Running head: CLIENT CASE STUDY

Client Case Study

Victoria Grigorita
Old Dominion University

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Client Case Study

For this assignment the student nurse selected one patient admitted to the Intensive Care
Unit (ICU) at Sentara Virginia Beach General Hospital. The student then collected information
on the patients health status during preclinical and clinical days. Based on the information
collected and knowledge utilized from nursing literature and theory, the student created an
individualized plan of care. The student then proposed interventions and evaluated patients
prognosis. The paper is supported with several nursing research articles, which were used to
analyze the patients situation and provide scientific rationale for the proposed interventions.
SV is a single 60 year old male, who presented to emergency department with complaints
of abdominal distention and 4+ pitting edema of lower extremities. Per computerized
tomography (CT) scan results, the diagnosis of pneumoperitoneum was made and exploratory
laparotomy was recommended. In addition, peripheral vascular lab procedure was done, which
demonstrated bilateral deep venous thrombosis (DVT) at the level of groin. Lastly,
echocardiogram was performed, and the diagnosis of heart failure with ejection fraction of 15%
was determined. At this point, the patient was admitted to ICU. When the patient was approached
with the plan of care, he refused surgery and expressed a desire to leave the hospital against
medical advice to take care of affairs. The patient ended up staying in a hospital for several
days for management of blood pressure and edema. However, on the third day his status
significantly worsened as he progressed to ventilatory respiratory failure. While being in severe
respiratory distress, the patient verbally consented to all treatments to keep [patient] alive.
Following intubation, emergency exploratory laparotomy was performed. However, due to the
delay in treatment, the patient developed sepsis. This, in turn, led to multiple organ dysfunction
syndrome, particularly, acute kidney failure.

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Medical Diagnosis

The patients main medical diagnosis is pneumoperitoneum, a condition where air and/or
fluid are present in the abdominal cavity. Normally, the cavity is covered with two layers:
parietal, which covers abdominal wall, and visceral, which covers internal organs within the
cavity. Between the layers, there is a serious fluid, which serves as a lubricant. When air and/or
fluid enter this space, pneumoperitoneum occurs (Ignatavicius, 2013). This condition is a
concern because it can lead to an increase in intra-abdominal pressure. This, in turn, can cause
hyperventilation, decreased cardiac output, infection, and abdominal compartment syndrome.
The most common causes of pneumoperitoneum are perforated abdominal viscous, abdominal
trauma, bowel obstruction, peritoneal dialysis, and abdominal surgery.
The patient presented with abdominal distention after recent fall. Patients vital signs
were the following: temperature 98.7, blood pressure 102/76, heart rate 103, respiratory rate 28,
and oxygen saturation 95% on room air. CT scan was performed, which demonstrated large
volume of air and fluid in the abdomen compatible with a raptured viscous. The diagnosis of
pneumoperitoneum was made. Due to the need for intensive monitoring and immediate
intervention secondary to life-threatening condition, the patient was admitted to ICU.
At this point, abdominal bleeding and sepsis were not suspected (HGB 13.2, HTC 41.1,
WBC 8.8, and PCT 3.8). However, due to failure to comply with the medical advice, exploratory
laparotomy was delayed. On the third day of hospitalization patents status worsened. Prolonged
increase in abdominal pressure pushes the diaphragm into the thorax (Behazin, Novero, Novack,
Talmor, & Loring, 2014). This caused a decrease in lung volume and, therefore, worsened
oxygenation status (PO2 75). As a compensatory mechanism, respiratory rate increased causing
hyperventilation and, therefore, increase in carbon dioxide blow-off (RR 28, PCO2 19.2).

CLIENT CASE STUDY

Simultaneously, due to prolonged time of unrepaired perforated bowel, the patient

