Running Head: NURSING CARE OF MR. R. S.
Nursing Care of Mr. R. S. in the GICU
Trishana Wallace
Old Dominion University
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Nursing Care of Mr. R. S. in the GICU
On October 14th 2014 Mr. R.S. was flown to Norfolk General Hospital from
Albemarle Hospital in Maryland. The 64 year old white male was found
unresponsive and incoherent that evening by his nephew. After performing a CT
scan, free air was found in his peritoneum from a suspected peptic ulcer disease
perforation. An exploratory laparotomy, gastric biopsy and graham patch procedure
was performed on Mr. R.S. in order to identify the location and severity of the ulcer.
In addition the procedure was used to repair the perforation. The procedure went
well however, the patient was severely acidotic towards the end the procedure. This
required the need to for continued intubation. He also required the use of a central
and arterial line to be placed in order to closely monitor his hemodynamic status
due to hypotension and the need for vasopressor therapy. The following paper will
address the medical and nursing care that Mr. R. S. received and how they relate to
one another.
Reason for ICU Admission and Pathophysiology
The patient was initially admitted to the intensive care unit because he had
severe metabolic acidosis. This required him to remain intubated and closely
monitored. Following his last surgical procedure Mr. R.S. had a blood pH of 7.21;
blood carbon dioxide level of 41.7; blood oxygen saturation of 116% and blood
bicarbonate level of 18.1. High blood pH, and low blood bicarbonate values are
indicative of metabolic acidosis (Kraut & Nicolaos, 2010). A low blood pH is a result
of the break down of fat into keto-acids to be used as energy in the absence of
glucose. This causes the blood acid level to increase. When the body has too little
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oxygen to perform metabolic functions, lactic acid is produced from anaerobic
respiration and increases the blood’s acid level as well. A low bicarbonate level is
result of a decrease in production from kidney dysfunction, dehydration or liver
dysfunction. Over elimination of bicarbonate, as in the case with diarrhea or
vomiting, can also result in base deficit that precludes metabolic acidosis
(Ignativicius & Workman, 2013). Without sufficient oxygen, the accumulation of
lactic acid causes blood vessels to loose their tone and hypotension results
(Ignativicius & Workman, 2013). The use of vasopressor therapy and hemodynamic
monitoring was necessary in order to stabilize his condition. Mr. R.S also exhibited
confusion, weakness, sensory and speech changes. These signs could be indicative of
multiple alterations in metabolic functions including lack of oxygenation to the
brain, alcohol toxicity, and accumulation of blood toxins as a result of liver damage.
Nursing Diagnosis
In order to treat Mr. R.S.’ medical problems several nursing diagnosis were
created that addressed different aspects of his presenting medical status to the
intensive care unit. Altered tissue perfusion was related to excess blood acid
production, which caused the inability of his blood to carry sufficient oxygen to his
tissues. This risk was increased by vasodilation as well.
The patient also displayed impaired gas exchange related to fluid
accumulation in the bases of his lungs. This diagnosis is also further purported by
the development of aspiration pneumonitis. Crackles heard on auscultation,
continued use of mechanical ventilation and positive expository pressure indicated
the need for this nursing diagnosis as well.
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Mr.R.S. had a risk for bleeding related to liver dysfunction, mal-nourishment,
gastric bleeding from his peptic ulcer disease multiple skin ulcers and the placement
of a central and arterial line. Evidence for this diagnosis include a hemoglobin level
of 6.8, a hematocrit level of 21 as well as multiple bruises on his arms.
A psychosocial nursing diagnosis would include anxiety as this related to the
use of mechanical ventilation, as well as an unfamiliar environment, personnel and
procedures. Mechanical ventilation is a prominent stressor for ICU patients because
it hinders them from getting adequate rest, communicating effectively and
significantly limits their mobility (Yucel, Eser, Guler & Khorshid, 2011). This was
demonstrated by severe irritability during routine assessments and nursing care,
which required the use of sedation as well as restraints. Another appropriate
nursing diagnoses was ineffective coping mechanisms related to the death of his
wife. Evidence for this diagnosis is indicated by his relapse of alcohol abuse prior to
hospital admission.
