Critical Care Clinical Case Study
NURS 451- Clinical Management of Adult Health Nursing III
Purpose of Assignment
The purpose of this case study is to integrate knowledge from the humanities and
sciences, including nursing research and theory, to plan, provide, and evaluate holistic care
provided to a client selected during this clinical rotation.
Student Approach to Assignment
This patient was chosen for this assignment because of the patient’s extensive medical
history and quick deterioration. He was a 74 year old Caucasian male whose past medical
history included: benign prostatic hypertrophy, hypertension, congestive heart failure, coronary
artery disease, endocarditis, mitral valve replacement, mitral valve regurgitation, paroxysmal
atrial fibrillation, stage three chronic kidney disease, cardiomyopathy, and hypothyroidism. He
had recently been hospitalized for pneumonia only weeks before the new condition began. He
was brought to the Emergency Department complaining of diarrhea, nausea, weakness, with a
slight altered mental status. His initial assessment revealed dehydration, and he was admitted for
further assessment and gentle rehydration. After being admitted, he was found to have Candida
albicans urinary tract infection related to long term catheter use. This patient’s health status
quickly deteriorated on April 7th, requiring mechanical ventilation and transfer to the intensive
care unit. The cause of the declining health status was unknown. I chose this patient because of
this mysterious decline and increasing medical and familial support required.
Reason for Inclusion
This required assignment was chosen to be added to this portfolio because it demonstrates a wide
variety of patient care provided. The following program curriculum objectives were addressed:
 Critical Thinking
 Uses nursing and other appropriate theories and models to guide professional practice.
 Example: In this case study, I used Sister Callisa Roy’s Adaption model to support
the the nursing interventions used during patient care. This theory states that the
patient strives to balance between biological, psychological, and social systems in
addition to their environment. This theory helped guide the patient care while he was
in the physiological stage as his status continued to improve and plans to balance
psychological and social aspects were being planned.
 Uses decision-making skills in making clinical or professional judgments.
 Example: In this case study, many interventions were performed to enhance and
maintain patient care. Clinical decisions to not use a tooth brush to provide patient
care due to extreme thrombocytopenia is one example. Daily interventions, such as
monitoring oxygenation, skin, and cardiac status required professional judgment
throughout the day. Additionally, the patient was being assessed for readiness to
wean from mechanical ventilation. Therefore, monitoring of patient’s respiratory
status, in conjugation with the respiratory therapists, was consistently performed. For
example, tidal volume-respiratory frequency curve on the ASV setting was monitored
to evaluate the patient’s effectiveness of the patient’s breathing pattern.
 Nursing Practice
 Applies appropriate knowledge of major health problems to guide nursing practice.
 Example: There were many comorbidities that complicated the patient’s recovery
and approach to care. Due to being a chronic catheter user, a previous Candida
albicans infection was present. This continued to a problem for the patient, as his
diagnosis of benign prostatic hypertrophy caused him to continue the use of the foley
catheter, making it difficult to treat the infection. Even through the time I was caring
for him, his urine culture results continued to show positive for the fungus, despite
strong antibiotic use. Also, a recent hospitalization for pneumonia complicated the
condition. As he was still recovering from the hospitalization, his family informed
the health care team that he was still suffering from shortness of breath and dyspnea
upon exertion. This, in conjunction to the ongoing urinary tract infection, may have
contributed to the patient’s quick deceleration in health status. For these reasons, it
was important for nursing care to concentrate on administration of antibiotics,
monitoring for worsening health, and collecting laboratory specimens for cultures and
testing.
 Implements traditional nursing care practices as appropriate to provide holistic health
care to diverse populations across the life span.
 Example: The traditional nursing interventions that were incorporated in this case
study included: medication administration, assessment, oral care of the ventilated
patient, and obtaining and recording patient information and data.
 Establishes and/or utilizes outcome measures to evaluate effectiveness of care.
 Example: In this case study, five nursing interventions were chosen and the top two
were discussed in detail including: outcome, interventions, and evaluations. The top
two nursing diagnosis chosen were “Impaired Gas Exchange” and “Ineffective Tissue
Perfusion”. In this patient’s situation, both diagnosis outcomes were only partially
met and future interventions were identified to assist with reaching goals of a positive
outcome.
 Communication
 Uses therapeutic communication within the nurse-patient relationship.
 Example: Therapeutic communication was used with the patient’s family while
discussing the patient’s future placement in a rehabilitation facility. This outlines
listening to families feelings, and answering questions that the family had regarding
the patient’s current status and future level of function.
 Research
 Evaluates research that focuses on the efficacy and effectiveness of nursing interventions.
 Example: In this case study, I used three nursing research articles to support nursing
interventions performed throughout the time of patient care. The first article, “A
nursing clinical decision support system and potential predictors of head of bed
position for patients receiving mechanical ventialtion” by Lyerla, LeRounge, Cooke,
Turpin, and Wilson from 2010 to support the use of a 45 degree bed angle to decrease
the risk of VAP. This research discussed an electronic tool that alerted nurses to
document the head of bed angle every four hours. Results showed that the nurses
became more compliant with the degree of angle by 60 percent, thus decreasing the
incidence of VAP. This article supports that the patient’s angle of bed to decrease
VAP.
 The second article, “” by Garcia, Jendresky, Colbert, Bailey, Zaman, and Mumjumder
in 2008 discussed the effects of oral care on VAP prevention. 1,538 patients on
ventilation for greater than 48 hours were observed while a oral care protocol was
enforced. Results showed that the total number of VAP during this time by 33
percent during the study period. This article supports the use of Sentara’s oral care
for mechanically ventilated patients.
 Lastly, the article “” by O’meara, Mireles-Cabodevila, Frame, Hummell, Hammel,
Dweik, and Arroliga in 2008 discussed the increase in complications in patients
whose enteral nutrition is interrupted. This article supports that mechanically
ventilated patients should be started on early enteral nutrition and that interuptions
should be minimized to increase positive outcomes. This patient was on enteral
nutrition early and interruptions related to testing and gastric residuals were
minimized throughout the patient stay.
 Leadership
 Articulates the values of the profession and the role of the nurse as member of the
interdisciplinary health care team.
 Example: In this case study I discussed the importance of multidisciplinary approach
for holistic and thorough care. This included physicians, nurses, respiratory therapist,
wound nurses and physical therapy. This was evidenced by the use of nursing led
multidisciplinary rounds every morning throughout the ICU setting. This allowed for
open discussion and decision making among the healthcare providers as a team,
improving communication and patient outcomes.
 Professionalism
 Differentiates between general, institutional, and specialty-specific standards of practice
to guide nursing care.
 Example: The American Association or Critical Care Nursing Stadards of Care
guidelines guided patient care by myself and the nurse throughout the patients care.
The standards discussed within the case study included assessment, implementation,
and collaboration. Comprehensive assessments were conducted through the entire
shift; including vital signs, oxygenation saturations, ventilator settings and drip and
tube feeding rates. Implementation of interventions such as, administering
medications, following mechanical ventilation protocol, and diagnostic testing were
performed throughout. Lastly, multidisciplinary collaboration among patient care
providers to discuss patient status and care occurred every day during morning
rounds.