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NUR443 Evidence Based Nursing Research And Practice

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Case Study

Joseph Russo was born on the 7th of July 1950 in Manarola, Italy. The youngest of six children, Joseph described his upbringing as ideal and he was very close to his parents and enjoyed school. At the age of 17, Joseph met Sophia and they married a year later. Joseph’s father encouraged him to move to Australia to work for his uncle who had emigrated 20 years previously.

Although somewhat reluctant, Joseph thought Australia sounded exciting and thought it would be a great start for both he and Sophia. Sophia was not as keen to move but wanted to do what would make Joseph happy.

They arrived in Australia in 1970 and were excited to find they were expecting their first child (Antonio was born in 1971, followed by a daughter Emma in 1972).  Joseph was overjoyed to be a father and while still working for his Uncle started to explore the idea of starting his own smallgoods business. This happened quite quickly when a nearby shop became vacant.  Joseph wanted to work close to home as he was worried about Sophia, since arriving in Australia she had only made a few friends in the Italian community and only spoke one or two words of English. Joseph tried to encourage her to learn English but each time she became frustrated.  Joseph recalls that Sophia cried frequently after the children were born - he felt it was because she was homesick.

While he was concerned about his wife, he felt that they needed to remain in Australia as his small business was becoming hugely successful, customers would travel long distances to buy his smallgoods. He worked hard, sometimes over 80 hours per week. He was well known in the community as a happy, hard-working and very likable man. His hospitality was well known and the family home was host to many memorable events and parties. Sophia was an excellent cook and no-one ever went hungry, although she preferred to stay in the kitchen cooking and washing up, while  Joseph entertained the guests with his stories and singing.

Sophia discovered in 1979 that she was pregnant again, although shocked she was excited; however the baby boy was stillborn at full term. Sophia felt deep sadness and a sense of failure, she lost her appetite (and as a result lost a significant amount of weight) and started smoking heavily (60 cigarettes per day). She rarely left the house.  Joseph said little and instead worked harder and spent the remainder of his time in his shed, working on old cars.

In 1990 after dropping out of university Antonio decided to work for his father – for Joseph  this was a defining moment as he now had a family business – this had been his dream and to celebrate he had the front of the shop repainted with “Russo & Son Family Butchery”.  Joseph was content and his daughter completed her education and was awarded a Bachelor of Science and worked for a number of years as a research assistant. Emma started a family with her partner Steven. Emma gave birth to Thomas in 2006 and started to notice he was ‘different to other children’ at around the age of two. Thomas was diagnosed with ASD. Steven left shortly after his diagnosis and returned to work in the west.

Joseph subdivided his very large block and built a house for Emma and Thomas next door. It was around this time that Sophia’s health started to deteriorate.  Joseph spent more time at home helping both Sophia and Emma. Antonio took over the running of the business and convinced his father to expand the business by buying second shop.  Joseph was incredibly proud and told everyone what a good business head his son had. However,  Joseph was unaware that Antonio had a gambling problem and was taking large sums of money from the business. In 2008 during the global financial crisis, Antonio left Australia and  Joseph and Sophia have not heard from him despite their efforts to trace and contact him. Due to the debts that Antonio accumulated in Joseph’s name, he lost the business and almost lost his family home.

Joseph now cares for Sophia full-time, she has COPD and heart failure.  Joseph now cooks, cleans and provides Sophia’s personal care. He has declined all offers of assistance from healthcare providers, family and friends, as it is “his job to care for his wife not a stranger”.  Joseph had planned a retirement in which they could both travel and enjoy their children and grandchildren –  Joseph had saved hard for retirement but the debts from the business took all of their savings and they now rely solely on the pension. Sophia has not left the house in over a year. The financial struggles, losing contact with his son and caring for his wife have taken an emotional toll on Joseph.

In June of this year, Emma saw the lights on in her father’s shed and thought she would go and have a chat as her father seemed quite down in the past few months. As she approached the shed she saw him sitting in his beloved 1962 EJ Holden, at first she thought he was sleeping but something didn’t seem right, when she opened the car door she found Joseph unresponsive and ran inside to call 000.

When the ambulance arrived,  Joseph was not responsive. He wasn't breathing but the ambulance officers could feel a faint carotid pulse. They inserted an oropharyngeal airway, intravenous (IV) cannula and provided ventilation with bag/valve/mask using 100% oxygen. 

The ambulance officers reassured Emma who was distraught after finding her beloved father in such a terrible state. After calling the ambulance, she had turned off the engine and pulled her dad out of the car toward fresh air – this was a difficult task as Joseph is 171 cms tall and weighs 89kgs. Emma kept saying ‘I didn’t know what to do? How could I have saved him?’ They asked Emma to travel to the hospital with them, but she declined, as she was worried about who would look after her mum and son Thomas.

