NR 536 Week 5 Develop an Evolving Case Study

NR 536: Advanced Pathophysiology, Health Assessment and Pharmacology for Nurse Educators:  Experiential Learning

Template for Week 5’s Assignment:  Development of an Evolving Case Study for Clinical or Classroom Setting

NR 536 Week 5 Develop an Evolving Case Study

Overview of Evolving Case Study
Learning Objectives 
Description of the Evolving Case Study:PurposeIdentify type learner Concept to be presented The purpose of the evolving case study is to create a treatment plan to prevent and relieve symptoms of ventilator acquired pneumonia in intensive care units in acute health care settingsNurse staff with at least 3 years of experience in intensive care unit is selected as type of learner.Concepts includes patient’s safety, infection prevention, VAP, HAP, evidence-based practice (Olanipekun & Snyder, 2019), oral hygiene (Hua et al., 2016), use of medical device, antibiotic resistance (Khan et al., 2017), physiotherapy (Zampieri et al., 2015), sedation management, and physical assessment (Álvarez-Lerma et al., 2018).
Description of the Setting:A patient with respiratory failure admitted in the ICU of an acute health care setting.  Oxygen supplementation, intubation, and mechanical ventilation is being used.  Pt is sedated, IV anticoagulant treatment, IV fluids infusion, wall suction set up, cardiac and pulmonary monitoring and vital sign machine set up.  
Description of Patient
NameMr. XYZ
Gender/Age/Weight/HeightMale/65/ 5ft 10″/252 lbs.
AllergiesCodeine
Past medical historyDiabetes, asthma, recent ischemic stroke December, 2019, paroxysmal atrial fibrillation, and coronary artery bypass surgery 2016, smoker 40 pack years, ETOH. 
History of present illnessPt admitted 2/82020, complaining of tachypnea, shortness of breath, chest pain with breathing and exertion starting 6 am.  Brought in by ambulance, CT confirmed massive pulmonary embolism.  Pt desaturated to 78% on 4 L of oxygen via nasal canula, went to respiratory distress, bp 86/40, temp 101, needing intubation in ER, transfer to ICU with vasopressors and mechanical intubation.  
Social historySmoking – yes, alcohol – yes, occupation – retired software engineer, lives at home with wife, 2 adult children out of stateBaseline functioning – on disability, uses a cane for long distance walking. 
Primary medical diagnosisPulmonary embolism, pleural effusion, pleurisy, respiratory failure. Complicated by Ventilator-associated pneumonia, hypoxemia. 
Surgeries and/or procedures with datesCT scan Chest – 2/8/2020Blood cultures – 2/8/2020Urine culture – 2/8/2020Arterial blood testing – 2/8/2020Covid19 test -2/8/2020 (negative)Daily EKGDaily blood test.Daily Chest Xray 
Report that Learners receive to prior start of the Evolving Case Study using SBAR Format
Time of report2/10/2020 1145 AM
Person providing the reportRegistered nurse
SituationDr.Abc, this is nurse Ms. Blt from ICU reporting that a 65 year old male, in room 2 in  MICU, who was intubated 2 days ago for respiratory failure is requiring higher FiO2 / PEEP.  
BackgroundThe patient was admitted 2/8/2020 with a massive pulmonary embolism, an endotracheal tube was placed the same day in the ED.  He is full code, on a heparin drip, mechanical ventilation, 122 HR BP 99/68, temp 39.6 centigrade, Patient’s chest x-ray today shows new infiltrates, WBC is went up to 22.
AssessmentI am afraid patient might have VAP given he is 2 days post intubation, and patient is having purulent and increase secretions, needing higher FiO2 and PEEP, and has spiked a fever. 
RecommendationI think it is better to obtain more diagnostics to verify VAP.  Like tracheal aspirate for gram stain and culture, CT chest, lung ultrasound, repeat blood culture and urine culture, check procalcitonin, and start empiric antibiotics after cultures are sent. Also, we can check for MRSA in the nares, repeat Covid-19, check for influenzas. If you think VAP is highly possible, maybe doing a bronchoalveolar lavage?
Evolving Case Study Progression
Evolving Case Study Information to be presented to the LearnerActions Learners SHOULD DemonstrateSocratic Question for each area to ask learner at end of stage
Stage One (Start of the case study)Patient requiring higher Fi)2 or PEEP, having decline in oxygenation level (Hellyer et al., 2016). Fever is reported.  Tachycardia – HR 120’sAssess the conditionEvaluate medical historyContact the doctor and report the issueProvide initial assistance to patients including respiratory managementPathophysiology: What caused the sudden change in oxygen requirement and desaturation? What causes the fever?
Physical Assessment: Is detailed physical assessment and vital sign enough? Or there is a need for more diagnostic procedure like labs, blood culture, sputum culture, CT, x-ray?
Pharmacology: Is starting an early broad- spectrum antimicrobial coverage necessary?




