Critical Care Clinical Case Study

NURS 451- Clinical Management of Adult Health Nursing III

Purpose of Assignment
The purpose of this case study is to integrate knowledge from the humanities and
sciences, including nursing research and theory, to plan, provide, and evaluate holistic care
provided to a client selected during this clinical rotation.

Student Approach to Assignment

In the following paper the medical and nursing diagnosis surrounding the identified
patient is discussed. A review of nursing literature is also performed. Nursing diagnoses as well
as interventions are supported with current nursing literature as well as nursing theories. My
identified patient was a 37-year-old male who sustained a renal hemorrhage in the MICU. His
initial injuries lead to an abundance of compilations, which included a myocardial infarction and
anoxic brain injury. The focus of my care and case study involved holistic end of life care and
family support.

Reason for Inclusion of the Assignment in the Portfolio

This critical care case study is included within the portfolio because it demonstrates the complex
care provided to a critical patient in an end of life situation. This assignment highlights a vast
number of end program behaviors derived from the great eights.

Critical Thinking
Uses decision-making skills in making clinical or professional judgments.
Example: Decision making skills are demonstrated throughout the case study
assignment. After a thorough nursing assessment an individualized and holistic plan
of care was developed. Specific clinical and professional judgments made included
maintaining droplet precautions during all aspects of patient care, encouraging the
incorporation of the chaplain to assist in family grieving, and altering the nurse and
respiratory therapist when the patient began having desaturations and irregular
breathing patterns.
Evaluates nursing care outcomes through the acquisition of data and the questioning of
inconsistencies.
Example: The nursing care for the patient and family often involved providing family
support during the end of life care discussions. One priority nursing diagnoses and
related outcomes centered upon impaired family coping and grieving. The family was
initialing unable to come to a consciences regarding initiating comfort care.
Unfortunately, there were some misconceptions regarding comfort care by the family.
A family conference would have been the ideal intervention in this scenario. A
comfort care councilor was requested to speak to the family and family was able to
 come together and place the patient on comfort care. After this conference our goals
were met.
Revises actions and goals based on evidence rather than conjecture.
Example: A goal for care was the family would identify resources to help them cope
with the help of the nurse. This goal was met. The family and nurse identified and
assessed the resources provided by the hospital chaplain and the comfort care
specialist. After assessing the families knowledge after these resources were utilized it
was clear an additional goal of participating in a family conference would assist all
members of the healthcare team and family.
Engages in creative problem solving
Example: With such a large family involved in the patients care there were many
misunderstanding and differing opinions regarding the course of treatment that should
be used. There were also basic misunderstandings regarding the patients medical
conditions. The nurse and I identified using the comfort care specialist to help clarify
some of these issues. In order to bring the entire family to a common understanding I
suggested the use of a family conference.

Nursing Practice
Applies appropriate knowledge of major health problems to guide nursing practice.
Example: Through this critical care case study I was able to assess the patients and
families physical, emotional, and psychosocial needs to develop a plan of care. Five
nursing diagnoses were identified: ineffective family coping, pain, risk for fear and
anxiety, risk for dysfunctional grieving, and impaired skin integrity. Because of my
knowledge of major health problems I was able to identify the fact that the patients
injuries were beyond repair. Care was now focused on maintaining the patients
comfort and providing family support.
Implements traditional nursing care practices as appropriate to provide holistic health
care to diverse populations across the life span.
Example: The nursing care practices performed are discussed in detail in the case
study and clinical logs. Nursing care included medication administration,
tracheostomy care, tube feedings, frequent assessments, family comfort and support,
comfort care education, and integrating additional health care resources into patient
and family care.
Demonstrates an awareness of complementary modalities and their usefulness in
promoting health.
Example: I demonstrated awareness of complementary modalities and their
usefulness in promoting health by identifying alternative sources of pain relief and
comfort through frequent turning, decreasing the stimulating environment, and
providing comfort measures such as mouth care, eye drops, and suctioning.
Establishes and/or utilizes outcome measures to evaluate the effectiveness of care
 Example: In the following case study five nursing diagnoses were identified. The top
two priority diagnosis, ineffective family coping and pain, were expounded upon by
identifying outcome goals, interventions, and evaluations. The effectiveness of the
intervention and achievement, or lack thereof, of the identified goals were discussed
in detail during the evaluation discussion. Examples of goals included increased
patient comfort and decreased pain as well as family use of resources and appropriate
coping mechanisms.
Performs therapeutic interventions that incorporates principles of quality management
and proper safety techniques based upon assessment findings.
Example: My intervention #1, based on my nursing diagnosis ineffective family
coping, outlines my specific nursing interventions related to this priority nursing
concern. Interventions included maintaining patient comfort, including the family in
the patients care, providing support and access to addition resources such as the
hospital chaplain, palliative care specialist, or local support groups. In addition
education was identified as a key need to assist the family in having all the accurate
information to enable them to make an educated decision regarding plan of care
moving forward. In addition when updates were given to family members code
passwords were utilized over the telephone.

