Critical Care Nursing: Interdisciplinary Care.

Critical Care Nursing: Interdisciplinary Care. An interdisciplinary approach, relies on health professionals from different disciplines, along with the patient, working collaboratively as a team. The most effective teams share responsibilities and promote role interdependence while respecting individual members’ experience and autonomy. If you need assistance with writing your nursing literature review, our professional nursing literature review writing service is here to help!

Critical Care Nursing: Interdisciplinary Care.

Background Information Summary.


Demographics:
Patient K.L is a fifty-two-year-old, Caucasian female; of Italian decent. She is married and lives with her spouse and three children ages 25, 21 and 13. K.L. worked as an Elementary school teacher for the past twenty-five years. She is currently on medical leave for the past few years due to health issues. She was a social drinker and never smoked. Denies any history of past alcohol or drug use.


History of present illness
: Patient presented to the emergency room in a wheelchair on May 19th, 2019 with manifestations of shortness of breath, and confusion. Husband stated over the past few days she has become increasingly confused before that patient has been doing well following review of oncology recently started on oral chemotherapy pill Verzenio about three to four weeks ago.


Past Medical History:
K.L. was diagnosed with stage 4 breast cancer ten years ago. Recently patient was diagnosed with metastasis to the adrenal, iliac crest, liver and spine. She also has history of gastrointestinal reflux disease. Patient is O2 dependent and uses 2L O2 at home.


Past surgical History:
Bilateral pleurX drain. Bilateral mastectomy and Abdominoplasty.


Admitting diagnoses:
Patient admitted for sepsis, bilateral pneumonia, hyponatremia and neutropenia.


Course of current hospitalization to date:
Patient was admitted to the emergency room for shortness of breath, and acute confusion. Despite confusion patient remains alert and oriented. Patient stated “I have been under a lot of stress this week” says symptoms have been going on for the last few days, but becoming increasingly worse.

Patient was placed on Vancomycin 1.25g IVPB, Zosyn 3.375g IVPB and placed on neutropenic precautions due to low white blood cell count. Blood work, blood cultures, were done. A chest x-ray, 12 lead EKG was performed in the ED. Results showed sinus tachycardia and right bundle branch block. Patient had CT Scan of the brain. Order pending for sputum culture. Upon admission to the ICU a deep vein thrombosis (DVT) was found in the patient’s right leg at which time an Intra vena cava filter (IVC filter) was placed.


Significant assessment findings during days of care:
Vital signs


Time

Temperature

HR

RR

BP

SaO2
0730 36.4C 108 23 118/81 87% on 2L O2
0930 98 22 93/67 97% on 5L O2
1000 97 23 93/67 86% on 2L O2
1030 36.5 C 105 20 97/72 93% on 4L
1100 88 22 100/72 94% on 4L O2
1130 96 22 95/74 98% on 4L O2
1230 36.5 C 100 23 101/79 99% on 4L O2


Focused Assessment

Patient is alert and oriented to person, place, and time her speech is clear. Skin is consistent with ethnic background unblemished and is warm and dry. Head is normocephalic with no lumps or lesions present. Hair is evenly distributed thin texture. No signs of infestations. Nail beds pink and capillary refill is brisk less than 3 seconds. Pupils are equal in size and PERRLA round, reactive to light and accommodation. Sclera is white and conjunctiva is pink. Pulses are 3+ and equal bilaterally. Breath sounds throughout crackles, course, diminished.

Left upper and lower lobes crackles, coarse. Right upper lobe fine crackles and diminished. Right middle lobe and right lower lobe diminished. Respiratory rate and rhythm excursion symmetrical no use of accessory muscles, no cough, productive sputum or shortness of breath. Abdomen non-tender, upon palpation with no lumps, lesions or masses noted. No rebound tenderness. Bowel sounds are present in all four quadrants. Patient has Pure wick female external catheter.

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Monitoring Devices

K.L. was being monitored continuously while in the intensive care unit. She had a five- lead bedside heart monitor. Spo2. blood pressure, temperature, respiratory rate and heart rate were being monitored continuously.


