Deserae Vickery
MS EBP
CASE STUDY
02/01/15 Patient c/o fever, chills, nausea, abdominal pain, and vomiting (green) for the past 5
hours escalating to the point of cramping and inability to stand or walk. Patient called EMS.
Upon admit to the ER vitals : Temp 95.3, P 81, BP 79/63, RR 12, 96% RA. INR > 17.2 and PT >
148.7 RT poor management of coumadin at home. Given 3 L NS bolus. DX: Toxic megacolon 
perforation  septic shock requiring emergent subcolectomy and ileocolostomy.
General patient information:
Age: 70 yr
Sex: F Height: 5’5”
Weight: 61.5 kg (135.3 lbs.)
Review of General Health :
A-fib (Past), HT (Past), Thrombocytopenia(Current), Bipolar (Current), Pneumonia (Past), GERD
(Current), Smoker (Current), Breast implants (80’s), hysterectomy (70s), Lap removal of
ovaries/tubes 07/19/13.
Potential medical/psycho/social/cultural barriers to care:
Acute trauma. Emergent subcolectomy and ileocolostomy. Elderly. Patient lives alone. Never
married. No children. Diagnosis of Bipolar. Patient is affiliated with the Baptist faith. Previous
career as a super model.
Current Pathology:
Toxic Megacolon
Marked enlargement of the colon, esp. the transverse colon. Manifestations include
tachycardia, fever, leukocytosis, abdominal tenderness, palpable abdominal mass,
confusion, cramping, and change in number of bowel movements. (Venes, &
Taber, 2009, pg. 1428)
Perforation
Abdominal crisis in which a hole forms in the GI tract resulting in the release of intestinal
fluids into the peritoneum encompassing abdominal organs. Requiring surgical
treatment ((Venes, & Taber, 2009, pg. 1742)
Septic Shock
Presence of pathogens and their toxins in the blood initiate a systemic inflammatory
response and vascular damage. (Venes, & Taber, 2009, pg. 2119)
Related Labs: (Kee, 2014)
Hct
34.5
LOW
NML
0.36 – 0.46
Hct is the volume of packed RBCs. Low Hct is found frequently in anemia and is
influenced byantibiotics. ( pg 228)
RT Patient: prescribed antibiotics and is postop (blood loss)
Hgb
12.0
LOW
NML
12-15
Hgb is a protein substance founds in RBCs. Gives blood its red color and is composed of
Fe, which is an O2 carrier. Low Hgb is found in anemias. Can be influenced by excess IV
fluids and antibiotics.
RT patient: prescribed antibiotics and is postop (blood loss)
WBC
3.9
LOW
NML
4,500 – 10,000
WBC’s are used to fight infection
RT patient: fighting infection and stores are becoming exhausted
RBC
2.74
LOW
NML
RT decreased Hct
4.0 – 6.0
Platelet Ct.
66
LOW
NML
150,000-400,000
Low levels indicate anemia and bleeding (pg 339)
RT Patient: Postop (loss of blood), and has excessively used Coumadin
BUN
53
HIGH
NML
5 – 25
Urea is a formed end product and excreted by the kidneys. High BUN could be an
indication of dehydration, renal insufficiency/failure RT shock/sepsis, GI bleeding. (Page
90)
RT Patient: multi-organ failure RT shock and sepsis
Creatinine
2.30
HIGH
NML
0.5 – 1.5
Creatinine is a by product of muscle catabolism and broken down by muscle creatine
phosphate. Creatinine is considered a more sensitive and specific indicator of renal
disease than BUN. It rises later and is not influenced by diet or fluid intake. High
creatinine is indicative of acute and chronic renal failure, prolonged shock ( pg 154)
RT: Patient: prolonged shock AEB decreased BP
Albumin
2
LOW
NML
3.5 – 5.0
Low levels may indicate cirrhosis of the liver, acute liver failure, severe burns, severe
malnutrition, preeclampsia, renal disorders, certain malignancies, ulcerative colitis,
