Page 1 of 3 FCC assessment item 1: Case 2015 Fundamentals of Critical Care Nursing: case for assessment 1 (Students’ copy) A 76-year-old male (Alfred Hermitage) was admitted to the intensive care unit (ICU) of a tertiary referral hospital from the operating room after surgical resection of the upper lobe of the left lung for stage IIIB adenocarcinoma of the lung and insertion of an underwater seal chest drain (left side). Presentation Early today (02.00 hours), he was brought into the emergency department (ED) by ambulance with chest pain. In the emergency department, he was drowsy and confused when roused and was peripherally cold with cyanosis. His systemic arterial blood pressure was 80/55 mm Hg, heart rate was 130 beats per minute (bpm), his respiratory rate was 40 bpm and he had notable restricted air entry to the left side of the chest. His work of breathing was high and he had an expiratory wheeze audible without a stethoscope. A computed tomographic (CT) scan of the chest performed in ED revealed a lesion approximately 7cm in diameter 2cm proximal to the carina in the left main bronchus and a small left sided pneumothorax. Past health history  Hypertension – treated with ace inhibitors  Hypercholesterolemia – treated with statins  Previous excessive alcohol intake (now abstains) and 80-pack-years of cigarette smoking  Mild cognitive impairment: Standardised Mini-Mental State Examination score: 24 (performed by GP 7 months ago) Social history Married to Doreen. Son lives in Canberra and daughter overseas. Clinical course On arrival in the ICU (13.00hrs), he was still deeply sedated and intubated. He was mechanically ventilated with a fraction of inspired oxygen (FiO2) of 0.6; the arterial blood pressure was supported with a noradrenaline (norepinephrine) infusion. When the patient was in the operating room he was haemodynamically unstable (had frequent hypotensive episodes) and received a total of 5 litres of crystalloid intravenous fluid. On his arrival in the ICU, the vital signs were: blood pressure 90/53 mm Hg; heart rate of 122 beats per minute (sinus rhythm), central venous pressure 7 mmHg, and temperature 35.6°C. An arterial blood sample was taken for blood gas analysis and blood samples were also taken for full blood count, coagulation studies and biochemistry. The chest Xray taken on arrival in ICU revealed diffuse bilateral pulmonary infiltrates. Right heart catherisation is performed (a pulmonary artery catheter inserted). Page 2 of 3 FCC assessment item 1: Case 2015 A Comprehensive health assessment was performed after the patient was stabilised at 15.00hrs. Here are the notes taken from the nurse’s entry in the health care records: Airway/ breathing / respiratory system  Airway: size 8.5mm endotracheal tube secured with white tape 23cm at lips (tip visualised 2cm from carina on Chest Xray)  Chest inspection and auscultation: Chest rising and falling equally in synchrony with ventilator, decreased breath sounds over the left lower lung field, diffuse endinspiratory crackles over the remaining lobes and right lung  Mechanical ventilation: Synchronised Intermittent Mandatory Ventilation: FiO2: 0.6, tidal volume: 450 ml, respiratory rate: 12 bpm, peak end expiratory pressure (PEEP): 5 cmH2O, minute volume: 5.4 L/min, constant flow breath delivery, inspiratory time: peak airway pressure limit: 35 cmH2O (occasional pressure limit alarm), no spontaneous respiratory effort noted  Arterial blood gas: pH 7.32; partial pressure of carbon dioxide (PaCO2) of 45 mm Hg; partial pressure of oxygen (PaO2) of 70 mm Hg; and a lactate level of 3.2 mmol/L  Underwater seal chest drain (Atrium Oasis)– swinging, 200ml of frank blood in chamber, intermittent bubbling (leak 2 on Oasis scale), on wall suction (80mmHg) and set at -15 cmH2O on drain Cardiovascular system  Vital signs: heart rate 130 beats per minute (sinus rhythm with ‘runs’ of atrial fibrillation), blood pressure 90/45 mmHg; and temperature 37.6°C, sluggish peripheral capillary return  Cardiac output studies and pulmonary artery pressures: cardiac output (CO): 7.74 L/min, cardiac index (CI): 4.1 L/min/m2, central venous pressure (CVP): 8 mmHg, systemic vascular resistance index (SVRI): 1110 dynes/sec/cm5/m2, pulmonary artery systolic pressure (PASP): 59 mmHg, pulmonary artery occlusion pressure (PAOP): 11 mmHg  Intravenous catheters and infusions: quadruple lumen pulmonary artery catheter (right internal jugular), large bore peripheral cannula (right antecubital fossa), noradrenaline at 8ml/hr (concentration: 4mg/100ml), maintenance (0.9% sodium chloride) at 100ml/hr  Full blood count and coagulation: haemoglobin (Hb): 9.0g/dL; white cell count: 11.1 x 109 /L; haematocrit: 0.32; Activated Partial Thromboplastin Time (APTT): 