Comprehensive Care Plan for Critically Ill Patient

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Table of Contents

Introduction
Pathophysiology
Medication Regimen
Laboratory and Diagnostic Data
Assessment
Cultural and Spiritual Aspects of Care
Nursing Plan of Care
References

Introduction

The patient was admitted with hypotension, hypoxia, and ventilator dependent respiratory failure. Upon initial examination, septic shock was assumed as the diagnosis, which was subsequently confirmed through the failure to maintain the patient’s blood pressure by intravenous fluid administration, which is a sign of resistance to hypotension treatment characteristic of septic shock (Yealy et al., 2014). Most dangerous possible complications include multiple organ dysfunction (heart, kidney, respiratory, liver).

Important aspects of the patient’s past medical history are chronic respiratory failure, a cerebrovascular accident with subsequent left hemiplegia, multidrug-resistant with recurrent infections, and epilepsy. The patient’s advance directive allows for all interventions that may be required to restore breathing or heart functioning in case of failures; these possible interventions effectively include the application of a breathing tube and defibrillation.

The patient has spent two days at the hospital. The patient lives with family and receives support from them as well as a visiting social support person. Transferring the patient to a nursing home has been repeatedly discussed. Recommendations proposed by physicians are in favor of this option. The patient was previously treated with gastrostomy and feeding tube placement, which determines certain potential discharge needs, such as constant monitoring for alerts. The patient’s bedbound status is debatable: a patient can transfer to a chair and sit up.

Pathophysiology

The patient has multiple medical conditions, which shapes the complexity of the clinical picture and patient experiences. It is necessary to take into consideration various aspects of the pathophysiological developments to address the complex state effectively. The most pertinent diagnoses include septic shock, anemia with tachycardia, and toxic metabolic encephalopathy. The pathophysiology of septic shock is understood through severe sepsis processes associated with the immune system’s and blood coagulation responses to infection normally caused by bacteria (Yealy et al., 2014). In response to inflammation caused by infection, anti-inflammatory substances are produced by the patient’s organism, which constitutes the compensatory anti-inflammatory response that leads to suppression of the immune system. Suppressed immune system presents risks of secondary infections.

Anemia with tachycardia is a state of increased cardiac output as a response to the low concentration of hemoglobin (Camaschella, 2015). Toxic metabolic encephalopathy occurs when various substances participating in metabolism are altered and begin to negatively affect the brain (Sharma, Eesa, & Scott, 2012). These substances may include water and electrolytes and may come from kidney and liver waste. Other diagnoses of the patient include malnutrition, decubitus ulcer stage four (due to the patient’s lifestyle; deep wound affecting muscles and possibly bones with the formation of eschar), ischemic colitis (poor blood supply of the large intestine causing damage and inflammation processes), and thrombocytopenia (a low number of platelets in the blood that may cause poor coagulation and various associated complications, such as internal bleedings).

Medication Regimen

Table 1. All Scheduled Medications and All PRN Medications Given within the Last 48 Hours.

