Critical Care Case Study
Crystal Meyer
Mohave Community College
Nursing 222
Mrs. Michelle Christensen
April 1, 2014

Critical Care Case Study
ADMISSION
TC is a 61-year-old English speaking Caucasian female born on April 29, 1952. She weighs 99.7 Kg and is 5 feet, 5 inches in height with a BMI of 35.84. On March 5, 2014, TC was brought into the emergency department after her daughter-in-law called 911 when she found TC unresponsive at home in her bathroom. When paramedics arrived, she was found to be cool, pale, and diaphoretic with oxygen saturations in the high 70’s. Emergency responders placed a non-rebreather high flow oxygen mask and her oxygenation began to improve with saturations in the low 90’s.
Upon arrival to the emergency department, TC’s vital signs were as follows: T 97.4; P 97; BP 120/95 mm Hg; RR 15 per minute; and O2 sats of 98% via NRB oxygen mask on 8L. A chest x-ray (CXR) revealed no abnormality and lungs were determined to be grossly clear. However, TC was checked for a pulmonary embolism via a pulmonary artery angiogram with IV contrast and found to have a large clot burden with a small saddle embolism. TC also complained of right ankle pain. An X-ray of her right ankle revealed a distal tib/fib fracture, which was presumed to be related to her fall during her hypoxic episode. With these findings, TC was admitted to the Intensive Care Unit of Kingman Regional Medical Center and placed on an NPO diet in preparation for placement of an inferior vena cava (IVC) filter.
TC’s past medical history is rather extensive and includes the following: Lupus; Crohn’s Disease; hypertension; hypothyroidism; depression; acid reflux; diabetes; kidney disease; Multiple Sclerosis (diagnosed in 2010); history of DVT (in 2002); and multiple pulmonary emboli. Surgical history includes a complete hysterectomy, appendectomy, and a tonsillectomy. Patient has multiple allergies, to include: latex; aspartame; cipro; codeine; Darvon; Feldene; Fioxin; Gabitril; Inderal LA; Paxil; penicillin G; Remeron; saccharin; seldane; and Zyprexa. The patient is a full code (Patient Chart, 2014).
ER LABORATORY DATA
*Collected March 5, 2013
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Results Normal Values
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Comp Metabolic Panel
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Glucose serum 171 H 80-110 mg/dL
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BUN 12 7-18 mg/dL
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Albumin serum 3.3 L 3.4-5.0 g/dL
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AST/(SGOT) 13 L 15-37 U/L
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ALT/(SGPT) 16 L 30-65 U/L
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GFR 37 L > 60 mL/min/1.73^2
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INR 1.3 L Therapeutic level 2.0-3.0
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PT 15.5 H 11.1-14.5 seconds
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CBC with PLT
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White blood count 13.1 H 4.8-10.8 x10*3
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HGb 14.7 14.0-18.0 gm/dL
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Hct 42.5 42-52 %
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Platelet count 226,000 140-440 x10*3
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(Patient Chart, 2014)
Analysis of Labs Done in Emergency Room 03/05/14 TC has a high glucose serum level due to her diabetes. In relation, her albumin serum level is most likely decreased due to her kidney disease of unknown degree. TC’s AST and ALT are also most likely related to her kidney disease, in addition to her low GFR. While the “normal” range of the INR is typically 0.8-1.2, the therapeutic range for patients on anticoagulant therapy should be between 2.0-3.0. Upon further evaluation, it was found that TC takes Coumadin at home and actually has low INR in comparison to the therapeutic range. Since TC’s chest x-ray was clear of infiltrates and she does not have a fever, her elevated WBC’s would be suggestive of an stress response (related to the secretion of epinephrine) to the stress of her hypoxic episode and hospitalization (Van Leeuwen, 2011).