On arrival at the Emergency Department (ED),  Joseph remained unconscious and was not breathing spontaneously. The ED Registrar, Dr Jaram, intubated Joseph so he could be mechanically ventilated. He was hypotensive despite 1.5 Litres of IV crystalloid, so an infusion of IV metaraminol was commenced with an aim of increasing his Mean arterial pressure greater than 65mm Hg. Joseph’s hypotension continued to be an issue, so Dr Jaram inserted a three lumen central venous catheter into Joseph ’s right subclavian vein using surgical aseptic nontouch technique (ANTT). Inotropes in the form of IV noradrenaline was commenced and titrated to maintain MAP > 65.  Joseph was transferred to the intensive care unit for ongoing care and close monitoring.

Emma arrived at the ED to see her father and was directed to the ICU. She was terribly frightened about how her father would be when she arrived. When she got the ICU, staff asked her to stay in the waiting room until  Joseph was ready for visitors. It was over an hour before the nurse came to get her and during this time, Emma imagined terrible things that could be happening to her dad. She felt guilty for worrying how she was going to manage without Joseph in her life. Her mum Sophia’s health was worsening and she relied heavily on Joseph for all of her personal care and management of her medications. Emma’s son Thomas is now 12 and becoming increasingly challenging in terms of behaviours related to his ASD. Since her partner left, Emma has managed everything by herself, and it was becoming increasingly challenging to juggle the responsibilities of work, her son, her home and her parents alone. She felt so guilty that her dad had come to this desperate state and she had not recognised it.

When Emma finally walked into her father’s ICU room, she saw a pale, frail man who was attached to a breathing machine which made his chest rise and fall at a strangely regular rate. There were tubes everywhere, which were attached to machines delivering medications and a tube down his nose which delivered nutrition to his stomach. The intensive care specialist Dr Prince, spoke to Emma about Joseph’s situation. She said that Joseph was stable at the moment but he wasn’t breathing on his own and medications were keeping his blood pressure up. Dr Prince explained that they didn’t know how long Joseph had been exposed to the carbon monoxide from the car which can cause damage to the brain, and they would need to wait and see if Joseph gained consciousness over the next 24 hours.

Emma had to return home to her mother and son who were being cared for by a neighbour. She wished she could contact her brother Antonio. Despite everything he had done, he was still her brother and she desperately wanted to share the current pressures and responsibilities.

On day two, Joseph had not regained consciousness.  He was not opening his eyes, although he was moving his limbs spontaneously but not with any purpose. Joseph ’s temperature was documented at 38.8 degrees Celsius, with an increased heart rate and he remained hypotensive. On assessment, the insertion site of his CVC was very red and warm.  No other site of infection was found so a diagnosis of Central Line Associated Bloodstream Infection (CLABSI) was made. A swab was taken from the site as well as peripheral and central blood cultures. A new CVC was inserted into the Left internal jugular vein under strict surgical ANTT and the suspected source of the infection, the original CVC was removed. Broad spectrum IV antibiotics were commenced and then changed when sensitivities were available.

On day four, Joseph regained consciousness. He opened his eyes to voice, responded to requests to move his arms/legs appropriately. He had reduced limb strength but there was equal and purposeful movements.  Joseph was weaned from the ventilator and extubated. Nasal prong oxygen was administered to maintain SPO2 > 93%. Joseph’s blood pressure continued to be reliant on inotropes, so he remained in the ICU. Emma was relieved her dad didn’t seem to have brain damage. She tried to talk to her father about what had happened but he refused and would avoid eye contact whenever she brought the subject up. He did not ask how Sophia was, which surprised Emma.

On the evening of day five, Joseph suddenly became agitated and restless and persistently tried to remove tubes and lines. When he wasn’t demonstrating this behaviour, he appeared withdrawn, apathetic, avoiding conversations and eye contact. Nursing staff suspected he was experiencing delirium, and implemented non-pharmacological protocols in an attempt to reassure Joseph and re-orientate to the environment. Interventions included encouraging communication and repeated reorientation, ensuring visible daylight, consistency of nursing staff, mobilisation activities and range of motion exercises. When Emma visited  Joseph in the morning, she was very distressed, thinking that Joseph had terrible brain damage. Nursing and medical staff reassured Emma and informed her of the strategies they were putting in place to support him during this period of delirium. During this period, Joseph's CVC became occluded, this was managed without having to remove the CVC.

On day eight, Joseph was no longer reliant on inotropes and was mentally alert and orientated. He transferred to the medical ward to continue IV antibiotics and follow up with the psychiatric team. On admission to the medical ward staff noted an intact fluid filled blister on Joseph 's left heel, measuring 3 cm by 3 cm.   

Five days later, Emma met with the Psychiatrist and Joseph’s physician who informed her that Joseph was ready for discharge.  Joseph was keen to be discharged from hospital however he refused to participate in any discussions around residential care for either Sophia or himself. Emma wanted her father to return home but acknowledged that additional services were required and Joseph agreed to this request. Joseph's CVC line was removed prior to discharge.

The insertion of a central venous access device (CVAD) was an essential component of care for Joseph Russo, however the rate of complications is high. In this assessment task, you will undertake a review of the literature to explore and critique the evidence-base surrounding this

aspect of care and argue what is considered best practice. Your essay will need to address the following specific complications experienced by Mr. Russo:

  • CVAD (central venous access device) associated bloodstream infection

– how could this have been prevented?

  • Occlusion – how could this have been prevented? And now it has

occurred, how could it be best managed

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