N 375
Case Study/ Respiratory Disorder
G.M, a 68-year-old CPA was involved in a motor vehicle accident; an on-coming car
drifted left of center and struck G.M. head on, pinning her behind the steering wheel. She
was extricated then transported to your trauma center. Her injuries were found to be
extensive: bilateral flail chest, right hemo/pneumothorax, fractured spleen, multiple small
liver lacerations, compound fracture of the right ankle, and probable cardiac contusion.
She was intubated on arrival to the ED and emergently she was taken to the OR. During
surgery she received 36 units of PRC (packed red cells), 20 units of platelets, 20 units
cryoprecipitate, 12 units FFP (fresh frozen plasma), and 18L of LR. A chest tube was
placed in her right lung, splenectomy was done and repair of her liver laceration. She was
admitted to the trauma ICU post-op. The plan at that time was to bring the patient back to
the OR to stabilize the ankle fracture in a day or two when the patient is
hemodynamically stable.
Discuss the legal implications of consent when this patient was brought in to the
hospital requiring immediate OR care? What is the nurse’s role in the pre-op care
of this patient?
Hinkle and Cheever Med Surg book
1. Because the patient is unconscious, informed consent and past medical history
would be obtained from a family member if possible. If next of kin could not be
reached with great effort, the surgeon may operate in order to save the patient’s life
without informed consent. THE GOOD SAMARITAN LAW
2. In the pre-op care of this patient, the nurse will obtain past medical information and
allergies from their family if possible. The nurse will do a quick pre-op assessment
when the patient first arrives to the ED and identify all sites of injury from the
trauma that has occurred. The nurse is also responsible for monitoring the patient’s
vital signs continuously. LARGE BORE CATHETER AND TWO LINES
Discuss the nursing considerations related to the emergent transfusions of this
patient?
Hinkle and Cheever Med Surg book
1. The nurse should already be familiar with the implications of administering
blood products. The patient’s blood should be cross-matched and typed,
consent should be obtained (if possible, this is a life-saving measure), two
nurses must ensure compatibility before administration, identify the patient,
examine the blood, and monitor the patient for adverse reactions. Vital signs
will be assessed frequently, especially because of the emergent situation.
UNIVERSAL DONOR O-, NO DEXTROSE CAUSES HEMOLYSIS, USE
LARGE BORE CATHETER, SAVE SUPPLIES, ALWAYS
ADMINISTER WITHIN 4 HOURS
Post-operatively G.M. was moved to the Trauma ICU. G.M. is on ventilator support,
assist-controlled ventilation, at 21 breaths/minute with PEEP of 8 cm H2O. Your
assessment in the ICU, approximately 12 hours since the MVA, reveals that she is
exhibiting restlessness, dyspnea, and tachypnea; her respiratory rate is 32/min. Her lung
sounds are clear with no crackles or wheezes. BP is 100/60. Temp is 101.1° F (38.4°C).
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Her chest x-ray is normal. Her body weight is 150 lbs. 68.2 kg.
As the day progresses she becomes difficult to ventilate, her heart rate is 76 beats/minute,
cardiac index is 2.3, central venous pressure is 14 mm Hg.
Review arterial gases and additional data below:
ABG’s: pH 7.30, PaO2 of 68 mm Hg, PaCo2 46, HCO3 26 mEq/L and O2 saturation of
95.5%.
HGb: 7.8
HCT: 30 WBC 28
K: 6.0 mEq/L
Vitals: BP 100/60 HR 108 RR 32
What are your immediate impressions of her respiratory presentation? How will
you address her nursing care goals at this time?
Describe your priority nursing interventions for this patient?
Hinkle and Cheever Med Surg book
1. My immediate impression of her respiratory presentation is that she may be in pain.
Increased respirations and heart rate are normal responses to pain. Additionally, she is
restless and short of breath, which are also normal pain responses.
2. At this time, I will address her nursing care goals by assessing her pain using the
CPOT (critical care pain observation tool) because the patient is intubated and unable
to express herself verbally.
3. My priority intervention will be to assess her pain and administer pain medication as
ordered. Then, I would reassess her vital signs 30 minutes-1 hour after the medication
administration.
Explain your concerns about the presenting conditions of this patient?
