ICU Observation Evidence-based Practice
ICU Observation Evidence-based Practice
Introduction of the Patient
The patient goes by the name T.P. A 72-year-old male who’s a retired truck driver. He’s immediate family includes his wife, daughter, and grandson (10 years old who is autistic and has turrets syndrome). He is currently diagnosed with myocardial infarction and altered mental state. The past medical history of this patient shows that he has suffered a lot of diseases including hypertension, diabetes mellitus Type 2, congested heart failure, peripheral neuropathy, CKD-3, CAD, dementia, chronic kidney disease and GERD.
The primary medical diagnosis is myocardial infarction which refers to regional myocardial necrosis that is typically endocardium-based. It is usually secondary to the occlusion of an epicardial artery. The occlusion is a result of an atherosclerotic plaque which stimulates the creation of an intracoronary thrombus. If the occlusion persists for, more than twenty minutes, irreversible myocardial damage and cell death occur.
The development of an atherosclerotic plaque occurs over a long period usually years to decades. The two core characteristics of a clinically significant symptomatic atherosclerotic plaque are an underlying lipid core and a fibro muscular cap. Plaque erosion is what follows due to the actions of metalloproteases and the freeing of other proteases and collagenases in the plaque (Burke & Virmani, 2007). Consequently, thinning the overlying fibro muscular cap. The hemodynamic forces coupled with the action of proteases lead to the disruption of the endothelium and rupturing of the fibro muscular cap and the vessel wall. Structural stability of the plaque is usually lost at the juncture of the vessel wall and the fibro muscular cap, a site commonly known as the shoulder region. When the endothelial surface is disrupted, thrombus formation may occur due to the platelet-mediated activation of the coagulation cascade. If the thrombus is large enough to obstruct coronary blood flow, myocardial infarction (MI) can result (Burke & Virmani, 2007).
MI can have unique clinical manifestations in individual patients. However, despite the diversity in clinical manifestations there are those characteristic symptoms which include chest pain described as a fullness, pressure sensation or squeezing at the midpoint of the thorax; associated dyspnea; impairment of cognitive function and syncope without other cause; associated diaphoresis and radiation of chest pain into the teeth, jaw, arm, shoulder, or back. 50% of the patients are said to have some warning symptoms (angina pectoris or angina equivalent) before the actual infarct.
Nursing Care given to the Patient
A lot of medication is prescribed for the patient after they are diagnosed with MI. Aspirin is one of them. It is an anticoagulant agent. It inhibits the formation of thromboxane A2 and irreversibly interferes with the function of cyclooxygenase. In just a matter of minutes, aspirin interferes with platelet cohesion and adhesion and bars additional platelet activation hence preventing thrombus formation. Some of its common side effects include gastrointestinal ulceration, cramping, upset stomach and abdominal pain.
Metoprolol was also prescribed for the patient. It was aimed at reducing blood pressure. It is a beta blocker. Thus, it decreases the force and rate of myocardial contraction and lowers the overall myocardial oxygen demand (Rang, Dale, Ritter, Flower, & Henderson, 2012). It has some side effects with the most serious being bronchospasms, bradycardia and heart failure.
Humalog (sliding scale) highly is efficient in achieving normal blood glucose levels within a short period in patients with DM2. It works by regulating glucose metabolism. It brings down blood glucose levels by inhibiting hepatic glucose production and stimulating peripheral glucose uptake by skeletal fat and muscle (Rang et al., 2012). It also inhibits proteolysis and lipolysis and enhances protein synthesis. Some of its side effects include diarrhea, abdominal pain, nausea, asthenia, myalgia, bronchitis, rhinitis, and pharyngitis.
Digoxin which in this case has been administered to control the heart rate is very effective as it works directly on the heart muscle. It increases the force of heart muscle contraction and also slows down the rate at which the heart beats. Consequently increasing the efficiency of each heartbeat when it comes to pumping blood around the body. It also slows down electrical conduction between the ventricles and the atria of the heart. Some of the common side effects of include loss of appetite, bloody or black stool, blurred vision, confusion, and hallucinations (Rang et al., 2012).
