Interdisciplinary Care Plan: Respiratory Failure
COURSE OUTCOMES
CO 1: Provide nursing care to patients and their families in critical and emergent care settings based on theories and principles of nursing and related disciplines.
CO 2: Initiate the use of appropriate resources in direct care responsibilities within critical‐care and emergent care settings.
CO 3: Demonstrate effective therapeutic communication and relationship skills in providing care to patients and families in critical‐care and emergent care settings.
CO 4: Demonstrate effective clinical decision‐making based on critical thinking skills and legal, ethical, and professional standards and principles when caring for patients and families in critical care and emergent care settings.
CO 5: Implement a plan of for continued personal, professional, and educational development related to nursing practice within critical‐care and emergent care settings.
CO 7: Use evidence including research findings from nursing and related disciplines to answer clinical questions related to nursing care of patients in critical care and emergent care settings.
Solution
Interdisciplinary Care Plan: Respiratory Failure
Table of Contents
Demographics and Information. 3
Laboratory Results and Diagnostic Tests. 5
Right biliary and Right Gallbladder drain 6
CT Scan: Pelvis and the Abdomen. 6
Ultrasound Test: Gallbladder 6
Dx#1: The risk of developing aspiration R/t endotracheal tube. 8
Dx: The risk of developing an impaired skin R/t stasis. 9
Dx: risk of developing am impaired oral mucous membrane R/t breathing through the mouth. 9
Interdisciplinary Care Plan
During my clinical practice at the John Hopkins Hospital, 1800 Orleans St, Baltimore, I was honored of providing critical care for patient W.M in the ICU unit. At first, I experienced nervousness regarding the experience. During the shift, I was on duty with a Registered Nurse(RN), T attending to patient W.M, who was critically ill. This essay transcends an interdisciplinary care plan for patient W.M.
Date of Interventional Care: December 2, 2016
Sex: Female
Date of Birth: 07/12/47
Initials: W.M
Age: 70 years
Marital Status: Married
Race: Black
Ethnicity: Black-American
Language: English
Religion: Pagan
Employment Status: Retired Bank Manager
Room Number: Intensive Care Unit No. 6
Allergies Present: No present allergies detected
Date of Admission: 12/1/16
The admitting diagnosis indicated cholecystitis and cholangitis. Socially, the patient smoked half a pack of cigarette for 50 years, and it is evident that he had quit smoking four months ago. He takes alcohol occasionally and lives happily with his wife at home. Family history suggests that his mother had gallbladder disorders and the father had a polycystic disease of the kidney. Past medical history suggests that the patient suffered hypertension, hypothyroidism, and diabetes mellitus. On the other hand, the patient underwent a superficial polyp removal surgery five years ago.
First, the patient underwent the HEENT test, and it was reported that the nose had a moist mucous membrane, indicating an elevated bilirubin. Additionally, the neck was supple with no jugular venous distention (JVD). Additionally, cardiovascular assessments indicated an irregular heart rate with peripheral edema. The rationale on this relates to a heart failure. Lung assessment indicated the presence of wheezing and reduced lung sounds in the lower lobes, as such, this relates to abnormalities in the respiratory system. The abdominal assessment shows that the patient had a firm abdomen with hypoactive bowel sounds relating to the development of sepsis. Since the patient was sedated, there were no neurological assessments made as no cyanosis was noted.
Laboratory Results and Diagnostic Tests
BP: 97/58
Pulse Rate: Strong and Bilateral
Heart Rhythm: Irregular
Apical Rate: 80: Radial Test: 74
Refilling of the Capillary: below 3
Murmur: present
No rubs in heart sounds
Distended and firm abdomen
Bowel sounds: hypoactive
Last BM: unknown
Urinary System
Amount: 870 mL
Continent urinal system
Foley Catheter bladder program
Urinary Tube Insertion (12/2/16)
It was suspected that the patient had an acute injury of the kidney. Therefore, urine collection was done. This test focused on monitoring the bladder pressures and output as well preventing the skin from the breakdown of involuntary control of urine.
Right biliary and Right Gallbladder drain (12/2/16)
The right biliary drain was performed to drain the bile duct and decrease the levels of bilirubin to measure output in case of sepsis accurately. On the other hand, Right gallbladder drain was performed for reasons of sepsis to drain bladder’s content since the patient was unstable for the administration of cholecystectomy.
