Running Head: Client Case Study
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Client Case Study
Kristel Cornejo
Old Dominion University
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Client Case Study
This case study will discuss clinical experience with a patient taken care for in the
intensive care unit and an in depth analysis and research regarding the patient's medical
diagnosis. Nursing aspects that will be discussed includes priority nursing diagnoses, nursing
interventions, outcomes, and evaluation.
Patient Case Introduction
Patient J.H. is a 73 year old white male with a history of severe pulmonary hypertension,
obstructive sleep apnea (OSA), congestive heart failure (CHF), diabetes mellitus (DM), lower
lobe lung squamous cell carcinoma and chronic obstructive pulmonary disease (COPD). He has
been a smoker for 50 years and consumes 3oz of alcohol a week. Patient came in with a chief
complaint of shortness of breath and he was admitted in the ICU on the 8th of September 2014
with the diagnosis of pneumothorax. Patient J.H. is currently on high-flow nasal cannula at
55L/min with FiO2 of 100% when eating and switches back to the BiPap when sleeping and
resting. A left apical chest tube was placed on the patient to drain air and fluid in the pleural
cavity. Chest x-ray showed left lung suprahilar mass, left lower lobe atelectasis with infiltrate
and effusion, and pulmonary venous congestion. He also had a PleurX catheter placed on the 5th
of August in the left upper lung because of recurrent pleural effusions. He receives
bronchodilators to manage COPD symptoms.
Medical Diagnosis
The patient's admitting diagnosis to the ICU is pneumothorax. Pneumothorax is an air
leak disorder that results in an accumulation of air and gasses in the pleural space. The two main
causes of an air leak disorder includes disruption of the parietal or visceral pleura, which allows
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air to leak into the pleural space; and the rupture of alveoli, which allows air to leak into the
interstitial space (Urden et al., 2014, pg. 538). The entry of air in the pleural space causes the
compression of the affected lung which then becomes underventilated. Increased pressure within
the chest can lead to shifting of the mediastinum, compression of the great vessels, and
eventually a decreased cardiac output (Urden et al., 2014, pg. 538). Pneumothorax can develop
as a result of possible underlying respiratory disease. In the case of patient J.H., his medical
history of COPD, squamous cell carcinoma in the lungs and recurrent pleural effusions
predisposed him to the development pneumothorax. Clinical manifestations of pneumothorax
include hyperresonance with decreased or absent breath sounds, inspiration more than expiration,
and a chest radiograph showing increased translucency on the affected side. Arterial blood gases
(ABGs) also demonstrate hypoxemia and hypercapnia. Patient J.H.s ABG results were as
follows: pH of 7.2, pO2 of 53, pCO2 of 43 and HCO3 of 34.4.
Patient J.H. also suffers from recurrent pleural effusions in his left lung. The patient's
physicians suspect that the squamous cell carcinoma in his lungs causes the pleural effusions.
Pleural effusion is the collection of fluid in the pleural space causing compression to the adjacent
lung where fluid settled in the thorax. Clinical manifestations of pleural effusions includes
crackles to auscultation, low to absent breath sounds and occasional pleural friction rub.
After a biopsy of the patient's lung tumor, the results came back as malignant. Tumors in
lung tissues can grow which can compress alveoli, nerves, blood, vessels, lymph vessels, airway
and interfere with oxygenation. Clinical manifestations will include labored or painful breathing,
prolonged exhalation with shallow breathing, use of accessory muscles, stridor, flared nares,
dyspnea and wheezing, hemoptysis and tenderness when palpating chest wall (Ignatavicius &
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Workman, 2013, p. 630). The newly diagnosis of his lung cancer creates an even grimmer
prognosis for patient J.H's condition.
Nursing Diagnoses and Nursing Theory
Nursing Diagnosis is the 2nd standard in the AACN Scope and Standards for Acute and
Critical Care Practice. It states that nursing diagnoses are derived from assessment data, is
validated throughout the nursing interactions with patients, family, community and other health
care providers and must be prioritized and documented (American Association of Critical-Care
Nurses). The chosen diagnoses for patient J.H. in prioritized order are ineffective breathing
pattern, impaired gas exchange, risk for trauma, acute pain and fear and anxiety.
Ineffective Breathing Pattern
The accumulation of air and fluid in patient J.H.'s pleural space prevents the lungs from
expanding. Decreased expansion of lungs leads to poor ventilation and therefore causing an
ineffective breathing pattern. Another factor that led to this diagnosis is pain. Pressure in the
pleural space and pain at the incision sites of the chest tubes while breathing discourages the
patient from breathing effectively. Patient J.H.'s ineffective breathing pattern is evidenced by
dyspnea, shortness of breath, increased rate of respiration, increased effort to breathe and
abnormal ABGs.