Medication	Class	Action	Dosage	Rationale	Nursing Monitoring
Albuterol-ipratropium	Bronchodilator	Dilation or enlargement of the bronchi by relaxing the muscles surrounding the airways.	2 inh 4 times a day	Respiratory issues	Inhalation according to instructions
Atorvastatin	Reductase inhibitor	Reduction of low-density lipoprotein and triglycerides in the blood and increasing high-density lipoprotein	10 mg to 20 mg once a day	Stroke and heart attack risk factors	Dosage and signs of the necessity to stop the use
Dextrose 50% PRN	Sugar	Restoring blood glucose levels	0.8 g/kg/hr	Hypoglycemia	Scheduling injections
Fondaparinux	Anticoagulant	Prevents deep vein thrombosis	7.5 mg once a day	Thrombosis risks	Signs of bleeding
Glucagon	Peptide hormone	Increases blood sugar	1 mg once a day	Hypoglycemia	Scheduling injections
Hydrocodone with acetaminophen PRN	Narcotic pain reliever	Relieving pain	15 ml as needed	Moderate to severe pain	Sign of the necessity of use
Hydromorphone PRN	Opioid pain reliever	Relieving pain	1 mg to 2 mg as needed	Moderate to severe pain	Sign of the necessity of use
Lansoprazole	Proton pump inhibitor	Decreasing the amount of acid generated in the stomach	15 mg once a day	Conditions involving excessive stomach acid, such as stomach and intestinal ulcers	Giving through a feeding tube and flushing
Levetiracetam	Anticonvulsant	Treating partial onset seizures and myoclonic seizures	500 ml twice a day	Epilepsy	Signs of necessity
Meropenem Q8H	Antibacterial	Treating severe infections (skin and stomach)	500 ml every 8 hours	Sepsis caused by infection	Scheduling injections
Vancomycin oral solution Q6H	Antibiotic	Treating infections in the intestines	125 mg 4 times a day	Sepsis caused by infection	Scheduling
Metronidazole Q8H	Antibiotic	Treating infections in the stomach and respiratory tract	7.5 mg/kg every 6 hours	Sepsis caused by infection	Scheduling
Magnesium sulfate	Inorganic salt	Laxative	1 g every 6 hours	Constipation	Dosage
Potassium chloride	Inorganic salt	Treating and preventing hypokalemia	40 to 100 mEq a day	Mitigation of other medications’ negative effects	Dosage

Considering the number of applied medications and the vastness of health problems addressed, the drug interactions should be examined with scrutiny. The patient’s age (55 years old) is an age of risk for several medications listed above. Also, the patient’s history of heart problems should be taken into account with possible reduction of the use of those drugs that indicate fast heart rate as their side effects. Also, a particularly challenging drug interaction in this case is the use of levetiracetam and meropenem. Among many antibacterials, meropenem is known to possibly cause seizures (Tanaka et al., 2013), which is why its use in this case may need to be reconsidered.

Laboratory and Diagnostic Data

Table 2. Laboratory Tests Results and Comments.

Laboratory Test	Result	Comment
White blood cell count	Leukocytosis or leukopenia	The presence of endotoxins may lead to leukopenia
Platelet count	Thrombocytosis or thrombocytopenia	Indicates an acute response
Coagulation cascade	Protein C deficiency and antithrombin deficiency	Abnormal response out of the context of organ dysfunction or bleeding
Creatinine level	Above baseline	May indicate acute injury
Lactic acid level	Lactic acid above 4 mmol/L	May indicate tissue hypoxia
Liver enzyme levels	Above alkaline phosphatase, AST, ALT, bilirubin levels	May indicate acute hepatic injury
Serum phosphate level	Hypophosphatemia	Inversely proportional to indicators of inflammation from the immune system
C-reactive protein (CRP) level	Above baseline	Indicates an acute response
Procalcitonin level	Above baseline	Differentiates systemic inflammatory responses to infections from noninfectious responses
Blood pressure test	Hypotension	Primary indication of septic shock
Blood tests	Hypoglycemia, anemia	Tissue hypoxia as a result an a characteristic of shock

Assessment

Physical assessment of the patient detected such characteristics and developments as generalized edema, diminished lung sounds, and hypoactive bowel sounds, which are abnormal and serve as possible indicators of inflammation, sepsis, and septic shock. Additional indicators needed for confirming the diagnosis come from assessing microvascular and cellular changes. Activation of inflammatory and coagulation cascades can be observed along with the dilation of blood vessels and the dysfunctional distribution of microvascular blood flow. Combined with the laboratory test results, physical assessment may indicate maldistribution of oxygen and nutrients on the microvascular level. All these developments may not be clearly displayed in vital signs, which makes them hard to detect under the conditions of a clinical examination.

However, vital signs examination can indicate certain relevant developments, such as tachycardia (fast heart rate, more than 100 BPM) and fever (presenting evidence for inflammation processes). Also, oxygen / ventilation settings were reduced, which showed the necessity for appropriate drugs (see Medication Regimen), and the patient had an indwelling catheter.

