Delivery of Nursing Care - Case Study Example

? Case Study Essay Assessment Case study essay Scenario You, the registered nurse, are working in the intensive care unit of a regional hospital. The patient you are delivering nursing care to is a 32 year old female patient by the name of Joanne. Joanne has had an intracerebral haemorrhage due to a ruptured berry aneurysm, and consequently, Joanne has suffered brain death. At this point in time, you are waiting for her husband of two years, and parents, to arrive for a family conference. Task Write an essay that focuses on the delivery of nursing care related to the above scenario. In your essay you need to: Introduction The nurses in the intensive care unit have extensive roles and duties upon them that have to be performed with great precision and care. The management of the brain dead patient and his family is a very important part of the duty of intensive care unit nurses and extensive knowledge with regard to this subject is needed for the nurses to have expertise in this management. Accurate skills and knowledge are required by a nurse to assess a patient as being brain dead. The nurse should be able to effectively differentiate between brain death and cardiac death and should be able explain to the family that brain death is a condition which cannot be reversed. She should also possess skills to counsel the family to allow for the organ donation of their patient. It is also the duty of the nurse to provide care to the patient so that his organs may be preserved for harvesting. The case of Joanne is also similar who is a brain dead patient in the intensive care unit. Joanne has suffered from a ruptured berry aneurysm. A ruptured berry aneurysm is a common cause of haemorrhage in the brain and it is associated with a mortality rate of 50% (Yachnis and Rivera-Zengotita 2013). Her family is on their way and it is the nurse who has to manage the family upon the arrival. The nurse should inform the family regarding the situation of Joanne and provide support to the family. At the same time the family should also be counselled for approval for organ donation. Pathophysiology of Berry Aneurysm A berry aneurysm is a point where a blood vessel in the Circle of Willis is weak and dilated. This weakness is mainly due to shortcomings in the proper formation of an artery, particularly at the points where they divide. The arteries at the weak points in the aneurysms only comprise of endothelium and an adventitia. The elastic lamina is not developed and the other muscular layers are also not structurally well formed. A rise in the intravascular pressure at these points results in further dilatation which leads to rupturing of these aneurysms (Rubin and Reisner 2009). The anatomical location of a berry aneurysm is mostly at the meeting point of the posterior communicating artery and the internal carotid. The other common site is where the anterior communicating artery joins with the anterior cerebral artery. The point at which the middle cerebral artery bifurcates is also a probable location of the berry aneurysm. In 15% of the patients there is more than one aneurysm. A genetic role in its causation is also known and it is believed that these aneurysms run in the family. Berry aneurysms are also known to co-exist with other pathological conditions which include Ehlers-Danlos syndrome as well as polycystic kidney disease and coarctation of aorta (Longmore 2007). Berry aneurysms have a greater predisposition for females as compared to males. They mostly rupture between the age of 55 and 60 years but early ruptures are also possible. The rupturing of this aneurysm can lead to bleeding in the subarachnoid space, within the brain tissue or in the ventricles of the brain. The main symptom following rupture that is presented by the patient is a headache of very severe intensity and the patient describe it as the “worst headache of life.” This is due to the subarachnoid haemorrhage. Also the patients who survive have a risk of having a vasospasm between the fourth and the fourteenth day of the rupture leading to cerebral ischemia (Yachnis and Rivera-Zengotita 2013). Rupture of Berry Aneurysm and Brain Death Berry aneurysm does not mainly have any symptoms when it is not ruptured but in cases where the aneurysm ruptures and the bleeding into the subarachnoid space or the brain tissue occurs, there is a rise in the intracranial pressure and a subsequent fall in the cerebral perfusion pressure. Cerebral perfusion pressure is basically “the difference between mean arterial pressure and the mean ICP” (intracranial pressure). Thus, a rise in the intracranial pressure due to the rupture results in a reduction in the cerebral perfusion pressure. Brain ischemia results when the pressure falls below 50 mmHg. This ischemia further leads to the release of free radicals and neurotransmitters which results in a further elevation of the intracranial pressure. At the point when the intracranial pressure rises to become equal to the value of the mean arterial pressure, the cerebral perfusion ratio falls to a value of zero and there is total loss of blood supply to the brain which leads to brain death (Raja 2007; Swearingen et al 2011). Thus, in Joanne’s case it can be assessed that excessive elevation of her intracranial pressure due to the rupture of the berry aneurysm resulted in brain death. Nursing Care A nurse who works in an intensive care unit should have competency over tackling the situation of brain death and she should be aware of the complications of dealing with this issue. The nurse should have good knowledge of being able to deal not only with the patient but also with the family. Brain death has been identified as a condition which cannot be reversed. The responsibility which lies on the nurse is to provide adequate care to the requirements of the