Impaired Gas Exchange
Impaired gas exchange usually accompanies ineffective breathing pattern. Poor
ventilation disables the gases to reach the alveoli for adequate gas exchange. Also, the presence
of atelectasis, or alveoli collapse, in the patient's lungs places him in an increased risk for
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hypoxemia and hypercapnia. The patient's blood will be unable to carry enough oxygen to
deliver throughout his body therefore his body cells and tissues will be hungry for oxygen.
Impaired gas exchange is evidenced by poor oxygen saturation, less than the patient's baseline of
93%, abnormal ABGs, altered level of consciousness, poor skin turgor, pallor, increased
respirations and tachycardia.
Risk for Trauma
In order to remove the fluid accumulated in the patient's pleural space, a chest tube was
placed in his left lung. Patient also has a PleurX catheter placed from previous draining of
pleural effusion. Another incision in the left lung was also done to retrieve a biopsy of the tumor.
The incision site for biopsy, insertion site of the chest tube and another insertion site of the
PleurX catheter places this patient at a great risk for trauma. Bleeding can occur from the
surgical sites and possible misplacement or dislodgment of the tubes can occur. In addition to
bleeding and dislodgement, the patient's chest tube can become kinked or obstructed resulting in
improper draining. The fluid in his lungs can accumulate creating trauma in his lungs.
Acute Pain
Patient J.H. constantly reports generalized pain but states that it is more prominent in his
chest area. Patient's pain is mostly related to surgical incisions, presence of chest tubes, and the
invasion of cancer cells in his lung tissues. He is also hypoxemic and hypoxic meaning his
tissues and vascular system are not receiving enough oxygen. Decreased oxygen perfusion to the
body especially in the extremities results in pain. Acute pain is evidenced by patient's
verbalization of presence of pain, guarding and restlessness, and an increase in heart rate,
respiratory rate and blood pressure.
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Fear and Anxiety
Patient J.H. was newly diagnosed with squamous cell carcinoma in the lungs. This
diagnosis of cancer significantly added fear and anxiety to the patient. The patient already was
dealing with his deteriorating condition related to recurrent pleural effusion and pneumothorax
and the additional diagnosis of cancer may have made the patient believe that death is now more
imminent. Fear and anxiety of patient J.H. is evidenced by restlessness, irritability, verbalization
of feeling anxious, asking the physician about how much longer does he have left to live, and
increasing pain levels.
Betty Neuman's Systems Model
The Neuman systems model (NSM) is a holistic framework that proposes a constant
interaction with the client and his or her environmental stressors. These environmental stressors
can invade the client's normal line of defense, or the client's baseline health state, causing a stress
response to occur (Skalski et al., 2006). The priority stressor that occurred in patient J.H. is the
pneumothorax. Also, he has a long history of alcohol and cigarette smoking abuse leading to his
deteriorating lung function. These physiological stressors invaded his normal line of defense and
significantly affected the state of his health. The immediate physiological result of the stressor is
ineffective breathing pattern, also his priority nursing diagnosis. Prompt identification and
assessment of this stressor provides the instrument in identifying appropriate treatments to return
the normal line of defense in the patient. Based on the NSM, the goal of nurses is to reestablish
the patient's line of defense and reduce severe health consequences (Skalski et al., 2006). In
patient's J.H.'s case, this means removing air and fluid in his lung spaces and promoting lung
expansion for an effective breathing pattern and reestablishment of his normal line of defense.
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Priority Outcomes
Outcome identification is the 3rd standard in the AACN Scope and Standards for Acute
and Critical Care Practice. It states that outcomes are derived from actual or potential diagnoses,
formulated in a collaboration with the patient, family and health care providers, are attainable
and provide direction for continuity of care, are modified in the basis of changes in patient
characteristics and are documented as attainable goals (American Association of Critical-Care
Nurses). The two outcomes identified for this patient are discussed below.
A desired outcome for patient J.H. is the reestablishment of lung expansion within 3-5
days of post operation which will promote an effective respiratory/breathing pattern. The patient
will exhibit reduced rate of respiration that falls within the normal range of 12-20 breaths per
minute. His chest tubes will show adequate amount of drainage and chest x-ray will show
reduction of air and fluid in the lung spaces. Another outcome for the patient is to maintain an
oxygen saturation above 93% during hospitalization which indicates adequate gas exchange.
Adequate oxygen perfusion will exhibit absence of pallor or cyanosis, ABGs within the patient's
baseline levels, no significant changes in level of consciousness, and return of vital signs (heart
rate, blood pressure and respiration rate) within the patient's baseline levels.
