Patient Profile Management Recommendations, Essay Example

Introduction

The essay is going to review the pathophysiology, complications, and management of a patient in the Intensive Care Unit brought to the A & E in an unconscious state. As per the Nursing and Midwifery Council’s Code of Conduct (NMC, 2015), the confidentiality of the patient, relatives, and the hospital will be maintained by applying pseudonyms. The patient will be named Matilda, and the hospital is allocated the name Hospital M. In this essay, there will be a focus on the respiratory, cardiology, renal, and neurological systems analyses, and detailed management of the symptoms and complications associated with the patient’s CKD, CNS hypoxic injury, COPD, and left bundle branch block (LBBB), as per the Appendix 1 patient’s profile. The essay will also focus on the analysis of the ethical, psychosocial, and legal considerations given in the management of Matilda. The analysis of Matilda’s management will be made over 12 hours and relevant recommendations given as per the authorized updated guidelines.

Respiratory System Management

Matilda presents with a long history of COPD, which is the fourth leading cause of death by 2020 (COPD 2019 Report, p.5). For her, obesity makes her a blue blotter. Chronic bronchitis manifests with lung injury due to inflammation caused by the bacterial pneumonitis in the lung parenchyma (NICE, 2017, p.5). The clear yellow purulent secretions are suctioned in the ICU and are evident in bacterial pneumonitis. Increased WOB can also be associated with type 2 diabetes. Due to obesity, increased fatty acids and adipose stores cause insulin resistance. The body, in turn, breaks down fatty acids in the absence of sufficient glucose, hence the end-product of fatty acids is keto acids that explain the increased arterial pH shown in Table 2. However, these are within the normal range, so diabetes is in control. The increase in the WOB can, therefore, be explained by recurrent pneumonia, or complicated COPD symptoms, as the elevated WBC count in Table 4. The increase in WOB can also be explained by the low Hb in Table 4, a compensatory increase in respiratory rate, as in Table 2 (NICE, 2017, p.5). This shows there is an increase in leukocytes to fight off the bacteria. This gives a general picture of labored breathing, where her GCS of 3 calls for the use of mechanical ventilator support.

Matilda required respiratory support due to her inflammatory activity that caused an increase in purulent substance in the alveoli, hence diminished oxygen saturation (SpO2 of below 90% at the time of admission at A & E, table 3). Moreover she was unconscious with a GCS of 3/15. She was put on oxygen therapy through invasive ventilation as managed by intubation with an endotracheal tube. The Pressure Regulated Volume Control (PRVC) mode includes a heated humidified ventilator circuit that helps with bronchodilation. However, considering the thick moderate purulent secretion, according to Masoompour et al. (2015, p.309), nebulization of either N-acetyl cysteine or normal saline would have helped the patient secret less dense purulent secretion. The thick purulent secretion can lead to mucus plugs that arise the need for mechanical ventilation due to the depressed activity of the mucociliary clearance (Masoompour et al., 2015, p.310). This means the management was inclusive of airway manoeuvres such as oropharyngeal airways and intubation that allowed suctioning (Masoompour et al., 2015, p.310).

Concerning respiratory pharmacology, the management of Matilda was right to include the use of Paracetamol. This was attributed to her history of confirmed X-rays showing pleural effusion on the left lung, hence managing the chest pains even though the patient is sedated. The management also considers the labored breathing by the administration of salbutamol, which is a bronchodilator that is meant to clear the airway and prevent bronchospasm (Masoompour et al., 2015, p.310). However, the drugs have the side effects of sinus tachycardia, as is evident with her LBBB. The drug enabled Matilda to attain the SpO2 levels of 94% by 0400hrs. The management was based on measuring the benefits versus the harm caused. Use of antibiotics on Matilda was essential since she had increased levels of white blood cells. Moreover, results from her rapid flu and Covid-19 swabs were not yet out. She had three symptoms of Covid-19 which included; diarrhea, increased temperatures, and shortness of breath. It was necessary to have Matilda put under isolation.