patient and at the same time recognize the requirements of the family as well. The nurse should complete these duties to prevent from making the family devastated regarding the loss of their loved one and at the same for the protection of the patient as “a potential organ donor.” (Davis and Lemke 1987) Nursing care for Joanne is very important and the delivery of care by the nurse becomes even more significant in this case because Joanne does not have her family with her at this time. Thus, the nurse has a central role to play in conveying all the information with regard to the health events of Joanne to her family after they arrive. Joanne has had brain death. It has been identified that the pivotal role that an intensive care nurse has in a patient of brain death is the proper identification of the patient for the confirmation of the brain death and the provision of care to the family of the patient. It is the duty of the nurse to convey the most precise and logical evidence and facts so that they become satisfied during this difficult period of loss. Communication is an effective tool that is to be utilized by the nurse in these situations. Proper charting and recording of health events should be made so that they can be conveyed to the family in a chronological manner so that they become satisfied with the healthcare provided to the patient (Henneman and Karras 2004). The nurse’s role in this situation is to act as a communicator for the family. Another important duty that the nurse has to provide is to act as a correspondent between the family of the patient and the entire medical team. Thus, the effective conveying of information is a vital part of the nurse’s duty. Nursing care is to be given to Joanne like the other patients present in the intensive care unit. This includes turning and changing her site for the prevention of ulcer formation. Skin should be kept clean and dressings should be regularly changed to prevent infections. Urinary catheter as well as the intravascular catheter should be checked and assessed like in other patients. Other devices which were inserted at the time of initial care and are of no use right now may also be removed. These include ventriculoperitoneal or ventriculoartrial shunts. Also if a urinary or intravascular catheter was previously inserted without following proper aseptic measures, when the patient arrived in emergency, should be changed. A nasogastric tube should be placed as it functions to decompress the stomach and also avoids the aspiration of gastric contents. The most significant part of Joanne’s management by a nurse is that she should be treated like a potential organ donor and the nurse should be aware that her organs may help save other lives. Measures in this regard include regular monitoring of temperature via temperature probes placed in the oesophagus, rectum or bladder. The heart rate should be maintained and checked by echocardiography or for accurate measurements through the pulmonary artery catheter. Correct volume of the body should also be maintained. Blood pressure, oxygen saturation through pulse oximetry and urine output should also be checked and noted to ensure that the organs remain viable and healthy (Irwin and Rippe 2008; Murthy 2009). The main aim is to achieve a normal volume of fluid in the body as well as a systolic blood pressure above 100 mmHg. The output of urine should be above 1mL per kilogram every hour (Kaplow and Hardin 2007). The Australia New Zealand Intensive Care Society has put forward guidelines which are to be followed for the prospective organ donor patients who have undergone brain death. These include proper medical assessments and management of the patient to ensure the viability of the organs as well as the support of the family of the brain dead patient. These duties are to be fulfilled by the nurse in the case of Joanne (Novitzky and Cooper 2013). Brain Death and Cardiac Death In Relation To End of Life Decision Making Brain death and cardiac death have been described as two different kinds of deaths and they both can have an impact on the end of life decision making. Brain death is basically used to describe the condition in which the brain loses all its functions in a patient and he is therefore dead. The proper description of brain death came in the year 1968 and was put forward by Henry Beecher and the Harvard Ad Hoc Committee's. According to Beecher and the Committee, “person could be diagnosed as dead when there was irreversible cessation of the function of the entire brain.” (Sade 2011). Despite of the wide recognition of this description throughout the world, brain death was still a debatable subject till the year 1990. The legal community had many questions with regard to it as the idea of considering an individual dead despite of a normal functioning heart was questionable (Hammer et al 2006). It was argued that brain dead patients were not actually dead as some of the functions of the brain were retained. But the medical community came forward and argued against this by explaining that even if such patients are provided life support, they are bound to lose their cardiac activity over time and die (Sade 2011). Thus it is rather a better option to counsel the family with regard to organ donation. The final diagnosis of brain death requires extensive testing and work up by the medical health team so that a final decision can be reached. When brain death results, any support or management that is provided does not yield any health benefits but it is just to maintain the viability of organs (Kaplow and Hardin 2007). Therefore, the most optimal end of life decision with regard to brain death is organ donation. This should be suggested to the family of Joanne after providing proper counselling as to what brain death is and how her organs may be able to save other precious