Nursing Interventions
Implementation is the 5th standard in the AACN Scope and Standards for Acute and
Critical Care Practice. It states that interventions are delivered in a manner that minimizes
complications, are responsive to the uniqueness of patient and family members, occurs in
collaboration with patient, family and other health care providers, are documented and facilitates
learning for patients, family, nursing staff and other members of health care team (American
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Association of Critical-Care Nurses). The immediate focus of nursing interventions for patient
J.H. includes delivering adequate oxygen supply, promoting lung expansion and preventing
complications. The patient has malignant pleural effusions so the previous medical treatment
applied to patient J.H. was the insertion of a PleurX catheter. After the admission to ICU, it was
suspected that there was a malfunction in his PleurX catheter that prevented it from properly
draining. A large bore chest tube was then inserted in the posterior lung to increase lung
expansion by effectively draining air and fluid out of his pleural space. In addition, patient J.H.
also receives high flow oxygen via cannula at a rate of 55L/min and with an FiO2 of 100% for
adequate ventilation and perfusion.
Managing Chest Tubes
The start of caring for a patient with chest tube begins with an assessment of the patient's
respiratory status including respiratory rate, effort, lung sounds and oxygen saturation. Any
sudden increase or decrease in respiratory rate, sudden increase of effort to breathe, worsening
adventitious lung sounds and decrease in oxygen saturation may indicate a problem with chest
drainage. The air and fluid in the chest cavity may not be draining properly causing an increasing
amount of air and fluid collection in the lungs furthering lung compression and eventually a
collapse. Another abnormal finding is the presence of crepitus, air leaking in the tissue, during
palpation around the insertion site of the chest tube. Crepitus is a sign of subcutaneous
emphysema which can occur as a result of malpositioning of the chest tube and if new or
increasing, a health care provider should be alerted (Frazer 2012). The next step is to assess the
chest tube drainage and tubing. The nurse must carefully inspect the tubing to make sure that it is
not kinked or obstructed and also the tube must be below the patient's chest to allow for
continuous drainage. Current research has discouraged the milking or stripping of chest tubes
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because of the extreme negative pressure it generates in the pleural spaces causing lung tissue
entrapment (Briggs 2010). Drainage type and amount from the chest tube must also be measured
and documented. A drainage volume rate of more than 100ml/hr is considered excessive and
may require surgical intervention. Patient J.H.'s rate of drainage was about 130cc of serous fluid
in 8 hours. Lastly, the chest drainage unit (CDU) should also be carefully inspected. The CDU
contains three separate chambers: collection chamber, water seal chamber and the suction
chamber. The drainage collection chamber is where the nurse can monitor and mark the amount
of fluid draining from the tube. The water seal chamber places a negative pressure inside the
pleural cavity allowing air to escape the pleural cavity but prevents air to enter the cavity. Since
the patient has pneumothorax, bubbling in the water seal chamber will be present and
documented as a normal finding as it is a sign of air properly evacuating out of the patient's chest
cavity (Frazer 2012). The suction chamber controls suction level and aids in removal of thick or
large drainage. The level of suction must be properly controlled because excessive suction can
cause damage to the lung tissues. When the air and fluid leakage in the pleural space has been
resolved and proven by a chest x-ray, lung expansion has been established and the patient can
have the chest tubes removed. Teaching components for the patient include avoiding obstructing
and kinking the tubes, avoid putting pressure in the incision sites, and alerting the nurse when the
chest tubes are accidentally pulled out of the chest.
Repetitive placement of chest tubes to a patient who has malignant pleural effusion can
place the patient at risk for infection and increased length of hospital stay. Research has showed
that PleurX catheter, an ambulatory device, significantly reduced the length of stay and
decreased risk of hospital acquired infections. The PleurX catheter is a small tunneled intrapleural drain attached intermittently to a drainage bottle useful for a long-term management of
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fluid leaks (Myatt 2011). Although there was a malfunctioning of the patient J.H.'s PleurX
catheter, reestablishing it's function would benefit the patient in the long run. According to the
research written by Rebecca Myatt in 2011, patient's with long term conditions like malignant
pleural effusions were successfully managed by ambulatory devices and regular telephone and
outpatient follow-up with a specialist nurse. An increased quality of life was also stated by the
patients especially by those who has a reduced life expectancy.