Laboratory and Diagnostic Tests


Diagnostic tests:
Patient had chest x-ray, duplex ultrasound of right leg and CT scan of brain.


Laboratory tests:
Abnormal findings


Lab test

Results

Normal Reference Range

Reasoning
Sodium 120 (L) 134-142 mEq/L Due to hyponatremia. Administering new chemotherapy drug Verzenio
Calcium 7.5 (L) 8.5-10.5 mg/dL Due to cancer diagnosis
Total Protein 6.0 (L) 6.4-8.2 g/dL Due to cancer diagnosis
Albumin 1.9 (L) 3.4-5.0 g/dL Due to cancer diagnosis
Alk. Phos. Total 220 (H) 40-150 u/L Due to chemotherapy medication/treatment
WBC 4.0 (L) 4.5-11.0 Due to chemotherapy medication or infection
RBC 3.4 (L) 4.2-5.4mcL Due to chemotherapy medication
Hgb 11.1 (L) 12- 16g/dL Due to chemotherapy medication
Hematocrit 32.2 (L) 37-47% Due to chemotherapy medication
Platelet 51 (L) 150-450 uL Due to sepsis
Glucose 148 (H) 70-110 May be pre-diabetic
Phosphorus 1.6 (L) 2.5-4.9 Possibly from malnutrition
PCO2 64 (H) 35-45 mEq/L Possibly due to respiratory acidosis
HCO3 31 (H) 24-26 mEq/L Possibly due to metabolic alkalosis

(Mosby’s Diagnostic and Laboratory Test Reference 2015)


Rationale for diagnostic and laboratory tests

Laboratory and diagnostic testing is done as part of routine checkups as well as looking for changes in the patient’s health, monitor diseases, and help physicians to diagnose medical conditions. K.L. had the following diagnostic and laboratory testing. A CT scan of the brain was done to check for metastasis to the brain from breast cancer.

The chest X-ray was done to check lungs for pneumonia. Duplex ultrasound of the leg was done to identify deep vein thrombosis (DVT). Intra Vena Cava filter was placed in groin to filter blood and reduce the risk of pulmonary embolism. Chest x-ray showed bilateral pneumonia. CT scan of brain was negative. The negative CT scan of the brain indicates no metastasis of cancer to the brain.

A complete blood count (CBC) was ordered for the patient to determine and or detect a wide range of disorders pertaining to the patient’s overall health. A comprehensive metabolic panel (CMP) was done to check the patient’s fluid balance. Knowing the levels of electrolytes such as sodium, potassium is crucial in knowing how well the patient’s kidneys and liver are working. An ABG is a blood test to measure the Ph, levels of oxygen, and carbon dioxide coming from an artery. The test was used to check the patient’s lungs and the ability to move oxygen and remove carbon dioxide form the body.


Medications

Trade name
Xanax
Generic name Alprazolam
Classification Benzodiazepine
Therapeutic use Treatment of anxiety
Major adverse effects CNS: Dizziness, drowsiness, lethargy, confusion, hangover, headache, mental depression, paradoxical excitation. EENT: blurred vision. GI: constipation, diarrhea, nausea, vomiting. DERM: rashes. MISC: physical dependence, psychological dependence, tolerance.
Nursing implications Teach client to take medication exactly as prescribed. May cause drowsiness or dizziness. Older clients may have increased “hangover effect” in the morning and are at increased risk for falls. Avoid drinking grapefruit juice during therapy.