When it comes to diet for the above patient the dietician may be more specific regarding the type of foods, he is supposed to consume. The goal is to drop extra weight for those who are already obese, get more active and lower the cholesterol levels. Consequently, helping in the prevention of and complication of heart disease, which is more common when one has diabetes. Fat should be limited to 25%-35% of the total daily calories. No more than 7% of the patient’s daily calories should come from saturated fat, up to 20% from monounsaturated fats (from things like nuts or plant oils) and less from polyunsaturated fats. Carbohydrates should make up 50%-60% of the daily calories and about 20-30 grams of fiber per day. Proteins should make up 15%-20% of the daily calories.
Some of the treatments administered during the day of care include Humalog (sliding scale) that was given two units subcutaneous to help lower blood sugar levels. Metoprolol, 12.5 mg per oral was administered to control blood pressure. Aspirin, 325 mg per oral was given as anticoagulant. Potassium, 5.7 was given intravenously to prevent arrhythmias.
Some of the monitoring methods that were used include cardiac telemetry whereby cardiac signals (pressure or electric derived) are transmitted to a receiving location where they get displayed for monitoring of cardiac activity including contractility and rhythmicity. Electrocardiogram (EKG) is a test used to record electrical activity over multiple heart beats and comes up with an EKG strip that is interpreted by health care practitioners. Blood glucose monitoring is the primary tool the patient has to check their diabetes control. It may involve the use of test strips and a meter that displays the glucose readings instantly.
The EKG strip was done at 10:00 am showed that the patient had sinus tachycardia (90-100) with premature ventricular contractions (PVC’s). A PVC occurs when a focus on the ventricle produces action potential right before the next scheduled Sino atrial nodal action potential. The EKG strip displayed a regular rhythm, a fast rate (90-100), a normal P wave that was merging with T wave at a very fast rate, PR interval was also normal (0.12-0.20se), the QRS complex was normal (0.60-0.10sec). It also showed that the QT interval was shortening when the heart rate was increasing.
Interpretation of ABGs
The pH usually determines the presence of alkalemia or academia. In this case, the pH is 7.35 (normal range 7.35 – 7.45) which is within normal range hence the patient does not have alkalemia or academia (Baylis & Till, 2009). Arterial PCO2, which reflects either alveolar hypoventilation or hyperventilation is normal in this case 39 mmHg (normal 35-45). PO2 when less, indicates hypoxemia but in our case 94 mmHg is within the normal range (80-100). Base excess of -4 mmol/L indicates metabolic acidosis since it is low (normal -2 - +2). Low HCO3 of 21.9 mmol/L (normal 22-30) indicates chronic alkalosis. HCO3, which is produced by the kidney, acts as a buffer to ensure a normal pH. Oxygen saturation of 97% is within a normal range (95-100%) hence, the patient has no hypoxemia.
Roles of the Multidisciplinary Team for the Patient
The multidisciplinary team is composed of different health professionals each having a different role to play so as to ensure delivery of comprehensive care to the patient. In a myocardial infarction and altered mental status management program, the core of the team comprises of a cardiologist, a cardiac care nurse, and a psychologist. These and other healthcare professionals are responsible for proper treatment, diagnosis, and care of the patient.
The cardiac care nurse has a major role in counseling and education of the patient and family and aiding the patient when they present with symptoms and signs of deterioration. Furthermore, they can help the patient in learning to live with the consequences of heart attack, which means: diet and exercise, comply with a regimen including medication. Also, monitor symptoms and seeking assistance when they occur, and take relevant actions in the event of exacerbation – for example, adjusting the dosage of medication and alerting health care providers.
