Acute Care Patient Case (451)

NURS 431- Transition to Professional Nursing Practice

Purpose of Assignment
The purpose of this assignment is to address the students attainment of all eight behaviors and/or
competencies that are specific outcomes of the program in relation to the acute care patient case
study including: critical thinking, nursing practice, communication, teaching, research,
leadership, professionalism, and culture.

Student Approach to Assignment

This paper summarizes the progression that I have made from my sophomore to senior year.
Specific examples provide insight into exactly how I grew in the eight core curriculum
objectives. I am able to highlight my personal progress as I move towards becoming a registered
nurse. This paper is an excellent reflection of my experiences in nursing school. The approach to
the acute care patient case study assignment was to prepare a paper reflecting a patient care
experience in 451.

Reason for Inclusion of the Assignment in the Portfolio

This assignment is included in the portfolio because it showcases my progress in the eight core
curriculum behaviors of: critical thinking, nursing practice, communication, teaching, research,
leadership, professionalism, and culture. It is a required component in my portfolio that
highlights how I fulfilled a number of the end program outcomes.

Critical Thinking
Uses nursing and other appropriate theories and models to guide professional
practice

Example: page 5 paragraph 5 (Senior year):

The Neuman Systems Model developed by Betty Neuman views the patient
as an open system that interacts with both internal and external environment
forces/stressors. The internal environment subsists within the patient. All forces
and interactive influences that are within bodily confines of the patient make up
this "environment. For this patient, that includes his current health and his
history of ARDS and severe asthma, along with a lengthy history of ED
admissions for respiratory distress.

Example: page 6 paragraph 2 (Senior year):

The physiological variable in the Neuman Systems Model refers to the
functionality of the internal structures of the patient. This would be the current
state of his lungs and the damage they have previously seen. The psychological
variable refers to the relationships the patient has with other people and with
himself. While the patient has a large support system through his gym clients who
 visited him often and in many numbers, he also was in a calm state of mind while
lightly sedated on a ventilator.

Engages in creative problem solving

Example: page 6 paragraph 1 (Senior year):

The external environment is everything outside the body that effects health. This
would be the patients home - which is above the kickboxing gym he owns and
operates and which smells like mold according to the patients friends and
clients. This could be a major contributing factor to his many ED visits for the
same issue of ineffective breathing pattern.

Nursing Practice
Applies appropriate knowledge of major health problems to guide nursing practice

Example: page 3 paragraph 2,3 (Senior year)

The diagnosis listed on this patient for his ICU admission was status
asthmaticus, which is an acute exacerbation of asthma in which the
bronchoconstriction does not respond to treatment attempts. This is what the
patient came into the ED with, though he would later go into bronchospasm
related to aspiration that would require re-intubation during his hospital stay.
Pathophysiology for status asthmaticus is a series of allergic hypersensitivity
reactions occurring multiple times with no pauses or breaks between them, often
related to inhaled allergens, irritants, microbes, stress, or exercise. This produces a
complex response characterized by bronchospasm and inflammation, edema in the
walls of the bronchioles, and secretion of highly viscous mucous into the airways.
This increases airways resistance and produces wheezing, dyspnea, and chest
tightness. The signs and symptoms related to status asthmaticus include an
increased respiratory rate, adventitious breath sounds on expiration, prolonged
expiration, shortness of breath, use of accessory muscles, retraction of intercostal
spaces, pallor and cyanosis, tachycardia, and diminished air movement (Jarvis,
2012).

Communication
Adapts communication methods to patients with special needs

Example: page 2 paragraph 2 (Senior year)

Fentanyl was also discontinued at that time to decrease RASS score to the point
of wakening. The patient had steroid induced hyperglycemia and was on IV
regular insulin, with 2-hour blood glucose checks. He was placed on a
spontaneous vent setting, lung sounds became clear bilaterally, he was writing to
 communicate

Teaching
Provides relevant and sensitive health education information and counseling to
patients, and families, in a variety of situations and settings
Example: page 8 paragraph 2 (Senior year)
Teaching for this patient was primarily focused on avoiding the triggers to his
asthma that we had identified such as mold in his living space in order to avoid
any reoccurrence of these episodes, but also included the management of
pneumonia and expectations of fatigue. Teaching also had to be done relating to
the use of wrist restraints while intubated and the importance of not pulling out
the tubing.
Example: page 9 paragraph 2 (Senior year)
A nursing intervention to increase adherence is to teach the patient to put the
preventative medication beside their toothbrush or alarm clock in order to remind
them every day. This also reminds them that, in like brushing their teeth, they will
not see results right away but could suffer later on if not taken.
Example: page 10 paragraph 2 (Senior year)
Teaching for this patient included breathing techniques such as pursed lip
breathing and planning their activities with rest periods between. For this patient
in particular, going outside to get air every break or rest period was crucial in
teaching since the friends and clients had all stated the gym he lived above
smelled slightly of mold. Getting his living space evaluated by an inspector was
taught to the patient as important due to the mold possibly being a causative
factor.

