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Running head: CLINICAL CASE STUDY 1

Critical Care Clinical Case Study: DW

Kimberly Price

Old Dominion University

CLINICAL CASE STUDY 2

Critical Care Clinical Case Study: DW

DW is a 73-year-old male who was admitted to the hospital February 10, 2014 for a distal

revascularization-interval ligation (DRIL) procedure on his right upper extremity (RUE) to

salvage an arteriovenous (AV) graft using his left saphenous vein after being diagnosed with

steal syndrome. DW has a history of end-stage renal disease (ESRD) treated with hemodialysis,

hypertension, diabetes mellitus, congestive heart failure, coronary artery disease, atrial

fibrillation, deep vein thrombosis (DVT), hyperlipidemia, pulmonary embolism, dyspnea on

exertion and reflux. The following paper will discuss his primary medical diagnoses, priority

nursing diagnoses, outcomes associated with the top two nursing diagnoses, interventions with

rationales supported by literature and an evaluation of the interventions over two days in the

Intensive Care Unit.

Medical Diagnosis

DW’s primary medical diagnoses are ESRD and steal syndrome. End-stage renal disease

is a chronic, progressive and irreparable decrease in kidney function in which the kidney can no

longer sustain life without intervention (i.e. transplant or dialysis). Glomerular filtration rate has

decreased to below 15 ml/min and blood urea nitrogen (BUN) and creatinine (Cr) levels

increase. Decreases in kidney function also cause acid/base, fluid and electrolyte imbalances and

patients must undergo dialysis to filter the blood or imbalances will become fatal (Ignatavicius &

Workman, 2013).

Steal syndrome is a decreased and potential reversal of blood flow distal to the site of an

AV fistula and blood is being “stolen” from the distal area (Reifsnyder & Arnaoutakis, 2010). A

DRIL procedure is a procedure in which “the site of the steal is bypassed, and the native vessel

just distal to the steal site is ligated” (Hubbard, Markel, Bendick & Long, 2009, p. 316) or tied

off.


DW has an extensive vascular history including thoracic fistulas; right arm/brachial,

subclavian and carotid arteriograms; basilica vein transposition in the RUE; and a vena cava

filter. During the DRIL procedure, DW’s blood pressure (BP) was labile and he required

vasopressors. On February 17, he was hemodynamically unstable and was placed on Levophed.

DW was not healing as anticipated and two wounds on his RUE were recorded: a right axillary

wound measuring 12 x 5 x 5 cm and an antecubital fossa wound measuring 7 x 4 x 3 cm, the

wounds were debrided and a wound-vac was placed. On February 24, his dialysis was restarted

and on the 26th the wound-vac was removed, after which he bled extensively, requiring electro-

cauterization. The patient’s vascular status continued to decline and on March 5, his right index

finger was partially amputated due to gangrene and the RUE wounds were recorded as 12 x 8 cm

and 6 x 2 cm dehisced. On April 7, DW had an exchange of his temporary dialysis catheter to his

left subclavian vein and a right AV brachial bypass repair and on April 8, he was emergently

taken to the OR because nurses were unable to assess his right ulnar pulse. Surgeons performed a

thrombectomy, arteriography, balloon angioplasty and debridement of the RUE wounds. On the

evening of April 9, DW became unresponsive to stimuli, his heart rate dropped into the 60’s, his

arterial BP fluttered around 70/40, his manual BP was 48/19 and he was intubated. The

following nursing care plan was written for care related to DW’s status on April 10-April 11.

Nursing Diagnosis

DW’s main concern is his vascular status which directly affects every other system,

therefore his primary nursing diagnosis should be ineffective tissue perfusion related to impaired

oxygen transportation, low hemoglobin counts (7.8), interruption in blood flow, peripheral

vasoconstriction, and multiple vascular grafting as evidenced by decreased peripheral pulses,


prolonged capillary refill, impaired wound healing, cool and shiny skin on his lower extremities,

and discolored peripheral skin.

A secondary nursing diagnosis would be impaired skin integrity related to decreased

tissue perfusion, impaired circulation, mechanical trauma and surgery, imbalanced nutrition, age

and immobility as evidenced by open, impaired wound healing, open sacral wounds and

generalized skin wounds.

A tertiary nursing diagnosis would be ineffective airway clearance related to excess

mucous production and mechanical ventilation as evidenced by bilateral course and diminished

lung sounds, mucous when suctioned and mucous around the intubation tube.

DW has ESRD and he has very low renal function: his glomerular filtration rate is 10 and

his phosphate level is increasing daily, going from 5.7 on day 1 to 5.9 on day 2 and his dialysis is

still on hold due to the use of his fistula for vasopressors. Therefore, his forth nursing diagnosis

is risk for injury related to impaired renal function, decreased glomerular filtration, and stalled

dialysis causing phosphate retention and inadequate calcium absorption.