The primary care physician is also involved in the patient's course of the heart attack at several stages. It commences with the important role of prevention of further complications through constant assessment of the various body systems. Also, he has a crucial role in the initial diagnosis, subsequent follow-up arrangement, and implementation of evidence-based treatment. All activities aimed at maximizing prognosis.
On the other hand, the dieticians can aid in the evaluation of dietary intake, formulation of tailored advice regarding precise patient needs (for example, combine a diabetes diet with a heart attack diet) and help the patients in the improvement of compliance with a prescribed nutrition recommendation.
Pharmacists have a well-established role in monitoring the interactions and possible treatment of side effects when new drugs are initiated. Also, the pharmacist can provide advice to the physician in choosing the appropriate drugs and doses and improving compliance and patient’s knowledge of M1. Studies have shown that goal setting and patient education by pharmacists can increase patient compliance, patient knowledge and the appropriateness of medication taken by the patient.
Psychologists can help patients cope with the altered mental state that can be linked to the effects of MI in their daily life. They can also help cardiac care nurses and doctors particularly to look for and identify manifestations of depression in patients with MI at an early stage.
The roles of the intensive care unit (ICU) nurse and the general floor nurse are very distinct when it comes to certain aspects of their work. When it comes to patient load, the medical, surgical nurse has to handle more patients per shift probably five to eight as compared to only two or sometimes three by the ICU nurse. However, these two or three patients looked after by the ICU nurse take up much of their time probably from the start to the end of the shift. In some cases, general floor nurses encounter patients that require two hourly assessment but in ICU, the patient needs two hourly assessment and charting promptly after they are done.
When it comes to the knowledge base, the differences between the two become even more distinct. On the general floor, there are IV pumps, telemetry boxes, compression devices, continuous motion machines and other standard equipment of the nursing profession. However, this is not the case in ICU. First off, learning how to successfully operate a ventilator could take up a whole nursing school class. It requires a wider knowledge base since it is temperamental, complex, and necessary to get to know how to operate them correctly.
Other equipment in the ICU includes aortic balloon pumps, banks of IV pump and bedside dialysis. The ICU nurse has to know which medication lowers or increases the blood pressure and the settings that are going to manifest those changes in the patient. Furthermore, ICU nurses have to know how to work this equipment without the help of others. Consequently, necessitating the need for a wider knowledge base. However, general floor nurses occasionally get help from other health professionals such as respiratory therapists. This shows that there is no need for a wider knowledge base for general floor nurses.
Nurses must be equipped with efficient organizational skills as it is a prerequisite in the provision of excellent patient care. However, the organizational skills vary among the different nurses in a hospital setup. For example, general floor nurses require more organizational skills as compared to the ICU nurse because they manage lots of patients per shift. One of the vital organizational skills is prioritizing. Out of the five to eight patients that general nurse has to care for she must prioritize them appropriately so that the patients benefit maximally from the care being provided. The prioritization requires thorough analysis and assessment of the patient’s conditions. On the other hand, prioritization is not more profound for ICU nurses who only need to care for two or three patients.
Basic Nursing Care for a Patient on a Ventilator
When it comes to airway management, a lot is to be taken into consideration. It is worth noting that the cuff on the tracheostomy or endotracheal tube provides airway occlusion. Proper inflation of the cuff ensures that the patient gets the proper ventilator parameters such as oxygenation. While observing the hospital policy, measure for proper inflation pressure after inflating the cuff using the minimal occlusive volume or the minimal leak technique. These techniques help prevent damage caused by high cuff pressure and tracheal irritation. Air should never be added to the cuff without using proper technique.
Infection prevention is also another is also another aspect of patient care on a ventilator which if not observed may lead to the development of complications such as ventilator-associated pneumonia (VAP). Some of the infection prevention techniques include providing oral care with chlorhexidine daily. This will keep bacteria out of the oral secretions. Making use of an endotracheal tube that has a suction lumen that is above the endotracheal cuff to allow for continuous suctioning of the tracheal secretions that collect in the subglottic area. Brushing the patient’s teeth twice a day and providing an oral moisturizer every 2 to 4 hours.