ASSESSMENT
Assessment of TC on March 3, 2014 is as follows: BP 135/74 mm Hg; MAP 94; P 93 b.p.m., normal sinus rhythm on telemetry monitor 12; RR 16 per minute; and a SaO2 of 98% on 4L oxygen via nasal cannula. TC’s blood glucose level was 115. TC had two 20 gauge intravenous catheters, placed on 3/02/14, one in her right AC, saline locked, and the other in her left hand, which was connected to her PCA pump, running hydromorphone, with a basal rate of 1mg Q hr. and a demand of 0.5mg Q 20 minutes, with a limit of 2.5mg/hr. TC’s right ankle was splinted and elevated. General Assessment: Patient lying supine in bed with HOB elevated to 30 degrees and in no apparent acute distress. When asked if in any pain, TC shook her head up and down and stated she was in “excruciating pain, an 8 on a scale of 0-10.” TC was alert and orientated x 3. She responded to commands and stimulus, but appeared sedated from her pain medication. Pupils were equal and reactive to light. Neck was supple with no signs of JVD or tracheal deviation. TC showed bilateral chest expansion upon inspiration. No wheezes, rales, or rhonchi were heard upon auscultation of her lungs. However, TC did have bilateral diminished lower lung sounds. Normal S1 and S2 sounds were heard, with no murmurs or shortness of breath. Palpable bilateral radial pulses and a capillary refill <3 seconds. Her abdomen was soft and non-tender with active bowel sounds present in all four quadrants. There was no clubbing or cyanosis of her extremities; however, there was noticeable swelling of her right lower leg and tenderness of her right lower leg at the area of her distal/tib fracture, in addition to tenderness and swelling of left lower leg. Skin was dry and warm, and her color was appropriate for her ethnicity. TC has been NPO since midnight in preparation for placement of her IVC filter. Upon admission, TC had a chest CT scan, as well as a pulmonary angiography. Results of her CT scan performed on March 2nd showed extensive bilateral pulmonary emboli with prominent saddle embolus. There was noted enlargement of the right ventricle, compatible with right heart strain. Lungs were clear with no pleural effusions. No mediastinal or hilar lymphadenopathy. There was normal appearance of the thoracic aorta without evidence of dissection or aneurysm. TC also had an ultrasound of her right and left leg following her CT scan and was positive for deep vein thrombosis of her left leg. It was suggested by the doctors that TC had a failed Coumadin therapy and had some sort of clotting disorder of unknown origin. When asked about her kidney disease, TC responded that she was aware of the issue but could not name anything specific, most likely due to the sedation she was receiving. TC was said to be hypercoagulable and was placed on strict bed rest (Patient Chart, 2014). The plan for today: TC is to have an IVC filter placed, maintain adequate oxygen saturation levels, maintain perfusion of organs, monitor urine output, and keep pain tolerable with use of the PCA pump. TC is also to be turned every 2 hours to prevent skin breakdown.
PATHOPHYSIOLOGY
Deep vein thrombosis, commonly referred to as DVT, is the underlying cause of TC’s current condition. Thrombophlebitis is the inflammation of the wall of a vein, usually resulting in the formation of a blood clot (thrombosis) that may partially or completely block the flow of blood through the vessel. Venous thrombophlebitis usually occurs in the lower extremities. It may occur in superficial veins, which although painful, is not life threatening and does not require hospitalization, or it may occur in a deep vein, which can be life threatening because clots may break free (embolize) and cause a pulmonary embolism. Three factors contribute to the development of deep vein thrombosis (DVT): venous stasis, hypercoagulability, and endothelial damage to the vein. Prolonged immobility is the primary cause of venous stasis. Hypercoagulability is seen in patients with deficient fluid volume, oral contraceptive use, smoking, and certain malignancies. Venous wall damage may occur secondary to intravenous (IV) infusions, certain medications, fractures, and contrast x-ray studies. DVT most commonly occurs in lower extremities, where it is often asymptomatic and resolves in a few days. More proximal DVTs are associated with greater symptomatology and carry a higher risk for dislodgement and migration. Treatment is