prolonged immobilizations, protein loosing enteropathies, or malabsorption (Pg 17)
RT Patient: malnourished and can absorb nutrients
ALT
158
HIGH
NML
10-35
Alanine aminotransferase is an enzyme found primarily in liver cells and is effective for
diagnosing hepatocellular destruction. High levels are seen in liver necrosis and acute
hepatitis (page 15)
RT patient: multi-organ failure
AST
205
HIGH
NML
8-35
Aspartate aminotransferase is an enzyme found mainly in the heart muscle and liver.
The concentration is normally low in blood except for when there is cellular injury. High
levels are found following an acute MI and liver damage (page 73).
RT Patient: multi-organ failure
ABG’s
PH
7.38
NML
7.35 – 7.45
PaCO2
38
NML
35 – 45
HCO3
24.1
NML
22 - 28
Mode: AC
Rate: 14
TV: 600 mL
Settings
FiO2: 50 %
Peep:
Medications (Vallerand, Sanoski,&Deglin, 2013)
Metronidazole (Flagyl) in NaCl 500 mg=100ml q8hrs
(pg 856)
Indications: (IV) perioperative prophylactic agent in colorectal surgery
Nursing Implications: Assess for infection throughout therapy, monitor neurologic
status, monitor I&O esp. pts. w/ Na restriction (each 500 mg contains 14 mEq of Na),
Assess for rash periodically – May cause Stevens Johnson syndrome, D/C if rash
accompanied w/ fever, general malaise, fatigue, muscle/joint aches, blisters, oral
lesions,conjunctivitis, hepatitis, and or eosinopilia
Pantoprazole (Protonix)
(pg 986)
Indications: GERD
40 mg = 100 ml q6hrs
Nursing Implications: Assess pt. periodically for epigastric or abdominal pain and for
frank or occult blood in stool, emesis, or gastric aspirate. May cause abnormal LFT (^
AST, ALT, alkaline phosphatase, and bilirubin). May cause hyperMg.
Piperacillian/tazobactam (Zosyn)
3.375 gm=100 ml
q6hrs
(pg 1030)
Indications: Appendicitis and peritonitis, skin infections, gynecologic infections,
Community acquired infections and nosocomial infections.
Nursing Implications: Assess pt. for infection, contraindicated in pts. w/ a
hypersensitivity to penicillians, Observe for s/s of anaphylaxis (rash, pruritis, laryngeal
edema,wheezing). Monitor bowel function ( report D, abd cramping, F, and bloody
stools – may be signs of pseudomembraneous colitis)
Nursing Assessment:
VS:
HR 137, P 142, BP 99/55, and RR 16.
NEURO.
Intubated. Doesn’t open the eyes. No motor or verbal response to a central stimulus.
PERRL. Sluggish response.
INTEGUMENT:
Skin mostly warm and dry with cooler extremities. Generalized Bruising. Various stages
of healing. Poor anticoagulant management at home. Generalized mild jaundice. Right
triple lumen subclavian central line and right femoral arterial central line. No site
redness. Dressings dry and intact. Sub colectomy abdominal incision. Edges well
approximated. Mild redness. Minimal serous drainage. Dressing dry and intact. Stoma
site mildly swollen; otherwise, beefy red. Illeostomy drainage is sanguineous without
presence of fecal matter. Closed endotracheal tube. Suctioned accordingly.
RESP:
Coarse bronchi heard upon auscultation throughout all lobes. Suctioned
accordingly. Mild improvement noted.
CV:
S1, S2 auscultated. Tachycardic rate. Amiodarone admin as ordered. Radialpulse 3+
bilat. CRT < 3 sec. Pedal pulse 2+ bilat.
MS:
Intubated. Flacid UE bilat and LE bilat. No motor response to PROM.
GI:
One day postop. Absent bowel sounds x 4. Abdomen soft. Mildly swollen. Last bowel
movement unknown.
GU:
Foley catheter present. Urine is light yellow without sediment.
3 Nursing Dx’s