Correlation of a Nursing Theory
Nursing theorist George Engel created the nursing theory termed the Biopsychosocial Model in order to create a holistic approach to providing medical care.
His theory required the nurse and physician to understand the biological,
psychological as well as sociological factors that affect the health of their patient. His
perspective on patient care was an alternative to the method health care providers
used in which a plan of care was created based solely on the biological or
physiological cause of illness. This model doesn’t necessarily illustrate a way to
prioritize Mr. R.S.’ nursing diagnosis. It is based on the idea that all biological,
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sociological and psychological factors contributing to an illness are equally
important (Ghaemi, 2009). To conclude that the nursing diagnoses of impaired gas
exchange should take priority over the diagnoses of anxiety would not be an
illustration of the use of Engel’s model. Instead, it would be more appropriate to
create a plan of care that placed equal importance on all of his diagnosis.
Prioritization of the Nursing Diagnosis
According to Mr. R.S’ family and medical history he struggled with alcoholism
and recently relapsed from sobriety. His wife passed away the same day that he was
admitted to Albermarle Hospital. Using Engel’s theory to plan care for Mr.R.S. his
nurse should incorporate this information as the psychological basis for his medical
problems. Metabolic acidosis was caused in part by liver damage as well other
metabolic damage created by a large amount of alcohol consumption. The alcohol
consumption was caused by a lack of coping skills in dealing with the death of a
loved one. With this in mind the top three nursing diagnosis should include a risk
for impaired tissue perfusion, impaired gas exchange and anxiety.
Interrelatedness of the Nursing Diagnosis
These nursing diagnosis can be related by using Engel’s theory to understand
the psychosocial and pathological basis for Mr.R.S. health status. The death of his
wife created a crisis of which was the catalyst for him to begin excessively using
alcohol as a coping mechanism. Stress caused by this event was not adequately
managed by the alcohol use but instead perpetuated damage to his gastrointestinal
system caused by peptic ulcer disease. The perforation caused by this disease
process created further health issues. The perforation strained the body’s capacity
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to effectively oxygenate itself. Acid production increases from lack of oxygen caused
further damage and dysfunction of the body’s metabolic processes. These processes
put the patient at risk for inadequate gas exchange as well as impaired tissue
perfusion. The combination of the death of his wife, along with the stress, pain and
discomfort of the medical attention that followed is the basis for the severe anxiety
manifested in Mr.R.S.’ behavior.
Outcomes for Nursing Diagnosis
The nursing outcome for altered tissue perfusion was to have a mean
arterial blood pressure of at least 60 mm Hg within two hours of admission to the
intensive care unit and for the remainder of the patient’s hospital admission. The
outcome for impaired gas exchange was to have a blood oxygen saturation of 98%
within one hour of admission to the intensive care unit and for the remainder of the
patient’s hospital admission.
Interventions for Altered tissue perfusion
In order to prevent Mr. R. S. from having further organ damage, his
physicians implemented a number of interventions to control and monitor his
hemodynamic status.. Norepinephrine and Midodrine were prescribed as a means
to raise this patient’s blood pressure by causing vasoconstriction (Lilley, Collins
Snyder, 2014). A central venous catheter was also placed in order to closely monitor
alterations in fluid volume. This device measures the pressure of blood in the right
side of heart and allows health care providers to ascertain the need for fluid
resuscitation. (Urden, Stacy, Lough & 2014). An arterial blood pressure monitoring
system was placed in the patient vascular system as well. This device measures
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systole, diastole and mean arterial pressure and provides the medical team with an
indication of how well blood is flowing through the patient’s arterial vasculature.