Communication
Uses therapeutic communication within the nurse-patient relationship.
Example: Most therapeutic communication occurred with the patients family. I
believe the most helping role I playing in the nurse-patient relationship was listening
to the family. They told me stories about my patient growing up and discussed their
fears, anxiety, and concerns. By listening and providing that emotional support I
provided therapeutic communication.
Adapts communications methods to patients with special needs.
Example: This was my first experience taking care of a vented, trached, and comatose
patient. At first it was uncomfortable, however I eventually became more familiar
with communicating with a patient who cannot communicate back. My approach was
to talk to him as if he could hear me and as if he were any other conscious patient. I
would communicate the steps of a procedure before I would continue and talked to
him about how his family was coming to visit later that day.
Produces clear, accurate, and relevant writing using correct grammar, spelling, and
punctuation.
Example: My critical care case study demonstrates my ability to produce clear,
accurate, and relevant writing. It also demonstrates my ability to use APA format,
correct grammar, spelling, and punctuation.

Teaching
 Provides relevant and sensitive health education information and counseling to patients,
and families, in a variety of situations and settings.
Example: This was central to my care of the patient and family throughout my week
with them. The nurse and I identified education as a primary concern and nursing
intervention for this family. There were misunderstandings regarding the patients
potential outcomes as well as a complete and accurate understanding of comfort care.
We had to provide straightforward and honest information about the patients status
while remaining compassionate and empathic. Without all of the accurate information
we cannot expect the family to be able to make an educated decision regarding care.

Research
Differentiates between descriptive nursing literature and published reports of nursing
research.
Example: In the following case study I identified relevant nursing research and theories
that supported my identified nursing interventions. These three nursing research articles
were then evaluated using a literature review. The purpose, participants, type of research
study design, methods, and results were outlines as well as the limitations to each study.
Descriptive nursing literature elaborates on a subject matter, while nursing research
conducts a formal study and publishes the results of the study.
Evaluates research that focuses on the efficacy and effectiveness of nursing interventions.
Example: In the following paper, I utilized a research article, Family Members
Perceptions of Most Helpful Interventions During End-of-Life Care to support my
identified nursing interventions. Families identified awareness of nurse valiance
towards loved ones, nursing presence, preparation for imminent death including
education and inclusion into the decision making process, and providing a peaceful
environment, to be with their loved one, as the most helpful nursing interventions
during these difficult times. These points were addressed in my nursing interventions.
Applies research-based knowledge from nursing as the basis for culturally sensitive
practice
Example: I identified a research study, An Evidence-Based Practice Approach to
End of Life Nursing Education in Intensive Care Units to assist in understanding the
best practices and potential barriers nurses experience when providing end of life care
and education. Patients and families who are dealing with end of life decisions and
care need sensitive and empathic care provided. The study identified areas in which
nurses needed to improve practice.

Leadership
Assumes a leadership role within ones scope of practice as the designer, manager and
coordinator of health care to meet the special needs of vulnerable populations in a
variety of settings.
 Example: Before clinical we are given the opportunity to gather patient data and
create a plan of care based upon identified nursing diagnosis. Throughout clinical I
was able to reassess my plan of care based on current information gathered. This
project allowed me to detail my priority nursing diagnosis, plan and identify
interventions and outcomes based on patient care data and evidence based practice,
and evaluate the effectiveness of my interventions. My identified patient was
considered vulnerable due to his end of life status, inability to make care decisions,
and comatose state.

Professionalism
Differentiates between general, institutional, and specialty-specific standards of practice
to guide nursing care.
Example: AACN Standards of Professional Practice guided Care provided to my
patient. Nursing ethics were also at the forefront of patient care. My nurse and I were
patient and family advocates. Due to my patients comatose state he was unable to
make his own health care decisions. We provided education to the family to best
prepare them for making those educated decisions. We also utilized additional staff
members such as the hospital chaplain and the comfort care specialist for family
support. For institutional standards of practice we utilized the UTI bundle care. In
addition, for general standards I utilized the nursing process.
Understands the effect of legal and regulatory processes on nursing practice and health
care delivery, as well as limits to ones own scope of practice.
Example: During my time spent providing patient care the family began asking
questions about organ donation. Discussing this topic is outside of our scope of
practice. As outlined by the federal government, notification must be made within 60
minutes when a patient meets clinical triggers. A representative from LifeNet was
contacted to speak to the family. During our clinical rotation nursing students could
not perform IV push medication administration. These limitations were respected and
followed.
Demonstrates accountability for ones own professional practice.
Example: Accountability is a core nursing value and an essential component of the
ANA code of ethics. During my clinical rotation I would be able to answer to myself
and others regarding my actions. One mistake I have made in critical care rotation
was walking off the unit for lunch with medication still in my scrub pocket. I
immediately returned to my unit, let my nurse know, and gave her the medication
before returning to lunch.

Culture
Articulates an understanding of how human behavior is affected by culture, race,
religion, gender, lifestyle and age.
 Example: My patients and families religion assisted in identifying the hospital
chaplain as a resource to assist in the coping and grieving process. My patients
culture was perceived as a key factor leading to his poor health outcomes. The family
discussed how the patient spent the last few years incarcerated or in halfway houses.
They stated that his multiple chronic illnesses were poorly controlled in these
settings.
Demonstrates sensitivity to personal and cultural definitions of health, and how these
beliefs influence an individuals reactions to the illness experience and end of life.
Example: My patients family defined health as the ability to live independently and
perform normal activities of daily living again. As discussed above the family
correlated the patients poor prognosis with the fact that his chronic illnesses were so
poorly controlled while incarcerated and in the halfway houses. Although the patient
was completely unresponsive the family interpreted the patients open moving eyes as
meaningful and purposeful. These factors made it difficult to come to terms with the
patients prognosis. It also made it difficult for them decide whether or not to initiate
comfort care.