DW’s family was having a very difficult time accepting his prognosis and seemed to be

in the first stage of grief: denial. A final nursing diagnosis would be ineffective coping related to

a poor prognosis as evidenced by the families statements that DW would “bounce back”, their

unwillingness to change his status from full code status to a DNR (Gulanick & Myers, 2011).

DW does not have a very good prognosis, but nurses can adopt Jean Watson’s Theory on

Human Caring, which describes the relationship between the nurse, the patient and the patient’s

family as one of understanding the patient’s ideas of health and illnesses with respect for their

views, which may oppose that of the nurse. It may be difficult for nurses to focus on curative

measures when their professional experience and critical thinking may indicate that palliative


care may be more appropriate, but nurses need to create a relationship of trust and understanding

with the patient and, in this case, DW’s family. Both the primary and secondary nursing

diagnoses focus on issues that are important to survival and will need personal touch and very

attentive interventions to treat and Watson believes that human contact and caring can assist in

the healing process (Johnson & Webber, 2010).

Outcomes

Primary Nursing Diagnosis

Outcomes for DW’s primary nursing diagnosis of ineffective tissue perfusion will focus

on stalling further decline because his condition is so labile. First, the patient should have audible

pulses using a Doppler at all peripheral pulse sites every four hours and his capillary refill will

not progress to being more than 3 seconds the entire shift.

Providing oxygen will promote oxygenation of the tissues, therefore DW’s O2 levels will

remain >93%. DW will not show signs of decreased cerebral perfusion: he will respond to

questions using nods during sedation vacations, he will be aroused by touch and gentle shaking

while sedated and will have equal, bilateral pupillary responses and he remain responsive to

stimuli during the shift.

DW will maintain bowel activity and bowel sounds throughout the shift. DW is also

receiving hemodialysis and his tissue perfusion can affect his kidneys as well so DW’s kidney

perfusion should be monitored. Although he is anureic, his kidney perfusion by not presenting

with an increasing BUN, Cr and phosphorus levels during the shift and day to day. DW will also

maintain a stable BP during the shift (Gulanick & Myers, 2011).

Secondary Nursing Diagnosis


It is unrealistic to expect DW’s skin to be intact due to his disease state and delayed

healing related to it. Therefore, a more realistic outcome is to expect no further reddened or open

areas of skin and no worsening/widening of the existing skin sores during the shift (Gulanick &

Myers, 2011).

Interventions


Assessments of DW’s perfusion status should be ongoing and vigilant and include

constant BP monitoring via an arterial line, and continuous O2 monitoring on his periphery.

Adequate BP is needed to perfuse the extremities and if it is not managed, blood flow will be

shunted away from the periphery first, causing a decrease in tissue perfusion and O2 flow to the

tissues. DW is on vasopressors to maintain a steady BP and mean arterial pressure (MAP),

however, vasopressors cause vasoconstriction of the peripheral vessels to improve cardiac

functioning and blood flow. This directly opposes promotion of peripheral tissue perfusion, but

is necessary for his survival. Close monitoring of his BP is crucial to try and decrease the amount

of vasopressor (norepinephrine/Levophed) through titration in the range between 2-10 mcg/min

to maintain a systolic BP >80mmHg. The sooner the vasopressors are discontinued, the better

chance DW has of perfusing his peripheral tissues.

Evaluation of perfusion should include “skin temperature, capillary refill, venous refill,

color changes, paresthesias, distal hail loss, [and] trophic skin changes” (CPM Resource Center,

2012, p. 1). Since DW had steal syndrome and a clot formation in his RUE it is important to

monitor for further clots and damage by assessing radial and ulnar pulses. DW’s peripheral

pulses were very weak and sometimes non-palpable and therefore monitoring them with a

Doppler is appropriate. His lower extremities also need to be monitored closely, especially


because he is a diabetic and has vascular problems related to his disease state and Doppler

assessments of his pedal and tibia pulses are appropriate as well.

Nurses are trying to prevent further injury from decreased tissue perfusion and one such

injury could be venous stasis ulcers. In a study evaluating assessments of outpatients at risk for

ulcers, researchers indicated that assessing for color changes, skin texture, skin temperature and

hair growth on extremities (Santos, de Melo, & Lopes, 2010). Although DW is an ICU patient,

the assessment can remain the same because signs and symptoms will be the same.

Deep vein thrombosis should be prevented using sequential compression devices (SCD)

to promote venous return, and thus cardiac output, and to prevent venous status in the legs.

According to the Sentara clinical pathway on ineffective peripheral tissue perfusion, the use of

SCDs and turning the patient every two hours to relieve pressure and to prevent occlusion of

vessels that may impede adequate blood flow (CPM Resource Center, 2012).