However, the management gets it wrong by not propping the patient immediately at the time of admission. Matilda had been diagnosed with aspiration pneumonia at the A & E. Therefore, the first management thought should have been propping her to about 45% lie. It could have improved ventilation that is one principle of gaseous exchange. Besides, she is a blue blotter who needs good aeration. This explains her respiratory acidosis and hypercapnia. She is nursed in the supine position instead of the prone position. This is evident in the tidal inspiratory readings, which seem to have stagnated in the first two hours, then improve later in the night, as per table 1. The patient aeration is important to improve the acidotic state. The administration of antibiotics is important due to aspiration pneumonia and her chronic disorders such as COPD and type 2 diabetes.

Cardiology System Management

Matilda has a medical history of type 2 diabetes, which makes her prone to cardiac complications, such as her visible obese state, and high cholesterol. Type 2 diabetes means she is predisposed to acute cardiovascular diseases such as diagnosed cardiac arrest. Her long history of COPD means she has been on salbutamol, which has the side effect of sinus tachycardia (COPD, 2019 Report, p.15). The hyperkalemia, as indicated in table 4 (4.4mmol/L), caused the cardiac arrhythmia, hence explains why she was found unconscious by the family, which was later demonstrated by the ECG as a left bundle branch block (LBBB), (Whitlock and MacInnes, 2010, p.518). The cardiac arrest can be attributed to being secondary to the renal failure stage 3. This causes fluid overload, hence causing a volume overload for the cardiac myocytes. These at first adapt by hypertrophy, which can cause myocyte apoptosis.

However, due to her aspiration pneumonia, this means the patient becomes hypoxic. The oxygen demand increases in the body, causing cardiac failure, as demonstrated by the elevated calcium ions at the time of admission. Symptoms of fluid overload include her edematous legs, and moisture breaks underneath her breasts, hypotension according to table 3 at the time of admission. The hypotension could also give sepsis, supported with recorded tachycardia, as in table 3. However, due to her CKD, the hyperkalemia caused arrhythmia, hence causing sudden cardiac death. Matilda also demonstrates symptoms of cardiogenic shock, where cold peripheries should have alarmed the nurses. According to MacLean (2016, p.2), cardiogenic shock is the end of heart failure and therefore carries the worst prognosis and needs the ICU healthcare team to be cautious.

Matilda was managed at first with the 2x adrenaline by the LAS. This is recommended as the patient is unconscious. Adrenaline, a neuro-hormone that enhances blood flow to the muscles of the heart, will cause an increase in the work-rate of the heart, increasing circulation to the blood hence arousing the patient. However, Matilda is a heart failure and renal failure stage 2 patient. Therefore, this will cause farther damage to the cardiac myocytes, exacerbating edema, and sinus tachycardia. The adrenaline was administered to attain consciousness first before the adverse effects are assessed later, as demonstrated in table 2 by the build-up arterial blood carbon (IV) oxide partial pressure.

The adrenal medulla secretes a naturally occurring catecholamine know as noradrenaline. It works through stimulating the smooth muscles Alpha-1 adrenoceptors leading to vasoconstriction. This further leads to increased systemic vascular resistance. Subsequently, venous return to the heart gets increased leading to a preload. In the case of Matilda, caution needs to be taken before administration of noradrenaline is done through an arterial line that is being used to monitor continuous blood pressure. Coronary perfusion and arterial pressure are increased reversing the cardiac arrest Matilda experienced. The patient had low blood pressure readings while being admitted into the hospital. A dosage of Noradrenaline (16mg in 50ml) was administered for the maintenance of mean arterial pressure (MAP) at >70 to 90mm Hg. The site of administration was the left internal jugular through a central venous catheter (CVP) of 12-16mmHg. Results upon administration of noradrenaline were a mean arterial pressure (MAP) aim is >70mmHg.

Matilda was never administered any IV loop diuretics, as per the NICE (2018, p.11) guidelines on suspected heart failure patients. Matilda had fluid overload, as per her edema legs, and therefore, administration of furosemide, which is then titrated accordingly to achieve optimum dosage for Matilda (NICE 2018, p.11). However, because she was a renal failure undergoing dialysis three times a week, and her anuria state, the nurses, did not administer any diuretic. Matilda could not be administered a beta-blocker because her volume overload was not controlled (Whitlock and MacInnes, 2010, p.522). These drugs could only be administered to her after her dialysis.