Trigger for Stage Two:  
Stage Two:

Increase in purulent secretions, needing more endotracheal suctioning.  Fever,  hypoxemia.   Implement VAP care – group of interventions related to ventilator care to enhance reduction of incidence of VAP. Understand the importance of identifying the cause and effectImplement bundle treatment processSafely remove and replace the tube with new one Thorough oral care with suctioning Head of bed elevation tat least to 30-degreesMeasure endotracheal tube cuff pressure to maintain pressure and prevent micro aspirationProper hand hygieneSedation monitoring and reportingProvide antibiotics
Pathophysiology: Is providing proper nursing practices like oral care and reducing secretion aspiration successfully contribute in preventing ventilator associated pneumonia? Physical Assessment: Is 30-degree head of bed positioning better for preventing secretion aspiration? 
Pharmacology: Is there a better alternative for chlorhexidine in oral care effective to reduce gram negative bacteria or prevent cytotoxic effect?
Trigger for Stage Three: hemoptysis and bronchospasm due to increased or purulent secretions in the lungs
Stage Three:

Confirm diagnosis of ventilator associated pneumonia.  Tracheal aspirates positive for pathogenic bacteria. CT and chest X-ray confirm new and progressing infiltrate, leukopenia, leukocytosis.Monitor patient for if ready to wean from intubation.
Narrow antibiotics based on sputum cultureRe-evaluate all data 24-48 hours after starting antibioticsStop antibiotics in a timely mannerProvide probioticsContinue to monitor and perform head to toe, vital signsRepeat labs and chest xray
Pathophysiology: Will purulent secretion result in morbidity?


Physical Assessment: Is it possible to reduce VAP rates by adopting spontaneous breathing trials (SBT), and daily sedation interruption (DSI)?
Pharmacology: Is it crucial to narrow and reevaluate after 24-48 hours after starting antibiotics in this situation? Is it beneficial to use probiotics?
Expected ending for case study if learner’s actions are APPROPRIATE: The learner might help in reducing the infection spread. However, it takes time as patients are still at high risk of contracting VAP (Hellyer et al., 2016). The process betters the breathing pattern, reduces infection and inflammation, prevent bacterial secretion, and conditions such as fever, increased or the purulent secretions, tachypnea, hemoptysis, crackles, rhonchi, reduced breathing sounds, and bronchospasm (Álvarez-Lerma et al., 2018). 
Debriefing
Socratic Question #1 (focusing on Stage 1)What precaution measures aid in preventing VAP rates in patients with chronic conditions?
Socratic Question #2 (focusing on Stage 2)Is bundle treatment stages of head inclination and oral hygiene should be carried out twice a day?
Socratic Question #3 (focusing on Stage 3)How to limit increased secretion of bacteria in trachea and lungs quickly?
Socratic Question #4 (focusing on the overall case study)What is the best multi-modal precaution, prevention, and treatment method for patients who are bed-ridden?

