Running Head: Clinical Leadership and Patient Care

Clinical Leadership and Patient Care Michelle C. Croasmun NURS 4450 Professional Nursing Leadership & Management Dr. Debra Hagerty April 16th, 2013

Clinical Leadership and Patient Care Introduction Having leadership clinical at a hospice facility has shown me the differences in care between the hospital and hospice, as well as caring for those with disease process that can be treated and/or

reversed versus those at the end of life due to disease that has won. Instead of treating the patient for morbidities, comfort measures are provided such as pain control. On your average floor of any hospital nurses are focused on treatment, medication passing and charting; on the floors at hospice nurses are focused on the patients comfort, mental health and the patients family well-being. Since my strengths are compassion and communication, I can totally see myself as a hospice nurse. W.M.s medical history is as follows: Type II diabetes, HTN, COPD, Peripheral vascular disease, GERD, Osteoporosis, Convulsive seizures, Crohns disease, Dyslipidemic, Obstructive Sleep Apnea, Stroke = 2011 Right Partial Infarct 2011, stents and plavix. Surgical history is as follows: ACID placement 2002, Appendectomy, Inguinal hernia repair 1980, Cholocystectomy, and Parathyroidectomy. Family History is as follows: HTN & Hyperlipidemia, father died of MI at age 63 and brother died of stroke at age 70. W.M. was presented to the emergency room in acute hypercapnic respitory failure. He appeared lethargic and confused upon arrival, having been hypotensive and hypothermic. W.M. was intubated and started on IV vasopressors. He was diagnosis was Septic Shock. His labs from the ER were as follows: CBC WB = 33.6, Hemoglobin = 9.3, Hematocrit = 28.7, Platelets = 451. CMP Glucose = 140, Sodium 146, potassium 6.0, chloride = 103, CO2 = 27, BUN = 35, Creatinine = 3.85, GFR 15, Albumin = 2.6, Bilirubin = 0.2, AST = 36, ALT = 17, Alkaline phosphate = 67, Lactic Acid = 24.7, PTT 44.1, Prothrombin = 15.2, INR = 1.24. Urinalysis Cloudy with 3(+) protein, WBC > 182 (few in clusters), 4 RBCs, many bacteria, mucus is positive, leukocyte esterase 3 (+), nitrites are (-). ABGs HO2= 7.085, PCo = 2 77.0, pO2 = 243.5, bicarbonate = 22.6. Potassium = 5.56, Sodium = 139.3.

Clinical Leadership and Patient Care A chest x-ray showed persistent right upper lobe infiltrate, but no evidence of pneumonia. Final diagnosis is as follows: Septic shock secondary to urinary tract infection. Toxic metabolic

encephalopathy. Acute respitory failure & hypercapnic. COPD Stage III. Patient was placed in Neuro ICU and on his 17th day a trach collar 40% was placed on patient and peg was placed for tube feedings via G-Tube. Patient was admitted to Hospice House of Savannah on 3/29. I foley catheter was placed and standard precautions were started. His respitory failure status was 30%. He was placed on 8 liters of O2, with suctioning as needed. Deep suctioning is not conducted as part of hospice care. Assessment and Family/Social History W. M. is a 75yr old male who is widowed and lives with an able caregiver. He is of the Christian faith and is a retired Air Force member. That being said, he receives VA benefits that play for his care in its entirety. At his bedside were his son and daughter-in-law who had, with permission and proper paperwork, his and their dogs in the room. His family felt this to be therapeutic and according to having animal visits is proven to be therapeutic for both the family and patient. Assessing W.M. was difficult, as he is very lethargic and does not respond well to command, with an occasional response to his daughter regarding the dogs. His vitals were as follows: temperature of 97.6, heart rate of 98, respitory rate of 41, blood pressure of 135/68. His head was normocephalic with eyes, ears symmetrically placed, as well as mouth and nose mid-line and symmetric. Neck is mid-line. His eyes were shut, so I could not evaluate pupils. Height and weight were not noted in his chart, so Height is approx. 61 and weight is approx. 180 lbs. per verbal from son. As stated earlier, patient has trach at 30%. Patient is hard of hearing with partial deafness in both ears per verbal from son. Patients lungs

Clinical Leadership and Patient Care are decreased with crackles noted. Heart sounds are normal with no adventitious sounds noted.

Patient had 2+ carotid, radial and dorsalis pedis pulses bisymmetrically. 2+ pitting edema was present in all extremities; skin was pale in color and warm/dry to touch. There was a stage two bed wound on patients left buttock 3inches in diameter; wound care was performed. Normal bowel sounds present in all four quadrants. Patient is incontinent and has a foley catheter, as well as wearing adult diapers. Nursing Care Plan of Care The care plan for W.M. is to include:1) Pain management as related to respitory distress and stage 2 wound, 2) Secretion control as related to respitory condition and active dying process , and 3) Family Education as related to imminent death. For pain management the patient was given morphine under the tongue Q4H as needed. Since the patient could not verbalize pain we watched for signs such as restlessness, moaning, and grimacing. The family at bedside also alerted us if they observed these signs. After having given the medication, if the patient was still exhibiting these signs then the dosage was allowed once more in the 4 hour period. Since hospice care focuses on comfort, then it is important to frequently access for pain and treat any suspected pain immediately. I liked how one study had referenced this subject, Freedom from pain and pain management is essential to a dying patients perception of life quality . Pain is regarded as one of the critical outcome measures for quality end-of-life care. (Steindal, 2011) For secretion control hospice nurses usually control symptoms by using Atropine drops under the tongue or a Scope patch if ordered. In this patients case there was a trach collar involved and the suctioning of the mouth was important, as well as oral care. However, deep suctioning is not done in hospice care because it might actually make secretions worse due to the active dying processes.