developed sepsis (WBC 12.1, PCT 14.36, temp 101F). Bacteremia resulted in increased
production of lactic acid secondary to anaerobic respiration. This, in turn, worsened oxygenation
status (PO2 54). As a result of compensation for metabolic acidosis, the rate of carbon dioxide
blow-off increased. Unfortunately, in the situation of this patient, his breathing couldnt keep up
with the demand to ventilate, which resulted in ventilatory respiratory failure.
Upon patents consent, intubation and emergency exploratory laparotomy were
performed. During the surgery, it was explored that the cause of pneumoperitoneum was
perforated diverticulum. The ruptured section was removed and a colostomy was created in the
left lower quadrant. Despite the fact that surgery was performed, the patient developed severe
sepsis due to the delay in treatment. Systemic inflammation led to third spacing and perceived
hypovolemia, which significantly lowered patients blood pressure (78/61). This situation was
worsened by patents heart failure and bilateral DVT, which tremendously decreased ability to
circulate blood efficiently. Subsequently, drop in cardiac output led to pre-renal kidney failure.
Nursing Diagnosis
Top five nursing diagnoses were identified for this patient. Primary nursing diagnosis is
ineffective breathing pattern. It is related to decreased lung capacity and ventilatory respiratory
insufficiency secondary to increased intra-abdominal pressure as evidenced by increased
respiratory rate (28), decreased partial pressure of carbon dioxide (19.2), and decreased partial
pressure of oxygen (54). In addition, ineffective breathing pattern is related to lactic acid buildup secondary to systemic infection and metabolic acidosis as evidenced by Kussmaul breathing
pattern, increased respiratory rate (28), and decreased partial pressure of oxygen (54).

CLIENT CASE STUDY

Secondary nursing diagnosis is decreased cardiac output. It is related to a decreased

systemic vascular resistance and increased capillary permeability secondary to systemic
inflammatory response. It is also related to a decreased myocardial contractility secondary to
bacteremia and systemic acidosis. It is evidenced by change in level of consciousness,
hypotension (78/61), tachycardia (103), decreased urine output, concentrated urine, and
generalized weakness.
The third nursing diagnosis is risk for infection. It is related to systemic spread of
bacterial organism secondary to the delay in treatment of ruptured diverticulum as evidenced by
changes in level of consciousness, fever (101), leukocytosis (WBC 12.1), and positive blood
cultures (gram negative E. coli). It is also related to presence of abdominal wound, endotracheal
tube (ET Tube), Foley catheter, and central venous line placement, which increases risk for
infection.
The fourth nursing diagnosis is imbalanced nutrition: less than body requirements. It is
related to the prolonged nothing by mouth (NPO) status secondary to the delay in treatment of
perforated abdominal viscous. It is also related to the postoperative NPO status and poor
functioning of new colostomy. It is evidenced by hypoactive bowel sounds in all four quadrants
and absence of colostomy output during four days post-surgery. Lastly, it is evidenced by
increased residuals of tube feeding via orogastric tube.
The fifth nursing diagnosis is deficient knowledge. It is related to an acute change in
health status, new condition, complexity of treatment, misinterpretation of information, and
emotional state affecting learning. It is evidenced by verbalizing inaccurate information, noncompliance with medical recommendations, and willingness to leave against medical advice in a
life-threatening condition.

CLIENT CASE STUDY

Several nursing theories were used for selection and prioritization of diagnoses. Evelyn
Adam in her Conceptual Model for Nursing focuses on nursing responsibility for meeting the
patents fundamental needs (Johnson & Webber, 2010). Some of the basic needs for human
survival are adequate breathing and circulation. Without both of them working adequately,
people are not able to survive. Therefore, ineffective breathing pattern and decreased cardiac
output are two primary nursing diagnoses. According to E. Adam, by facilitating these needs, the
nurse promotes patients independence. While in the case of this patient, he is not able to be fully
independent, improvement of respiratory and cardiovascular status will help to facilitate tissue
perfusion, which can further improve overall patients status. Another theory that supports these
two diagnoses is Conservation Principles by Myra Estrin Levine. In her theory she talks about
the importance of conserving energy for faster recovery (Johnson & Webber, 2010). It takes
much effort for a patient to breathe and circulate blood; therefore, assisting patient in meeting
these needs will help conserve energy necessary to recover.
The next theory utilized was Environmental Model by Florence Nightingale. In her
theory she describes 12 concepts essential for prevention of illness and restoration of health
(Johnson & Webber, 2010). Five of the concepts focus on environmental and personal
cleanliness. Therefore, risk for infection is included in top five nursing diagnoses. Based on
clinical presentation and lab results, patient has already developed infection. Therefore, active
restoration of personal cleanliness is necessary for this patient. Besides, this patient has several
invasive lines, such as ET Tube, Foley catheter, and central venous line, which put patient at an
increased risk for infection. Therefore, maintenance of personal and environmental cleanliness is
of tremendous importance.

