CORTNEY OCONNORS

Critical Care Clinical Case Study

NURS 451- Clinical Management of Adult Health Nursing III
Purpose of Assignment
The purpose of this case study is to integrate knowledge from the humanities and
sciences, including nursing research and theory, to plan, provide, and evaluate holistic care
provided to a client selected during this clinical rotation.
Student Approach to Assignment
The patient chosen for this case study was my first patient during the clinical rotation.
The patient was a 22-year-old male of mixed race who presented to the emergency department
after a self-inflicted gunshot wound to the head that occurred at a local gun range. The patient
was a military officer. The patient was resuscitated while in the emergency department, but his
condition was determined to be permanently incapable of sustaining life on his own. While in the
ICU, the patient was supported entirely by medical interventions so that the family would have
time to come in from out of state to say their goodbyes and make a decision regarding organ
donation. The patient was not previously signed up for organ donation, so this option was left to
the parents. The parents did decide to have their son participate in organ donation, which was a
very interesting process to be a part of. This patient taught me many things about how to care for
an organ donation patient as well as how to care for a grieving family.
Reason for Inclusion of the Assignment in the Portfolio
Critical Thinking
Uses nursing and other appropriate theories and models to guide professional
practice
Example: While developing this case study, I applied Dorothea E. Orems
Theory of Self-Care Deficit to my patient. Orems Theory of Self-Care Deficit
discusses that it is the nurses job to provide basic care to the patient until he or
she is able to care for themselves again. This applies to the patient in that he
was unable to perform any for of self-care activity whatsoever. This patient
was even incapable of performing basic life-sustaining task such as breathing.
In this, the interdisciplinary healthcare team including the nurse and I had to
participate in Orems theory by maintaining these basic life processes for him.
Evaluates nursing care outcomes through the acquisition of data and the questioning
of inconsistencies
Example: A requirement of this case study was to identify outcomes for two
different nursing diagnoses. The first nursing diagnosis was ineffective
breathing pattern related to neuromuscular impairment. For this diagnosis, the
outcome identified was that he would be able to take at least ten spontaneous
breaths per minute before the end of the shift that day. Because the patient
was taking about three spontaneous breaths the day before, an increase in this
effort to a ten would have been a significant neurological and respiratory
improvement. However, the next day, the patient was not taking any
spontaneous breaths and was deemed brain dead after other testing per

protocol. The inconsistency in question was the patients inability to meet the
expected outcome of taking ten breaths per minute during the shift. Therefore,
the patient centered goals were revised to focus on the possibility of and
success of organ donation.
Nursing Practice
Applies appropriate knowledge of major health problems to guide nursing practice
Example: Near the beginning of the clinical case study, there is a Medical
Diagnosis section in which the patients diagnosis of self-inflicted
penetrative brain injury is identified and thoroughly described. In this
section, the pathophysiology of this diagnosis was explored, which laid
groundwork for making the nursing diagnoses. When evaluating the
pathophysiology of the medical diagnosis, I recognized that his injury was
actually a perforating brain injury, as the bullet travelled completely through
the brain and out of the other side of the skull. If it were a penetrating brain
injury, the bullet would have stayed imbedded in the brain matter. This
actuality served to be important when evaluating the damage endured by the
patient. Knowledge about respiratory failure and tissue perfusion was also
applied in depth in this paper.
Performs therapeutic interventions that incorporate principles of quality
management and proper safety techniques based upon assessment findings
Example: As a requirement of this paper, therapeutic interventions applied
when caring for the patient had to be identified for the top two nursing
interventions. These interventions were based on head-to-toe assessment
findings when caring for the patient and were based off of providing quality,
holistic, and safe care. Interventions applied to this patient included
dependent, collaborative, and independent nursing interventions.
Collaborative and dependent interventions for the primary nursing diagnosis
of ineffective breathing pattern included intubation and ABG draws, as nurses
collaborate with the respiratory therapists when accomplishing these tasks and
nurses depend on the physician to intubate the patient and to order ABG
draws. Independent interventions included close monitoring of lung sounds,
respiratory rate and oxygen saturations as well as raising the head of the bed
and suctioning excess respiratory secretions. Examples of safety techniques
implemented for this patient included raising the head of the bed to prevent
aspiration, providing oral care every four hours to prevent ventilator
associated pneumonia, and using aseptic technique when accessing central and
peripheral lines (per hospital protocol).
Implements traditional nursing care practices as appropriate to provide holistic
health care to diverse populations across the life span.
Example: Traditional nursing care practices discussed in this case study
included continuous assessments, medication administration, mechanical
ventilation, oral care, suctioning, central venous access, preventing infection,