Risk for infection RT secondary complications of mechanical ventilation, multiple invasive lines,
and ileocolostomy

Ineffective airway clearance RT inability to clear secretions AEB presence of endotracheal tube ,
and coarse ronchi heard upon auscultation

Risk for situational low self esteem RT lack of support system and recent trauma requiring
hospitalization, subcolectomy, and permanent ileostomy
Priority Nursing Dx :

Risk for infection RT secondary complications of mechanical ventilation, multiple invasive lines,
and ileocolostomy
(ASPECT: Oral Care of the ventilated patient)
ARTICLE: Intermittent subglottic secretion drainage on ventilator-associated pneumonia: A clinical trial
(Safdari,Yazdannik, & Abbasi, 2014)
DESIGN:

Four general ICUs of selected educational hospitals in Isfahan, Iran with medical,
surgical, and trauma patients between November 2012 and February 2013.

Randomized control trial to determine the incidence of early-onset VAP (Ventricular
Associated Pneumonia) among patients who receive SSD (Subglottic Secretion Drainage)
compared to patients who receive endotracheal suctioning without SSD.

Frequency : suctioning every 3 hours
POPULATION:

408 patients were admitted in the participating ICUs who were 18 – 60 years of age,
intubated with a cuffed polyvinyl chloride endotracheal tube (PVC ETT) and likely
required mechanical ventilation for at least 48 hrs.

Exclusion criteria and unforeseen events limited the analysis to 76 patients
38 patients received SSD via the inspiratory pause method (SSD group)
38 patients received endotracheal suctioning without SSD (Control group)

Exclusion Criteria:
Patients who were admitted to the ICUs with tracheostomy
Patients whose mechanical ventilation was normally shorter than 48 h
(psychotropic drug overdose, etc.)
Patients who were likely to die in the next 48 h (those who were
admitted after cardiac arrest, etc.)
Patients who were admitted to these units for treatment of pneumonia
Others with lung complications like fibrosis or cancer
METHOD:

SSD via the inspiratory pause method or endotracheal suctioning without SSD every 3
hours.

Oropharyngeal suctioning was performed prior to each suctioning.

The Inspiratory Pause Method :
Performed using the inspiratory pause or inspiratory hold keys on the ventilator,
an inspiratory hold was applied. Inspiration was held in the patient for 3 sec only
until the cuff of the ETT was depleted. Air flow rising past the deflated cuff
drove the subglottic secretions toward the oropharynx .Secretions were
removed with repeated oropharyngeal suctioning by a nurse specialist in critical
care. The cuff pressure was maintained between 20 and 30 mm H2O.
RESULTS:

Within 5 days of mechanical ventilation, 28 patients developed pneumonia:
10 (26.3%) in the SSD group and 18 (47.4%) in the control group.
CONCLUSION:

Secretions contaminated with oral, nasal, and gastric bacteria accumulate in the
subglottic space, above the endotracheal tube cuff.

If these secretions are aspirated into lower airways, the intubated patient will be
susceptible to ventilator-associated pneumonia (VAP)

Endotracheal suctioning is effective at reducing bacterial colonization of the lower
airways; however, subglottic secretion drainage is more effective
LIMITATIONS:

Small sample size

Family member gave permission
ARTICLE: The effect of different oral hygiene treatments on the occurrence of ventilator associated
pneumonia (VAP) in ventilated patients (Lev, Aied, & Arshed 2015).
DESIGN:

General ICU in the Emek Medical Center, Israel between August 2007 and October 2009.

Prospective, controlled study to determine the incidence of VAP in ventilated Patients
who received a comprehensive oral hygiene regimen compared to a conventional
treatment regimen
POPULATION:

Upon admission to the ICU, ventilated patients were alternately allocated to either the
study group (n=45) or the control group (n=45).

