PDP Exemplar

Presentation

Nick Ehrhardt

ICU

Augustana College

Had felt nauseated night before.

Day of hospitalization, found in bed by granddaughter :

“cold, barely breathing, lips blue.”

Ambulance called.

a sketch of my memory of working in C.G.’s room.

C.G.

Admitted to MCK ED.

Sys BP 50’s, pH 7.06, EF 15%, ST elevation.

Diagnosis: Acute anterolateral MI.

Started on Levophed and transferred to Cath

Lab.

-occluded LAD “widowmaker”

and OM coronary arteries.

-stents placed

-Intra-arterial balloon pump (IABP) placed.

-Transferred to ICU.

Story of Hospitalization

Stroke, DM,

Renal Insufficiency,

hyperlipidemia, arthritis, neuropathy,

memory loss.

Refuses medication,

“has not taken any medication for past year”

Past Medical History

Neuro:

GCS 3-5, intermittent deep

pain response, no

cough/gag response, Min

pupillary Response

Cardiovascular:

HR 100’s

MAP, sagging <60

Weak pulses (doppler)

2-3+ pitting Edema LE

Scleral Edema,

Pulmonary:

ETT, scant blood tinged

secretions.

Coarse/Dim Lung sounds

GI/GU:

Freq. loose watery stools

5-10cc/hr urine output

Temps ~101

Labs: RBC 3.6 Plt 126

D-dimer 20,000, Na 123,

AST 23921, ALT 9767

HCO3 9

Assessment

Physiology Concept Map

Dr Notes:“I am not sure how

much myocardium

there is to salvage.

She is critically ill,

cardiogenic shock.

I think her mortality

rate is going to be

extremely high.”

Acute Interventions

focus on cardiac and

systemic reperfusion

MedsHeparin Drip, Amiodorone

Levophed, Dobutamine

Novolin Drip, 3% Hypertonic

Saline

Clindamycin, Ceftriaxone,

Prognosis

IABP

“We may be able to keep this patient alive, but to what end, and at what

cost?”

Flash Forward

The following shift:

-Palliative Care meeting with family during

development of a Code Blue.

-“goals discussed with family, and the decision

was made to stop the code and transition to

comfort care after a few moments of the code”

-”monitors put in privacy mode and cords, etc

removed.” palliative care/chaplaincy at

bedside.

Time of Death:

1207

Collaboration between:-ICU nursing team.

(Updates on VS, assessments,

IABP operation, patient cares, family needs)

-Nursing and managing/consulted providers

(Intensivist, cardiology, neurology,

nephrology, Endocrinology, ID, IR,

palliative care, social work, chaplaincy.)

Interprofessional Collaboration

-Manage Interventions

-Ensure dignity for patient

-Allow for Mourning/closure by family,

and adequate time for decision making

-Utilize ICU as a steward of life/death

journey

Nursing Plan

-Confidence

-Competence

-But as is the case while

working with many ICU patients...

it is easy to start feeling like an...

What I Learned/Professional Growth

Loving Kindness

Practicing Metta

Meditation

while working

with C.G.

Loving Kindness

Self ---- Local ---- Global

Thanks to:

Emily Miller

ICU

Darcy and the

PDP program

Avera