Characteristics of admitted patients
In Australia as well as in other parts of the world the characteristics of the typical patient admitted for care is changing. Increasingly patients are presenting with complicated cases that occur in a co-morbid nature; whereby such patients present with more than one condition, resulting into numerous vulnerabilities that predispose the patient to deterioration if proper and vigilant care is not provided. Patient’s presenting with co-morbidities present a unique challenge to care givers, as they present a need for constant and vigilant observation, without which they at times may deteriorate in condition severely, and at times without timely intervention, they may even end up dying (Aehlert & Vroman, 2011). This deterioration may occur despite proper management and care, probably due to the mismanagement of the other co-occurring conditions other than the one that led to hospitalization. In less severe outcomes, the deterioration may lead to unplanned admissions into the intensive or high dependency units, or even cardiac or respitratory arrest, necessitating the calls for a code blue. As already mentioned, close monitoring of the vital signs of such can go a long way towards helping prevent such eventualities, by detecting the cause of the deterioration and addressing it early (Kollef & Isakow, 2012).
History of Present Illness
The patient is a married 90 year old male, with a height of 165 cm, weighing 74 kgs with a body mass index of 27.4 kg/m2. The patient was admitted with sepsis, delirium and a decreased state of consciousness. In addition the patient also had an exacerbation of CCF. The patient had a history of Ischaemic Heart Disease, observed by the fact that he had suffered a case of acute myocardial infarction (Mancia, Laurent, & European Society of Hypertension, 2011). This is further complicated by the fact that he was suffering from congestive cardiac failure, type 2 diabetes, hypertension, and chronic obstructive airway disease. Other conditions the patient is suffering from include: duodenal ulcers, gout, polymyalgia rheumatica and anxiety.
Current Treatment Options
In terms of medication, the patient was on antihypertensive medication such as Nebivolol, lercanidipine and Candesartan. He was also on coronary artery medication clopidogrel, anti-ulcer medication pantoprazole and anti-anxiety medication diazepam.
The patient was admitted for the management of sepsis, delirium and reduced consciousness.
Episode of deterioration explained
The patient experienced 2 cases of code blue:
First Code Blue
The first code blue occurred 3 days after admission, due to an altered state of consciousness, due to a GCS score of 4 and delirium. The patient appeared to be confused, incontinent and unco-ordinated. The main reason for the calling of the code blue, was the alarmingly low GCS score of 4. The patient was referred to the ICU for further management. Haemodynamic stability was achieved, with the GCS score improving to 13, with no localizing neurology, although the patient was still agitated. An Electrocardiogram on the patient revealed a Right bundle branch block and a Left anterior Fasicular block (Sanders, Lewis, Quick, & McKenna, 2012).
Second Code Blue
The second deterioration episode was a code blue called for de-saturation, as the patient had an oxygen concentration of 70% (SPO2), an alarmingly low level, indicative of poor respiration, perhaps even respiratory failure due to aspiration. Further, the patient had a low urinary output, indicating potential kidney failure, cold and clammy extremities indicating circulatory abnormalities, as well as showed signs of confusion, reaffirming failures in the respiratory as well as circulatory systems. The patient also had a significantly elevated blood pressure of 160/90mmHg and an elevated pulse rate of 111, indicative of sinus tachycardia. The basic life support criteria of ABC was followed in order to stabilize the patient (Mallet, Albarran, & Richardson, 2013). As such, airway management was the priority, with 12 litres of oxygen being administered within the first five minutes through a back and valve mask stat, leading to an improvement of the saturation level to 77%. This management ran concurrently with the monitoring of the patient’s vital signs every five minutes (Bope, Kellerman, Rakkel, & Conn, 2012). The administration of the second round of 12 litres of oxygen within five minutes led to a saturation of 85%, and 88% following the subsequent 5 minutes of administration of 12 litres of oxygen (15 minutes at 12 litres). This was followed by the administration of 3L for the subsequent five minutes, leading to an improvement to 95% and a subsequent drop to 91%, necessitating adjustment of the amount of oxygen to 5L for the next five minutes through a breath mask, leading to a saturation level of 94% (Criner, Barnette, & D’Alonzo, 2010). The monitoring of the vital signs revealed persistent Sinus tachycardia, and a rising blood pressure, reaching 190/70, although the diastolic remained within normal range. In order to enable the stabilization of the patient through use of IV fluids, an intravenous line was installed on the right arm within the first 10 minutes. Further, in order to correct the significantly elevated systolic pressure, 80mg of lasix was administered intravenously as a stat dose (Grossman & Rosen, 2011).