CT Scan: Pelvis and the Abdomen (12/02/16)
To identify abnormalities, a CT scan was performed on the abdomen and the pelvis. Splenic and hepatic granulomas were present. Additionally, the liver was enlarged with moderate fat presence. Aortoiliac atherosclerosis was present, and there was a bilateral presence of the inguinal hernias. These findings relate to acute cholecystitis.
X-ray: Abdomen and Chest (12/02/16)
There were no abnormalities through X-Ray Scan
This test was performed to identify abnormalities in the gallbladder. As such, a distended gallbladder was observed with the bile dilated.
To avoid respiratory distress, intubation was administered. An analysis catheter was administered for patent line access. Additionally, a gastric tube was inserted for feeding and Activity Gauges on the left and right were put on IV medication and fluids.
The patient was taken to the emergency section after he was diagnosed with sepsis coupled with cholecystitis and a suspicion of a mounting cholangitis. Additionally, the patient had experiences with heart and respiratory failures indicating minor sepsis(Kogelmann, Druener, Jarcza, & Schneider, 2013). As per the lab report, the patient was admitted to an intensive as a result of hypotension and sepsis that required urgent intubation.
| Generic and Trade Name | Classification | Medical Use | Side Effects | Nursing Implications | Rationale |
| Vancomycin Vancocin | Anti-infective | Acts against vulnerable organisms | Hypotension Vomiting, Nausea, superinfection | The nurse has to assess an infection during therapy and monitor areas where IV are administered | Prevent infections |
| Fentanyl Innovar | Opioid and analgesic | Tranquilizing and producing an analgesia during surgery | Sedation, confusion, depression, hyperactivity, hallucinations and urinary retention | The RN has to assess the intensity, location, and type of pain through an analysis of Blood pressure pulse rate and respirations | This was administered to relieve the patient of excessive pain |
| Albumin human Optison | Blood products | Expands the plasma volume and maintains the cardiovascular output | Headaches, hypotension, Increased salivation, fever, and flushing | The RN must monitor the hemoglobin levels as well as the serum levels | Increase the RBC count for the patient |
| Lasix Furosemide | Diuretics | Edema as a result of heart failure or renal disease | Blurred vision, headaches, loss of hearing, dry mouth, vomiting, excessive urine production, hyperglycemia, hemolytic anemia, muscle cramps and dehydration | The RN must monitor fluid levels in the body of the patient, evaluate the location and amount of edema on the patient as well as monitor the lung sounds and blood pressure | Treating edema |
| Versed Midazolam | Sedatives and antianxiety agents | Provides sedative effect or amnesia during surgery process | Drowsiness, headaches, apneas, nausea, coughing and rashes | The RN must assess the patient of the level of sedation 2-6 hours before administering the medication | Sedating the patient for surgical operations |
Dx#1: The risk of developing aspiration R/t endotracheal tube
The nurse will expect the patient to maintain a clear airway during the intervention. In this case, the nursing interventions will entail as an assessment of the pulmonary status for clinical proof of aspiration. As such, for patient W.M there were auscultate breathing sounds for the development of wheezes and sizzles. The dynamics of collaborative interventions will entail a respiratory specialist to assess the respiratory and the pulmonary status before and after breathing treatments to guarantee vibrant and clear airway. Furthermore, the patient is expected to decrease the risk of aspiration after assessment and treatment. As such, to foster invention the nurse must monitor the efficiency of the cuff from the exercise tolerance testing in collaboration with a respiratory specialist who will evaluate the cuff pressure assessment to prevent the unpredictable extubating process. Last, the RN’s outcome will entail freeing the patient from excessive mucus production during therapy. The intervention, in this case, will entail an administration of the meticulous oral hygiene and suction of the upper airway to deter secretions in the oral cavity in collaboration with the respiratory specialist through a rotational framework.
Dx: The risk of developing an impaired skin R/t stasis
Second, the nurse outcome will entail that the patient’s skin remains intact throughout therapy by assessing the skin thoroughly and applying foam dressings. The RN will collaborate with a care technician who will notify the RN if the dressing has worn off or of any skin breakdown. Also, the RN will ensure that the skin of the patient is free from irritation and redness, while in bed, by repositioning the patient regularly, per se, 2 hours, to guarantee pressure relief and air circulation. The care technician will come in handy by using the buddy system to ensure efficient repositioning of the patient. Last, the RN will expect the patient to form bed sores during treatment by utilizing the Braden Scale tool to evaluate the ulcer pressure risk. The care technician will assist the RN in repositioning to avoid the ulcer pressures.