Matilda was also never seen by a cardiologist specialist as recommended by the NICE (2018, p.9) guidelines for acute heart failure patients. Matilda should have been seen by a specialist because she had no history of a previous heart failure attack. Because this was a primary attack, there was no single measurement of BNP and NT-proBNP, which is recommended for monitoring heart failure and confirming the diagnosis. In acute heart failure, the BNPs are supposed to guide echocardiography. However, based on McLean (2016), critical care of patients, echocardiography is mandatory in basic critical care of an acute case. Echocardiography will guide the initiation of care. The ICU, therefore, got it right and was able to diagnose the LBBB.

Moreover, the management of the confirmed left bundle branch block of Matilda was achieved through the use of noradrenaline. Cardiac resynchronization therapy entailed a pacemaker therapy facilitating the contraction of ventricles at a similar period of time. This was attained through increasing the volume of blood that was being ejected by the heart bettering the breathing patterns of Matilda. It was confirmed through physical assessments that noradrenaline administration led to palpable peripheral pulses and a measurable CRT of less than three seconds. Eventually, Matilda had her breathing difficulties brought under control leading to her discharge from the intensive care unit. She was put awaiting formal ECHO upon getting discharged from her isolation room.

Renal System Management

Matilda came to the A & E with a long history of renal failure stage 3. According to Han and Ryu (2011, p.565), renal failure can lead to fluid overload, leading to venous congestion. Considering Matilda’s volume overload, and elevated intra-abdominal pressure, it was majorly due to congestion of the major abdominal vessels. Abdominal symptoms manifest as diarrhea. The acute renal symptoms, like elevated sodium and potassium ions levels in table 4, can lead to mortality, especially Matilda’s acute heart failure that is characterized by dyspnea and pulmonary congestion. According to Han and Ryu (2011, p.565), elimination of the excess fluid that is causing the fluid overload should be the primary therapeutic target. Besides, Matilda includes anuria since 2016. The use of intravenous fluids like lactated Ringer solution and sodium chloride could have increased urine output levels within 4-6 hours. However, the patient had peripheral edema and was obese contradicting the requirements of administering intravenous fluids. Although she usually undergoes dialysis three times a week, the fluid overload and elevated electrolytes are likely to cause mortality.

She also had AKI signs based on her elevated creatinine levels in table 4, and her history of anuria. According to KDIGO (2012, p.14), Matilda has all the predisposing factors to the disease, including aspiration pneumonia, making her susceptible to sepsis, which can cause AKI. Septic bacteria launch virulent substances at the renal tubules, causing the responding immune system to cause damage to the tubules via reactive oxygen species (Kanagasundaram & Arunachalam, 2015, p.440). Matilda also has acute heart failure, which causes prerenal kidney injury by inhibiting adequate perfusion of the kidneys. In such a case, KDIGO (2012, p.14) recommends the administration of a protein-based diet, via the enteral route. Insulin therapy is also recommended for insulin therapy for patients who are critically ill, such as Matilda, who also had type 2 diabetes. Also, patients should be administered fluid therapy, based on isotonic crystalloids, rather than colloids.

The patient, Matilda is rightly managed by administering crystalloids, which will help correct and expand the intravascular volume, especially now that she has AKI. However, due to her volume overload status caused by her acute heart failure, there is a dilemma over the prescription of the IV fluids, which will worsen her fluid overload status, causing more harm. Matilda is also administered with antibiotics that are aimed at aiding the immune system in clearing the septic bacteria, especially avoiding aminoglycosides (KDIGO, 2012, p.22). However, the administering of fluids to Matilda is contradictory as the hospital later recommends the removal of fluids via dialysis at the rate of 150ml/hr, exposing Matilda to adverse effects of frequent dialysis such as infections. The hospital also does not take precautions on the history of the VASCATH, which will predispose Matilda to nosocomial infections, thrombocytopenia, and thrombus formation. However, the management is cautious of thrombus formation by the administering of the Tinzaparin Sodium, which is an anticoagulant.

The current care of Matilda due to her requirement of renal replacement therapy is a prescription of CVVHDF through a VASCATH localized on her internal jugular on the right side. This was done by the doctors in her prescription. An aim of this prescription was to control her raised levels of both potassium and serum creatinine which were life-threatening. She is a long term patient receiving three times dialysis treatments every week signifying type one filtration. However, her current state of unconscious during admission dictated for a level two filtration through a citrate anticoagulant.