The goal for Mr. R.S. was to have a mean arterial pressure of 60 mm Hg which
indicated that his vital organs were being perfused adequately (Urden, Stacy, Lough
& 2014). A pilot study was conducted in the cardiology unit of a Brazilian teaching
hospital to evaluate the efficacy of nursing interventions implemented to manage
patients with fluid volume imbalance. A total of 83 interventions were evaluated
and hemodynamic monitoring was among those that ranked the highest in terms of
its usefulness (De Lopes, De Barros, Liliane & Michel, 2009).
The nurses caring for this patient played a significant role in implementing
and managing the interventions set forth by his physicians. Because the nurse
administered blood pressure-altering medications, the need to assess and document
these changes in Mr. R.S was imperative. If his blood pressure raised significantly
higher then his baseline, the nurse would need to question whether the
administration of the drug was appropriate based on the parameters set by his
physician. Because Mr. R.S. was receiving norepinephrine via continuous infusion it
was important for his nurse to also monitor for side effects including dysrhythmia
and alterations in neurological status such as seizures (Lilley, Collins Snyder, 2014).
Caring for a patient with a central venous monitor requires several nursing
interventions to ensure accuracy of reading and safety to the patient. The nurse was
required to keep the monitor level with the site of the access portal. This eliminates
the risk for inaccurate reading of central venous pressure. To prevent complications
such as air emboli the nurse needed to keep the patients head of bed below 60
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degrees as well as listening for murmurs over the right side of the heart (Urden,
Stacy & Lough, 2013).
Other nursing interventions used to monitor the status of MR. R.S.’ tissue
perfusion was his skin color, bowel sounds, level of consciousness and urine out put.
A decline in any of these attributes could be an indication that an insufficient
amount of blood was circulating to the organs that control these functions.
Preventing infection by using aseptic technique during dressing changes for the
blood pressure monitoring ports is also necessary to the safety of the patient.
Interventions for Impaired Gas exchange
Mr. R.S.’ arterial blood pH was 7.21 following his exploratory laparotomy
procedure. This indicated the need for mechanical ventilation. He was also
prescribed Albuterol and Atrovent via nebulizer treatment. This medication helps to
open the patient’s bronchiole passageways allowing oxygen to flow through the
lungs for better gas exchange. The physician ordered these two medications in the
event that Mr. R. S. appeared to have respiratory distress symptoms such as
wheezing or difficulty clearing his airway. The nurse and the respiratory therapist
worked cohesively to implement this intervention. The nurse had the responsibility
of assessing the patient’s lungs for adventitious sounds and notifying the respiratory
therapist promptly of significant changes. Once notified, the respiratory therapist
would initialize nebulizer treatment. Following the treatment the nurse would
continue to assess the patient’s respiratory status in order to evaluate the efficacy of
the treatment. In addition, the nurse was also required to notifying the rapid
response team if they observed the patient displaying signs of acute respiratory
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distress. Indications for this intervention included a sudden drop in blood pressure
or blood oxygen saturation that continuous to fall despite other nursing
interventions utilized to correct the problem (Urden, Stacy & Lough, 2013).
Other indications included an abrupt change in ventilation settings in which the
system will switch to an emergency ventilator mode to compensate for the lack of
respiratory effort made by the patient.
Mr. R.S.’ nurse also needed to employ measures to prevent ventilator
associated infection by using oral care such as Chlorhexidine swabs, brushing and
suctioning on a routine basis. These interventions help to reduce the amount of
bacteria in the patient’s airway from traveling to the lungs. A study comparing three
methods of oral care to prevent ventilator associated pneumonia revealed that the
mechanical removal of plaque was what determined the efficacy of each method
rather than the substance used (Berry, Davidson, Masters, Rolls & Ollerton, 2009).
Other interventions to monitor for the development of this complication include
assessing for a temperature increase as well as a change in white blood cell count. A
rise in either of these values is indicative of a possible infection.