Research
Shares research findings with colleagues

Example: page 12 paragraph 2 (Senior year)

In this Emergency Medicine Nursing article, a 49-year-old female with a prior
diagnosis of asthma presented to the emergency department in respiratory distress
- similar to Y.L.. She immediately received one bronchodilator aerosol and then 4
more nebulizers over 2 hours. ABGs and a lactate was taken (pH 7.38, lactate
7.96), then a second series of 4 nebulizer treatments were administered. ABGs
and lactate was taken again with a lower pH and higher lactate (7.29, lactate
10.47). This showed that the nebulizer treatments directly related to the pH and
lactate levels and indicates a requirement for constant reassessment of need for
the nebulizer treatments. This case study showed no hypoxemia, no inadequate
cardiac output, no anemia, and no sepsis in the 49-year-old female after the first
 round of nebulizer treatments. This study, along with previous studies, have
suggested that administration of beta agonists can lead to lactic acidosis in the
absence of sepsis or shock (because in sepsis and shock, lactate level would be
used to mark severity) and need to be closely monitored to prevent this
occurrence (Claret, 2012).

Differentiates between descriptive nursing literature and published reports of

nursing research

Example: page 11 paragraph 1,2 (Senior year)

Focusing on both the AACN evaluation and intervention/implementation phases
of nursing care, the journal Practice Nurse published a study to review,
summarize, and provide suggestions for nursing interventions relating to the new
asthma quality care standards set out by the National Institute of Health and Care
Excellence (NICE). Nursing care is focusing on the reduction of symptoms
and asthma-related hospitalizations through the use of personalized written plans
of care, annual evaluations, re-evaluations after hospitalization, and
home/workplace evaluations. The goal is to achieve asthma control through no
day time symptoms, no wakening at night due to symptoms, and no need for
rescue medications (Smith, 2013).

Leadership
Organizes, manages, and evaluates the development of strategies to promote
healthy communities

Example: page 14 paragraph 1 (Senior year)

To decrease the risk of reoccurrence of asthmatic episodes, a written plan of care
should be made and evaluated yearly and the home and workplace should both be
evaluated for sources of triggers.

Professionalism
Differentiates between general, institutional, and specialty-specific standards of
practice to guide nursing care

Example: page 8 paragraph 1 (Senior year)

The AACN Standards of Practice dictates that in the interventional phase of
nursing care, the nurse will coordinate with the patient and entire care team. This
was done through handwritten notes and verbal exchanges back and forth from
the patient to the nurse. Through this, the patient was able to stay an active
member of his care even though he was intubated. Another competency in the
AACN implementation phase is that the nurse facilitates learning for patients.
 This was done through teaching the patient more about his condition and the
medications he would be taking when he left the hospital.

Culture
Integrates knowledge of cultural diversity in performing nursing interventions

Example: page 8 paragraph 2 (Senior year)

The AACN Standards of Practice are used in outcome identification to respect
the patients cultural needs and values in creating culturally appropriate outcomes
and interventions.
Example: page 10 paragraph 2 (Senior year)
Cultural considerations for this patient included advising him on complementary
alternative medical practices such as deep breathing. Another cultural
consideration was the assurance of access to medications he needed to control his
asthma when he left the hospital, in the form of assessment of his community and
his needs relating to being a private business owner and operator.

Articulates an understanding of how human behavior is affected by culture, race,

religion, gender, lifestyle, and age

Example: page 6 paragraph 2 (Senior year)

The psychological variable refers to the relationships the patient has with other
people and with himself. While the patient has a large support system through his
gym clients who visited him often and in many numbers, he also was in a calm
state of mind while lightly sedated on a ventilator. The MD doing the assessments
and communicating with the patient stated that the MD himself would not be that
calm while on a ventilator.