Critical Integration Competency Clinical
Case Study Assignment
1. Medical History.
a. Medical diagnoses before hospitalization
• The client had no pre-existing medical conditions.
b. How long the client had been in the hospital care was provided
• He had not been hospitalized before
c. Reason for hospitalization
• Not applicable (N/A)
d. Change in condition during the shift of care
The patient came to the emergency room at 1152 with a chief complaint of fever. Initial assessment revealed that his temperature was 103.6 F, pulse was 90, respiration was 20, and blood pressure was 122/86. At 1355, he complained of a 5/10 chest pain. His vitals were reassessed and his blood pressure had increased significantly to 269/164 with a pulse of 142. On receiving 0.25mg/kg of Cardizem in a concentration of 5mg/ml IV bolus, the patient’s blood pressure reduced to 238/132 in the first 10 minutes and his HR to 119. The cardiologist then ordered Cardizem continuous IV at 2 mL /hour. The patient’s BP gradually reduced to 158/102, and his HR was 101 after 1 hour of intervention. The patient remained calm and stable. At 1513, laboratory results indicated that the patient tested positive for coronavirus disease 2019 (COVID-19).
2. Medication History
Home Medications
Generic name Brand name Pharmacological Classification Therapeutic Classification Dose, route, frequency Mechanism of action Most common adverse/side effects Most common life-threatening effects Reason for this medication
N/A N/A N/A N/A N/A N/A N/A N/A N/A
Ordered once in the Hospital before Change in Condition
Generic name Brand name Pharmacological Classification Therapeutic Classification Dose, route, frequency Mechanism of action Most common adverse/side effects Most common life-threatening effects Reason for this medication
9% Sodium chloride injection Normal saline Crystalloid therapy For the treatment of dehydration or hypovolemia 100 ml/hr administered intravenously Controls homeostasis and facilitates binding between carbon dioxide and oxygen to hemoglobin. Fever; swelling of the injection site. Fast heartbeat; shortness of breath. To promote electrolyte balance and help the patient regain stability.
Acetaminophen Ofirmev Analgesic and antipyretic For pain management 1000mg/100ml, IV at a rate of 15ml/hr Inhibits the COX pathway in the central nervous system thereby inhibiting the synthesis of prostaglandins, leading to its analgesic and antipyretic effects. Nausea; headache; loss of appetite. Liver damage/liver failure; severe skin reactions. Fever management.
Ordered once in the Hospital after a Change in Condition
Generic name Brand name Pharmacological Classification Therapeutic Classification Dose, route, frequency Mechanism of action Most common adverse/side effects Most common life-threatening effects Reason for this medication
Adenosine Adenocard IV Miscellaneous antiarrhythmic drug Arrhythmia management 3 mg for 2 seconds Mechanism of action entails the activation of specific potassium channels at the cardiac AV node. This drives potassium outside of cells and inhibits calcium influx. Eventually, the resting potential of the slow nodal cardiac myocyte is disrupted. The conduction time is significantly lowered in the process. Dizziness; lightheadedness Chest discomfort; tightness in the chest; difficulty breathing. EKG results have confirmed the presence of paroxysmal supraventricular tachycardia (PSVT) which is an evidence of increased heart rhythm. Adenosine is administered to control the heart rate.
Sodium chloride (flush) Normal saline flush STAT Crystalloid therapy For the treatment of dehydration or hypovolemia/shock. 20 ml via the peripheral IV Facilitate binding between carbon dioxide and oxygen to hemoglobin and control homeostasis. Fever; swelling of the injection site. Fast heartbeat; shortness of breath. To promote electrolyte balance.
0.25mg/kg of Diltiazem 0.25mg/kg of Cardizem Antidysrhythmic Controls heart rhythm and reduces blood pressure. 5 mg/ml IV bolus Calcium channel blocker. It works by relaxing the muscles of the heart and blood vessels Nausea; weakness; dizziness, lightheadedness; flushing; headache; and constipation. Persistent nausea and vomiting; fainting; heart failure as evidenced by shortness of breath, extreme tiredness, and pounding heartbeat. The patient’s blood pressure and heart rate are extremely high. The medication is administered to control blood pressure and heart rate.
