Question

The Older Adult in Critical Care Unit

Mr. J is transferred to the ICU setting where he is intubated immediately for acute respiratory failure secondary to sepsis. He is unconscious. His blood pressure is 80/40 and a central venous line is placed. On intubation, the oral mucosa is friable and bleeding with evidence of massive stomatitis and esophagitis. He is treated empirically with several IV antibiotics and inotropic agents; his prognosis is poor.

Clinical Data

•       Mr. J is unable to speak, but within 72 hours of aggressive therapy, he begins to improve, showing conscious responses to external stimuli, although responses are limited and erratic.

•       Daily spontaneous breathing trials shows signs of improvement and a possibility for extubation exists.

•       However, he begins to pull at his tubing. He has a wide-eyed fearful look as he attempts to mouth words around the endotracheal tubing. Staff can’t understand Mr. J’s communication attempts. He becomes intermittently lethargic then restless, reaching in space for imaginary objects.

•       During this time his blood pressure climbs and heart rate peaks over 120 beats per minute. Staff attribute these vital sign changes to anxiety and tell Mr. J that he is improving. They remind him not to pull the tubing or they will have to restrain his hand.

•       Mr.J’s care and treatment are discussed at the Care Conference with his son. Discussion centers on his mental status, communication difficulties, and ventilator weaning progress. Staff are fearful that he is in danger of harm from accidental medical treatment device (endotracheal tube/central venous line) removal and may need to be physically restrained.

Follow up Care

•       Mr. J’s sepsis resolved, he was extubated, and his physical strength improved over several weeks. Use of physical restraint was avoided. Mr. J gradually began to sit on the side of the bed with nursing assistance and physical and occupational therapy. His pain was managed with oral solutions 15 minutes prior to activity and as assessed as necessary by the nurse. Staff worked to incorporate family participation into Mr. J’s care and recovery.

Take home points

•       Several important decisions were made at crucial points in time and led to the many successful outcomes experienced by Mr. J. These included increased nursing involvement in communication, early identification, care and treatment of delirium, prevention of aspiration, prevention of further deconditioning, and the decision to avoid physical restraint use. A coordinated team approach involving his son coupled with open channels of communication and consultation with other team members who knew this patient earlier in his hospital stay helped contribute to his successful recovery

Patient Outcome

•       Ultimately Mr. J was transferred to a sub-acute rehabilitation setting for care and treatment of reduced mobility, and to increase muscular strength, endurance and independence in daily living.  

•       He developed many friendships with other residents and began to transport himself, via wheelchair, to the cooking club held at the facility. Over the course of several months, he regained muscle strength and endurance in the walking program.

Case Study Questions

1. What additional comorbidities are Mr. J at risk for and how would you determine this?
2. How would you determine the development of delirium?
3. What care strategies need to be addressed for the delirium?
4. What other co-morbidities or other issues need interventions?
5. What modifications in communication strategies need to be used when caring for Mr. J in the ICU setting?

Answer 1

#.The additional comorbidities Mr. J are at risk for are

• Central nervous system :Delirium
• Respiratory system :Pneumonia ,respiratory tract infection
• Musculoskeletal :weakness ,malaise
• General :Risk for infection due to reduced oral altered function of the immune system

#.The development of delirium in the patient can be determined by doing the cognitive assessment periodically ,physical examination ,neurological assessment .The other way to determine the development of delirium in by doing metabolic panel test ,urine test ,toxicology screening if necessary.

#The strategies needed to be addressed for delirium are

• Ensuring the client is physically active at the earliest and continues it as a routine.
• Medication adherence
• Maintaining good sleep hygiene and pattern
• Avoiding triggers of anxiety or anger
• Formulation of a routine
• Provide relaxation and diversional therapy
• Ensure to keep patient hydrated and maintain a well balanced nutritious diet

#The other comorbidities which needs interventions are

• Respiratory :to maintain respiratory hygiene
• Infection control practice
• Hydration to prevent renal issues
• To maintain blood pressure in normal level a d prevent any cardiovascular issues

#The modifications in the communication strategies which has to be done are

• Communicate in a low and audible tone to patient
• Convey one thing or one information at a time to avoid confusion
• Ensure to communicate being in the front of the patient so that the patient will have no issues with the sensory problems and pay attention or concentration to the conversation .