Oxygen Therapy
Based on the patient's deteriorating lung function, oxygen therapy plays a
significant role in managing his disease and its processes. Supplemental oxygen will aid the
patient in maximizing the available oxygen especially when ventilation and perfusion is
compromised. Patient J.H. was placed on high-flow nasal cannula at 55L/min with an FiO2 of
100%. Assessments to monitor adequate oxygen flow includes monitoring of vital signs (heart
rate, respiration rate and blood pressure), adequate perfusion of extremities and monitoring of the
arterial blood gasses. The patient's arterial blood gasses (pH of 7.2, pO2 of 53, pCO2 of 43 and
HCO2 of 34.4) indicates severe hypoxemia and hypercapnia urging the need for immediate
oxygen therapy. For a patient severely compromised, high flow oxygen aids in opening collapsed
alveoli and increases surface for gas exchange (Urden et al., 2014, pg. 1144) It is also important
to collaborate with the physician and respiratory care providers to determine the target rate of
oxygen saturation. For patient J.H., his goal is to maintain oxygen saturation at or above 93%.
Teaching components for the patient includes allowing rests in between activities procedures to
reduce oxygen consumption, avoid removing high flow nasal cannula unless he prefers to switch
to the BiPap, and alerting the nurse when difficulty breathing occurs.
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Patients with a do-not-intubate (DNI) code status like patient J.H. can benefit greatly
from noninvasive ventilation (NIV) including a high flow nasal cannula therapy (HFNC). HFNC
supplies a high flow of heated and humidified mixed gas through a nasal cannula and generates a
low level of positive airway pressure which provides an effective oxygen support and comfort (G
Peters et al., 2013). In a research article that studied the outcome of HFNC in 50 patients with
DNI status, the results were as follows: mean pre-HFNC breaths/minute was 30.6, post-HFNC
was 24.7, mean pre-HFNC O2 saturation was 89.1% and mean post-HFNC O2 saturation was
94.7% (G Peters et al., 2013). The study results suggests that HFNC oxygen therapy can
adequately provide oxygen to hypoxemic patients declining intubation.
Medication Administration
In order to supply and deliver patient J.H. with adequate oxygen, his upper airways must
be dilated enough to receive them and any obstruction must be cleared. Patient J.H. also suffers
from COPD which can cause bronchospasms, inflammation and production of thick secretions.
Prescribed medications that the patient receives to increase respiratory and airway function
includes albuterol, fluticasone-salmetrol (Advair), and tiotropium (Spiriva). Albuterol is a
bronchodilator that works in increasing the diameter of the patient's airways symptoms of COPD
including wheezing, shortness of breath, coughing and chest tightness. Advair also prevents
symptoms of COPD but is used as a long-term therapy. Spiriva is a bronchodilator that also acts
in preventing bronchospasms brought on by COPD. The combination of these medications
allows patient J.H. to have a patent airway passages that can make breathing and oxygen therapy
effective. Nursing care will focus on timely administration and assessment of medication
effectiveness. The nurse can assess for adequate oxygenation, improved pulmonary function with
pulse oximetry, ABGs at baseline and peak expiratory flow meter, and absence of COPD
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symptoms including wheezing and rhonchi. Teaching component includes pharmacological
processes of medications, proper use of metered dose inhaler and compliance with medications
to assure adequate and patent airway.
Evaluation
Evaluation is the 6th standard in the AACN Scope and Standards for Acute and Critical
Care Practice. It states that evaluation is systematic and ongoing; patient, family members and
other health care providers are involved in the evaluation process, evaluates effectiveness of
interventions towards achieving the desired outcome, uses ongoing assessment and documents
the results of the evaluation (American Association of Critical-Care Nurses).
The first outcome for the patient is to reestablish lung expansion 3-5 days after post
operation and the patient is progressing towards this goal. Evaluations include chest tubes are
effectively draining air and fluid, no trauma has occurred with the chest tubes, and the patient
denies any difficulty breathing. He also states the understanding of the chest tubes and verbalizes
signs and symptoms that needs to be reported to the nurse or health care provider. An alternative
plan for patient J.H. is to restore the function of his PleurX catheter. Once he no longer needs the
chest tubes, he can return to using his PleurX catheter to manage his malignant pleural effusions.
The second outcome for the patient was maintaining an oxygen saturation at or above 93%
throughout the hospitalization. The patient is also progressing towards this goal and maintained
an average of 95% throughout the clinical day. However, the patient's ABGs were still abnormal.
He still indicated hypoxemia and hypercapnia and will still need continuous supply of high flow
oxygen. Patient demonstrated adequate perfusion of the extremities by exhibiting warm skin
without pallor or cyanosis. The patient's vital signs were at his baseline levels: heart rate of 91,
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blood pressure of 99/59 and respiration rate of 14. If patient undergoes respiratory arrest, the
alternative of using intubation will not be used. He is a DNI/DNR status and the chances of
mortality is higher without intubation. Overall, the patient is exhibiting a forward progression
towards his goals.