supportive, usually with anticoagulant therapy. Goals are to reduce risk for complications and prevent reoccurrence. In the case of TC, she is hypercoagulable with a failed Coumadin therapy. In addition, she had a left knee replacement one month prior to this current episode, which had left her immobile, suggestive of an increased risk of developing DVTs (Gulanick & Myers, 2011, p. 350). Pulmonary embolism (PE) occurs when a thrombus (blood clot) originating in the venous system or the right side of the heart, obstructs blood flow in the pulmonary artery or one of its branches. The clinical picture varies according to the size and location of the embolus, making diagnosing challenging. Careful analysis of risk factors aids in diagnosis; these include prolonged immobility, deep vein thrombosis, recent surgery, postpartum state, trauma to vessel walls, hypercoagulable states, and certain disease states such as heart failure and trauma. Treatment approaches vary depending on the degree of cardiopulmonary compromise associated with the PE. They can range from thrombolytic therapy in acute situations to anticoagulant therapy and general care measures to optimize respiratory and vascular status (e.g., oxygen, compression stockings). PE is a frequent hospital-acquired condition, and one of the most common causes of death in hospitalized patients, resulting from a variety of factors that predispose one to intravascular clotting (Gulanick & Myers, 2011, p. 439). In this particular case, TC’s hypercoagulability, alongside her limited mobility, led to formation of multiple DVTs, which broke free and traveled through her venous system, resulting in multiple pulmonary emboli with a massive saddle embolism, which lies on the pulmonary aortic arch, potentially occluding blood flow to each lung. MEDICATIONS TC was ordered and administered the following medications on March 6, 2014 – patient teaching refers to if the patient is alert and oriented: * Enoxaparin 100mg BID via IM injection in lower left abdomen at 0900 and 2100: prevention of thrombi formation * Nursing Implications: Assess for signs of bleeding or hemorrhage. Observe injection site for hematomas, ecchymosis or inflammation. Alternate injection sites daily and do not massage injection site. * Teaching: Discuss the purpose of the medication and report any S/S of bruising, itchiness, dizziness, fever, swelling or difficulty breathing (Deglin, et al, 2013, p. 660). * Duloxetine (Cymbalta) 2 capsules (60mg) PO daily at 0900: treatment of depression * Nursing Implications: Monitor BP before and periodically during therapy for hypertension. Monitor weight weekly and report continued weight loss. Monitor for suicidal thoughts or worsening behavior. * Teaching: Discuss the purpose of this medication and instruct the patient to take it as directed at the same time each day. If TC was more alert, she should be taught to watch for increased anxiety, agitation, panic attacks, and irritability and to notify provider if any of these signs or symptoms occur (Deglin, et al, 2013, p. 482). * Levothyroxine (Synthroid) 1 tablet (50mcg) PO daily at 0700: treatment of hypothyroidism, thyroid supplement * Nursing Implications: Assess apical pulse and BP prior to and periodically during therapy. Assess for tachyarrhythmias and chest pain. Monitor blood and urine glucose levels in diabetic patients, such as TC, as insulin or oral hypoglycemic dose may need to be decreased. * Teaching: Instruct patient of the importance of taking the medication at the same time each morning and that therapy will be lifelong as the medication is not a cure for hypothyroidism. Instruct pt. to notify healthcare professional if headache, nervousness, diarrhea, excessive sweating, heat intolerance, chest pain, increased pulse rate, palpitations, weight loss greater than 2 pounds per week, or if any other unusual symptoms occur. Emphasize importance of follow up exams to monitor for effectiveness of therapy and the importance of thyroid function tests to be performed at least once a year (Deglin, et al, 2013, p. 781). * Pregabalin (Lyrica) 3 capsules (150mg) PO BID at 0900 and 2100: relief of pain related to diabetic neuropathy * Nursing Implications: Monitor closely for changes in behavior that could indicate the emergence or worsening of suicidal thoughts or depression. Assess location, characteristics, and intensity of pain periodically during therapy. May cause an increase