lives. Cardiac death is defined as the form of death where the brain functioning is intact and the reflexes of the brain are present. But in cardiac death, the heart stops beating and the patient is kept on ventilator support for that. Organ donation in the cases of cardiac death has become more pronounced over the last two decades as the number of donors has gone low. Discuss key issues surrounding organ donation (Sade 2011). A difference in cardiac death and brain death is that the nurse needs to counsel the family of the patients differently. In the case of brain death, removal of ventilator leads to death. In the case of cardiac death, the family is informed that the patient will be taken off the ventilator and his cardiac activity would be checked. The patient is checked for two to five minutes following the removal and if his heart does not pump blood and resume activity, the process of organ donation is commenced (O'Donnell and Na?cul 2010). The end of life decision making for cardiac death and brain death is different. This decision is taken in cardiac death when all measures of trying to improve the health of the patient fail. On the other hand, in the case of brain death, it is already clarified by the nurse that it is a form of irreversible damage to the brain and hence there is no chance of recovery. Organ donation is a breakthrough achievement in the field of medicine which has helped to provide a cure to many diseases. Nurses form an important mediator in the carrying out of this important medical practice throughout the world. They are counsellors who can assist the family in overcoming their grief and in choosing this option for their patient. In the case of Joanne, the nursing staffs are to focus on a similar role. Her family needs to be provided support and proper guidance so that they opt for this path. Australia has a very good record in organ transplantation. It commenced its organ transplantation since the year 1960 and it has good survival rates of 80% for its recipients of the donated organs. Despite of its high success rate, it is known that there are still more donors needed in the country for the organ harvesting to take place. Ethical issues also form an important barrier in the transplantation of organs. These include problems with regard to “transplantation of limbs and faces” and issues that may arise due to the direct link between the family of the deceased patient whose organs were donated and the recipients. It is thus essential that proper counselling of families is done by the nurse. Also, it is the role of healthcare practitioners to work towards keeping the recipient as well as the donor confidential (National Health and Medical Research Council (Australia)2007). This implies in the case of Joanne as well if her family approves of the donation. Conclusion Joanne was a patient who suffered brain death due to a ruptured berry aneurysm. She is admitted in the intensive care unit and the duty of the care of the patient as well as the counselling is the job of the intensive care unit nurse. Proper nursing management of Joanne is to be done till her family arrives. Furthermore, the nurse is also to play a role of an effective communicator between the family of Joanne and the healthcare team. The healthcare status is to be revealed to the family in a proper order and they are to be informed as to what brain death is. Support for the family is also to be provided and they are to be encouraged for organ donation. References Calvin, A. O., Kite-Powell, D. M., & Hickey, J. V. (January 01, 2007). The neuroscience ICU nurse's perceptions about end-of-life care. The Journal of Neuroscience Nursing : Journal of the American Association of Neuroscience Nurses, 39, 3, 143-50. Davis, K. M., & Lemke, D. M. (February 01, 1987). Brain Death: Nursing Roles and Responsibilities. Journal of Neuroscience Nursing, 19, 1, 36-39. Hammer, R. M., Moynihan, B., & Pagliaro, E. M. (2006). Forensic nursing: A handbook for practice. Sudbury, Mass: Jones and Bartlett. Henneman, E. A., Karras, G. E. J., & Massachusetts Mercy Medical Center. (January 01, 2004). Determining brain death in adults: a guideline for use in critical care. Mercy Medical Center, Springfield, Mass. Critical Care Nurse, 24, 5, 50-2. Irwin, R. S., & Rippe, J. M. (2008). Irwin and Rippe's intensive care medicine. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Kaplow, R., & Hardin, S. R. (2007). Critical care nursing: Synergy for optimal outcomes. Sudbury, Mass: Jones and Bartlett. Longmore, J. M. (2007). Oxford handbook of clinical medicine. Oxford: Oxford University Press. Murthy, T. V. S. P. (April 01, 2009). Organ donation : Intensive care issues in managing brain dead. Medical Journal Armed Forces India, 65, 2, 155-160. National Health and Medical Research Council (Australia). (2007). Organ and tissue donation after death, for transplantation: Guidelines for ethical practice for health professionals. Canberra: National Health and Medical Research and Council. Novitzky, D., & Cooper, D. K. C. (2013). The brain-dead organ donor: Pathophysiology and management. New York, NY: Springer New York. O'Donnell, J. M., & Na?cul, F. E. (2010). Surgical intensive care medicine. New York: Springer. Raja, S. G. (2007). Access to surgery. Knutsford: PasTest. Rubin, E., & Reisner, H. M. (2009). Essentials of Rubin's pathology. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Sade, R. M. (January 01, 2011). Brain death, cardiac death, and the dead donor rule.Journal of the South Carolina Medical Association (1975), 107, 4, 146-9. Swearingen, P. L., Monahan, F. D., Neighbors, M., & Green, C. J. (2011). Swearingen's manual of medical-surgical nursing: A care planning resource. Maryland Heights, MO: Mosby. Yachnis, A. T., & Rivera-Zengotita, M. L. (2014). Neuropathology. Philadelphia: Saunders/Elsevier. Read More