Conclusion
Patient J.H. displayed a complex combination of respiratory diseases that will continue to
deteriorate his respiratory function. He is aware that death can occur at any time in his situation
and has decided to declare a DNI/DNR status. Care performed for the patient in the ICU were
directed at slowing the progression of his disease and managing symptoms. The physician
suspected that the patient's sudden pneumothorax was caused by a combination of underlying
diseases including COPD, lung cancer and malignant pleural effusions. Since pneumothorax
greatly affects respiratory function, the top two nursing diagnoses are ineffective breathing
pattern and impaired gas exchange. Nursing interventions included management of chest tubes,
oxygen therapy and medication administration. The clinical experience and learning I received
from assuming care for the patient includes proper management of chest tubes and assessments,
the use of high flow oxygen as an alternative to invasive ventilations and pathophysiology of
lung cancer that causes malignant pleural effusions. Although patient J.H. did not exhibit
exacerbation of respiratory diseases during the clinical day, his prognosis remains grim.
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References
American Association of Critical-Care Nurses. (2008). AACN Scope and Standards for Acute
and Critical Care Practice. Aliso Viejo, CA: American Association of Critical-Care
Nurses.
Briggs, D. (2010). Nursing care and management of patients with intrapleural drains. Nursing
Standard, 24(21), 47-56.
Frazer, C. (2012). Managing chest tubes. Med-Surg Matters, 21(1), 1.
G Peters, S., R Holets, S., & C Gay, P. (2013). High-Flow Nasal Cannula Therapy in Do-NotIntubate Patients With Hypoxemic Respiratory Distress. Respiratory Care, 58(4), 597600. doi:10.4187/respcare.01887
Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered
collaborative care (7th ed.). St. Louis, MO: Elsevier.
Myatt, R. (2011). Reducing length of stay through the use of ambulatory chest drains and nurseled follow-up. British Journal Of Cardiac Nursing, 6(11), 549-552.
Skalski, C., DiGerolamo, L., & Gigliotti, E. (2006). Stressors in five client populations: Neuman
systems model-based literature review. Journal Of Advanced Nursing,56(1), 69-78.
doi:10.1111/j.1365-2648.2006.03981.x
Urden, Linda D., Stacy, Kathleen M., Lough, Mary E. (2014). Crital Care Nursing: Diagnosis
and Management (7th ed.). St. Louis, MO: Elsevier.
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Honor Pledge
Honor Pledge:
"I pledge to support the Honor System of Old Dominion University. I will refrain from any form
of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a
member of the academic community, it is my responsibility to turn in all suspected violators of
the Honor Code. I will report to a hearing if summoned."
Kristel Cornejo
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NURS 451 Client Case Study
Grading Criteria
Student:
__________________________
Grading Criteria
Points
Introduction
Pt. Overview
Scope of paper
2
1
Medical Diagnosis
Dx for ICU adm.
Patho
Related S/S
2
4
4
Nursing Diagnosis
5 NANDA (1+ psych/soc)
Priority with theorist support
5
10
Outcomes for top 2 NDX
Appropriate for NDX
Attainable within timeframe
#1 #2
2.5 2.5
2.5 2.5
Interventions for top 2 NDX
Interventions with rationale
SOP /Clinical Path
Patient/family teaching
Critical Thinking
Cultural Considerations
#1
6
2
2
2
Evaluation
Progress toward outcomes
Additional/alternative plan
#1 #2
5 5
1 1
Conclusion
Review of learning
#2
6
2
2
2
3
3
Score:
Faculty Comments
__________
Points
Awarded
17
Grading Criteria
Sources
5+ sources
3+ primary nursing research
Study results reviewed/applied
Study poorly reviewed/applied
Research omitted
Points
1
3 3 3
1 1 1
0 0 0
APA Format (Cover page,
headings, margins, type size)
Format conforms to APA Format
Format includes 1-3 APA errors
Format includes 4-6 APA errors
Format includes >6 errors
3
2
1
0
APA- References/Reference Page
Conform to APA Format
Include 1-3 APA errors
Include 4-6 APA errors
Include >6 APA errors
Do not conform to APA format
4
3
2
1
0
Writing Style (Grammar, spelling,
punctuation, language)
Logical, organized, without errors
3
Logical, organized minor errors
(<5)
2
Lacks logic/organization OR major
spelling/grammar/errors (>5)
1
Lacks logic / organization AND
major spelling / grammar / errors
(>5)
0
Comments:
Faculty Comments
Points
Awarded