in creatine kinase levels and a decrease in platelet count, so TC should be monitored closely for any changes. * Teaching: If TC was more alert, she should be instructed to promptly report unexplained muscle pain, tenderness, or weakness, especially if accompanied by malaise or fever. Inform TC that pregabalin may cause edema and weight gain, so TC’s weight should be monitored at least once per week (Deglin, et al, 2013, p. 1048). * Pantoprazole (Protonix) 1 tablet (40mg) PO daily at 0900 – prophylaxis treatment of peptic ulcer * Nursing Implications: Assess patient for abdominal pain and frank or occult blood in stool or sputum. May increase AST and ALT, so TC should be monitored closely. * Teaching: Discuss avoidance of concurrent use of alcohol, drugs or other foods that cause GI irritation. Notify physician to report onset of abdominal pain, presence of black, tarry stools or diarrhea (Deglin, et al, 2013, p. 991). * Hydromorphone (Dilaudid) PCA pump: Basal rate @ 1mg/hour, Demand rate @ 0.5 mg Q 20 minutes, with a limit of 2.5 mg/hour – pain control for fractured ankle * Nursing Implications: Assess BP, pulse, and respirations before and periodically during administration. If RR is less than 10 per minute, assess level of sedation. Assess bowel function routinely and institute prevention of constipation with increased intake of fluids and bulk, and laxatives to minimize constipating effects. May cause an increase in plasma amylase and lipase concentrations, so TC should be monitored closely. * Teaching: Instruct patient and family that medication may cause drowsiness or dizziness. Instruct patient to change position slowly and to call for assistance when ambulating. Encourage patient to turn, cough, and breathe deeply every 2 hours to prevent atelectasis (Deglin, et al, 2013, p. 668). TC takes the following medications at home, however, doses of home medications were not specified: * Warfarin * Actos * Soma * Hydromorphone * Levothyroxine * Lisinopril * Lyrica * Ranitidine (Patient Chart, 2014) LABORATORY DATA
*Collected March 6, 2013
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Results Normal Values
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Comp Metabolic Panel
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Glucose serum 125 H 80-110 mg/dL
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BUN 15 7-18 mg/dL
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Albumin serum 3.0 L 3.4-5.0 g/dL
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AST/(SGOT) 18 15-37 U/L
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ALT/(SGPT) 14 L 30-65 U/L
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GFR 48 L > 60 mL/min/1.73^2
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INR 1.3 L Therapeutic level 2.0-3.0
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PT 15.5 H 11.1-14.5 seconds
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CBC with PLT
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White blood count 9.9 4.8-10.8 x10*3
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HGb 14.7 14.0-18.0 gm/dL
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Hct 42.5 42-52 %
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Platelet count 226,000 140-440 x10*3
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(Patient Chart, 2014)
ANALYSIS OF LABS DONE ON 03/06/2014 TC has an elevated serum glucose level due to her diabetes. Her decreased albumin serum level is in relation to her kidney disease of unknown degree. In addition, her ALT is likely low in relation to her compromised kidneys as well, as well as her low GFR. Her INR level is considered low since she is hypercoagulable and on anticoagulant therapy. Elevated PT level is due to circulating anticoagulants. DIAGNOSTIC TESTS * CXR, Single View in ER on 3/05/14 * Findings: Normal, lungs grossly clear, no presence of infiltrates. * This test was indicated due to TC’s hypoxic episode, which was followed by a syncopal episode. * Ankle X-ray, Multiple Views in ER on 3/05/14 * Findings: Trimalleolar fracture, distal tib/fib fracture due to fall during syncopal episode. * This test was indicated due to TC’s syncopal episode in which she fell and awoke to pain in right ankle. * Pulmonary Artery Angiogram w/IV contrast on 3/05/14 * Findings: Extensive bilateral pulmonary emboli with prominent saddle embolus * Impression: History of DVTs and PEs, as well as history of being