No source used, just my brain
1. I believe this patient is in pain, which is not conducive to healing and maintaining
stable vital signs. I am concerned that this patient is taking shallow breaths as she is
tachypneic. Her ABG’s show she is experiencing respiratory acidosis with no
compensation, and I believe this is because she is not blowing off enough CO2 with
her shallow breaths. Additionally, full respirations are important after surgery to
prevent pneumonia. I am hopeful that after administering the appropriate pain relief,
she will be easier to ventilate, and her care plan may be resumed. I am also
concerned that her potassium is elevated and could be contributing to her increased
heart rate, so administration of a diuretic (such as furosemide) would likely be
included in her plan of care and of urgent concern. SOMETIMES PEOPLE
GETTING TRANSFUSIONS TEND TO HAVE A HIGHER POTASSIUM
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Discuss the hemodynamic effects you will assess related to this patient receiving
mechanical ventilation?
Hinkle and Cheever Med Surg book
1. Assist control ventilation is a common method of mechanical ventilation in
the ICU. It is a volume-cycled mode of ventilation that works by setting a
fixed tidal volume that the ventilator will deliver at set intervals of time or
when the patient initiates a breath (usually 12 to 16 breaths/min). The SpO2
should be greater than 92%. Peak inspiratory pressure (PIP) should be 15 to
20 cm H2O (this increases if there is increased airway resistance). A 2 cm
H2O inspiratory force should trigger the ventilator. CARDIAC OUTPUT IS
DECREASED DUE TO THE PRESSURE OF THE VENT – COULD LEAD
TO HEART FAILURE. COULD DEVELOP SPONTANEOUS
PNEUMOTHORAX.
What ECG effects might be observed in the presence of hypoxemia in this patient?
https://pubmed.ncbi.nlm.nih.gov/25561515/#:~:text=The%20amplitudes%20of%20the%2
0R,II%2C%20V5%2C%20and%20V6.
1. Decreased ST segment would be shown on an ECG in the presence of hypoxemia in
this patient. PEAKED T WAVES
The patient is currently receiving mechanical ventilation. What are your impressions
related to the finding that G.M. is becoming increasingly more difficult to ventilate?
What medication/ intervention(s) would you suggest to help with the ventilation of this
patient, particularly in view of the increased agitation?
Hinkle and Cheever Med Surg book
1. I would suggest pain relief, if pain is causing the patient’s discomfort. If the patient is
determined to not be in pain, I would suggest Versed (midazolam) intravenously which is a
benzodiazepine. That would induce sleepiness, decrease anxiety, and cause a loss of ability to
create new memories.
G.M.’s husband has come to the ICU to visit. He has provided some additional details
about what happened to G.M. What information might be helpful to you, in
determining if there are any underlying risk factors that may be contributing to
G.M.’s presenting problems?
No source used
1. Does G.M. have a history of asthma, COPD, cigarette smoking, or drug use? What
medications, if any, does she take? Does she have any allergies to medications?
DETERMINE BASELINE, ADVANCED DIRECTIVE, DURABLE POWER OF
ATTORNEY
The following day, G.M’s respiratory status continues to decline despite increasing FIO2
levels, PEEP increased to 10 and a change in mode of ventilation to pressure-controlled
ventilation. Her symptoms of respiratory distress continue to increase in severity. She
now has developed cyanosis and coarse bilateral crackles which are heard on auscultation
of the lungs. Chest x-ray shows patchy bilateral alveolar infiltrates in the dependent lung
fields. A dry cough is present at this time. ABGs show a decreased SaO2, and increasing
metabolic acidosis. Her heart rate is currently 108 and she has a low pulmonary artery
wedge pressure. She is agitated and restless. Temp is 101.1° F.
Discuss the significance of these assessment findings.
Hinkle and Cheever Med Surg book
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1. The patient’s condition is deteriorating. It is possible that she is developing a lung
infection due to the increase in temperature and fluid buildup in the lungs as
evidence by bilateral crackles. A risk factor being intubated is ventilator-associated
pneumonia (VAP).
The nurse hears in report that this patient had been agitated and pulling on the ET
despite continued sedation. Restraints have been recently ordered and placed on the
patient, but she continues to move her head and chew at the tube. The nurse
realizes that dislodgment of the ET may be a concern due to this agitation.
What does the nurse do to ensure proper placement of the ET tube?
What medications will be important at this time to prevent G.M.’s attempts at
breathing and dysynchrony with the ventilator?
Hinkle and Cheever Med Surg book
1. To ensure proper placement of the ET tube, the nurse would check end-tidal
carbon dioxide levels. IF IT WAS IN THE STOMACH, CO2 WOULD NOT
BE DETECTED, also portable chest x-ray, lip line marking
2. At this time, it would be important to administer medication that sedates G.M.
to prevent her attempts at breathing. A medication such as versed (midazolam)
or propofol (diprivan) will likely be used.