NR 536 Week 5 Develop an Evolving Case Study

References

Álvarez-Lerma, F., Palomar-Martínez, M., Sánchez-García, M., Martínez-Alonso, M., Álvarez-Rodríguez, J., & Lorente, L. et al. (2018). Prevention of ventilator-associated pneumonia. Critical Care Medicine46(2), 181-188. https://doi.org/10.1097/ccm.0000000000002736

Bardia, A., Blitz, D., Dai, F., Hersey, D., Jinadasa, S., Tickoo, M., & Schonberger, R. (2019). Preoperative chlorhexidine mouthwash to reduce pneumonia after cardiac surgery: A systematic review and meta-analysis. The Journal Of Thoracic And Cardiovascular Surgery158(4), 1094-1100. https://doi.org/10.1016/j.jtcvs.2019.01.014

Fortaleza, C., Filho, S., Silva, M., Queiroz, S., & Cavalcante, R. (2020). Sustained reduction of healthcare-associated infections after the introduction of a bundle for prevention of ventilator-associated pneumonia in medical-surgical intensive care units. The Brazilian Journal Of Infectious Diseases24(5), 373-379. https://doi.org/10.1016/j.bjid.2020.08.004

NR 536 Week 5 Develop an Evolving Case Study

Hellyer, T., Ewan, V., Wilson, P., & Simpson, A. (2016). the intensive care society recommended bundle of interventions for the prevention of ventilator-associated pneumonia. Journal Of The Intensive Care Society17(3), 238-243. https://doi.org/10.1177/1751143716644461

Hua, F., Xie, H., Worthington, H., Furness, S., Zhang, Q., & Li, C. (2016). Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Of Systematic Reviews. https://doi.org/10.1002/14651858.cd008367.pub3

Khan, Z., Ceriana, P., & Donner, C. (2017). Ventilator-associated pneumonia or ventilator-induced pneumonia. Multidisciplinary Respiratory Medicine12. https://doi.org/10.4081/mrm.2017.224

Olanipekun, T., & Snyder, R. (2019). Mortality risk in ventilator-acquired bacterial pneumonia and nonventilator icu-acquired bacterial pneumonia. Critical Care Medicine47(10), e851-e852. https://doi.org/10.1097/ccm.0000000000003662

Pinho, R., Tanure, L., Pessoa, J., Santos, L., Couto, B., & Starling, C. (2020). Impact of each component of a ventilator bundle on preventing ventilator-associated pneumonia and lower respiratory infection. Infection Control & Hospital Epidemiology41(S1), s259-s260. https://doi.org/10.1017/ice.2020.824

Prasad, R., Daly, B., & Manley, G. (2019). The impact of 0.2% chlorhexidine gel on oral health and the incidence of pneumonia amongst adults with profound complex neurodisability. Special Care In Dentistry39(5), 524-532. https://doi.org/10.1111/scd.12414

NR 536 Week 5 Develop an Evolving Case Study

Vieira, P., de Oliveira, R., & da Silva Mendonça, T. (2020). Should oral chlorhexidine remain in ventilator-associated pneumonia prevention bundles?. Medicina Intensiva. https://doi.org/10.1016/j.medin.2020.09.009

Xie, X., Lyu, J., Hussain, F., & Li, M. (2019). Drug prevention and control of ventilator-associated pneumonia. Front Pharmacol10(298). https://doi.org/10.3389/fphar.2019.00298

Zampieri, F., Nassar Jr, A., Gusmao-Flores, D., Taniguchi, L., Torres, A., & Ranzani, O. (2015). Nebulized antibiotics for ventilator-associated pneumonia: a systematic review and meta-analysis. Critical Care19(1). https://doi.org/10.1186/s13054-015-0868-y

Zhao, J., Li, L., Chen, C., Zhang, G., Cui, W., & Tian, B. (2020). Do probiotics help prevent ventilator-associated pneumonia in the critically ill patients? A systematic review with meta-analysis. ERJ Open Research, 00302-2020. https://doi.org/10.1183/23120541.00302-2020

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