Physical Examination and Diagnostic Studies
Further, due to the need to rule out aspiration pneumonia a chest x-ray was done, with the family being consulted and consent for NFR being obtained, considering the patient’s advanced age and multiple complications. The patient was started on IV fluids and transferred to room 18, where due to his COAD he was put on Bilevel positive airway pressure (BIPAP) for 24 hours (Mebazaa, 2008). By mid day the following day, the patient was stable and alert, with an oxygen saturation of 94%. This conservative administration of O2 was due to the patients COPD, which made him a CO2 retainer, necessitating vigilant observation of pCO2 for any signs of hypercapnia. BIPAP was particularly selected because it reduces the effort required for breathing, while at the same time eliminates the chances of the patient experiencing dyspnoea. Because the patient was on BIPAP regular mouth care was done with Biotene mouth gel. Once he was off BIPAP speech pathology review was done due to intubation, and the fact that the patient was an aspiration risk (Albert, Spiro, & Jett, 2008). Lasix administration was continued twice a day in order to diuress the patient. Auscultation of the patient’s lungs showed no wheeze or bibasal crackles. There was however decreased air entry into the left base. The x-ray showed signs of mild pulmonary congestion due to infection.
Due to the infection, the patient was suspected to be suffering from reversible aspiration pneumonia, and was therefore, treated for the infection using IV antibiotics and maintained on IV Lasix, as well as using his prescription medicine. Further, the nursing management of the patient involved the strict monitoring of the vital signs, maintenance of an input output chart, with 1.5 fluid restrictions being effected due to the patient’s CCF and a continuous monitoring of the patient’s state of consciousness, using the Glascow Coma Scale (Cooper, 2008). Due to the immobile nature of the patient, 2 hourly turning was done to maintain skin integrity, as well as the maintenance of personal and oral hygiene. The physiotherapist was also involved to ensure the patient remained fairly active to prevent the occurrence of atrophy as well as other conditions such as orthostatic pneumonia, especially considering the degree of respiratory distress the patient has suffered and the potential effects of allowing any further deterioration in respiratory function Carskadon, Lee-Chiong, & Sateia, 2007). Constant monitoring and measurement of Urea and Electrolytes as well as potassium was constantly done, due to the administration of Lasix, as well as the fact that potassium is a cardiac electrolyte (Steinberg, Myers, & Jaipaul, 2008). In cases where the levels of potassium dropped significantly, slow potassium 600mg was administered I.V. After the second code blue, an ECG was repeated with no significant changes being noted (Ferrell & Coyle, 2010). Further, due to the patient’s history of CCF and AMI, vigilant monitoring of cardiac function was done, with the family members also being incorporated and advised on further management of the patient
Mr. X-Man, presents an example of the numerous cases that usually complicate due to the existence of multiple conditions affecting patients, especially of an advanced age. Such patients usually present with co-morbid conditions, which undoubtedly make them vulnerable to infections, while at the same time slowing their speed of recovery. In the case of Mr. X-Man, the existence of prior obstructive pulmonary disease led to his deterioration, more so due to the fact that impaired respiratory function was further complicated by the existence of a pulmonary infection. Although the patient was admitted due to delirium and sepsis, his condition took a significant turn for the worst due to a simple chest infect that would otherwise not have led to the significant levels of de-saturation observed (Muir, Ambrosino, & Simmonds, 2008). Further, the fact that he also had significant cardiovascular system abnormalities, made him significantly more vulnerable to any further complications. Based on this one case, it is obvious that the monitoring of the vital signs for patients of such advanced ages, as well; as patients presenting with comorbid conditions, must be done with utmost vigilance and any slight variation from the normal reported promptly (Stacey, 2012). Each variation must also be treated uniquely, more so when it touches on the systems that have been compromised by the conditions in question. For instance, the decreased levels of oxygen saturation, indicated impaired respiratory function, an examination of the lungs through auscultation and the use of an X-ray confirmed the existence of an infection, which once treated, led to the stabilization of the patient (Hughes & Blacke, 2011). In short, the cause of deterioration can at times be inferred from the findings of regular monitoring, more so the abnormal findings. A full head to toe secondary assessment of the patient was done as indicated in Appendix 2. Finally the patient was discharged for further care, management and observation at a rehabilitation centre. Prior to discharge, health education on nutrition and on the need to observe daily for any weight changes was emphasized, with the dietician providing a comprehensive recommendation on the type of diet the patient must observe in light of his cardiac condition (Azuaje, 2007).
