medications, as well as, outpatient pulmonary rehabilitation treatment necessary for the patient. Nutritional, as well as, psychological counseling was also provided as needed associated with the holistic care provided to the patient.

It is important and necessary to acknowledge that both the person, as well as, the family-centred care should be focused on the whole individual as a unique personality and not just on the basis of the patient’s illness or ailments. In viewing the patient through this lens, all the health-care providers are able to know, as well as, understand the life story of the patient, his experience related to the health, the role of family played in the patient’s life, as well as, the role they have to play in supporting the patient to achieve his/her health ("The Future of Nursing and Holistic Care", 2011). Multidisciplinary approach, as well as, holistic health care is very important in the present times. The team should work in collaboration with each other and should discuss and provide all the relevant information related to the patient for better care and management. The practice of holistic nursing is very important as the goal of this approach is to heal the individual as a whole and not just his symptoms and diseases (Sampalli, 2008).  

References

Brown, T. (2012). Endotracheal tubes and intubation. Pediatric Anesthesia, no-no.

Dickinson, J. D., & Kollef, M. H. (2011). Early and adequate antibiotic therapy in the treatment of severe sepsis and septic shock. Current infectious disease reports, 13(5), 399-405.

Featherstone, C. & Krist, N. (2016). A Multidisciplinary Approach to Improving Communication Across the Care Continuum. Biology Of Blood And Marrow Transplantation, 22(3), S439-S440.

Ferrer, M., Cosentini, R., & Nava, S. (2012). The use of non-invasive ventilation during acute respiratory failure due to pneumonia. European Journal of Internal Medicine, 23(5), 420-428.

Keenan, S. P., Sinuff, T., Burns, K. E., Muscedere, J., Kutsogiannis, J., Mehta, S., . . . Hand, L. (2011). Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. Canadian Medical Association Journal, 183(3), E195-E214.

Marik, P. (2004). Propofol: Therapeutic Indications and Side-Effects. CPD, 10(29), 3639-3649.

Ruokonen, E., Parviainen, I., Jakob, S. M., Nunes, S., Kaukonen, M., Shepherd, S. T., . . . Takala, J. (2009). Dexmedetomidine versus propofol/midazolam for long-term sedation during mechanical ventilation. Intensive care medicine, 35(2), 282-290.

Sampalli, T. (2008). Measuring health outcomes of a multidisciplinary care approach in individuals with chronic environmental conditions using an abbreviated symptoms questionnaire. Journal Of Multidisciplinary Healthcare, 97.

Swischuk, L. (2007). Respiratory Symptoms, Pneumonia, What Is the Organism?. Pediatric Emergency Care, 23(9), 676-677.

The Future of Nursing and Holistic Care. (2011). Holistic Nursing Practice, 25(2), 57.

Vincent, W. & Hatton, K. (2009). Critically ill patients need “FAST HUGS BID” (an updated mnemonic). Critical Care Medicine, 37(7), 2326-2327.