Diltiazem Cardizem Antidysrhythmic Controls heart rhythm and reduces blood pressure. Continuous IV at 2 mL/hour Calcium channel blocker. It relaxes the muscles of the heart and blood vessels. Nausea; weakness; dizziness, lightheadedness; flushing; headache; and constipation. Persistent nausea and vomiting; fainting; heart failure as evidenced by shortness of breath, extreme tiredness, and pounding heartbeat. The patient’s blood pressure and heart rate are extremely high. The medication is administered to control blood pressure and heart rate.
3. Diagnostic Tests Performed
a. A complete list of ALL laboratory, radiology, and other diagnostic tests performed.
Imaging/Radiology and Other Diagnostics Tests Conducted
• EKG: To monitor cardiac performance
o EKG 12 lead
• Chest x-ray
o Chest 1 Vw
Laboratory tests
• SARS/FLU NAAT
o Specimen: Swab from nasopharynx
• ABG COOX CSTAT Current oxygen
o Specimen: Blood, arterial
• CBC and differential
o Specimen: Blood, venous
• CK
o Blood, venous
• Comprehensive metabolic panel
o Specimen: Blood, venous
• High Sensitivity Troponin-I
o Specimen: Blood, venous
b. For laboratory tests include in serial comparison form such as:
Test Reference Range Date and Time collected Date and Time updated
Test: SARS/FLU by NAAT
Specimen: Swab from Nasopharynx
The Xpert Xpress SARS-CoV-2/Flu test is a rapid, multiplexed real-time RT-PCT test intended for the simultaneous qualitative detection and differentiation of SARS-CoV-2, influenza A, and influenza B viral RNA in either nasopharyngeal swab or nasal swab collected from individuals suspected of respiratory viral infection consistent with COVID-19 by the healthcare provider. 06/20/22 at 1347hrs 06/20/22 at 1440
ABG COOX CSTAT Current oxygen Oxygen Saturation (O2Sat) normal values: 95-100%
Results: Current oxygen 06/20/2022 at 1513hrs 06/20/2022 at 1513hrs
CBC and differentials 1. WBC; normal values: 3.9-10.4 K/CMM
Results: 3.8 K/CMM (below normal values-abnormal)
2. Relative Monocytes; normal values: 2-8%
Results: 12.6% (raised-abnormal)
3. Relative Basophils; normal values: 0.5% -1%
Results: 1.3% (raised-abnormal)
4. Absolute lymphocytes; normal values: 1.0-4.0 K/CMM
Results: 0.79 K/CMM (below normal values-abnormal) 06/20/2022 at 1352hrs 06/20/2022 at 1359hrs
Creatine Kinase (CK) Total CK normal; normal values: 22-198 U/L
Results; 149 U/L (normal) 06/20/2022 at 1352hrs 06/20/2022 at 1428hrs
Comprehensive Metabolic Panel 1.Total protein; normal values: 6.0-8.3 g/dl
Results: 8.6 g/dl (raised-abnormal)
2.ALT (SGPT); normal values: 7-56 U/L
Results: 145 U/L (raised-abnormal)
3. AST; 8-33 U/L
Results: 66 U/L (raised-abnormal) 06/20/2022 at 1352hrs 06/20/2022 at 1428hrs
High Sensitivity Troponin-I HS Troponin-I; normal values: 0-0.04 pg/ml
Results: 102 pg/ml (Extremely raised-abnormal) 06/20/2022 at 1352hrs 06/20/2022 at 1429hrs
c. Interpretation of what the diagnostic tests mean in regards to the client’s health.
A number of laboratory and radiologic/imaging tests were conducted as part of the patient’s physical exam. The specific laboratory tests conducted include SARS/FLU NAAT, ABG COOX CSTAT, Complete Blood Count (CBC) and differentials, Creatine Kinase (CK) total, Comprehensive metabolic panel, and High Sensitivity Troponin-I test. Additional diagnostic tests conducted are chest x-ray and electrocardiogram (EKG) 12 lead. The purpose of EKG 12 lead is to examine heart performance by assessing electrical signals to establish whether they are associated with increased heart rate and blood pressure (Baek et al., 2021). 12-lead EKG results revealed the presence of paroxysmal supraventricular tachycardia (PSVT) which is an evidence of increased heart rhythm and abnormal cardiac performance (Soulaidopoulos et al., 2021). A chest x-ray was ordered to assess the extent of abnormality in the heart. Findings revealed that the patient’s heart is mediastinum, and lungs appear unremarkable. The demonstrated osseous structures appear intact. The impression of these results is that there are no significant abnormalities (Bae et al., 2022).