Avoid the use of alcohol or other CNS depressants con-currently with these drugs. Kava, valerian, and chamomile can increase CNS depression. Assess degree and manifestations of anxiety during therapy. Monitor CBC with differential and liver and renal function. Showing no

Route/Dosage/Reason given 0.5 mg tablet oral, PRN every 6 hours/anxiety
Trade name
Zosyn
Generic name Piperacillin
Classification Anti-infective/extended-spectrum penicillins
Therapeutic use Treatment of infection
Major adverse effects CNS: seizures at higher doses, confusion, dizziness, headache, insomnia, lethargy. GI: diarrhea, constipation, drug-induced hepatitis, nausea, vomiting. GU: interstitial nephritis. Derm: rashes Hemat: bleeding, leukopenia, neutropenia, thrombocytopenia. Local: pain, phlebitis at IV site. Misc: hypersensitivity reactions including anaphylaxis and serum sickness, fever and superinfection.
Nursing implications Teach client to report rash/itching immediately. Notify HCP if fever and diarrhea occue, especially if stool contains blood, pus or mucus. Obtain specimens for culture prior to beginning medication. Assess for improvement of infection. Obtain a history before initiating therapy to determine previous use of and reactions to penicillin’s or cephalosporin’s Observe patient for signs and symptoms of anaphylaxis. Evaluate CBC, serum K+, BUN, serum bilirubin, alkaline phosphatase, and PT/aPTT.
Route/Dosage/Reason 3.375 gm IVPB/ sepsis
Trade name
Xarelto
Generic name Rivaroxaban
Classification Anticoagulant
Therapeutic use Prevention and treatment of DVT and PE.
Major adverse effects CNS: confusion, dizziness, headache, insomnia. CV: edema, hypotension. GI: constipation, diarrhea, dyspepsia, increased liver enzymes, nausea, vomiting. GU: urinary retention. Derm: bullous eruption, hematoma purpura, rash. Hemat: bleeding, thrombocytopenia. F and E: hypokalemia. Misc.: fever, increased wound drainage.
Nursing implications Teach client to report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever, swelling or difficulty breathing. Assess for signs of bleeding and hemorrhage from any orifice. Assess for evidence of additional or increased thrombosis. Monitor for neurologic changes. Monitor platelet count closely. Monitor CBC, serum creatinine levels and stool for occult blood during therapy.
Route/Dosage/Reason 20 mg orally daily for DVT
Trade name
Solu-MEDROL
Generic name Methylprednisolone
Classification Anti-inflammatory (steroidal) agent, immunosuppressant/glucocorticosteroids.
Therapeutic use Systemic and local treatment of a wide variety of inflammatory diseases and conditions. Suppresses inflammation and the normal immune response.
Major adverse effects CNS: depression, euphoria, headache., personality changes, psychoses, restlessness. EENT: cataracts, increased intraocular pressure. CV: HTN. GI: peptic ulceration. Derm: acne, hirsutism, petechiae. Endo: adrenal suppression, hyperglycemia. F and E: fluid retention, hypokalemia. Hemat: thromboembolism, thrombophlebitis. Metab: weight gain, hyperglycemia. MS: muscle wasting, osteoporosis, aseptic necrosis of joints, muscle pain. Misc: cushingoid appearance, increased susceptibility to infection.
Nursing implications Teach client not to stop medication suddenly. Avoid grapefruit juice and limit caffeine when taking oral forms. Monitor I & O, daily weights, edema, lung sounds, serum electrolytes and glucose level. Give with food in the AM to decrease gastric upset.
Route/Dosage/Reason 125 mg IV push daily / pneumonia
Trade name
Vancomycin
Generic name Proamatine
Classification Anti-infective
Therapeutic use Treatment of life threatening infections.
Major adverse effects EENT: ototoxicity. CV: hypotension, massive histamine release called “red man syndrome” with rapid IV infusion. GI: nausea, vomiting. GU: nephrotoxicity. Derm: rashes. Hemat: eosinophilia, leukopenia. Local: phlebitis. MS: back and neck pain. Misc: anaphylaxis, superinfection.
Nursing implications Teach client that oral forms are to be taken exactly as prescribed. Report tinnitus, rash, vertigo, hearing loss, flushing, of the skin or dizziness. Perform culture and sensitivity tests prior to initiating therapy. Monitor the IV site closely to avoid extravasation.

Monitor blood pressure and presence of skin flushing throughout IV infusion. Monitor I&O and daily weight. Cloudy or pink urine may be a sign of nephrotoxicity. Assess bowel status. Monitor CBC with differential and liver and renal function. Monitor peak and trough drug levels. Report toxic levels immediately. Administer IV over at least 60-90 minutes to prevent “red man syndrome”.

