NR 536 Week 5 Develop an Evolving Case Study

Name

Chamberlain University

NR-536: Advanced Health Assessment, Pathophysiology & Pharmacology for Advanced Nursing Practice

Prof. Name

Date

NR 536 Week 5: Development of an Evolving Case Study

Overview of Evolving Case Study

The objective of this case study is to create a comprehensive treatment plan aimed at preventing and alleviating symptoms associated with ventilator-associated pneumonia (VAP) in the intensive care units (ICU) of acute healthcare settings. This case study is particularly targeted at nursing staff who have accrued at least three years of ICU experience. Key concepts covered include patient safety, infection control, and evidence-based practices in preventing VAP, such as the use of oral hygiene protocols (Hua et al., 2016), awareness of antibiotic resistance (Khan et al., 2017), sedation management, and physical assessment practices (Álvarez-Lerma et al., 2018). Additional topics include physiotherapy (Zampieri et al., 2015), and appropriate medical device use to enhance patient care and reduce VAP risk.

Case Study Setting

This scenario unfolds within the ICU of an acute healthcare facility, where a patient with respiratory failure receives oxygen supplementation, intubation, and mechanical ventilation. The patient is under sedation and is also receiving IV anticoagulants, IV fluid infusions, and is connected to monitoring equipment, including cardiac and pulmonary monitors and a vital sign machine. Wall suction is also in place.

Patient Profile

Name: Mr. XYZ
Gender/Age/Weight/Height: Male, 65, 252 lbs, 5’10”
Allergies: Codeine
Past Medical History: Patient has a history of diabetes, asthma, an ischemic stroke in December 2019, paroxysmal atrial fibrillation, coronary artery bypass surgery in 2016, as well as a history of smoking (40 pack years) and alcohol use.
Present Illness History: Mr. XYZ was admitted on February 8, 2020, with complaints of tachypnea, shortness of breath, and chest pain. The patient experienced a rapid desaturation and developed respiratory distress, necessitating intubation in the emergency room.
Social History: He is a retired software engineer living with his wife, with two adult children residing out of state.
Primary Medical Diagnosis: The patient’s main diagnosis is pulmonary embolism, complicated by pleural effusion, respiratory failure, and hypoxemia.
Surgeries and Procedures: These include a CT scan, blood and urine cultures, arterial blood gas testing, a COVID-19 test, daily EKGs, blood tests, and chest X-rays.

Table: Evolving Case Study Information and Learning Objectives

Evolving Case Stage	Case Study Information Presented to Learners	Learner Actions and Socratic Questions
Stage One	The patient’s oxygen levels are declining, requiring increased FiO2/PEEP. Tachycardia is noted (Hellyer et al., 2016).	Learner Actions: Evaluate the patient’s medical history, contact the doctor, assess the condition, and provide initial respiratory management. Socratic Questions: What factors contribute to increased oxygen demand and desaturation? Is further diagnostic testing like cultures or imaging needed? Is early broad-spectrum antibiotic treatment warranted?
Stage Two	The patient exhibits increased purulent secretions, frequent suctioning needs, and hypoxemia, prompting the implementation of VAP prevention protocols.	Learner Actions: Implement bundle treatment for VAP prevention, ensure thorough oral care, elevate the head of the bed, monitor sedation, and manage endotracheal tube pressure. Socratic Questions: How does proper oral care reduce VAP risk? Is bed elevation effective for secretion prevention? Could there be a more effective alternative to chlorhexidine?
Stage Three	Diagnosis of VAP is confirmed through tracheal aspirate and imaging. The patient exhibits signs of bacterial infection progression.	Learner Actions: Narrow antibiotic therapy, evaluate all data after 24-48 hours, monitor for readiness to wean, consider probiotic administration, and maintain regular assessments. Socratic Questions: Does spontaneous breathing trials and sedation management reduce VAP? Is narrowing antibiotics after culture results optimal? How might probiotics benefit the patient?

Debriefing

Stage 1 Focus: What preventive measures are effective in reducing VAP in chronically ill patients?
Stage 2 Focus: Should components of the VAP bundle, such as head inclination and oral hygiene, be implemented more than once daily?
Stage 3 Focus: How can we swiftly control bacterial growth in the lungs and trachea?
Overall Case Study Focus: What comprehensive methods ensure prevention and treatment of VAP in bed-bound patients?