The patient’s change in condition has caused the healthcare provider to suspect coronavirus disease or flu caused by either SARS-CoV-2, influenza A, or influenza B. The SARS/FLU NAAT was conducted to detect and differentiate SARS-CoV-2, influenza A, and influenza B viral RNA in the patient’s nasopharyngeal swab. The test turned positive for SARS-CoV-2. Decreased oxygen saturation is one of the risk factors for abnormal heart rate and respiratory rate (Pipek et al., 2021). The healthcare provider performed ABG COOX CSTAT to establish the level of oxygen saturation in the patient. Results have revealed a normal value of oxygen saturation. The rationale for conducting a Complete Blood Count (CBC) and differentials is to evaluate the overall health of the patient to establish whether blood-related disorders such as anemia or pathogens might be contributing to his current symptoms. In the event of the presence of disease-causing micro-organisms, the blood levels of cells that form the body’s defense mechanisms are often elevated (Sun et al., 2021). CBC results have revealed abnormally raised levels of white blood cells (WBC), relative monocytes, and relative basophils. These results confirm the presence of a disease-causing pathogen in the patient’s body. Similar findings have been observed in COVID-19 patients (Palladino, 2021).
Creatine Kinase test is one of the tests performed on patients to determine the performance of the heart, skeletal muscle, or brain. In the current scenario, the test was performed to assess the patient’s heart status and performance (Soto-Fajardo et al., 2022). The exam has produced normal values of 149 U/L which is within the normal range of 22 and 198 U/L. This indicates that the patient heart is not damaged (Soto-Fajardo et al., 2022). Considering the patient’s symptoms, a comprehensive metabolic panel has been performed to detect issues with metabolism and chemical balance. Results have revealed abnormally raised levels of total proteins, ALT (SGPT), and AST which is an evidence of metabolism issues in relation to these substances (National Library of Medicine, 2022). High Sensitivity Troponin-I test is often conducted to detect heart attack by evaluating the blood levels of Troponin enzyme (Khaloo et al., 2022). From the results, the patient has extremely elevated levels of High Sensitivity Troponin-I at a value of 102 pg/ml compared against normal values of between 0-0.04 pg/ml. This confirms that he has severe heart attack and increased mortality risk which are common cardiovascular issues in COVID-19 patients (Khaloo et al., 2022). The laboratory findings provide useful guidance for the healthcare provider when making a decision when choosing the best care plan that will help to improve the patient’s symptoms.
4. Documentation of what was assessed and any abnormalities
a. Cardiovascular system
• EKG was performed to monitor cardiac performance. The rhythm displayed was Paroxysmal supraventricular tachycardia (PSVT). This is an evidence of abnormal heart rhythm or arrhythmia.
• High Sensitivity Troponin-1 test revealed severe heart attack.
b. Pulmonary system
• The Xpert Xpress SARS-CoV-2/Flu test was performed to detect the presence of SARS-CoV-2, influenza A, or influenza B. The test confirmed the presence of SARS-CoV-2 and the absence of influenza A and influenza B.
c. Gastrointestinal system
• Comprehensive metabolic panel was performed to assess abnormalities in the gastrointestinal system that could result in metabolism problems. Results indicate abnormally raised blood levels of total proteins, ALT (STPG), and AST.
d. Neurological system
i. Include complete PAIN assessment
• Vagal maneuvers were initially attempted by asking the patient to act like he was bearing down and blowing some air into a syringe but were unsuccessful as the rhythm remained unchanged. PAIN assessment was done on the pain scale. The patient’s chest pain was rated at 5/10 on the pain scale.
e. Musculoskeletal system
• Palpation of the patient’s joints did not reveal evidence of musculoskeletal issues
f. Endocrine system
• Not assessed.
g. Renal/GU system
• Comprehensive metabolic panel revealed normal potassium, sodium, chloride, and creatinine values.