You call the physician and inform her that the patient is very agitated and pulling at the
ET tube. The doctor orders state: Diprivan 5 mcg/kg/min for the first 5 minutes, then
increase by increments of 5-10mcg/kg/min over 15 minutes until the desired clinical
effect is reached. Maintain at 50 mcg/kg/min IV- 100 mcg/kg/min as necessary for
sedation.
Describe the use of this medication, dosing as ordered, and precautions for the use
of this drug. How will you achieve “the desired effect”?
Lippincott Advisor (drug info included in Hinkle and Cheever resources)
1. This medication is commonly used to sedate patients in the ICU who are intubated.
The therapeutic class is hypnotics and the pharmacologic class is phenol
derivatives. The dosing as ordered is incorrect. You would administer the initial
dose as ordered, however the maintenance rate should be 5 to 50 mcg/kg/min with
a maximum dosage of 4mg/kg/hour unless the benefits outweigh the risks. Adverse
reactions to the drug include bradycardia, apnea, and respiratory acidosis. Nursing
considerations include, continuously monitoring vital signs, urine may turn green if
used for prolonged sedation, and stop gradually to prevent abrupt awakening and
increased agitation. The “desired effect” will be achieved when the patient relaxes,
stops pulling at the ET tube, and falls asleep.
In addition to frequent position changes, what positioning of this patient will be
important to prevent and reverse atelectasis and facilitate removal of secretions
from the airways?
Hinkle and Cheever Med Surg book + Trends in Caring for the ARDS Patient Article
1. The patient should lie prone and on both their left and right sides to facilitate removal
of secretions from the airway. Gravity can even assist by placing the head of the bed
lower than the body to help loosen secretions. Placing the patient in the prone position
will improve oxygenation.
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What diagnostic test will continue to be necessary at least daily to continue to
evaluate the patient’s condition?
Hinkle and Cheever Med Surg book
1. It would be important to monitor the patient’s ABGs daily. MAYBE CHEST X-RAY,
MAYBE ECG, MAYBE SPUTUM CULTURE, BASIC SMA PANEL?, WBC’S
H&H
What have you determined is this patient’s current diagnosis?
Hinkle and Cheever Med Surg book
1. I believe the patient has acute respiratory distress syndrome (ARDS).
Identify the factors/hallmarks of this diagnosis? What are the most important
criteria in determining her current diagnosis? Describe her clinical presentation and
diagnostic evidence of ARDS?
Hinkle and Cheever Med Surg book
1. Hallmarks of this diagnosis include a rapid onset of severe dyspnea that usually
occurs less than 72 hours after the precipitating event (MVA). Arterial hypoxemia
that does not respond to supplemental oxygen is characteristic. Findings on chest xray are similar to those seen with cardiogenic pulmonary edema and are visible as
bilateral infiltrates that quickly worsen.
2. The most important criteria in determining her current diagnosis is persistent
hypoxemia, bilateral infiltrates, and crackles bilaterally.
3. The patient’s clinical presentation is consistent with the findings of ARDS. She has
persistent hypoxemia that does not respond to supplemental oxygen, cyanosis,
bilateral crackles, patchy, bilateral infiltrates, and rapid-worsening condition.
Analyze the risk factors associated with her MVA and emergency care that may
have contributed to G.M.’s development of this syndrome?
Hinkle and Cheever Med Surg book
1. Risk factors that lead to this patient’s development of ARDS include trauma,
massive transfusions, and shock.
Update: G.M. has been in the ICU now for the past three days. G.M. continues to run a
temp, which you currently assess at, 102.8° F. Cultures are sent and new medication
orders have been written by the physician. She appears less responsive which may be
related to sedation which was required to maintain adequate ventilation. How will you
assess this finding? She has worsening hypoxemia, decreased lung volumes. Her
hemodynamic assessment is becoming increasingly worse. You notice that she has
generalized edema, worsening hypoxemia, and decreased gut motility.
Hinkle and Cheever Med Surg book
1. This finding may be assessed by slowly reducing the dose of propofol that is being
administered. If she appears more responsive, then we would know the sedation is
related to the medication. ASSESS WITH GCS
There are several considerations for this patient that you prepared to discuss with
the physician as you re-evaluate the goals of care. Discuss your concerns related to
the age of G.M.
https://www.frontiersin.org/articles/10.3389/fmed.2020.589553/full
1. G.M. is 68 years old, which places her in the geriatric category. There are many
concerns regarding this patient, but due to her age I am mostly worried about her
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ability to recover. Her lungs have naturally decreased in function and elasticity, and
have impaired regenerative abilities.