Cultural and Spiritual Aspects of Care

It has been repeatedly stressed by researchers and health care practitioners that cultural differences and religious or ethnical characteristics of patients can become barriers in providing high-quality care (Levesque, Harris, & Russell, 2013). The fundamental reason for that is a lack of understanding between medical staff and a patient. Also, there are often cases where a patient may be unwilling to follow treatment instructions or cooperate with physicians and nurses due to his or her beliefs. In this context, traditions should not be disregarded, as the communication between patients and providers, which is a prerequisite for appropriate care, can be undermined if a nurse or a doctor fails to adopt such forms of communication and interaction that are acceptable and appropriate according to the patient’s cultural norms.

In the examined case, no such complications are expected because the patient and the medical staff share cultural context. The members of the medical team are diverse, i.e. they are representatives of different ethnicities and religions, but years of working together have taught them to overcome possible misunderstandings and cooperate effectively. This indicates that health care providers will also be able to find appropriate forms of communicating with the patient.

Another important aspect of care is family engagement. For better patient outcomes, the medical team should strive for establishing favorable relationships with the patient’s family members and close one. Since the patient is critically ill, there is a need for intensive psychological support from the family, and a role of a nurse in this context is to create an environment where family members understand their role in treatment and their importance for it and are encouraged to provide the patient with necessary support.

Nursing Plan of Care

Table 3. Actual Nursing Diagnoses.

Nursing Problem / Diagnosis	Overall Outcome / Goal	Nursing Interventions	Rationales	Evaluation
Hyperthermia	No complications will occur. The temperature will be balanced. The patient will demonstrate normal temperature and be free of adverse effects of fever.	A nurse should measure temperature and change (add or reduce) bed linens accordingly. Also, a nurse can provide sponge baths and a cooling blanket, if necessary.	High temperature comes from infection and immune responses and it can cause the patient considerable discomfort that may disrupt other aspects of treatment, which is why it should be alleviated.	The patient’s positive feedback on the feeling of temperature will be used as an indication of success or failure.
Impaired gas exchange	Respiration is unlabored, and blood gases are within normal range.	A nurse should position the patient properly to promote better ventilation.	The patient’s improper position makes breathing harder.	Eventual independent breathing.
Deficient knowledge	The patient will understand the main aspects of care and measures taken under it. Also, the patient will acquire relevant knowledge on how to contribute to better health outcomes through behavioral patterns.	A nurse should explain disease processes and treatment and discuss diet, drug therapy, and side effects.	A critically ill patient may experience perplexity and fear because of facing a grave disease. Explaining the disease will improve the patient’s psychological state and ensure that the patient’s behavior is adequate to the condition.	The patient will be asked a series of questions after conversations with a nurse to assess whether the materials delivered by the nurse were understood and correctly interpreted.

References

Camaschella, C. (2015). Iron-deficiency anemia. New England Journal of Medicine, 372(19), 1832-1843.

Levesque, J. F., Harris, M. F., & Russell, G. (2013). Patient-centred access to health care: conceptualising access at the interface of health systems and populations. International Journal for Equity in Health, 12(1), 18-29.

Sharma, P., Eesa, M., & Scott, J. N. (2012). Toxic and acquired metabolic encephalopathies: MRI appearance. American Journal of Roentgenology, 193(1), 879-886.

Tanaka, A., Takechi, K., Watanabe, S., Tanaka, M., Suemaru, K., & Araki, H. (2013). Comparison of the prevalence of convulsions associated with the use of cefepime and meropenem. International Journal of Clinical Pharmacy, 35(5), 683-687.

Yealy, D. M., Kellum, J. A., Huang, D. T., Barnato, A. E., Weissfeld, L. A., Pike, F., … Angus, D. C. (2014). A randomized trial of protocol-based care for early septic shock. New England Journal of Medicine, 370(1), 1683-1693.