Teaching
After Mr. R.S. was ex-tubated it was apparent that he was very confused and
did not understand the reasoning behind his medical treatment. This presented his
nurse with many teaching opportunities. For example, because of his severely
malnourished state he was given enteral feedings. He had recently developed
pneumonitis from the aspiration of his stomach contents, which increased the need
for a nasogastric feeding tube. He did not understand the need for the tube and
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pulled it out on several occasions. He was very uncooperative and refused to allow
us to have it replaced. Finally, his nurse and I talked with him about the importance
of him receiving his feedings. We explained that he was expressing very confused
and erratic behavior and because of this it was legally and medically appropriate for
us to place the tube as it was in his best interest. He finally conceded to the
procedure after some struggle and did not pull it out for the remainder of the
clinical day.
Evaluation of the Plan of Care for Altered Tissue Perfusion
Mr. R.S. was admitted to the GICU on October 27th and by the 29th his mean
arterial pressure reached 63 mm Hg which indicated that the nursing outcome for
altered tissue perfusion was partially met. I was not able to access Mr. R.S. medical
records to determine whether his MAP stayed at this value. However, the plan of
care to monitor and stabilize his tissue perfusion was effective based on the
consistency of his MAP value throughout the clinical week that I cared for him.
There was an instance during my care in which one of his medications needed to be
held because of its potential adverse affects. Metoprolol is indicated to treat
tachycardia as well as to help the heart pump blood efficiently. Our patient’s pulse
rate during the morning clinical shift of the 28th of October was about 90 beats per
minute. It wouldn’t have been appropriate to give the patient this medication
because it would have made his heart rate slow even further. Our decision to hold
the medication was based on the understanding that lowing his heart rate further
could decrease blood perfusion to his vital organs.
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Additional interventions implemented to help tissue perfusion included
allowing this patient to get out of bed and recline in a chair once he was ex-tubated.
This activity helps the patient use their muscles to stimulate the flow of blood
though the body’s vasculature. In addition, clots are prevented from forming from
lack of movement of the extremities.
Evaluation of the Plan of Care for Impaired gas Exchange
The plan of care to improve gas exchange was effective based on the
significant improvement of Mr. R.S.’ blood gas values. Our patient’s blood oxygen
saturation remained above 100% while he was mechanically ventilated. By October
28th Mr.R.S. blood pH went from 7.21 to 7.34. His blood carbon dioxide level
changed from 41.7 to 35.7 and his bicarbonate level changed from 18.1 to 19.3. This
was a significant improvement and indicative of the body’s ability to compensate for
increased acid production. On October 29th Mr. R.S. was stable enough to be extubated. His blood oxygen saturation remained between 96 to 100% for the
duration of the clinical week. As previously mentioned, I wasn’t able to revisit this
patient’s medical records to see whether these values remained a constant. The
outcome for impaired gas exchange is partially met based on lack of information.
Conclusion
Mr. R.S. was admitted to the hospital because of his altered mental status and
treated for complications of a peptic ulcer perforation. He developed fluid in his
pleural cavity, which resulted in him becoming severely acidotic. Damage to his liver
and severe malnourishment along with other factors contributed to poor tissue
perfusion. Although he was in poor condition after his reparative surgery, the use of
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mechanical ventilation, hemodynamic monitoring and medication to improve gas
exchange and blood flow helped this patient’s respiratory and hemodynamic system
to become stabilized.
Mr. R.S was the first patient I cared for during my ICU rotation and was the
most interesting. Watching his nurse care for him taught me a lot about the
knowledge base and confidence critical care nurses have to have in order to make
independent decisions about medication use and assistance from other specialized
medical personnel. This patient suffered a lot emotionally with the loss of his wife
and as result, caused significant damage to his body with the use of alcohol. Mr. R.S.
may have been discharged in physically stable condition but if he doesn’t get
assistance with grieving the loss of his wife he may very well continue to abuse
alcohol and cause himself to be admitted to the hospital again. His care in the ICU
focused mainly on stabilizing his physiological status. However nurses must
remember to incorporate interventions in their care that focus on the psychological
contributions to the illness as well.
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References
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Çinar Yücel, Ş., Eşer, İ., Kocaçal Güler, E., & Khorshid, L. (2011). Nursing diagnoses in
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