As the nurse responsible for the care of this patient, what medications will you
expect the physician to order to respond to the acute needs of this patient?
Hinkle and Cheever Med Surg book + Trends in Caring for ARDS Patients
Article
1. I anticipate the physician will order acetaminophen to reduce the patient’s fever.
Additionally, I believe IV antibiotics will be ordered. IV furosemide will assist in
reducing the generalized edema. I believe the propofol dose will be decreased as
well. Additionally, a vasopressor may be included in the orders to induce
vasoconstriction and elevate mean arterial pressure. Lastly, I expect the physician to
order a corticosteroid to decrease inflammation in the lungs.
There is a progression in the pathological changes associated with ARDS. Discuss
the current stage that G.M. is in and provide the key pathological evidence/data that
supports your impression. What are the priorities in the management of this patient
at this time? What do you feel is G.M.’s prognosis at this time? Provide evidence
that supports your impression.
https://www.ncbi.nlm.nih.gov/books/NBK538311/
1. I believe G.M. is currently in the exudative stage. It has been 3 days since the
accident, which is consistent with the exudative phase, that occurs over the first 7 to
10 days. The inflammatory response has caused the patient to accumulate fluid in her
lungs (bilateral crackles) and is beginning to damage her alveoli. This has resulted in
her worsening condition, as it has been becoming increasingly difficult to ventilate
her.
2. At this time, maintaining her airway, breathing, and circulation remains priority. It is
important to continuously monitor the patient with frequent VS checks. Additionally,
it is important to ensure her ventilator settings are appropriate. The patient will
continue to be turned frequently, especially to the prone position which will help to
reduce fluid buildup in her lungs and promote drainage.
3. I feel that her prognosis is hopeful. I believe in the saying, “you get worse before you
get better,” and I think she is going to get better. I believe increasing her sedation was
important to promote rest and allow the ventilator to take some of the stress off her
body by breathing for her. By treating her symptoms, she will likely be able to
recover.
While (you) the nurse are caring for this patient on a mechanical ventilator, you
hear G.S. making noises that sound like she is talking. What is your priority action?
What is this indicative of?
Hinkle and Cheever Med Surg book
1. My priority action is to assess the patient.
2. This may be indicative that the patient is “fighting” the ventilator and likely needs
medication to help reduce her anxiety and relax her. She also may be trying to breath
spontaneously. ATMOSPHERIC AIR IS GETTING TO THE VOCAL CORDS,
THE CUFF IS DEFLATED, ADD AIR TO THE CUFF AFTER ANALYZING
CUFF PRESSURE
Later you hear the ventilator alarm that signals the ventilator is not able to give the
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patient a breath (high pressure). What are the possible reasons that would trigger
this alarm to go off in this particular patient? (Discuss giving consideration to the
patient’s diagnosis.
Hinkle and Cheever Med Surg book
1. Reasons for a high-pressure alarm:
-
Coughing or plugged airway tube (suction airway for secretions; empty
condensation fluid from circuit)
-
Patient “fighting” ventilator (adjust sensitivity; consider administering sedatives as
prescribed)
-
Decreasing lung compliance (manually ventilate patient, assess for hypoxia or
bronchospasm, check ABGs, sedate only if necessary)
-
Tubing kinked (check tubing; reposition patient; notify provider)
-
Atelectasis or bronchospasm (clear secretions)
I believe the plugged airway tube due to excessive secretions and decreasing lung
compliance are the most likely reasons for the alarm. Her worsening hypoxemia is
consistent with these reasons.
LOW PRESSURE ALARM MEANS MACHINE IS MALFUNCTIONING AND CAN’T
DO WHAT IT IS SUPPOSED TO
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You have been asked to administer 80 mg of furosemide IVP after reporting that G.M.
has bilateral crackles. Why is this medication indicated? What are the nursing
considerations for giving this drug IVP? What effect if any will furosemide have on
the clinical presentation of G.S.? Are there any lab values that concern you in light
of the fact that you are about to administer furosemide?