References

Álvarez-Lerma, F., Palomar-Martínez, M., Sánchez-García, M., Martínez-Alonso, M., Álvarez-Rodríguez, J., & Lorente, L. et al. (2018). Prevention of ventilator-associated pneumonia. Critical Care Medicine, 46(2), 181-188. https://doi.org/10.1097/ccm.0000000000002736

Bardia, A., Blitz, D., Dai, F., Hersey, D., Jinadasa, S., Tickoo, M., & Schonberger, R. (2019). Preoperative chlorhexidine mouthwash to reduce pneumonia after cardiac surgery: A systematic review and meta-analysis. The Journal Of Thoracic And Cardiovascular Surgery, 158(4), 1094-1100. https://doi.org/10.1016/j.jtcvs.2019.01.014

Fortaleza, C., Filho, S., Silva, M., Queiroz, S., & Cavalcante, R. (2020). Sustained reduction of healthcare-associated infections after the introduction of a bundle for prevention of ventilator-associated pneumonia in medical-surgical intensive care units. The Brazilian Journal Of Infectious Diseases, 24(5), 373-379. https://doi.org/10.1016/j.bjid.2020.08.004

NR 536 Week 5 Develop an Evolving Case Study Hellyer, T., Ewan, V., Wilson, P., & Simpson, A. (2016). the intensive care society recommended bundle of interventions for the prevention of ventilator-associated pneumonia. Journal Of The Intensive Care Society, 17(3), 238-243. https://doi.org/10.1177/1751143716644461

Hua, F., Xie, H., Worthington, H., Furness, S., Zhang, Q., & Li, C. (2016). Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database Of Systematic Reviews. https://doi.org/10.1002/14651858.cd008367.pub3

NR 536 Week 5 Develop an Evolving Case Study

Khan, Z., Ceriana, P., & Donner, C. (2017). Ventilator-associated pneumonia or ventilator-induced pneumonia. Multidisciplinary Respiratory Medicine, 12. https://doi.org/10.4081/mrm.2017.224

Olanipekun, T., & Snyder, R. (2019). Mortality risk in ventilator-acquired bacterial pneumonia and nonventilator icu-acquired bacterial pneumonia. Critical Care Medicine, 47(10), e851-e852. https://doi.org/10.1097/ccm.0000000000003662

Pinho, R., Tanure, L., Pessoa, J., Santos, L., Couto, B., & Starling, C. (2020). Impact of each component of a ventilator bundle on preventing ventilator-associated pneumonia and lower respiratory infection. Infection Control & Hospital Epidemiology, 41(S1), s259-s260. https://doi.org/10.1017/ice.2020.824

Prasad, R., Daly, B., & Manley, G. (2019). The impact of 0.2% chlorhexidine gel on oral health and the incidence of pneumonia amongst adults with profound complex neurodisability. Special Care In Dentistry, 39(5), 524-532. https://doi.org/10.1111/scd.12414

NR 536 Week 5 Develop an Evolving Case Study

NR 536 Week 5 Develop an Evolving Case Study Vieira, P., de Oliveira, R., & da Silva Mendonça, T. (2020). Should oral chlorhexidine remain in ventilator-associated pneumonia prevention bundles?. Medicina Intensiva. https://doi.org/10.1016/j.medin.2020.09.009

Xie, X., Lyu, J., Hussain, F., & Li, M. (2019). Drug prevention and control of ventilator-associated pneumonia. Front Pharmacol, 10(298). https://doi.org/10.3389/fphar.2019.00298

Zampieri, F., Nassar Jr, A., Gusmao-Flores, D., Taniguchi, L., Torres, A., & Ranzani, O. (2015). Nebulized antibiotics for ventilator-associated pneumonia: a systematic review and meta-analysis. Critical Care, 19(1). https://doi.org/10.1186/s13054-015-0868-y

NR 536 Week 5 Develop an Evolving Case Study

Zhao, J., Li, L., Chen, C., Zhang, G., Cui, W., & Tian, B. (2020). Do probiotics help prevent ventilator-associated pneumonia in the critically ill patients? A systematic review with meta-analysis. ERJ Open Research, 00302-2020. https://doi.org/10.1183/23120541.00302-2020