CLIENT CASE STUDY

Nutrition is another fundamental need. Both theorists, Evelyn Adam and Florence
Nightingale, speak about importance of good nutrition. It is a nursing responsibility to assure
adequate nutrition intake. In addition to being advocates of good nutrition, nurses should also
provide environment that facilitates appetite and intake of food.
The last theory that was used in the selection of nursing diagnoses is Interpersonal
Relations in Nursing by Hildegard E. Peplau. In her theory she speaks about importance of
nurses and patients to become partners (Johnson & Webber, 2010). She describes nurses as
teachers and counselors who not only provide physical care through technical skills, but also
provide information and help recognize and resolve problems. This is very important as it gives
patients an opportunity to become responsible for their own health and be able to make informed
decisions. Upon discharge from the hospital, the patients successful outcomes will depend on
patients ability to manage his own health. Therefore, deficient knowledge, which was
demonstrated by the patient, is very important to address.
Outcomes
Patients outcomes for two primary nursing diagnoses were identified. Patients outcome
for ineffective breathing pattern is patient's breathing pattern will be improved by the end of
hospitalization as evidenced by successful weaning from intubation, regular respiratory pattern
and rate (12-20), oxygen saturation within normal limits (95-100) on room air, appropriate skin
color, partial pressure of carbon dioxide within normal limits (35-45), and partial pressure of
oxygen within normal limits (80-100). Patients outcome for decreased cardiac output is patient
will maintain adequate cardiac output by the end of hospitalization as evidenced by successful
wean from vasopressors, urine output greater than 30mL/hr., heart rate within normal limits (60100), systolic blood pressure greater than 90, warm and dry skin, and return of level of

CLIENT CASE STUDY

consciousness to patents baseline. The time frame, by the end of hospitalization, was chosen
because of the complexity of treatments. In order to successfully wean patient off ventilator,
patient has to be off vasopressors. However, most likely blood pressure will remain an issue until
sepsis is resolved.
Interventions
Interventions for the diagnosis of ineffective breathing pattern should be focused on
maintaining adequate oxygenation with the goal of weaning the patient off the ventilator.
Ongoing assessment is one of the most important standards of practice in critical care nursing.
The nurse should assess lungs for adventitious sounds, presence of cough and secretions, skin
and mucosal color, and oxygen saturation. The progress should be monitored in collaboration
with respiratory therapists who monitor ventilator settings. Current ventilator settings are the
following: CMV mode, FiO2 40, PEEP 5, and set rate 15. Nurses, respiratory therapists, and
doctors should work together on weaning the patient off the ventilator when his condition
becomes more stabilized. Several weaning trials may be necessary for this patient as previous
attempts were unsuccessful.
In addition, respiratory status of the patient should be monitored with radiology and
laboratory studies per doctors order such as chest X-ray and arterial blood gases (ABGs). These
studies provide objective information of oxygenation status and, as a result, effectiveness of
breathing pattern. Results of chest x-ray can demonstrate development of acute respiratory
distress syndrome (ARDS), while ABGs can demonstrate development of hypercarbia and
hypoxemia. Early detection of both by the members of the team can prevent complications.
Positioning is an independent nursing intervention. Nurses should strive to position
patients to maximize ventilation-perfusion ratio in order to improve oxygenation. Luckily,

CLIENT CASE STUDY

patient did not demonstrate signs and symptoms of developing ARDS. However, all attempts
should be made to prevent this condition. Changing position every two hours to decrease
ventilation-perfusion mismatch is important. In addition, it promotes mobilization of secretions.
Another good technique is a prone position. However, it cannot be used for this patient due to the
recent abdominal surgery, and therefore, risk for dehiscence, evisceration, and infection.
Oral care should be implemented for this patient as a part of prevention of ventilator
associated pneumonia (VAP) bundle. Per Sentara policy, when patents are intubated, oral care
has to be provided every four hours (Sentara Healthcare, 2011). Nurses have to brush or swab
both sides of the tube, oral cavity, and tongue with green swabs and chlorhexidine. In addition,
nurses and respiratory therapist should suction oral and endotracheal secretions as needed.
Respiratory therapists suction above the cuff of ET Tube per their routine and before cuff
deflation.
VAP is a big issue in the critical care which can cause complications and prolong length
of hospital stay. One research was done to explore nursing knowledge about oral care in
ventilated patents (Lin, Chang, Chang, & Lou, 2011). The authors conducted questionnaires with
205 ICU nurses. The results demonstrated that only 50% of nurses were knowledgeable about
oral care. Among those who were knowledgeable, the compliance rate was 70%. Despite the
existence of evidence-based polices, nurses are not knowledgeable about oral care. The
implication of the study is to provide continuous education for nurses on importance of oral care
in ventilated patients. Furthermore, compliance with polices should be reinforced by the nursing
leadership.
In Sentara facility the nurses dont administer respiratory medications such as Albuterol
and Ipratropium, which are necessary for airway clearance. It is done by respiratory therapists