Lippincott Advisor
1. This medication is indicated due to the patient’s generalized edema.
2. Furosemide IVP must be given over 1-2 minutes. This dose appears high for an initial
dose so her response must be monitored. 80 MG OVER 4 MINUTES UNDILUTED
3. The furosemide should reduce the patient’s bilateral lung crackles and generalized
edema. This will likely improve her breathing after taking effect, because fluid in the
lungs is abnormal.
4. Of the most concern, G.M.’s potassium value is low (normal range 3.5-5), and she
will need a potassium supplement because furosemide is a loop diuretic. The patient’s
calcium is low (normal 8.5-10) and she will need a calcium supplement as more
calcium will be lost through her urine. Additionally, her creatinine is high (normal is
0.5-1), and her BUN (normal is 6 to 24) which indicates poor kidney function. This is
important because she will be excreting fluid with impaired kidneys.
The current laboratory values are as follows: Na 129 mmol/L, K3.0 mmol/L, Cl 92
mmol/L, HCO3 26 mmol/ L, BUN 37 mg/dl, creatinine 2 mg/dl, glucose 128 mg/dl,
calcium 7.1 mg/dl, ABGs on FIO2 /50%: pH 7.38, PaCO2 49 mm Hg, PaO2, 90 mm Hg,
HCO3 36 mmol/L, BE =2.2, SaO2 88%.
What any nursing action if any, should be taken before administering the
furosemide and why?
Lippincott Advisor
1. The patient’s BP, pulse, and weight should be monitored. The patient’s
BP and HR can decrease after the fluid is pulled from the body as a result
of decreased volume. The weight will indicate the effectiveness of the
fluid being excreted. Monitor I&O’s (looking for urine retention or
dehydration). The patient’s lab values (electrolytes, BUN, creatinine)
should be monitored before and after medication. Assess for signs of
hypokalemia because furosemide is a loop diuretic that does NOT spare
potassium.
The physician prescribes the following: Draw STAT Mg level; if below 1.4 mg/dl, give
MgSO4 3Grams in 100 ml D5W over 4 hours, administer KCL 40 mEq in 100 ml D5W
IVPB over 1 hour; and give CaCl2 grams in 100 ml D5W IVPB over 3 hrs. The
laboratory is called to draw a STAT Mg. level.
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Knowing that KCL and CaCL are compatible, would you mix them in the same bag
of D5W? State your rationale (why or why not)?
Lippincott Advisor
1. I would not mix them in the same bag. Both drugs are very irritating and need to be
properly diluted to ensure safety. RUN OVER DIFFERENT TIMES
Discuss safe administration of IV KCL and CaCL?
Lippincott Advisor
1. IV KCL should NEVER be IVP or IM, only by slow and diluted infusion. It should only be
used when oral replacement is not feasible or when hypokalemia is life-threatening. If
burning occurs, decrease the rate. It is also important that the access is intact and properly
placed, the drug is irritating.
2. IV CaCL should only be administered IV and diluted.
What additional nursing action is necessary?
Lippincott Advisor
1. Monitor ECG when giving calcium IV.
What additional bloodwork should be ordered?
1. It would be beneficial to obtain a CBC w/ differential for this patient to determine if an
infection is present and to monitor her hemoglobin.
What clinical implications may be anticipated based on these current laboratory
findings?
Trends In Caring for ARDS Patients Article
1. Based on these lab findings, the patient is deteriorating in condition. Her ABGs
show an increase of 10 mmol/L of HCO3, from 26 mmol/L to 36 mmol/L which
indicates metabolic compensation. Her SPO2 is 88% while being mechanically
ventilated and is not sufficient enough. I believe the FIO2 should be increased to
55-60% (currently 50%) to see if improvements occur. FIO2 higher than 60%
can risk oxygen toxicity, but this patient’s deteriorating condition may only get
worse without intervention.
While you are administering furosemide you notice that G.M.’s pulse is irregular and the
cardiac monitor shows frequent couplets and short runs of VT. Her BP is now 92/70 and
her heart rate is 158. Another RN comes in the room to help you and obtains a 12 lead
ECG. At the same time, you connect G.M. to the code cart monitor for a “quick look”.
You are able to distinguish normal P-QRS-T complexes but you also note approximately
22 very wide complexes per minute. The wide complexes come early and are not
preceded by a P wave. There are also “couplets” evident in the 12 lead ECG as you have
also noted on her telemetry monitor.
https://www.consultant360.com/articles/evaluation-and-management-ventricularprematurebeats#:~:text=Ventricular%20couplets%20are%20defined%20as,may%20differ%
20(multifocal%20couplet).