Can any of you think of relevance of the activity we did at the start of the presentation to the case study?
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Albert, R. K., Spiro, S. G., & Jett, J. R. (2008). Clinical respiratory medicine. Philadelphia: Mosby / Elsevier.
Azuaje, F. (2007). Bioinformatics and Biomarker Discovery: Omic Data Analysis for Personalized Medicine. Hoboken: John Wiley & Sons.
Bledsoe, B., Porter, R., & Cherry, R. (2012). Paramedic Care: Principles and Practice, Volume 3, Patient Assessment (4th Ed.). Prentice Hall
Bope, E. T., Kellerman, R. D., Rakel, R. E., & Conn, H. F. (2012). Conn’s current therapy 2012. Philadelphia, Pa: Saunders.
Carskadon, M. A., Lee-Chiong, T. L., & Sateia, M. J. (2007). Sleep medicine. Philadelphia, Pa: Hanley & Belfus.
Cooper, N. (2008). Essential Guide to Acute Care. Oxford: John Wiley & Sons.
Criner, G. J., Barnette, R. E., & D’Alonzo, G. E. (2010). Critical care study guide: Text and review. New York: Springer.
Ferrell, B. R., & Coyle, N. (2010). Oxford Textbook of Palliative Nursing. Oxford: Oxford University Press, USA.
Grossman, S. A., & Rosen, P. (2011). Cardiovascular problems in emergency medicine: A discussion-based review. Chichester, West Sussex: John Wiley & Sons.
Hughes, M., & Black, R. (2011). Advanced respiratory critical care. Oxford: Oxford University Press.
Irwin, R. S., & Rippe, J. M. (2008). Irwin and Rippe’s intensive care medicine. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Kollef, M. H., & Isakow, W. (2012). The Washington manual of critical care. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Mallett, J., Albarran, J., & Richardson, A. (2013). Critical Care Manual of Clinical Procedures and Competencies. Chicester: Wiley.
Mancia, G., Laurent, S., & European Society of Hypertension. (2011). Reappraisal of European guidelines on hypertension management: A European Society of Hypertension Task Force document. London: Springer Healthcare Ltd.
Mebazaa, A. (2008). Acute heart failure. London: Springer.
Muir, J.-F., Ambrosino, N., & Simonds, A. K. (2008). Noninvasive Ventilation. Sheffield: European Respiratory Society Journals.
Sanders, M. J., Lewis, L. M., Quick, G., & McKenna, K. (2012). Mosby’s paramedic textbook. St. Louis, Mo: Elsevier/Mosby Jems.
Stacey, V. (2012). Revision notes for MCEM part B. Oxford: Oxford University Press.
Steinberg, D. I., Myers, J. S., & Jaipaul, C. K. (2008). Evidence-based medical consultation. Philadelphia, Pa: Saunders / Elsevier.
Secondary System Assessment
The Central Nervous System
The patient was alert and appropriate; with an initial GCS score of 13. However, the patient was still slightly delirious and agitated. A complete CNS assessment revealed no localized neurologic lesions, with an assessment of the pupil dilatation revealing no abnormalities (PEARL).
The Cardiovascular System
Circulation was normal with warm extremities, and slight peripheral oedema, partly due to the CCF. On auscultation, the heart sounds were present. The patient’s B.P was stable, at 140/70. Following an ECG, the patient was found to have RBBB and LAFB. In addition, the chest X-ray also revealed an enlarged heart, consistent with CCF.
The Respiratory System
Although the patient reported a slight shortness of breath, there were no signs of respiratory distress. The oxygen saturation levels were 94% when put on 4 litres of oxygen via face mask, although air entry to the left base was markedly lower on auscultation of chest, partly due to the chest infection as well as the COPD. Bibasal crackles were also present on auscultation with no wheeze, as well as signs of chest congestion.
The Digestive System
There was slight abdominal distension, with fluid found in the peritoneum. Although reduced, bowel sounds were present in all four quadrants.
The urine passage was regular and of the required quantity, as per the intake, more so considering that the patient was on lasix. The patient passed stool regularly, of the required texture and color, although the quantity was less than expected. The patient was still incontinent, hence maintained on a catheter.
Due to the regular turning and pressure area care, the skin was intact, with no instances of pressure ulcers.
Social Support Systems
The patient was discharged to a rehabilitation centre, as although he has a wife and two daughters who are very supportive, and seem keen to participated in his further management, the complicated nature of the patient’s condition necessitated further professional care that could not be home based (Bledsoe, Porter, & Cherry, 2012).