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Running head: INTERDISCIPLINARY CARE
Interdisciplinary Care
June 6, 2017
INTERDISCIPLINARY CARE
Background and Information
The patients initials are AB and date of birth is October 3, 1930 who is 86 years old. The
patient is a Hispanic male. He was brought to the ICU on May 12, 2017 after a right foot
amputation. The patient lives with his family which includes his wife and his son. Family
members at the hospital and who have visit him include wife, son and two younger sisters. He is
a full code patient who has a history of diabetes type II, renal failure, hypertension, pulmonary
artery disease and a history of myocardial infarction. He also has a below the knee amputation on
his left leg as well. The patient does not have any allergic reaction to medication. He does
ambulate in a wheelchair and also has hearing devices and glass. His son is the power of attorney
and says he understands what is going on with this father and has no questions.
When the patient was admitted to the ICU he was sedated and LOCx1 to this name. The
patient was unable to answer any question regarding pain, how he feels, where he was. His first
set of vital signs were BP 90/45, MAP 58, HR 90, respiration 18, oxygen saturation 90% with 4
liters via nasal cannula and temperature of 36.8. When asked if he had any pain and gave a scale
of 0-10 he was unable to respond to that question. The patient was initially in post-operative
when his blood pressure dropped and did not rebound after several interventions. His admitting
diagnosis was decrease blood pressure due to surgery and loss of blood along with renal failure.
His heart rhythm showed to be normal sinus rhythm with no alterations present or increase in
heart rate.
The report from the post-operative nurse said that the physician said everything went
alright during surgery, but he is concern about his low blood pressure along with his renal
failure. Due to the multiple medical conditions he faces and the need for the medication
Levophed it was safer to admit him to the intensive care unit until there was a stable blood
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pressure of systolic over 110 and diastolic of 60 with a MAP of 65. During surgery, his dialysis
catheter was removed and replaced. After the family members saw the new catheter they were
concerned that this one would not work with the dialysis treatment since looked different and
had an extra lumen on it. The nurse insured the family that this catheter would still work and he
is going to have his dialysis within the next hour or so.
Before his dialysis treatment I was able to do a full head to toe assessment. During my
assessment of the patient I found he was free of any bumps or lesions on the head. His skin was
warm to touch and radial pulses were a +2 and equal bilaterally. His capillary refill was less than
three seconds and heart sounds were normal with no sound of a murmur or other complications.
His lungs were clear in the upper lobes with some crackles in the lower lobes. His rate of
respirations were normal at 17 respirations per minute. Due to the amputation, I used femoral
pulses which were a +2 bilaterally.
His skin color was appropriate and no discoloration of the body was found. His bowel
sounds were present in all four quadrants. His blood sugar was 94 and to be checked every four
hours. He was being given fluids of D5 ½ Normal saline to assist with his possible low sugars
from no meals for so long. I was able to assess his eyes and pupils were equal, round, reactive to
light and accommodating.
Patient is to remain on bed rest until blood pressures have become stable and sedation has
warn off. He is being kept at a 30 degree angle at the head of the bed to prevent aspiration and
increase blood flow. His vital signs will be taken every 4 hours and blood pressure will be
monitored closely using the bed side monitor with a blood pressure cuff being uses every 15
minutes. He has a Foley catheter in place to monitor his input and output and there is an order to
discontinue the catheter as soon as he is alert and oriented to prevent infection as he is ver
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susceptible due to his age and diabetes. The dressing change on his foot to be done by the
physician and nurse is asked to monitor for bleeding only until first dressing is changed by the
physician.
His lab orders are to have blood drawn daily until results are all stabilized. He is to
remain on oxygen until he can handle room air only with a 95% or greater oxygen saturation. His
right wrist has an IV line and he also has central line placed for medications. He had a chest xray done prior to his surgery which showed no abnormalities. His heart will be monitored
continuously throughout his stay for possible changes in rate and rhythm.
Laboratory Results
Abnormal labs were as follows: white blood count: 21.1 which is too high for any person.