Dx: risk of developing am impaired oral mucous membrane R/t breathing through the mouth
The RN will ensure that the patient will have an intact mucous membrane through the treatment plan by providing proper oral care by utilizing oral kits. The respiratory specialist and the care technician will help in switching off the care protocol. Additionally, the patient is expected to have a healthy and moist membrane during and after treatment. This will be facilitated by the use an assessment of the membrane to ensure that it is sufficiently moist as well as applying a moisturizing cream after oral care. The respiratory specialist and the care technician will collaborate with the RN through switching between shifts by providing oral care and prevent mouth dryness and cracked tongues and lips. Last, the RN will ensure that the patient is free of any oral lesions by providing hourly oral care and evaluate any formation of oral lesions in collaboration with the care technician and the respiratory specialist.
First, since the patient was sedated, intubated, and on bed rest, it was my duty with the RN to reposition and turn the patient every 2 hours. Also, W. M’s diet was NPO, as such, provision of tube feeding was imperative. Blood glucose checks were administered since the patient was on an insulin drip. Furthermore, oral care such as brushing the teeth and tongue as well as cleaning gums was imperative since he was an intubated patient. Intubated patients tend to develop dry mouth or get sores when oral care is not administered. Also, W.M had to undergo suctioning only as needed. W.M had to be frequently monitored for any vital signs and were recorded on an electronic chart to determine the health status of the patient. Also, due to the medications administered, the adverse effects such as hypotension had to be monitored.
To add on, daily bathing was imperative to foster proper hygienic conditions for the patient as well as respect for the patient. The bath was given each and every morning of the day as well as an assessment of the skin. Last, Foley Catheter Care was administered to W.M to ensure cleanliness and risk of contracting CAUTI. Th Rn and I utilized leg straps on the patient as we did not tighten too much on W. M’s thigh.
Interdisciplinary teams are imperative in any healthcare intervention. For this case, W.M utilized a number of healthcare professionals as listed below:
- Registered Nurse- The RN is always with the patient and monitors lab, vitals, evaluations, feeding and the overall primary care of the patient. They are also obliged to communicate with the family of the patient and other healthcare members of the progress of the patient.
- Doctor/ Physician- The doctor is in charge of assessing and determining the type of medication that a patient will undergo as well as the relevant test for the patient coupled with relevant decisions regarding the care plan for the patient. Also, the doctor takes part in the collaborative decision making on when the patient should be discharged.
- Respiratory Specialist- In the case of W. M, the RS was responsible for monitor the respiratory status through an assessment of the lung sounds and the ventilator. Also, he placed the patient on a portable vent.
- Laboratory Technician- The LT was responsible for analyzing specimens from W.M and reporting any abnormalities that were critical for treatment. He reports directly to the RN.
- Pharmacologist – Responsible for management and release of drugs and medication for the patient.
- Occupational Therapist- The OT will come in handy after the patient is able to extubate.
- Social Worker- Responsible for discharge plans and proper disbursement of necessary equipment to the patient once discharged. Fosters patient advocacy and expedite communication with other practitioners.
- Pastor/Priest- Provision of pastoral care and meeting up with the patient’s family and the patient for spiritual and religious help.
- Pulmonologist- In this case, the pulmonologist was assigned a task to assess the patient’s respiratory distress and imminent respiratory failure.
- Cardiologist – Assigned the task of assessing any traces of heart failure since the patient presented a reactive feature to sepsis, known as tachycardia.
- Care Technician- Assist the RN in repositioning and turning the patient, maintaining hygiene, and ensuring skin integrity for the patient.
- Radiologist – Responsible for trialysis catheter
- Gastroenterologist/ Surgeon – When W.M becomes stable to undertake cholecystectomy, he/she will come in handy during surgery.
- Nephrologist- Responsible for assessing W. M’s acute kidney failure.
- Sequential Compressive Devices – This device was used to help the patient with adequate blood circulation and prevent blood clots. The nurse has the responsibility of ensuring that the device the machine is properly placed on the patient’s legs during bedrest and ensure that the machine is switched on.
- Cardiac Monitor – The device was used to monitor the patient’s heart rate and rhythm. The nurse must make sure that the cardiac monitor leads are attached to the patient properly. The nurse must have the capacity to read and interpret the readings on the cardiac monitor.