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per doctors order. However, the nurses are often the first team members who observe changes
that may require respiratory therapists and doctors to intervene, such as providing breathing
treatment or ordering additional labs and/or procedures.
Lastly, the nurses should implement teaching. Despite generalized weakness, the patient
is alert and oriented; therefore, patient should be involved in decision making about his care.
Unfortunately, at this point, the patient is unable to speak; therefore, it is a challenge for nurses to
receive feedback from the patient on what is being taught. Nevertheless, the nurses should strive
to keep the patient updated on his condition. In addition, the nurses should teach the patient
about the importance of mechanical ventilation at this stage of care and emphasize the positive
outcomes of it. There were no family at the bedside; otherwise, it would be important to include
family in the teaching session.
Interventions for the diagnosis of decreased cardiac output should be focused on
improving cardiac contractility and stabilizing blood pressure with the goal of weaning the
patient off the vasopressors. At the point of care, the patient was on maintenance fluids (0.9%
NS) at the rate of 75 mL/hr per doctors order. However, due to severe sepsis, the patient
required more aggressive treatment to keep his blood pressure at the adequate level. The patient
was on Norepinephrine drip per doctors order. As blood pressure was stabilized with
vasopressors, the nurse independently decreased the infusion rate of the medication. This was
done as a wean trial to eventually wean the patient off the vasopressors.
Another method of increasing blood pressure, which was actually done for this patient, is
administration of albumin. Usually, Albumin is given in cases of third spacing in order to pull
fluids out of interstitial space into intravascular space by increasing oncotic pressure. However,
Albumin, like any other blood or plasma products can cause reactions of the recipient. Therefore,

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after some time post-administration, the reaction to albumin causes fluids to third space again.
Thats why very often albumin is given together with Lasix, so-called push-pull procedure.
The Lasix is given to get rid of fluids before fluids third space again. Unfortunately, due to
instability of patients blood pressure, Lasix couldnt be given as it can further lower blood
pressure. Therefore, it helped for a couple of hours and then the dose of Norepinephrine had to
be increased. In order to decrease patients edema, the pull-push procedure has to be
implemented after the patient is weaned off vasopressors.
Adequate monitoring of blood pressure is critical for this patient. Arterial blood pressure
monitoring, an invasive method, was used for this patient. One research was done to compare
effectiveness of arterial blood pressure with noninvasive blood pressure monitoring (Liwei,
Saeed, Talmor, Mark, & Malhotra, 2013). The retrospective study was conducted through
analysis of acute kidney injury and mortality rates in ICU. The results demonstrated that
noninvasive blood pressure readings were associated with higher acute kidney injury mortality;
while invasive arterial blood pressure readings were associated with lower mortality rates. The
implication of the study is to employ more effective method of blood pressure management for
patients with significantly unstable blood pressure. In cases of life-threatening situations
secondary to hemodynamic instability, risk for infection from invasive blood pressure monitoring
is a lesser concern.
Positive inotropes are used in order to increase contractility of heart. Surprisingly, this
patient had no scheduled medications specific for heart failure. However, the patient was on
Norepinephrine, which has inotropic stimulator properties (Bockenstedt, Baker, Weant, &
Mason, 2012). It increases ability of heart to pump effectively. After the patient is weaned off
vasopressors, Coreg will be given per doctors order.