This result in his white blood cells tells us he may be fighting an infection and being he is also
diabetic there is a greater risk for infection occurring. Hemoglobin: 9.2 which is a decrease in his
red blood cells most likely a reaction from the amputation and the loss of blood he incurred
during the surgery. The surgery was only hours ago and labs were performed immediately after
surgery. An order has been written to transfuse one unit of red blood cells for a hemoglobin of
less than 7. PT/INR: 1.4 which is higher than normal and may be a result of his medication of
Plavix he has been taking for years according to the family. Although this medication was
discontinued prior to surgery there is still a possibility the medication is in the blood stream not
allowing a proper clotting time. BUN: 53 is a high result most likely due to the renal failure the
patient is in and the fact that he had no received his dialysis treatment that day. Creatinine: 5.7
which is also an elevated result of his impaired renal function. This patient is in need of his
dialysis treatment and the delay in hemodialysis will cause an increased BUN and creatinine.
Potassium: 5.4 is another direct look at his renal function and the fact that his kidneys are unable
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to rid of waste and potassium. The physician has ordered all his labs be drawn again after
dialysis treatment to determine if further action is needed regarding the potassium result.
Medications
Our patient’s primary reason for admission was his low blood pressures and to correct
them the physician has asked that he be given Levophed which is only given in the intensive care
unit. The primary medication administered was Levophed 5mcg per minute and to be titrated up
or down as needed dependent on his blood pressure. Levophed, also known as norepinephrine, is
a “therapeutic vasopressor most commonly prescribed for severe hypotension.” (Davis’ Drug
Guide for Nurses, 2013) The medication was administered via IV and continuous until blood
pressures and MAP goals were met. Some contraindications are “vascular, mesenteric or
peripheral thrombosis.” (Davis’ Drug Guide for Nurses, 2013) Due to this contraindication the
central line was placed to provide the IV medication through this line instead of the peripheral
line to avoid the thrombosis. Adverse reactions include “anxiety, dizziness, headache, insomnia
and dyspnea.” (Davis’ Drug Guide for Nurses, 2013) As the patient’s nurse my most concern
was the dyspnea because he had some crackles and he was recently sedated. The other adverse
reactions were hard to determine as the patient was currently not alert and oriented times four.
Nursing implications should be to assess his blood pressure frequently to adjust the medication
dosage when needed as the medication can easily cause a toxicity if the blood pressure is not
monitored closely. His heart rate is also an indicator as to whether or not the medication should
be adjusted. The physician ordered the medication to be titrated as needed depending on the
patient blood pressure and map. Another consideration is to monitor the IV site for phlebitis as
this medication is known to cause phlebitis. The medication was originally being given through
his right IV site until the central line was placed therefore monitoring the site was still relevant.
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Vancomycin also known as Vancocin is an anti-infective or antibiotic used to treat
multiple infections or unknown infections. This medication is mainly given to treat “life
threatening infections such as endocarditis, meningitis and osteomyelitis.” (Davis’ Drug Guide
for Nurses, 2013) some “contraindications are renal impairment, intestinal obstruction or
inflammation, and hearing impairment.” (Davis’ Drug Guide for Nurses, 2013) Adverse
reactions include, “nephrotoxicity, ototoxicity, and red man syndrome.” (Davis’ Drug Guide for
Nurses, 2013) Medication is ordered to be given IV route over two hours 1000 mg every 24
hours. Nursing implications specific to this patient should include watching his labs for increased
renal impairment as he is already in renal failure, Renal issues would be of most concern to me
as a nurse also because he is need of hemodialysis.
Plavix: Plavix is an “antiplatelet agent also known as clopidogrel.” (Davis’ Drug Guide
for Nurses, 2013) This patient is taking Plavix to decrease his risk of having another myocardial
infarction. The major contraindication for this patient is bleeding because he was recently out of
surgery which was already a source of blood loss. Adverse reactions most important are
“dyspnea, chest pain, edema and hypertension.” (Davis’ Drug Guide for Nurses, 2013) I felt as
the nurse once again the most important adverse reaction would be anything related to
respiratory because of his recent sedation from surgery. Nursing implication for this patient
would be to monitor his labs daily and look for any signs of bleeding, stroke or myocardial
infarction such as keeping him on the telemetry monitor. His PT/INR should be done to give us
an idea if he is taking too little or too much.
Gabapentin: also known as “nerontin is an anticonvulsant analgesic.” (Davis’ Drug Guide
for Nurses, 2013) Indication for this patient was to reduce nerve pain he was experiencing more
than likely due to diabetes progression into the nerves causing pain. Contraindications “include
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renal insufficiency,” (Davis’ Drug Guide for Nurses, 2013) Adverse reactions “confusion,
drowsiness, sedation and weight gain.” (Davis’ Drug Guide for Nurses, 2013) Nursing
implications for this patient should include “monitor for changes in behavior and pain.” (Davis’
Drug Guide for Nurses, 2013) This medication is ordered as PO 100mg twice a day.