- Ventilator – Expediting proper ventilation for the patient. The nurse has a responsibility of ensuring that the ETT tube is properly placed. The RN must report to the RS immediately in the event of an alarm or the tube being pulled out.
- BG Monitor – There was a need to check blood glucose since the patient was under insulin drips to ensure that the patient does not exhibit cases of hypo/hyperglycemia. The nurse must be able to accurately interpret reading on the meter and ensure that it works effectively.
- Infusion Pumps- These were used to suffuse patient medication as well as fluids intravenously. The nurse was responsible for administering all IV infusions, drugs, and food relevant to the infusion pumps. The nurse must also ensure that the device works properly.
- Suctioning Kit – This kit was used to remove oral secretions, and the Rn must be able to know the appropriate technique of suctioning as well as utilize critical thinking skills to realize when the patient requires suctioning.
As s nurse practitioner, such an experience illuminated my professional development and role as an RN. First, I understood that communication is one of the most crucial element when it comes to critical care. Even though patient W.M was in a sedated state, the RN was not able to communicate verbally but utilized the use of therapeutic touch to communicate with the patient during positioning and turning process. Additionally, my experience with the patient’s wife revealed to me the need to use comforting language as the husband was in the ICU. Furthermore, I realized the communication system within healthcare organizations such as John Hopkins Hospital is integrated and simplified using current technological advances such as pagers. I would prefer verbal communication since am confident with my communication skills as such can bear handling critically sick patients and their families.
The area that I would suggest a recommendation is on fostering effective communication between doctors and patients. Chiarchiaro, Buddadhumaruk, Arnold, and White (2015) found out in their research that the quality of communication when attending to patients with respiratory distress fostered better patient outcome compared to poor communication. As such it is important for the physician to communicate with the patient family as well as the patient in question to foster better patient outcome.
I understood the fact that there is need to utilize evidence-based research in administering critical care to patients. The diagnosis and treatment plans were all based on the current research to employ the best intervention plan for patient W.M. Additionally, research by Lane, Ferri, Lemaire, McLaughlin, and Stelfox (2013) suggest the need for RNs to perform effective rounds as they care for patients in ICU. It can be recommended that there would be at least four nurses for a 24-hour ICU attendance of the patient regardless of the presence of the RS and The care technician.
In regards to the case I experienced at John Hopkins Hospital, I cannot figure out any barriers to the system since the communication between the interdisciplinary team was impeccable. For instance, the RN who attended to patient W.M had adequate knowledge and experience in handling ICU patients in that when she experienced anything abnormal she could reach out to a physician even if it were at night.
Last, in regards
to my self-developmental plan and my career as a nurse, I came to a realization
that respect and collaboration are they underlying foundations in delivering
health care services to patients with critical illness. Furthermore, I was inspired by the way the RN, in this case, undertook the treatment plan
with utmost care and passion for work. I am looking forward to emulating such a
personality. She guided me well during my practice,
and I appreciate her as a role model.
References
Chiarchiaro, J., Buddadhumaruk, P., Arnold, R., & White, D. (2015). Quality of Communication in the ICU and Surrogate’s Understanding of Prognosis. Critical Care Medicine, 43(3), 542–548. https://doi.org/10.1097/CCM.0000000000000719.Quality
Kogelmann, K., Druener, M., Jarcza, D., & Schneider, U. (2013). Protocol guided therapy of sepsis and an interdisciplinary ICU concept. Benefit in 28-day mortality 5 years after implementing a sepsis protocol and an interdisciplinary intensive care unit. Infection, Supplement, 41(1), S62. https://doi.org/http://dx.doi.org/10.1007/s15010-013-0513-0
Lane, D., Ferri, M., Lemaire, J., McLaughlin, K., & Stelfox, H. T. (2013). A Systematic Review of Evidence-Informed Practices for Patient Care Rounds in the ICU. Critical Care Medicine, 41(8), 2015–2029. https://doi.org/10.1097/CCM.0b013e31828a435f
Mitchell, P., Wynia, M., Golden, R., McNellis, B., Okun, S., Webb, C. E., … Von Kohorn, I. (2012). Core Principles & Values of Effective Team-Based Health Care. Institute of Medicine., (October), 1–32. https://doi.org/10.3109/13561820.2013.820906
