CAPSTONE PROJECT
Capstone Project
Sitorabonu Nematova
St. Joseph’s University
NU211 Senior Clinical Practicum
Professor Mogbejule Inweh
April 20, 2024
Patient Background
E.L is a 25-year-old African American male with spontaneous eye opening that at this point suggests a vegetative state. He was admitted to the ED via ambulance on 1/25/2024 after overdosing on fentanyl. Patient doesn’t have any significant past medical histories. Patient was not hospitalized for any other acute physical or mental health related issues in the past. Patient is a Chemistry professor who recently broke up with his girlfriend. Parent’s live in New Jersey while patient lives in an apartment with his friend who is also his roommate. On the day of the incident, patient’s roommate called the ambulance when he found E.L breathing very slow and unconscious on the floor in his room. Patient was admitted to the ER via the ambulance. His parents were notified by his roommate, and they arrived shortly after. The patient was intubated. An MRI of the brain was performed and showed extensive supratentorial white matter and posterior cerebral ischemic change. No intracranial hemorrhage. After he was stabilized, he was transferred to ICU on 1/27/24. Then he was transferred to PCU on 2/07/24. During his evaluation, he was trach (tracheostomy) to Vent (ventilator) and had 100% O2 saturation, he did not respond to his name or follow any commands. In PCU EEG was done on 2/08/24 in the morning and showed “moderate diffuse cerebral dysfunction and no epileptiform discharges are seen”. Patient’s rhabdomyolysis is improving based on CPK (creatine phosphokinase) level down trending from 28,604 on admission to 5,214 on 2/02/24. Peg Tube (Percutaneous endoscopic gastrostomy) placement was performed. Possible seizures this morning. This was related to suctioning. Plan is to continue present PCU care.
Subjective Data
Name: EL
DOB: 08/24/1998
Age: 25
Gender: Male
Race: African American
Marital Status: Single
Date of Admission: Admitted to ED on 2/7/2024 and admitted to the PCU unit on 2/8/2024.
Reason for Admission: Fentanyl overdose.
Date of Care: 2/8/2024
Code Status: Full Code
Allergies: Mother denies allergies
Past Medical History: No childhood diseases reported by mother. No immunizations reported. Chief Complaint: Mother states patient’s roommate found the patient laying on the floor unconscious with slow breathing.
Social History: As per mother, patient worked as a chemistry professor in a CUNY college. She also stated she is not sure if he smoked or used illicit drugs since he lived away from her but from what she knows she does not think he used illicit drugs before. She also states he drinks alcohol socially occasionally on weekends. As per the roommate, he recently broke up with his girlfriend and was having hard time coping.
Family History: As per mother, patient is single. Patient has no siblings. Patient’s mother and father live in New Jersey, and they were commuting to New York occasionally to visit the patient.
Objective Data Height: 5’7”
Weight: 130 lbs
BMI: 20.4
Braden Scale: 9
Richmond Agitation Sedation Scale (RASS): -4
Chief Complaint: Anoxic Encephalopathy drug related.
Home Medications: None
Vital Signs
7:00 AM (at the beginning of the shift)
7:00 PM (at the end of the shift)
Blood Pressure
136/72
112/62
Heart Rate
88
84
Respiration
21
17
Oxygen Saturation
98
100
Temperature
37.4
36.8
Pain
0
0
Labs
Results
Normal Ranges
WBC
10.6
4.50 – 10.90 K/uL
HGB
10.3
14.0 – 18.0 g/dL
HCT
30.3
42.0 – 52.0%
PLTS
495
130 – 400 K/uL
Potassium
3.9
3.5 – 4.5 mEq/L
Magnesium
1.7
1.8 – 2.6 mEq/L
PHOSP
4.4
3.0 – 4.5 mg/dL
Calcium
8.6
9 – 10.5 mg/dL
Sodium
131
135 – 145 mEq/L
Chloride
97
97 – 106 mEq/L
ALK PHOS
80
44 – 147 U/L
Bilirubin
0.6
0.0 – 1.2 mg/dL
Creatine
0.84
0.6 – 1.2 mg/dL
CO2
25.0
23 – 29 mEq/L
BUN
16
10 – 20
CPK
5,214
30 – 200 U/L
Medication
Medication
Dose
Indication
levetiracetam
750 mg IV push Q12H
Seizure prevention
Coenzyme Q10
400 mg feeding tube BID
As a supplement
Vitamin E
2,000 Units feeding tube BID
As a supplement
Ascorbic acid (Vitamin C)
1,000 mg feeding tube BID
As a supplement
clotrimazole
Topical BID
To prevent fungal infection
famotidine
20 mg Nasogastric Q12H
To prevent gastric ulcers
Artificial tears
2 drop each eye TID
To prevent eyes from drying out
chlorhexidine
15 ml swish and spit BID
To prevent VAP (ventilator associated pneumonia)
heparin (porcine)
5,000 Units subQ Q12H
To reduce the formation of clots
Focused Physical Assessment
Neurologic: Coma with response to tactile stimuli and no response to verbal stimuli. GSC (Glasgow Coma Scale) is 6. Cranial Nerves: Pupils are reactive, no corneals, spontaneous eye opening, no blink to threat, positive oculocephalic response, positive facial grimace to pain, some mouth movements noted. Positive conjugate eye movements noted today. Reflexes: Bilateral Babinski signs and triple flexion response present bilaterally.