Nursing Diagnosis
Decreased cardiac output: the low blood pressure tell us that the heart is currently unable
to produce adequate cardiac output possibly due to the decrease in fluids, loss of blood during
surgery or kidney impairment. The decrease is as evidenced by the consistent low blood pressure
and related to right foot amputation surgery. Goal: “Patient blood pressure will stabilize within
hours of Levophed administration” (All In One Care Planning Resource, Swearingen, 2008)
Intervention: “nurse will monitor blood pressure at frequent intervals and adjust medication
depending on blood pressure.” (All In One Care Planning Resource, Swearingen, 2008)
Rationale: “decreased systolic blood pressure signifies low perfusion and a need for immediate
intervention.” (All In One Care Planning Resource, Swearingen, 2008) Goal: “Patient will show
signs of improved kidney function through lab results in 24 hours.” (All In One Care Planning
Resource, Swearingen, 2008) Intervention: “Monitor blood results for elevated BUN and
creatinine.” (All In One Care Planning Resource, Swearingen, 2008) Rationale: “an increase in
BUN and creatinine are signs of decreased perfusion to the kidneys.” (All In One Care Planning
Resource, Swearingen, 2008) Intervention: “be alert to restlessness, confusion and mental staus
changes.” (All In One Care Planning Resource, Swearingen, 2008) Rationale: “these are signs of
decreased cerebral perfusion, which could result in injury to patient do to disorientation.” (All In
One Care Planning Resource, Swearingen, 2008)
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Interventions: Routine Nursing Management
This patient was monitored closely for the medication being administered and the intense
need to titrate the medication and assure he can provide adequate cardiac output on his own. The
frequent vital sign monitoring and daily labs were key to assisting this patient in improving his
condition. There was also a great need in assuring he was free from infections as his diabetes
would be an obstacle in fighting off any infections that can occur. Washing hands, sterile
dressing changes and using gloves are all a practice needed to prevent him from a lifethreatening infection.
Proper assessment on this patient after his sedation has warn off is also a major need as
we have not established a baseline to his orientation and neurological status. His orientation is a
great indicator to the organs being properly perfused. Due to his sedation upon admission we
were unable to obtain a clear picture of his status other than his vital signs. The fact that the
patient can no longer walk is another obstacle in nursing and will require frequent monitoring of
his extremities to prevent any DVT’s and assure his pulses are adequate as well.
Collaborative Management
The surgeon who performed the patient surgery was his primary care physician postsurgery. He was now responsible for the wound of the patient and assuring all guidelines for
preventing infection were in place as well as monitoring his lab results for infections as well as
blood loss that may occur after surgery. The wound would need to be closely monitored by the
surgeon to assure his healing process has begun and his extremities were perfusing correctly.
Patient was also followed by a nephrologist for his dialysis and monitoring of the kidneys. Our
patient was admitted with a history of renal failure and previous dialysis treatments that are
greatly affected by this surgery. The nephrologist involved would focus on the kidney function
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and trying to bring his kidney function back to a stable status so he can return home. This
process was also very important being his blood pressures were keeping him in the intensive care
unit. The kidneys have a great influence on the blood pressure therefore the nephrologist
involved would possibly be able to restore his blood pressures back to a stable status as well.
A team of residents are also following the patient as his overall medical physician which
will oversee his entire status and closely monitor the blood pressures and most importantly his
diabetes and heart conditions. These physicians will adjust the insulin dosages, add or remove
cardiac medications, titrate the Levophed and balance his electrolytes according to lab results.
This team of physicians are in the hospital twenty-four hours a day and would be his team in the
case of an emergency.
Physical therapy will eventually be involved to assist the patient in his mobility needs to
assure perfusion through the limbs and help him with coping and movements. Physical therapy
will also assist with new ways to assure there is exercise being done although both his feet are
not present. They will teach him ways to move on his own and ways in which he may need
assistance as well as use of the wheelchair and other possible equipment.