5. A description of the change in condition, its pathophysiology including how it was recognized, and what was done about it.
The patient’s condition has changed from the original fever to symptoms that are associated with cardiovascular and respiratory conditions. His new complaint is a chest pain that rates at 5/10 on the pain scale. He also has a high blood pressure level of 269/164 with a heart rate of 142. The administration of Cardizem continuous IV at 2 mL /hour has reduced the blood pressure further to 158/102 with a heart rate of 101. While Adenosine, Normal saline flush STAT, acetaminophen, and Cardizem have helped to stabilize and calm the patient, laboratory tests have confirmed that he has COVID-19. COVID-19 was recognized by performing SARS/FLU by NAAT test. The disease occurs together with supraventricular (SVT) tachycardia. In response to the patient’s diagnosis, the healthcare provider transferred the patient to a negative pressure room for continuous monitoring and disease management.
The pathophysiology of COVID-19 involves the infection of the lung tissues by SARS-CoV-2 virus. The inflammation occurs in the affected lung tissues as a result of the infection. It triggers massive inflammatory response which causes acute respiratory distress syndrome (ARDS) coupled with a dysfunction in multiple organs (Yuki et al., 2020). Patients who experience problems in the cardiovascular system usually experience chest pain due to complications that are caused by the infection of the heart tissues.
6. Care plan for the next shift on the primary nursing diagnosis after the change in condition occurred.
a. A three-part nursing diagnosis (problem/etiology/as evidenced by)
• Chest pain related to a significant abnormality in the heart as evidenced by high blood pressure and increased pulse rate.
b. ONE goal for the next shift and goals to work toward the discharge
• GOAL: Educate the patient about COVID-19 including its symptoms, risks, and management approaches
Other goals toward the discharge
• Improve chest pain
• Reduce heart pressure
• Lower heart rate
c. Outcome criteria using SMART format for each of the clinical manifestations indicated by the as evidenced by section of the diagnosis and the goals written
• 1. To improve chest pain from 5/10 to 2/10 within 24 hours of hospitalization
• 2. To reduce heart rate from 119 to 98 within 2 hours of hospitalization
• 3. To reduce blood pressure from 238/132 to 200/100 within 24 hours of hospitalization
d. Interventions to reach each outcome criteria and goals including how often the interventions are to be completed
• Continue acetaminophen (Ofirmev) 1000mg/100ml, IV at a rate of 15ml/hr to reduce chest pain.
• Continue Cardizem IV at 2 mL/hour and continue observing the patient. The rationale is to reduce heart rate.
• Give adenosine 3mg IV to help reduce the blood pressure further.
7. A shift report using the I PASS the BATON format.
a. Introduce self
Nurse details:
b. Patient identifiers (Use day, shift, age, and gender)
Day: 6/20/2022
Shift: Daytime
Age: 22 years
Gender: Male
c. Assessment data (abnormal findings)
• Positive for SARS CoV-2/COVID-19
• Supraventricular (SVT) tachycardia
d. Situation (summary of patient’s current situation)
• The patient is calm and stable. He has been transferred to a negative pressure room for continuous monitoring and disease management.
e. Safety concerns
• Risk of secondary infection with COVID if there is no proper isolation.
• Risk of developing complications from the disease when not educated about the disease as quickly as possible
f. Background (summary of patient’s history)
The patient came to the emergency room at 1152 with a chief complaint of fever.
Initial vitals:
• Temperature: 103.6 F
• Pulse: 90
• Respiration: 20
• Blood pressure: 122/86.
At 1355, he complained of 5/10 chest pain. Blood pressure increased significantly to 269/164 with a pulse of 142. 0.25mg/kg of Cardizem was administered in a concentration of 5mg/ml IV bolus and the patient’s blood pressure reduced to 238/132 in the first 10 minutes and his HR to 119. He was then placed on Cardizem continuous IV at 2 mL /hour and the BP gradually reduced to 158/102. His HR was 101 after 1 hour of intervention. The patient remained calm and stable. At 1513, laboratory results indicated that the patient tested positive for coronavirus disease 2019 (COVID-19).
