Nursing care is provided in all hospitals, in different states, different countries with different practices. But with that being said, the nursing process using NANDA –I Taxonomy of Nursing diagnoses, the Nursing Outcomes Classification (NOC) and Nursing Intervention Classification (NIC) can provide some standards in care where it is received. Throughout this paper, we will discuss a clinical case that uses these tools in providing care and looking at the patient outcome and discuss the systems that were in place.
Clinical Encounter
This patient was admitted to a medical surgical unit with the diagnosis of pulmonary fibrosis, shortness of breath and pain with inspiration, atrial fibrillation and MRSA in the urine. Patient’s other history included chronic kidney disease, oxygen dependent at home and a low ejection fraction. With this being said, this patient had several things happening, but was being treated with antibiotics and Cardizem to control A-Fib. In the middle of the night, the patient was a rapid response for hypotension and moved to the intensive care. Because of a previous echo that revealed the patient’s EF was only 12%, large fluid boluses were not really an option to treat hypotension. The hypotension was caused by a few different reasons, the nurse in med surg had given this patient multiple blood pressure medications, and the critical care doctor felt that she was becoming septic due to her presentation. Also, the critical care doctor decided that the patient needed a stat VQ scan to rule out the possibility of a pulmonary embolism. The patient results concluded that there was a high probability of a pulmonary embolism which warranted the patient to be placed on IV heparin, have a venous ultrasound of her legs and an echo. These tests reviewed no clots in her legs or heart.
With heparin, a PT/INR was drawn for baseline and then a hep xa was drawn every 6 hours until the heparin was therapeutic. A BNP and CBC were drawn to monitor blood cell counts and a central line was placed and the patient was placed on Levophed to prevent hypotension for a few hours. After a few hours, the patient was able to keep blood pressure controlled without medications. Antibiotics were continued as patients WBC’s were 14000 and the patient was continuously monitored in the ICU for a few days. CVP’s were measured at 5 and urine output was monitored closely.