Excluded: patients who were younger than 18 years, patients with a clinical diagnosis of
pneumonia at the time of intubation, immunosuppressed patients, pregnant women,
and burn patients
METHOD:

The oral care protocol was implemented 3x/ day

Patients in the study group received a comprehensive oral hygiene treatment regimen
that involved a soft-bristle suction toothbrush w/ sodium bicarbonate (to mechanically
clean, refresh, and deodorize the oral cavity), rinsing with an antiseptic solution (1.5%
hydrogen peroxide) and applying a mouth moisturizer containing vitamin E to promote
the healing of lesions

Patients in the control group received a more conventional treatment that included
cleaning with a sponge and rinsing with an antiseptic solution (0.2% chlorhexidine
gluconate.)
RESULTS

8.9% of the study group (comprehensive) developed VAP compared with 33.3% of the
control group (conventional).

Patients in the study group spent a mean of 11.09 days in the ICU compared to those in
the control group (14.98 days).

The mean number of days on a ventilator was 8.39 in the study group compared to
12.69 days in the control group.

The mean number of days of hospitalization was 25.38 in the study group compared to
31.71 days in the control group .

The study group patients had a mean of 7.2 treatment days with antibiotics compared
with 9.7 days in the control group
CONCLUSION

In patients who are ventilated, a comprehensive oral hygiene treatment regimen that
includes tooth brushing, suctioning, rinsing with an antiseptic, and application of a
moisturizer is more effective in preventing VAP than more conventional protocols.

Comprehensive oral hygiene decreases length of hospitalization, antibiotic use, and days
on mechanical ventilation
LIMITATIONS

Patients were alternately allocated to either the study or control group. The unblinded
nature of the study has the potential to introduce bias.

Patients received varying antibiotic regimens, which could have affected VAP rates.

Providers of oral care could have varying skill in the application of the protocol,
introducing the possibility of operator bias.
CARE PLAN: Risk for infection RT secondary complications of mechanical ventilation, multiple invasive
lines, and ileocolostomy

Patient goals/outcomes
Patient will maintain a patent airway remaining clear of secretions for the entire shift.
Patient will remain free of respiratory infection for length of hospitalization.
Nursing Intervention
Nurse will perform subglottic suctioning q 3 hrs to maintain a patent airway and reduce
bacterial colonization
Rationale
Secretions contaminated with oral, nasal, and gastric bacteria accumulate in the
subglottic space, above the endotracheal tube cuff. If these secretions are aspirated into
lower airways, the intubated patient will be susceptible to ventilator-associated
pneumonia (VAP) (Safdari,Yazdannik, & Abbasi, 2014).

Patient goals/outcomes
Patient will remain free from respiratory infection for length of hospital stay
Nursing Interventions
Nurse will perform oral care 2 x while on shift using a suction toothbrush
Rationale
Mouth-related risk factors for infection include the formation of bacterial colonies in the
mouth, the accumulation of pathogenic bacteria on the surface of the teeth,
development of plaque, and aspiration of secretions from the oral cavity (Lev, Aied, &
Arshed 2015).
REFERENCES
Kee, J. L. (2014). Laboratory and diagnostic tests with nursing implications (9th ed.). Upper
Saddle River, NJ: Pearson.
Lev, A., Aied, A. S., & Arshed, S. (2015). The effect of different oral hygiene treatments on the
occurrence of ventilator associated pneumonia (VAP) in ventilated patients. Journal of Infection
Prevention, 16(2), 76-81.
Safdari, R., Yazdannik, A., & Abbasi, S. (2014). Effect of intermittent subglottic secretion drainage
on ventilator-associated pneumonia: A clinical trial. Iranian Journal of Nursing & Midwifery
Research, 19(4), 376-380.
Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2013). Davis's drug guide for nurses(13th ed.). PA:
F.A Davis.
Venes, D., & Taber, C. W. (2009). Taber's cyclopedic medical dictionary (21st ed.). Philadelphia,
PA: F. A. Davis Co.