g. Actions (Tasks performed on your shift)
• Measured vitals: Temperature, blood pressure, pulse rate, respiratory rate
• Diagnostic tests conducted: Chest X-ray and EKG 12-lead
• Laboratory tests:
o SARS/FLU NAAT
Specimen: Swab from nasopharynx
o ABG COOX CSTAT Current oxygen
Specimen: Blood, arterial
o CBC and differential
Specimen: Blood, venous
o CK
Blood, venous
o Comprehensive metabolic panel
Specimen: Blood, venous
o High Sensitivity Troponin-I
o Specimen: Blood, venous
• Medications given:
o 9% Sodium chloride injection: 100 ml/hr administered intravenously
o Acetaminophen: 1000mg/100ml, IV at a rate of 15ml/hr
o Adenosine: 3 mg for 2 seconds
o Normal saline flush STAT: 20 ml via the peripheral IV
o 0.25mg/kg of Cardizem: 5 mg/ml IV bolus
o Cardizem: Continuous IV at 2 mL/hour
h. Timely (Actions coming up with a time designation such as lab draws or glucose assessments)
• Assess vitals after every 1 hour
i. Ownership (Specialties of the doctors caring for the client)
• Cardiologist
j. Next (Plan for the next shift)
• Isolate the patient to prevent disease spread and secondary infection
• Educate about the disease and its management
• Administer medications as indicated
• Provide counselling or invite a psychologist to address anxiety
• Monitor the patient closely for any changes
References
Bae, K., Oh, D. Y., Yun, I. D., & Jeon, K. N. (2022). Bone suppression on chest radiographs for pulmonary nodule detection: comparison between a generative adversarial network and dual-energy subtraction. Korean Journal of Radiology, 23(1), 139–149. https://doi.org/10.3348/kjr.2021.0146
Baek, Y. S., Lee, S. C., Choi, W., & Kim, D. H. (2021). A new deep learning algorithm of 12-lead electrocardiogram for identifying atrial fibrillation during sinus rhythm. Scientific Reports, 11(1), 12818. https://doi.org/10.1038/s41598-021-92172-5
Khaloo, P., Shaqdan, A., Ledesma, P. A., Uzomah, U. A., Galvin, J., Ptaszek, L. M., & Ruskin, J. N. (2022). Distinct etiologies of high-sensitivity troponin T elevation predict different mortality risks for patients hospitalized with COVID-19. International Journal of Cardiology, 351, 118–125. https://doi.org/10.1016/j.ijcard.2021.12.029
National Library of Medicine. (2022). Comprehensive Metabolic Panel (CMP). https://medlineplus.gov/lab-tests/comprehensive-metabolic-panel-cmp/
Palladino M. (2021). Complete blood count alterations in COVID-19 patients: A narrative review. Biochemia Medica, 31(3), 030501. https://doi.org/10.11613/BM.2021.030501
Pipek, L. Z., Nascimento, R., Acencio, M., & Teixeira, L. R. (2021). Comparison of SpO2 and heart rate values on Apple Watch and conventional commercial oximeters devices in patients with lung disease. Scientific Reports, 11(1), 18901. https://doi.org/10.1038/s41598-021-98453-3.
Soto-Fajardo, J. M., Castillo-Avalos, V. J., Hernandez-Paredes, E. N., Santillán-Cerón, A., Gaytan-Arocha, J. E., Vega-Vega, O., Uribe, N., Correa-Rotter, R., & Ramirez-Sandoval, J. C. (2022). Longitudinal changes of serum creatine kinase and acute kidney injury among patients with severe COVID-19. International Journal of Nephrology, 2022, 8556793. https://doi.org/10.1155/2022/8556793
Soulaidopoulos, S., Arsenos, P., Doundoulakis, I., Tsiachris, D., Antoniou, C. K., Dilaveris, P., Fragakis, N., Sotiriadou, M., Sideris, S., Kordalis, A., Laina, A., Tousoulis, D., Tsioufis, K., & Gatzoulis, K. A. (2021). Syncope associated with supraventricular tachycardia: Diagnostic role of implantable loop recorders. Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc, 26(5), e12850. https://doi.org/10.1111/anec.12850
Sun, Y., Zhou, J., & Ye, K. (2021). White blood cells and severe COVID-19: A mendelian randomization study. Journal of Personalized Medicine, 11(3), 195. https://doi.org/10.3390/jpm11030195