fluid resuscitation, and others. The patient was young adult. The family
included adolescents and middle-aged adults.
Communication
Produces clear, accurate, and relevant writing using correct grammar, spelling, and
punctuation.
Example: When graded on this paper by my clinical faculty, I received all
available points for Writing Style which included grammar, spelling,
punctuation and language. The comment in the grade rubric read, Very well
organized and logical flow. This shows that I have accomplished this
requirement through the development of this case study.
Teaching
Provides teaching to patients and/or professionals about health care procedures and
technologies in preparation for and following nursing or medical interventions
Example: As a requirement, education provided to this patient during the
clinical experience had to be identified for the top two nursing diagnoses. All
of the education was provided to the family in this case, as the patient was
unresponsive throughout the entire time he was in the hospital. Most of the
teaching was focused on anticipatory guidance for the family regarding
procedures, brain death testing and organ donation. As identified in the case
study, the family was not ready to be taught about physiological processes that
the patient was going through, as the family was grieving at that time.
Provides relevant and sensitive health education information and counseling to
patients, and families, in a variety of situations and settings
Example: The relevant and sensitive health information provided to this
patient as identified in the case study as regarding organ donation. The nurse
and I participated in the discussion with the family provided by LifeNet and
the physician regarding specificities about how the patient was determined to
be brain dead and about how valuable the patient was in terms of organ
donation. Because these are very sensitive topics, this discussion was done in
a private room with the chaplain nearby.

Research
Differentiates between descriptive nursing literature and published reports of nursing
research
Example: As a requirement, there were to be three research articles included
in this case study. Two of the research studies included were nursing research
articles. Also included were non-research types of literature including books
and articles describing the protocols of the facility in which the patient was
staying. One of the two nursing research articles was about noninfectious
hyperthermia in brain-injured patients, and the other was about the
optimization of organ procurement with certain medication administration.

 Evaluates research that focuses on the efficacy and effectiveness of nursing

interventions
Example: One research article that I evaluated for this case study was the
effectiveness of administration of Levothyroxine, synthetic thyroid hormone,
on organ procurement rates. The study found that administrating this drug
before the declaration of brain death, as opposed to after the patient is already
declared brain dead, increases the rates in which the organs can be harvested
and donated to save another life.
Leadership
Articulates the values of the profession and the role of the nurse as member of the
interdisciplinary health care team
Example:Whendiscussingtheinterventionsprovidedtothepatientinthe
clinicalcasestudy,dependent,collaborative,andindependentinterventions
wereidentified.Thereweremorecollaborativeinterventionsthatinvolvedthe
interdisciplinaryhealthcareteamthananyothertypeofintervention.These
includedmedicationadministration,mechanicalventilationmaintenance,
organdonation,andothers.Bydemonstratingthesecollaborative
interventionsaswellasindependentnursinginterventionsinthecasestudy,
thevalueofthenursesroleishighlighted.
Professionalism
Differentiatesbetweengeneral,institutional,andspecialtyspecificstandardsof
practicetoguidenursingcare.
Example:Asarequirementforthisassignment,Iidentifiedinstitutionaland
specialtyspecific(criticalcaresetting)standardsofpracticethatguidedmy
nursingpracticeofthispatient.Theseincludedstandardsofpracticeregarding
ventilatorassociatedpneumoniaandcentrallines.Ialsoidentifiedgeneral
ANAstandardsofcarethroughoutthepaperincluding,butnotlimitedto,
assessment,diagnosis,outcomeidentification,planning,implementation,
evaluation,education,qualityofpractice,andcollaboration.

Culture
Demonstratessensitivitytopersonalandculturaldefinitionsofhealth,andhowthese
beliefsinfluenceanindividualsreactionstotheillnessexperienceandendoflife.
Example:DuringthetimeIhadwiththepatientdiscussedinthecasestudy,I
demonstratedsensitivitytothepersonalandculturaldefinitionsofhealthof
thepatientsfamily.Asidentifiedinthepaper,oneparticularexampleofthe
differentdefinitionsofhealthandreactionstodeathwasexhibitedbythe
patientsmother.Themotherverbalizedtomeandthenursethatshewas
angryaboutallofthetubesandlinesthatwerestillattachedtothepatient
afterhewasdeclaredbraindead.Sheunderstandablywantedthemremoved
assoonaspossible.Anger,thesecondstageofgriefresultingfromillnessand

endoflife,wasdisplayedatthistime.Culturally,shefeltasthoughthepatient
wasnotabletoputtorestuntilhewasdetachedfromthemachines.So,she
wassensitivelytaughtthatsincetheyhaddecidedtogoalongwiththeorgan
donationprocess,thelineswouldhavetobeleftattacheduntilaftertheorgans
wereharvested.Furthermore,thenurseandLifeNetprofessionaldidtheirbest
toensurethattheorganprocurementwastotakeplaceassoonaspossiblein
ordertoreducethisdiscomfortexpressedbythemother.