Therapeutic Modalities
This patient’s therapeutic modality was the surgery performed. The need for the surgery
was due to nerve damage that occurred from the uncontrolled diabetes. The patient’s blood
glucose levels were significantly high and caused the foot to lose blood circulation to the
extremity. The tissue in the foot died and risk of an infection was evident had there not been an
amputation done immediately.
In this situation the nurse is responsible for assuring tissue perfusion is present in the rest
of his extremity so he would avoid further damage. The nursing role will also consist of
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educating the patient on proper management of diabetes and kidney failure. Diet is a the biggest
issue in this case and therefore informing the patient and his family of the importance of
following a proper diet and using medication properly will assist the patient in avoiding another
limb amputation. Informing the family of how this happened and why may prevent another
surgery in the future.
Nursing Role Reflection
The nursing staff is the primary eyes and ears of the patient and the first person to assess
the patient at all times. The nurse will not only inform the physicians of their specialty changes
in condition but collaborate closely with the family and patient himself to assure a speedy
recovery. The nurse will monitor all his vitals and be responsible to inform physicians of any
abnormal changes in mental status, lab results, mobility deficits and life threatening vital signs.
The nurse is also responsible for educating the patient on what he should expect and changes to
be aware of as well as educating the family of changes to look for when discharged. The nurse
will assist in preparing for discharge to either another floor or home. The nurse is responsible for
the overall complete health of the patient and the one who initiates collaboration between all care
givers, patient and family.
The communication barrier with this patient was his inability to speak and understand
English. His family was English speaking but an interpreter would be needed to assure the
patient understood himself. As the nurse you should never assume the family understands
enough to interpret appropriately. The patient’s life is the most important and knowing he
understands is truly the main focus prior to discharging him to another floor or even home. Also
assuring he has the proper support at home is key to making sure he avoids further major health
issues.
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When researching collaboration I came across what I found to be the perfect example of
why a team of collaborators were needed. “A frequently cited advantage of teamwork is that
merging the expertise and knowledge from different disciplines maximizes creativity with
today’s complex problems.” (A Model for Interdisciplinary Collaboration Laura R. Bronstein,
PhD, ACSW, 2003) These team members are all professionals in their field and by putting them
all together we can create a team of well rounded individuals who are experts in that specialty.
By involving all these members we enhance the knowledge and put together a plan most
appropriate for the patient. Coming up with a team is very important for many reasons such as,
“promote improved communication and collaboration; and enhance patient safety.”
(Interdisciplinary Communication and Collaboration Among Physicians, Nurses, and Unlicensed
Assistive Personnel, Gwendolyn Lancaster EdD, MSN, RN, CCRN, 2015)
As I cared for this patient I felt the family was very loving, concerned and willing to do
what they had to but I didn’t feel they were well educated on his condition being this was his
second amputation. I felt as the nurse if I had more time I would have involved a nutritionist and
maybe added some examples of a healthy meal choice to the patient and family. I felt with more
time I could have found out more of what he liked to eat so I could suggest alternatives. Overall
when I reflect back on the situation I realized that more education is needed at the start of the
patient becoming stable even if it meant starting with the family. I felt had he been more
educated maybe we could have avoided needing another amputation but with the way the
intensive care unit operates it was almost impossible for the nurse to sit and educate the patient
and family. I feel a nurse educator as a separate position would be the most beneficial to this
family and future patients.
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References:
Bronstein, L. R. (2003). A Model for Interdisciplinary Collaboration. Social Work, 48(3), 297306. doi:10.1093/sw/48.3.297
Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology. St. Louis, Mo:
Elsevier.
Lancaster, G., Kolakowsky-Hayner, S., Kovacich, J., & Greer-Williams, N. (2015).
Interdisciplinary Communication and Collaboration Among Physicians, Nurses, and
Unlicensed Assistive Personnel. Journal of Nursing Scholarship, 47(3), 275-284.
doi:10.1111/jnu.12130
Pagana, K. D., & Pagana, T. J. (2010). Mosby's manual of diagnostic and laboratory tests. St.
Louis, MO: Mosby/Elsevier.
Ralph, S. S., & Taylor, C. M. (2014). Sparks & Taylor's nursing diagnosis pocket guide.
Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health.
Swearingen, P. L. (2008). All-in-one care planning resource: Medical-surgical, pediatric,
maternity, & psychiatric nursing care plans. St. Louis, MO: Mosby Elsevier.
Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2013). Davis's drug guide for nurses.
Philadelphia: F.A. Davis.