24 seconds (norm ref: 26-36 seconds) Neurological system /comfort  Conscious level: Opens eyes to voice, moving all four limbs but not to command (Glasgow coma score: (E = 4, V= 1(T), M = 5), pupils equal and reacting to light briskly (2mm), cough reflex (occasionally spontaneously and when suctioned via tracheal), Page 3 of 3 FCC assessment item 1: Case 2015 restless – hand moving towards endotracheal tube intermittently (does not respond to instructions to leave it; needs to be stopped from pulling it)  Comfort: Critical-Care Pain Observation Tool (CPOT) score = 6 (grimacing intermittently, evidence of muscular tension), sedation level -Richmond Agitation Sedation Scale (RASS) score: +1. Morphine infusion at 5ml/hr and midazolam infusion at 2ml/hr (syringe drivers) Renal /electrolytes  Serum electrolytes: potassium (K+): 4.5mmol/L and sodium (Na+): 132mmol/L  Urea 10mmol/L and creatinine 0.14mmol/L  Urinary output: urinary catheter in situ 10ml/hr (clear, dark urine) GIT/Endocrine  Abdomen tense and distended: hypoactive bowel sounds  Blood glucose level: 12mmol/L  No enteral tube and no nutritional replacement in progress Integumentary  Reactive hyperaemia sluggish – capillary return 5 seconds on sacral skin  Waterlow score: 30  Thoractomy and chest drain wound sites covered and dressing intact (very small strike through of fresh blood on both)  No other skin abrasions noted Social Doreen (wife) in attendance (10 years his younger) but not yet seen by medical team. Appears anxious. Stated that ‘I told Alfred to go to the doctors weeks ago when he started to have trouble breathing but he wouldn’t listen’. FUNDAMENTALS OF CRITICAL CARE NURSING: ASSESSMENT ITEM 1 DETAILED MARKING CRITERIA Page 1 of 1 Fundamentals of Critical Care Nursing 2015 1. Concise patient history providing context (5 marks) Succinct overview of the patients’ history and clinical findings on presentation, providing context for the case study HD D C P F Vague description of patients’ history and clinical findings with no clear context 2. Care plan explaining physiological alterations and pathophysiological processes in relation to the body systems and priorities for treatment (10 marks) Demonstrates understanding of the impact on bodily systems through analysis of physiological alterations (4) HD D C P F Limited understanding of the impact on bodily systems. Superficial analysis / discussion Correctly identifies priorities of care and treatment (6) HD D C P F Incorrect prioritisation which could put the patient at risk of harm 3. Rationale for management strategy / nursing intervention (10 marks) Thorough balanced rationale provided for the selected strategy/nursing intervention (3) HD D C P F Shallow/superficial explanation rationale provided for the selected strategy/nursing intervention Thoroughly evaluates the selected strategy/nursing intervention in relation to relevant research (7) HD D C P F Superficial evaluation of the selected strategy/nursing intervention in relation to relevant research. 4. Discussion of impact of critical care environment on the patient and their family (5 marks) Thorough discussion of the potential effects of the critical care environment, demonstrating an understanding of the impact on the patient and their family HD D C P F Superficial description of the potential impact of the critical care environment on the patient and their family 5. Depth of insight into legal and ethical issues (4 marks) Correct identification of relevant legal and/or ethical issues, providing insight into their influence/s on patient care and clinical decision making HD D C P F Superficial description of legal and ethical issues 6. Currency and relevance of literature (6 marks) Current scholarly, and where relevant, evidenced-based literature integrated within essay to support discussion (majority from peer reviewed journals) HD D C P F Minimal use of current and relevant literature to support discussion. Literature not integrated within essay. 7. Essay format and presentation (4 marks) Structured approach clearly identifying the Introduction, Body and Conclusion, with appropriate formatting HD D C P F Lack of structure and logical flow, with introduction, body and conclusion not clearly identifiable 8. Accuracy of spelling and grammar (2 marks) Correct spelling and grammar throughout with no clinical shorthand and / or ambiguous abbreviations HD D C P F Common instances of incorrect spelling and grammar, and use of clinical shorthand and/or ambiguous abbreviations 9. Conformity to UTS Faculty of Health referencing style (4 marks) Correct and consistent in-text referencing and reference list using the UTS-Harvard style HD D C P F Errors and inconsistencies in the in-text referencing and reference list