Clinical Leadership and Patient Care

According to a study done by Kjonegaard, Fields and King in 2010, The oral care program consists of brushing patients teeth and tongue every shift, using toothettes every 4 hours, suctioning above the endotracheal tube every 6hours, This is exactly what care W.M . was given, along with the atropine to help with the secretions that were making him uncomfortable and upsetting the family, who thought he was choking. The next important part of this patients hospice plan of care was education of the dying process for the family. It is very hard for many family members to accept what changes are happening as deaths imminence; it is important for the nurse to educate and assure them that the patient is not suffering. Through discussion and the use of aids, such as pamphlets, the nurse can reassure the family that signs such as secretions, fever, gurgling (rattles), the mouth staying open, and hallucinations are all signs of death. One of the other signs, slowed respirations with periods of apnea, also puts fear into family/friends that their loved one is suffering. Hospice Savannah gives a pamphlet out When Death is Near, which was created by Hospice of Santa Cruz County, that goes over the dying process and aids the nurse in her job of assisting family and friends with dealing with death. As noted on page 19, Caring for someone who is in the final weeks and days of life can be physically and emotionally demanding. For this reason the nurse needs to provide family care to ensure the finality of death isnt a burden, but understood and to be, in a sense, celebrated. Conclusion In conclusion, W.M. was given the best patient-centered care at Hospice House. His comfort needs were met, his familys emotional needs were met and W.M. passed away peacefully with his family at his side. I hope to work someday in the hospice setting. I feel my gifts of communication and compassion lend me to the hospice/palliative atmosphere. W.M. was a wonderful patient, his family was supportive and loving; I hope in the end they all were at peace.

Clinical Leadership and Patient Care Trade Names Amlodipine (Norvasc) Carvedilol (Coreg) Dicyclomine (Bentyl, Bentylol, Formulex & Spasmoban) Gapapentin (Neurontin) Nystatin (Mycostatin, Nadostin) Phenytoin (Dilantin, Phenytek) Dosage 2.5mg = 1 tablet Once daily 6.25mg = 1 tablet 1 tablet BID 1 capsule = 10 mg Once daily Use/Class Antihypertensive/Calcium channel blocker Antihypertensive/ Beta blocker Antispasmodic/ anticholinergics Use for Patient

Reduce Blood Pressure Reduce Blood Pressure and heart rate Reduce abdominal spasms

Omeprazole (Losec, Prilosec) Ranitidine (Zantac) Sulfasalazine (Azulfidine) Valproic Acid (Depakene) PRN MEDs Atropine (Atro-pen) Bisacoydyl (Ducolax)

1 capsule = 300mg 1 capsule TID 100,000 units/mL Swish 1 mL around mouth and swallow QID for 10 days 125mg/ 5mL susp. 12mL (300mg)at bedtime, flush w/20mL of water after admin. 2mg/mL liquid 2tsp. (10mL) a day 150mg = 1 tablet 1 tablet daily 1 tablet = 500mg 1 tablet BID 250mg/5mL soln Take 1 tsp (5mL) TID /////////////////////// 1% eyedrops 2 drops under tongue Q4H 10mg suppository or 5mg tablets Insert 1 supp. or Take 2 tablets daily 1 tablet = 0.5mg Take 1tablet under the tongue Q4H
20mg/mL 0.25mL=5mg

Analgesic adjunct, Anticonvulsants, Mood Stabilizer Antifungal

Reduce nerve pain To treat oral thrush

Antiarrhythmics (group IB), Anticonvulsants/ Hydantoins

To control seizures

Antiulcer agent/proton-pump inhibitors Antiulcer agent/ histamine H2 antagonist

For dyspepsia For stomach ulcer prevention and dypepsia To treat pt.s colitis

Antirheumatics, Gastrointestinal anti-inflammatories Anticonvulsant, Vascular Seizure control Headache suppressant /////////////////////////// ///////////////////////// Antiarrhythmics/Anticholinergic, To control secretions Antimuscarinic Laxitives/Stimulant laxatives For constipation

Lorazepam (Ativan) Morphine (Roxanol)

Antianxiety agent, Sedative/ Benzodiazepines Opioid analgesics/Opioid agonists

For agitation and anxiety For pain or breathlessness

Take 0.25 under the tongue Q4H

Clinical Leadership and Patient Care References

Hospice of Santa Cruz County (2008). When Death is Near: A Caregivers Guide. Quality of Life Publishing Company, Naples, FL. Kjonegaard, R., Fields, W., & King, M.L. (2010). CURRENT PRACTICE IN AIRWAY MANAGEMENT : A DESCRIPTIVE EVALUATION. American Journal Of Critical Care, 19(2), 168-174. doi:10.4037/ajcc2009803 Steindal, S., Bredal, I., Srbye, L., & Lerdal, A. (2011). Pain control at the end of life: a comparative study of hospitalized cancer and noncancer patients. Scandinavian Journal Of Caring Sciences, 25(4), 771-779. doi:10.1111/j.1471-6712.2011.00892.x