Head: Normocephalic. Shape is rounded, symmetrical. Upon palpation, no nodules, masses, or depressions are identified. Face appears smooth and symmetrical with no nodules or masses present, positive facial grimace to pain.
Eyes and Vision: Pupils are reactive, no corneal reflex, spontaneous eye opening, no blink to threat, positive oculocephalic response. Positive conjugate eye movements noted today.
Ears and Hearing: Ears are normally implanted. No response to voice. Tympanic membranes gray and intact with light reflexes noted.
Nose & Sinuses: Nose is symmetric, nares patent without exudate – mucous membranes moist. No nasal flaring noted.
Throat & Mouth: Oropharynx moist, no lesions or exudate. Lips light pink and mildly dry, gums are pale pink and moist, tongue is midline, some mouth movements noted. Patient has tracheostomy and is connected to the ventilator.
Neck/ Lymphatic: No lesions or scars noted. Tracheostomy present and is connected to the ventilator. Area around tracheostomy is clean and dry. Neck is supple- small nodes without lymphadenopathy noted. Carotid pulses are palpable and equal in strength and rhythm – No bruits- thyroid midline, small and firm.
Respiratory: Breathes at ventilator rate and Oxygen saturation is 100%, cuff pressure is 22 mm Hg, FiO2 at 45% – lung sounds are clear bilaterally. Bilateral chest expansion, no retractions noted.
Cardiac: Patient is on cardiac monitoring and has normal sinus rhythm- Heart rate of 84 bpm, regular rate and rhythm w/o murmur, rubs or gallops, S1 and S2 heard upon auscultation. BP 112/62, normal distal pulses bilaterally.
Gastrointestinal: Patient is on enteral feeding/PEG tube – Abdomen is symmetrical, soft, non-tender, normoactive bowel sounds auscultated in all four quadrants fields. No organomegaly noted – Bowel incontinent- wears a diaper. No bowel movements were recorder for the shift.
Genitourinary: No distention of bladder – patient is urinary incontinent. Has a condom catheter draining yellow and clear urine appearance. Total urine output is 22 ml/hr, which is less than normal.
Musculoskeletal: No range of motion in all 4 extremities. Motor: now with increased tone in the arms, and legs with bilateral cortical thumbs. Sensory: no response to tactile stimuli including no spinal cord reflexes.
Peripheral Vascular: No cyanosis or clubbing noted on nails beds- radial, ulnar, and pedal pulses are palpated and equal in strength (+2) and rhythm bilaterally. Skin: Skin is intact, dry, warm to touch. No wounds, edema, erythema, or discharges noted.
Diagnostic Findings:
MRI of the Brain
Extensive supratentorial white matter and posterior cerebellar ischemic change. While this could represent ischemic encephalopathy, the pattern of involvement is more consistent with heroin inhalation toxic encephalopathy.
No intracranial hemorrhage or contrast enhancement. No intracranial mass effect.
EEG Summary of findings
Moderate diffuse slowing. No epileptiform discharges are seen. This abnormal EEG is indicative of moderate diffuse cerebral dysfunction.
Nursing Diagnosis:
Nursing Diagnosis # 1: Impaired spontaneous breathing related to vegetative state as evidenced by reliance on a mechanical ventilation for respiratory support.
Expected Outcome/ Goals:
Patient will maintain a clear, open airway as evidenced by normal breath sounds, normal rate, depth of respiration, and the ability to effectively cough up secretions.
Patient will be free of aspiration.
Patient will have no complications from the mechanical ventilation.
Interventions
Rationale
Institute mechanical ventilation with prescribed settings.
Modes for ventilating (assist/ control, synchronized intermittent mandatory ventilation), tidal volume, rate per minute, fraction of oxygen in inspired gas (FiO2), pressure support, positive end- expiratory pressure, and the like must be preset and carefully evaluated for response. Appropriate attention to prescribed settings minimizes the risk of harm to the patient. QSEN: Safety (Gulanick & Myers, 2021).
Institute aseptic suctioning of the airway.
Suctioning maintains a clear airway. Suctioning procedures should be based on need rather than preset time intervals, to reduce the risk for infection and airway trauma. QSEN: Safety (Gulanick & Myers, 2021).
Check the cuff volume by assessing whether the patient can talk or make sounds around the tube or whether exhaled volumes are significantly less than volumes delivered. To correct, slowly reinflate the cuff with air until no leak is detected. Notify the respiratory therapist to check cuff pressure.