What do these findings indicate?
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1. These findings indicate the patient is experiencing periods of ventricular tachycardia and
“couplets” which are two PVC’s in a row.
What is your priority action?
1. My priority action would be to report these findings to the patient’s doctor. It is likely he
would order a beta-blocker, calcium channel blocker, or amiodarone.
What factors have contributed to these clinical findings?
1. Factors that may have contributed to these findings are hypomagnesemia and hypokalemia.
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0
Explain the prognosis of ARDS and describe Stages 3 and 4. What physical
assessment findings would you expect for each of these stages? Discuss the
diagnostic test results that would be indicative of a worsening prognosis and what
the nursing care of this patient would include? Discuss the implications of late stages
of ARDS and the recent cardiac complications that you have noted while caring for
GM.
Nurse Sarah ARDS Review Video
1. ARDS has a poor prognosis if not treated properly, especially when accompanied by
sepsis. There is a mortality rate of 26-58% (Hinkle and Cheever med surg book).
Stage 3 is the proliferative stage, which occurs approximately 14 days after the initial
injury. The lungs are trying to repair themselves from the fluid leakage, which results
in dense and fibrous lung tissue. Hypoxemia increases due to the decrease oxygen
perfusion. The fluid that has leaked into the alveoli sacs, is reabsorbed. Assessment
findings would include hypoxemia. Crackles upon auscultation due to leaked fluid,
difficulty breathing, increased respiratory rate, low SPO2, mental status changes, and
an increased heart rate as a result of compensation. Stage 4 is the fibrotic stage, which
not every patient will experience, however it does have the worst prognosis. Gas
exchange cannot take place due to fibrosis of the lung tissue. Assessment findings
would include progression to acute respiratory failure (ARF), extreme hypoxemia,
bilateral crackles, and bilateral infiltrates seen on chest x-ray.
2. A chest x-ray would show bilateral infiltrates, whiteout areas, throughout the lungs.
Nursing care of this patient would include mechanical ventilation with PEEP at a high
pressure (10-20cm H20). The high pressure is necessary to open the alveolar sacs in
order for gas exchange to occur. Additionally, the nurse would need to frequently
reposition the patient and perform vent care. Frequently monitoring the patient’s vital
signs and laboratory data is crucial. The nurse will draw and interpret the patient’s
ABGs at least once per day to determine effectiveness of perfusion and ventilation.
3. Late stages of ARDS can turn into ARF. Pulmonary edema will continuously get
worse, refractory hypoxemia, cyanosis, and mental status changes may be noted. The
patient experienced recent cardiac complications as evidenced by ECG changes (PVC
couplets and periods of VT), increased HR, and decreased BP.
Based on the recent turn of events the team of physicians recommend convening that a
family meeting to determine what G.M.’s wishes are in the event that her condition
worsens and her heart and lungs stop functioning.
Who is responsible for the decision-making at this point in this case?
Hinkle and Cheever Med Surg book
1. Her advance directive would be examined at time to determine the patient’s wishes.
Her appointed durable power of attorney is responsible for the decision making at
this point in the case.
Examine the ethical issues related to moving this patient or keeping her in the ICU.
Even if death is imminent, a transfer from the ICU could be disruptive to the
patient, family and staff members. Provide nursing evidence to support your
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position on this issue.
https://www.mypcnow.org/fast-fact/hospice-referral-moving-from-hospital-tohome/
1. I believe it would be important to determine the patient’s wishes via her advance
directive and keep them in consideration when making this decision. If the doctors
have determined they have done everything they can and nothing is improving in
this patient, and it is determined that she wishes to die in her home on hospice, then
I would support moving her. It would be imperative to inform the family that this
move could be too stressful for her, and she may expire during the move. This may
be disruptive to staff members; however, I believe they would have compassion for
this patient and comply. Ethically, I believe this is a very personal decision and the
patient’s wishes should be followed if possible.
2. What nursing action(s) can or will you take to respond to this situation?
1. I will advocate for the patient’s wishes to respond to this situation. I will also
educate the family of risk factors and the possibility of the death of their loved one.
If they proceed to home hospice, then I would offer anticipatory guidance and allow
them to ask questions.
What resources may be helpful to support the ICU nurses in the loss of their
patient?
1. Nurses supporting one another, visitng the hospital chaplin, attending the
patient’s funeral, if necessary, online grief resources, and encouraging the
nurse to voice her feelings are all ways to support the ICU nurses in the loss
of their patient.
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