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Different types of medications for heart failure and blood pressure management can be
very confusing. The nurse should do his or her best in order to educate patient about different
types of treatment, effectiveness, and side effects. With ejection fraction of 15% the patient is
most likely to be discharged on heart failure medication(s), such as Coreg. Teaching, as a part of
implementation, is one of the main standards of practice in critical care nursing. One study was
done to examine effectiveness of early teaching implementation among 78 patients with heart
failure and its influence on readmission rates (Sethares, Flimlin, & Elliott, 2014). The results of
the study demonstrated that early teaching implementation led to higher responsibility and selfcare. This, in turn, led to decreased rates of readmissions. The implication of the study is to
provide early teaching and complete discharge instructions in order to increase medication
adherence rates and improve outcomes after discharge.
There are several cultural concerns for this patient. Firstly, he is a single man with no
close family living nearby. Currently, he is in unstable condition. According to the multiple
research studies, without family involvement patients tend to have poorer prognosis than patients
with active family members. This is due to physical, emotional, and financial support (Sethares,
Flimlin, & Elliott, 2014).). Another concern is a demonstration of non-adherence to medical
advice. Upon admission, patient denied the seriousness of his situation because he felt relatively
good. As a result, he delayed his own care, which led to severe sepsis. If upon discharge patient
is feeling better, he may be at risk for non-adherence to the therapeutic regimen.
Evaluation
The patients current condition remains unstable. His blood pressure is fluctuating, which
makes attempts of weaning off ventilator and vasopressors unsuccessful. However, the patient is
in severe sepsis. He is currently being treated for blood stream infection with antibiotics. The

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prognosis should improve when patient is free of infection. This will lead to stabilization of
blood pressure and, therefore, successful wean off vasopressors. The tissue perfusion should be
improved, which, in turn, will promote successful wean off the ventilator. In addition, increased
cardiac output will promote kidney perfusion and, therefore, resolve kidney failure. However,
this process is most likely to be lengthy. The patients respiratory and cardiovascular status may
not be able to return to the baseline completely; however, the overall health status should be
improved within the timeframe of hospitalization.
In case if patients condition will not improve and wean of the ventilator is not successful
after 14 days, alternative plan is to place tracheostomy and percutaneous endoscopic gastrostomy
tubes. However, this will require additional care at least during rehabilitation period. If after
rehabilitation the patent is not able to function independently, due to the absence of family the
patient will most likely require placement in assisted living facility.
Conclusion
The comprehensive analysis of the individual case study allowed the student to learn a
great deal of patient care in the critical care settings. Firstly, the student learned that continuous
monitoring and ongoing assessment are of tremendous importance as patients condition may
change rapidly. In addition, the student learned about the significance of communication and
collaboration among members of critical care team. Although, nurse has continuous support from
doctors, respiratory therapists, and other nurses; the primary nurse is often the first team member
who recognizes the changes and communicates them to other team members. Lastly, the student
learned that being proactive in patients care is much more beneficial than being reactive. The
knowledge gained form this assignment is valuable information for the students future nursing
practice.

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References

Behazin, N., Novero, A., Novack, V., Talmor, D. S., & Loring, S. H. (2014). Respiratory
mechanical effects of surgical pneumoperitoneum In Humans. Am J Respir Crit Care
Med, 189, A1194.
Bockenstedt, T. L., Baker, S. N., Weant, K. A., & Mason, M. A. (2012). Review of vasopressor
therapy in the setting of vasodilatory shock. Advanced Emergency Nursing Journal,
34(1), 16-23.
Ignatavicius, D. D. (2013). Clinical decision-making study guide for medical-surgical nursing:
Patient-centered collaborative care (7th ed.). Philadelphia, PA: Saunders.
Johnson, M., & Webber, P. B. (2010). An introduction to theory and reasoning in nursing (3rd
ed.). Philadelphia, PA: Wolters Kluwer.
Lin, Y., Chang, J., Chang, T., & Lou, M. (2011). Critical care nurses' knowledge, attitudes and
practices of oral care for patients with oral endotracheal intubation: A questionnaire
survey. Journal of Clinical Nursing, 20(21/22), 3204-3214.
Liwei, H. L., Saeed, M., Talmor, D., Mark, R., & Malhotra, A. (2013). Methods of blood
pressure measurement in the ICU. Critical Care Medicine, 41(1), 34.
Sentara Healthcare. (2011). Oral Care for Intensive Care Patients Stop & Think.
Sethares, K. A., Flimlin, H. E., & Elliott, K. M. (2014). Perceived benefits and barriers of heart
failure self-care during and after hospitalization. Home Healthcare Nurse, 32(8), 482488.