Neurology System Management

Matilda was found unconscious and brought to the hospital, where her GCS was 3/15. The MRI findings confirm the diagnosis of moderate hypoxic brain injury. This is due to the aspiration pneumonia that exacerbated oxygen tension, hence causing an increasing demand in oxygen. Acute heart failure caused further reduced blood supply to the brain, causing Matilda to faint. There is no maxillofacial trauma, hence no scare for a hypoxic stroke. However, the impending cardiogenic shock also caused the hypoxic brain injury, by causing diminished blood flow to the brain. In such hypoxic injury, there is always the scare of reperfusion brain injury, where the ICU puts her into the Pressure Regulated Volume Control (PRVC). Matilda’s breathing is given priority to improve the oxygen saturation, which is low, according to table 3, at the time of admission.

Matilda is also managed for perfusion of the brain through the infusion of the crystalloids to provide adequate fluid balance. This is because her neurology exam reveals damage to the left ciliary nerve, which is the reason why her right pupil lost the light reflex action, supporting farther that the brain sustained injury. Therefore, according to a patient with moderate hypoxic injury, there is a suggestion to the use of hypothermia, especially when the brain injury is due to a cardiac arrest. However, studies have not yet defined on the specifics behind the exact timing and temperature of the therapeutic approach.

In the ICU, Matilda is managed through sedation by the IV Propofol, which makes it difficult for the CCPOT team to assess for pain reception. This produces the credibility behind the administration of the fentanyl and Paracetamol. This seems to be a prophylaxis administration. However, it predisposes Matilda to the side effects of the opioid in her acute heart failure condition, such as respiratory depression and farther damage to the neurologic function such as aphasia, dyspepsia, urinary retention, shortness of breath, and dry mouth. These side effects will cause more harm to Matilda, especially after repeated administration of the drug. The Paracetamol administration would have provided enough analgesia.

Psychosocial, Ethical, and Legal Issues

In the event of emergency response, Matilda was put under sedation and ventilated upon being found unconscious with a GCS of 3/15. The patient lacked the ability to consent and she was put on oxygen due to her previous medical history of COPD as suggested by (dos Santos et al., 2017, pp. 140). Autonomy as an ethical principle was not implemented since the patient was unconscious. Exceptional for patient consents before receiving any medical services are allowed for unresponsive patients whose conditions are life-threatening. However, the nurses in both the emergency response team and those working within the intensive care unit applied the principle of beneficence. Their actions of sedating and ventilating Matilda were aimed at benefiting the patient who was unresponsive with a history of COPD. This was in accordance with the Nursing and Midwifery Council nursing code of conduct (Dean, 2017, pp. 13).

Besides, Matilda was treated with fentanyl due to suspected pain. It was the role of healthcare workers like nurses to ensure that she was accurately graded on a pain scale before drug administration. The principle of non-maleficence was not applied since the drug fentanyl would expose Matilda into respiratory depression. We failed as nurses to restrain from maltreatment of unconfirmed pain and using a drug, fentanyl that has increased harm for the patient according to (Mathew and Thomas, 2020, p. 359). Moreover, the decision of ventilating Matilda without consulting her family members shows that we failed to uphold the principle of non-maleficence. It can be equated to subjecting the patient to a procedure that affects the patient both physically and emotionally. The family members could have sought for another option. Justice as an ethic was observed in the case of Matilda. Upon arriving at the accident and emergency department, she was put under intensive care unit. It implies that a fair medical decision was made in relation to the unconscious state of Matilda.

Conclusion

In conclusion, Matilda’s situation is an emergency case that many healthcare givers do not think of the outcomes of the decisions adopted. Many caregivers weigh the benefits of the management procedures and give little consideration to the negative outcomes. However, the complexity of the various body systems makes it difficult to manage the patients risk-free. For example, the call to administer crystalloids to Matilda is made according to the renal failure guidelines, in which the crystalloids are meant to correct the prerenal injury to the kidneys. However, ate the same time, Matilda has acute heart failure and comorbid anuria, which include existing volume overload, hence compromising the decision to use IV fluids, which will eventually compromise the pulmonary system. Therefore, there are many ethical and legal outcomes from Matilda’s case that many healthcare givers find a dilemma to accommodate every guideline.