hypercoagulable. Hypercoagulability can be caused from certain disorders. In TC’s case, it may be due to her Lupus. * This test was indicated due to TC’s hypoxic episode, which was followed by a syncopal episode, as well as continued decreased oxygen saturation levels. In addition, this test was indicated due to pt’s history of thrombi. * Ultrasound of Lower Extremities on 3/05/14 * Findings: Prominent deep vein thrombosis in lower left extremity. * This test was indicated due to tenderness and pain during palpation of calf muscle, as well as pt’s history of thromboembolisms. NURSING DIAGNOSES (N.D.) 1. Impaired gas exchange R/T decreased perfusion to lung tissues caused by obstruction in pulmonary aortic branch by saddle embolus AEB confusion and dyspnea (Gulanick & Myers, 2011, p. 440). 2. Decreased cardiac output R/T decreased oxygenation AEB syncopal episode (Gulanick & Myers, 2011, p. 320). 3. Ineffective breathing pattern R/T hypoxia AEB dyspnea and hypoxemia (Gulanick & Myers, 2011, p. 439). 4. Ineffective peripheral tissue perfusion R/T hypercoagulability of blood AEB tenderness of LLE and pain during palpitation of calf muscle (Gulanick & Myers, 2011, p. 350). 5. Pain, acute R/T fractured ankle AEB observed evidence of pain, including expressive behavior and changes in vital signs (Doenges et al, 2011, p. 608). 6. Activity intolerance R/T imposed activity restriction AEB unable to endure or complete desired activities (Gulanick & Myers, 2011, p. 8). 7. Risk for infection R/T IV’s and surgical incision (Doenges, et al, 2011, p. 467). 8. Deficient knowledge R/T unfamiliarity with treatment and prevention AEB poor health maintenance (Gulanick & Myers, 2011, p. 352). TOP TWO PRIORITY N.D. / NURSING PLAN OF CARE NURSING DIAGNOSIS #1: Impaired gas exchange R/T decreased perfusion to lung tissues caused by obstruction in pulmonary aortic branch by saddle embolus AEB confusion and dyspnea (Gulanick & Myers, 2011, p. 440). SHORT TERM OUTCOME: Patient will maintain optimal gas exchange as evidenced by relaxed breathing and no further shortness of breath for remainder of shift on March 6, 2014. LONG TERM OUTCOME: Patient will achieve and maintain therapeutic blood level of anticoagulant as evidenced by PTT/PT/INR within desired range. INTERVENTIONS/RATIONALES: * Intervention: Assess skin color, nail beds, and mucous membranes for color changes. Rationale: Cool, pale skin may be secondary to a compensatory response to hypoxemia. As oxygen and perfusion become impaired, peripheral tissues become cyanotic. (Gulanick & Myers, 2011, p. 441). * Intervention: Assess for presence of signs and symptoms of pulmonary infarction. Rationale: A large pulmonary embolus or multiple small clots in a specific area of the lung can cause an ischemic necrosis/infarction of the lung area. Signs include cough, hemoptysis, pleuritic pain, consolidation, pleural effusion, bronchial breathing, pleural friction rub, and/or fever (Gulanick & Myers, 2011, p. 441). * Intervention: Administer oxygen as needed and monitor oxygen saturation level to maintain > 90%. Rationale: Supplemental oxygen may be required to maintain PO2 at an acceptable level (Gulanick & Myers, 2011, p. 441). * Intervention: Position the patient properly to facilitate ventilation perfusion matching. Rationale: Upright and sitting positions optimize diaphragmatic excursions and lung perfusion. When the patient is positioned on one side, the affected area should not be dependent (Gulanick & Myers, 2011, p. 441). * Intervention: Administer anticoagulant therapy as prescribed. Rationale: Anticoagulants are given to prevent further clot formation. The type of medication varies per protocol and severity of clot (Gulanick & Myers, 2011, p. 352). * Intervention: Monitor platelet counts, coagulation test results (INR, PT, PTT). Rationale: Effects of anticoagulation therapy must be closely monitored to reduce risk for bleeding. EVALUATION: * TC maintained oxygen saturation levels > 90% on 4 liters via nasal cannula with appropriate capillary refill of < 3 seconds and skin remained pink and dry. * TC remained free of cough and hemoptysis throughout shift. * TC was turned side-to-side Q 2 hours as permitted by fractured ankle. HOB was maintained at 30 degrees to assist in adequate ventilation and perfusion. * Administered anticoagulant therapy as prescribed by attending physician. TC was to begin additional anticoagulant therapy of Xarelto. Labs