Route/Dosage/Reason 1 gm IV push, for sepsis
Trade name
Diflucan
Generic name Fluconazole
Classification Antifungal
Therapeutic use Treatment of fungal infections caused by susceptible organisms.
Major adverse effects CNS: headache, dizziness, tremor, seizures. GI: hepatoxicity, abdominal discomfort, diarrhea, nausea, vomiting. Derm: skin disorders. Endo: hypokalemia, hypocalcemia, hypomagnesemia, hypertriglyceridemia. Misc.: allergic reactions, including dyspnea, hypoxia, wheezing CV: hypotension, arrhythmias. GU: nephrotoxicity, hematuria, MS: arthralgia, myalgia. Neuro: peripheral neuropathy.
Nursing implications Teach client to take medication as prescribed. Notify health care provider if skin rash, abdominal pain, fever, diarrhea, unusual fatigue, anorexia, nausea, vomiting, jaundice, unusual bruising, bleeding, palpitations, dark urine, or pale stools occur. Report any development of a rash immediately.

Obtain specimens for culture before therapy starts. Monitor LFT, RFT, and CBC with differential. Monitor vital signs every 15-30 minutes during test dose and every 30 minutes for 2-4 hours after administration of amphotericin. Assess respiratory status daily after administration of amphotericin.

Route/Dosage/Reason 20 mg tablet, by mouth daily for neutropenia.
Trade name
Lovenox
Generic name Enoxaparin
Classification Anticoagulant
Therapeutic use Prevention of DVT and PE
Major side effects CNS: dizziness, headache, insomnia. CV: edema. GI: constipation, nausea, vomiting, Derm: ecchymosis, pruritus, rash. Hemat: bleeding, anemia, thrombocytopenia. Local: pain in the injection site, hematoma. Misc.: fever, hypersensitivity. Neuro: epidural or spinal hematoma with use during spinal procedures.
Nursing implications Teach client to report any symptoms of unusual bleeding or bruising to health care provider immediately. Do not take concurrently with antiplatelet agents. Use soft toothbrush and an electric razor. Follow instructions for proper method of injecting the drug. Assess client for signs of bleeding and hemorrhage. Monitor for hypersensitivity reactions. Monitor CBC with platelets and D-dimer studies. Monitor LFT. Antidote is protamine sulfate.
Route/Dosage/Reason 40mg sub-q injection daily for DVT

(Davis Drug Guide 2017)

Critical Care Nursing.
Critical care nurse career overview.


Nursing Diagnoses


1

: Risk for fluid and electrolyte imbalance related to side effects of treatment-related medication

Interventions

: Monitor I & O’s and weigh client daily. Monitor lab values.

Nursing outcomes

: Patient’s will display a heart rate, blood pressure and laboratory results within normal limits. Patient will have absence of muscle weakness. Patient will show no neurological irritability.

Collaborative interventions

: Refer patient to nephrology consult in order to monitor renal function. Refer patient for neurology an PT consult.

2

: Impaired gas exchange related to inflammation of airways and alveoli secondary to pneumonia as evidence by tachypnea.

Interventions

: Assess respiratory rate, rhythm, depth and use of accessory muscles Assess patient’s mental status and any changes in level of consciousness.

Nursing outcomes

: Patient will demonstrate improved ventilation and oxygenation of tissues. Patients ABG’S will be within acceptable range. Patient will show no signs of respiratory distress.

Collaborative interventions

: Refer patient for pulmonology consult. Refer to respiratory therapy for treatments.

3

: Imbalanced nutrition: Less than body requirements related to hypermetabolic state due to cancer as evidenced by inadequate food intake, altered taste sensation and loss of interest in food. and generalized edema.

Interventions

: Monitor patient’s daily food intake. Encourage patient to eat high-calorie, nutrient rich foods and have adequate fluid intake. Encourage the use of supplements.
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Critical Care Nursing: Interdisciplinary Care.

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