Appendix 1: Patient Profile

As per Nursing and Midwifery Council’s Code of Conduct (NMC, 2015) confidentiality of the patient, relatives and hospital will be maintained by applying pseudonyms

Matilda is a 59-year-old female, admitted into the hospital via A&E after being found unconscious/unresponsive for 5 minutes, foaming at the mouth and was unarousable in her bed at her family home where she lives with her family. Her family carried out CPR on her and called 999. Glasgow Coma Scale (GCS) determined by London ambulance services (LAS) was 3/15. LAS administered Advanced Life Support, accompanied by 2x adrenaline. The initial rhythm as was recorded as asystole, then Pulseless electrical activity (PEA). Before being intubated and later being admitted to Accident and Emergency (A&E).

In the A&E, a working diagnosis of Cardiac arrest, secondary to hyperkalemia, and aspiration pneumonia, was made. In A&E at Hospital M, Matilda was admitted to the intensive care unit (ICU) due to severe respiratory acidosis and rising serum potassium.

Once stabilized, she was transferred to Magnetic Resonance Imaging (MRI) for computerized tomography.

Findings from the MRI:

There is grey matter reduced diffusivity and abnormal FLAIR signal most apparent within the pre and postcentral gyri, occipital lobes, deep grey nuclei, and the hippocampi bilaterally.

There is some minimal cortical swelling most apparent in the occipital lobes. Stable ventricular configuration. The basal cisterns and foramen magnum are capacious.

Opinion:

Appearances are consistent with a moderately severe hypoxic brain injury with only mild parenchymal swelling present. Appearances are consistent with a moderately severe hypoxic brain injury with only mild parenchymal swelling present.

Past Medical History

Matilda had no known drug allergies (NKDA), Chronic Obstructive Pulmonary Disease (COPD), Chronic kidney disease (CKD), on dialysis – 3x a week, Type 2 diabetes, obesity, Anaemia- on EPO; Jan 2020 – sepsis secondary to pneumonia- left-sided pleural effusion RxIV antibiotics and filtration for overload- also needed respiratory and vasopressor sport; Echo showed pericardial effusion noncompromising – mostly posteriorly LV, High cholesterol, anaphylaxis. She was visibly obese currently weighing 120kg; with an ideal body weight (IBW) 90.4kg

Intensive Care Unit: Day one

This is a twelve-hour systematic assessment done using cephalocaudal approached, which as per Munroe et al (2013) this approach enhances the interaction between nurses and patients. To comprehensively explore this case-study the ABCDE assessment tool approach is used.

Airway

Matilda is a grade 1 intubation with a size 7.5 mm endotracheal tube (ETT) in situ, currently positioned 24cm at his teeth, confirmed with a chest X-ray and appropriate CO2 trace. Secured with an anchor fast as there is presently no evidence of any maxillofacial trauma. The cuff pressure was regularly inflated between 25 to 30 cm H20 enabling monitoring of the airway pressure. Her airway remains patent though Matilda had no cough reflex on suctioning there were moderate amounts of thick creamy/yellow secretions.

Breathing

Presently, Matilda is ventilated via the Pressure Regulated Volume Control (PRVC) mode, which contains a heated humidified ventilator circuit. However, overnight she had an increase in work of breathing (WOB) and the ITU Reg change her Vent mode to Synchronized Intermittent Mandatory Ventilation (SIMV)

On the initial inspection, chest expansions are symmetrical; auscultation was performed with reduced bilateral breath sounds; however, no other abnormalities detected. An outline of her ventilator setting with her arterial blood gas (ABG) and filter calcium analysis which demonstrates a combined metabolic and respiratory acidosis, with a low arterial pH and hypercapnia. Is displayed in Table 1&2 for the entire shift which includes any alteration done.

Table 1.

Table 2.

Cardiovascular 

Matilda was in sinus tachycardia with left bundle branch block (LBBB) which is currently reading on the electrocardiogram (ECG).

Being acutely hypotensive controlled quadruple strength Noradrenaline (16mg in 50ml) to maintain a mean arterial pressure (MAP) >70 to 90mm Hg, running via a central venous catheter (CVP) of 12-16mmHg situated in the left internal jugular, aiming for a mean arterial pressure (MAP) aim is >70mmHg. Capillary refill time (CRT) to peripherals have been frequently monitored, CRT <3seconds, pulses to peripherals are palpable, the patient feels warm to touch and appears well-perfused No cyanosis

Pyrexia temperature 37.9 as per hand over to cool patient and try to maintain Temperature 36.0. The patient is awaiting formal ECHO if moved out of isolation?