were closely monitored to follow TC’s INR in hope of reaching therapeutic levels. * Placement of I.V.C. filter on March 6, 2014 to prevent any further embolisms. TC handled the procedure well and was optimistic it would help her recovery. * TC’s room was dimly lit, quiet, and calm to promote relaxation and reduce anxiety. TC remained partially sedated and calm. NURSING DIAGNOSIS #2 Decreased cardiac output R/T decreased oxygenation AEB syncopal episode (Gulanick & Myers, 2011, p. 320). SHORT TERM OUTCOME: Patient will maintain adequate cardiac output and an oxygen saturation greater than 90% for remainder of shit on March 6, 2014. LONG TERM OUTCOME: Patient will remain hemodynamically stable and have no episodes of presyncope/syncope by March 13, 2014. INTERVENTIONS/RATIONALES: * Intervention: Assess rate and quality of apical pulse. Rationale: Most patients have compensatory tachycardia in response to low cardiac output, fever, or worsening disease. Dysrhythmias may occur, in addition to atrial fibrillation, and the pulse will be irregular and rapid (Gulanick & Myers. 2011, p.320). * Intervention: Assess BP, including any related light-headedness with exertion. Rationale: Most patients will have a systolic pressure greater than 90 mm Hg. BP lower than 90 mm HG or a MAP less than 60 mm Hg needs to be reported as a MAP of 70 mm Hg ensures appropriate cerebral perfusion. Patients are unable to raise their own cardiac output with activity and presyncope/syncope may occur (Gulanick & Myers. 2011, p.320). * Intervention: Assess respiratory rate, rhythm, breath sounds and maintain patent airway. Rationale: Lungs will be clear in the absence of left-sided heart failure. Orthopnea and paroxysmal nocturnal dyspnea are signs of left-sided heart failure (Gulanick & Myers, 2011, p. 321). * Intervention: Assess pt. for signs of infection, regardless of lab values. Rationale: With increased pulmonary hypertension due to PE, patients may have no cardiac reserve; infections need to be treated early and aggressively. Also, patients that are already immune compromised and ill are at greater risk for acquiring infection and need to be closely monitored, as in TC’s case (Gulanick & Myers, 2011, p. 321). * Intervention: Assess urine output. Rationale: Oliguria or inadequate urine output are signs of low renal perfusion. Oral diuretics may not be absorbed. Intravenous diuretics may be needed. (Gulanick & Myers, 2011, p. 321). * Intervention: Determine changes in level of consciousness. Rationale: Hypoxia and reduced cerebral perfusion will present with restlessness, irritability, and sleepiness (Gulanick & Myers, 2011, p. 321). EVALUATION: * TC maintained an adequate apical pulse rate of 90-105 b.p.m. and remained hemodynamically stable throughout shift. * TC maintained BP with a systolic pressure >90 mm Hg throughout shift, as well as a MAP of 94 mm HG, which is well above the requirement of 70 mm Hg to maintain adequate cerebral perfusion. * TC’s airway was maintained throughout shift, requiring no emergent interventions by RN or RT. Lung sounds were free of rales, wheezes, or rhonchi. * TC was unable to void for majority of shift. With no urine output, a Foley catheter was inserted @ 1600 with prompt urine output of 70 mL, which was dark amber in color. While TC was able to immediately void, 70 mLs in 10 hours proves to be insufficient as the minimum required output should be > 30 mL per hour. Unable to evaluate whether diuretics were started due to leaving the floor for post conference and patient was not in ICU the following clinical. * Neuro checks were performed on TC Q hour to ensure that her LOC remained stable. Patient remained responsive to commands although was partially sedated from use of PCA pump.

References
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2011). Nurse’s Pocket Guide (12th ed.). Philadelphia, PA: F.A. Davis Company.
Gulanick, M., & Myers, J. L. (2011). Nursing Care Plans Diagnoses, Interventions, and Outcomes (7th ed.). St. Louis, MI: Elsevier Mosby.
Kingman Regional Medical Center. March 6, 2014. Retrieved from patient chart.
Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2013). Davis’s Drug Guide for Nurses (13th ed.). Philadelphia, PA: F.A. Davis Company.
Van Leeuwen, A. M., Poelhuis-Leth, D., & Bladh, M. L. (2011). Davis’s Comprehensive Handbook of Laboratory & Diagnostic Tests with Nursing Implications (4th ed.). Philadelphia, PA: F.A. Davis Company.