Cuff pressure should be maintained at 20 to 30 mm Hg. Maintenance of low- pressure cuffs prevents many tracheal complications formerly associated with tracheostomy tubes. Notify the physician if the leak persists. The tracheostomy tube cuff may be defective, requiring the physician to change the tube. QSEN: Safety; Teamwork and collaboration (Gulanick & Myers, 2021).
Evaluation:
The patient is breathing at the ventilator rate set according to the hospital’s protocol. Oxygen saturation has decreased to 99%, and cuff pressure remains at 22 mm Hg, as per the hospital’s protocol. Additionally, the FiO2 remains at 45%. The patient’s lung sounds are clear on both sides upon auscultation, and bilateral chest expansion with no retractions is noted upon inspection. There are no signs of distress or discomfort. The mechanical ventilator settings are appropriate for the patient’s condition per hospital’s protocol.
The patient is unable to effectively cough up secretions. There are no signs of infection, with a stable temperature of 36.8 F. No airway trauma is noted. The patient’s airways were suctioned using an aseptic technique and remained clear after each suctioning. Patient had no complications from the mechanical ventilation and remained free of aspiration.
Nursing Diagnosis # 2: Impaired mobility related to neuromuscular impairment as evidenced by inability to move purposefully within physical environment, including bed mobility, transfers, and ambulation.
Expected Outcome/ Goals:
Patient will be able to tolerate 3 hours of physical therapy sessions per day.
Patient will have improvement in muscle tone.
Interventions
Rationales
Assess the ability to perform ROM to all joints.
This assessment provides data on extend of any physical problems and guides therapy. Testing by a physical therapist may be needed. QSEN: Teamwork and collaboration (Gulanick & Myers, 2021).
Perform a passive or active assistance ROM exercises to all extremities.
Exercise promotes increased venous return, prevents, stiffness, and maintains muscle strength and endurance. To be most effective, all joints should be exercised to prevent contractures (Gulanick & Myers, 2021).
Use the following manual principles of body mechanics:
Maintain a wide, stable base with your feet.
Put the bed at the correct height (waist level when providing care, hip level when moving the patient).
Try to keep the work directly in front of you to avoid rotating the spine.
Keep the patient as close to your body as possible to minimize reaching.
These principles should be used in conjunction with SPH measures when handling and moving patients to reduce potential for injury to patient and staff. QSEN: Evidence based practice; Safety (Gulanick & Myers, 2021).
Evaluation:
The patient’s mobility remains impaired due to neuromuscular impairment, as evidenced by the inability to move purposefully within the physical environment. Neurologic assessment revealed a coma with response to tactile stimuli and no response to verbal stimuli, GSC (Glasgow Coma Scale) remains 6.
Musculoskeletal assessment revealed no range of motion in all 4 extremities. Patient was able to tolerate 3 hours of physical therapy sessions per day. No improvement in muscle tone noted. Patient is on a ventilator, with a maintained oxygen saturation of 99%, indicating respiratory stability for now. The patient’s vital signs remain relatively stable, reflected in the cardiac monitoring results and peripheral vascular assessment.
Nursing Diagnosis # 3: Risk for pressure ulcers related to immobility and alteration in sensation.
Expected Outcome/ Goals:
Patient’s skin integrity will be maintained without any signs of breakdown.
Patient will remain free from pressure ulcers.
Interventions
Rationales
Specifically assess the skin over bony prominences (e.g., sacrum, trochanters, scapulae, elbows, heels, inner and outer malleoli, inner and outer knees, back of head).
Areas where skin is stretched tautly over bony prominences are a higher risk for breakdown because the possibility of ischemia to skin is high as a result of compression of skin capillaries between a hard surface (e.g., mattress, chair, or table) and the bone. Pressure areas initially appear as persistent reddened areas in light pigmented skin. In darker skin tones, the area may appear as red, blue, or purple hue spots (Gulanick & Myers, 2021).
Use pillows or foam wedges to keep bony prominences from direct contact with each other. Keep pillows under the heels to raise off the bed.
These measures reduce shearing forces on the skin. QSEN: Safety (Gulanick & Myers, 2021).
Teach the patient and caregiver the causes of pressure injury development:
Pressure on skin, especially over bony prominences.
Incontinence.
Poor nutrition.
Shearing or friction against skin.
This information can assist the patient or caregiver in finding methods to prevent skin breakdown (Gulanick & Myers, 2021).
Evaluation:
Based on the patient-focused assessment, the patient’s risk for impaired skin integrity related to immobility and alteration in sensation is being mitigated effectively. The patient’s skin is intact, dry, and warm to touch, with no signs of wounds, edema, erythema, or discharges. Foam wedges were in place and rotated every two hours per hospitals protocol, heel protector boots were in place, and no redness or discoloration was observed on bony prominences. Patient remained free from pressure ulcers. This indicates no immediate threat to skin integrity. However, the patient’s consistent immobility and inability to respond to tactile stimuli necessitate continuous monitoring for potential skin integrity issues.
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