Table 3.

Table: Continuous infusions

Disability 

GCS was 3/15 chemically sedated with continuous Propofol infusion; Richmond Agitation Sedation Score (RASS) -5; Right pupil fixed with no response to light; Left pupil appears to have cataract so it is unable to assess. Critical Care Pain Observation Tool (CPOT) was unable to assess the pain sensation, as the patient was already sedated with a RASS -5. However, she is on continuous Fentanyl infusion with regular Paracetamol as an adjunct.

Initially, Matilda was being nursed in the supine position. However, she was later repositioned to a prone position.

Exposure 

Matilda was obese and her legs were very edematous, on examination it was noted that she had moisture breaks underneath her breast and underneath the cracks of her stomach and groin area. She was very warm centrally but felt cold to touch peripheries with evidence of mottled extremity. Matilda was nursed on a Nimbus 3 mattress with her heels offloaded on a pillow as she had a level 2 healing pressure sore on her sacral area. The patient had a few bruising on her chest caused by CPR. No other skin abnormalities noted.

Fluids 

Matilda has been had been anuria since 2016 as per handover hence her being in a positive fluid balance of 3250ml. In A&E 2L of crystalloid challenge and ITU was 2 units of RBCs contains approximately 200mL including 1L of playmate running at 100ml/hr as background fluid as Matilda was nil by mouth (NBM).

At 2100 the doctors prescribed Matilda to commence on CVVHDF via a VASCATH situated in her right internal jugular. As Matilda is a long term dialysis patient who receives treatment 3 times a week she would usually be a level one filter patient. However, due to her reasons for admission and her now critical condition she is being treated as a level 2 filter with citrate for anticoagulation. Fluid removal 150ml/hr to achieve a negative fluid balance of 500ml in 24hours.

Gastrointestinal 

Matilda was NBM though she had a nasogastric tube (NGT) inserted as she was awaiting an X-Ray confirmation. Even Though she was visibly obese her abdomen was distended but soft and palpable with good bowel sound. As per handover, Matilda has diarrhea with copious type 7 bowel movement with some traces of bright red blood, therefore, a Faecal management system was institute and a sample sent for Clostridium difficile (CDIFF).

At 2300 she had the NGT, X-rayed, and confirmed by the doctor that it can be used for NGT feeding; the out of hours (OOH) feeding regime commenced with Jevity 1.1 @ 30mls/hrs until reviewed by the dietitian.  Blood glucose (BM) monitored and the patient has been commenced on Insulin sliding scale aiming 4-11.1mmol/L as per protocol.

Hematology

As per handover, Mathilda’s latest blood results were pending and she already had 1 unit of RBC and was due another. However, at 2200 the latest results were back and are displayed in Table 6; all required electrolytes were replaced as charted, though her urea and creatinine levels were elevated her baseline level is unknown.

Table Four: Latest blood results

Infections

Matilda is at present being nursed inside room for isolation as she had a fever at home before admission and her recent temperature is 37.9; * Blood culture was done* Sputum MCS * Rapid flu swab * Atypical screen * COVID 19 swab sent * CIDFF sample stool sent MCS * WBC high and increasing* Patient commenced on Antibiotics

Table 8. Scheduled Medications

Psychosocial 

Matilda lived with her family, her daughter (aged 32), and son (aged 28) who is her main career. She independently mobilized around the house with her children assisting in her activities of daily living. Her family is the one who takes her to have her dialysis done three times a week.   At present all communication is through Mathilda’s children as she is sedated and ventilated

References List

Dean, E., 2017. Unlocking the NMC code of conduct. Emergency Nurse, 25(2), pp.13-13.

dos Santos, C., Vidotto, L., da Silva, M., Probst, V., Buzzachera, C. and Felcar, J., 2017. Relationship between peripheral muscle strength and muscle oxygenation in healthy elderly and COPD patients. Physiotherapy, 103, pp.e139-e140.

Mathew, A. and Thomas, V., 2020. Truth-telling: Apply the principle of beneficence. Cancer Research, Statistics, and Treatment, 3(2), p.359.