The positioning of the patient is also vital when it comes to managing a patient on a ventilator. Changing the patient's position is associated with twisting and bending of the patient’s circuit, accidental extubation, and changes in the patient’s level of oxygenation. Reduced oxygenation can occur with repositioning of the patient whereby the diseased lung is positioned in a dependent manner. Changes in a patient’s position can cause pulmonary embolism a thrombus may be dislodged and migrate to the lungs. All this must be taken into consideration when positioning the patient on a ventilator. It is recommended that the patient is placed in a prone position with the head at 35-40 degrees.
Poor patient outcomes can result from inappropriate ventilator pressure alarm volume settings. This can be prevented by being familiar with the ventilators in the facility since not all ventilators have similar features or safety mechanisms including alarms. Confirming that audible pressure alarms can be heard in the environment of use. The facilities protocols should be followed to ensure ventilator setting information is relayed to other staff members particularly during patient admissions, transfers and during shift changes. Also during one’s shift and as clinically intended the ventilator settings should be corrected, and pressure alarms are appropriately set. When the pressure alarm of the ventilator is heard, the nurse should respond quickly and intervene appropriately.
Nursing Infection Control Intervention Observed in the ICU Setting
Hand hygiene is vital to patient care in the ICU setting and is extremely cost effective. Continuous monitoring and encouragement with reinforcement of policies on hand hygiene are vital to improving and maintaining compliance rates and in the reduction of ICU-acquired infection rates.
A hand hygiene task force compiled trials that compared alcohol to soap-based foam and determined that alcohol-based gel/foams are more effective in reducing bacterial colony counts and in reducing the number of multidrug-resistant pathogens as compared to the traditional hand washing with soap and water. This is true with the exception of visibly soiled hands and for health care personnel that are caring for patients with spores-forming organisms since the form does not kill the spores. Studies have shown no profound differences difference in bacterial colony counts on the hands of ICU staff who made use of alcohol-based foam versus chlorhexidine-containing antiseptic (Hyaustralia, 2010). However, the former is more cost effective and produces less skin irritation.
2 Ways Evidence-based intervention will Affect Nursing Practice
The evidence-based intervention provides for patient-centered care. It helps in the identification, respect, and care for patients expressed needs, preferences, values, and differences. This ensures faster relief of pain and suffering. The evidence-based practice also ensures proper coordination of continuous care as it encourages the nurse to listen to, communicate with, clearly inform and educate the patients (Scott & McSherry, 2009). Also, it advocates for disease prevention and promotion of a healthy lifestyle which includes a focus on population health.
Evidenced-practice also affects the practice of an RN by applying quality improvement. This involves identification of errors and hazards in care. It goes further to include understanding and implementing basic safety design principles including simplification and standardization. It fosters continuous understanding and measuring of quality of care regarding outcomes, process, and structure of the patients and community needs. Lastly, it will encourage designing and testing of interventions so as to change the processes and systems of care with the sole aim of improving quality.
References
Baylis, C., & Till, C. (2009). Interpretation of arterial blood gases. Surgery (Oxford), 27(11), 470–474.
Burke, A. P., & Virmani, R. (2007). Pathophysiology of acute myocardial infarction. The Medical Clinics of North America, 91(4), 553–72; ix.
Hyaustralia, W. (2010). Prevention and Control of Infection in Healthcare. National Health Medical Research Council.
Rang, H., Dale, M., Ritter, M., Flower, R., & Henderson, G. . (2012). Pharmacology. Rang and Dale’s Pharmacology.
Scott, K., & McSherry, R. (2009). Evidence-based nursing: Clarifying the concepts for nurses in practice. Journal of Clinical Nursing, 18(8), 1085–1095.