Adequate oxygenation needs to be provided through mechanical ventilation in

collaboration with respiratory therapy and the patient should be in semi-Fowler’s position to

promote oxygenation.

Teaching the family the importance of rest and clustering care as well as energy

preservation to avoid unnecessary increases in oxygen consumption is important and visitors and

stimulation should be limited. It is also important for them to understand the interventions stated

above and how they help promote adequate perfusion. Nurses should explain procedures,

especially the need for the ventilator and the use of the Doppler because equipment can cause

families unnecessary anxiety(Gulanick & Myers, 2011).



DW already has a lot of open skin areas due to unhealed surgical wounds, a sacral

pressure ulcer and some redness related to pressure. Skin assessments should be performed to

assess the overall skin condition, bony prominences and existing wounds to ensure that no

further damage will be done and that no new sites are developing. Head to toe assessments need

to focus on pressure points, but nurses cannot overlook areas such as the trunk. Research

indicates that nurses overlook sites such as the trunk, especially when the patient is overweight,

such as in the case of DW, and worsening skin conditions may be overlooked, therefore skin

assessments should include the trunk, especially creases and pressure points in that area (Kaitani,

Tokunaga, Matsui & Sanada, 2010).

One of the most crucial interventions related to skin integrity is turning and repositioning

every two hours using pillows or wedges, remembering to prop arms and legs to relieve pressure

and floating heels. According to research “any individual in bed who was assessed to be at risk

for developing pressure ulcers should be repositioned at least every two hours” (Kaitani et al.,

2010, p. 419).

The Sentara clinical pathway on skin integrity, nurses should include skin care at least

once a day and as needed to keep DW’s skin clean and dry, taking special care in the folds of his

skin. Skin should be moisturized and if no moisturizers are ordered, nurses can advocate for

Aquaphor ointment, which had not yet been ordered for DW (CPM Resource Center, 2012).

Since DW is on a mechanical vent, his mouth should also be closely inspected for skin

breakdown and respiratory can assist in moving the ventilation tubing, and moisturizer can be

provided to the lips and mucous membranes using a suction swab.

Nurses should provide wound care collaboratively with the wound ostomy nurse and

wounds should be measured at least once a week, noting any drainage, exudate, or differences in


the wound bed. Trypsin-castor-balsam should be used, which has been ordered for DW by his

physician, and is a debriding and dermatological agent with a proteolytic enzyme (Saunders,

2013) that should assist in healing and promoting new tissue growth.

Adequate nutrition is essential to tissue healing and therefore, nutrition should be

provided according to the physicians orders. Due to the instability of DW and the potential need

for surgical placement of a PEG tube, he has been NPO. Nurses can restart feedings as ordered,

which was Jevity 1.5 cal at 10 ml/hr and pro-stat liquid protein once per day. Physicians also

ordered a b-complex, vitamin c, and folic acid for supplementation. B vitamins promote healthy

skin, vitamin C promotes collagen production needed for wound healing and folic acid is needed

for proper cell division (Saunders, 2013).

DW also had a Mepilex pad placed on his existing sacral pressure sore to protect that sore

from further damage and also to protect the skin around it from pressure as well. Nurses should

continue to assess skin below and change the dressing as needed to prevent further skin damage.

Although DW was not able to participate in his direct care, it may be possible for the

family to take a more active role in his care, thus potentially helping them to cope with his

prognosis. The family should be taught about why nursing staff turns the patient every two

hours, reinforcing the importance of relieving pressure points such as the sacrum, heels and

elbows. The family can be taught to assist in ensuring that his heels are floating and that his arms

are padded by pillows and not resting directly on the side rails. This teaching can let the family

feel less helpless, but also the hands on experience of seeing his poor skin condition can also

highlight his condition and put his prognosis into perspective (Gulanick & Myers, 2011).

Evaluation



Assessments of peripheral vascular flow were performed at shift change and q2h

thereafter and documented consistently as +2 left pedal and tibial pulses, +1 right pedal and tibial

pulses, +1 and weak right ulnar and radial pulses and +2 left ulnar and radial pulses with a

Doppler. There was no change in the temperature of his skin, which remained warm to the touch

with slightly cooler lower extremities and right hand. Capillary refill on DW’s fingers and toes

was >3 seconds bilaterally. His lower extremities were discolored and shiny with no hair growth

on his shins. One case study of a man with steal syndrome after an AV fistula surgery showed

“the right hand was slightly cooler than the left, with equal palpable radial pulses present.

Capillary refill was less than 3 seconds bilaterally” (Raml, 2012, p. 95), so vigilant assessment

for the symptoms will assist in prevention and/or early detection of recurrent steal syndrome. He

was not, however, showing worsening signs/symptoms, so this outcome was met.

DW’s BP remained labile for the entire shift and if his Levophed was titrated down, his

BP would simultaneously drop, and on day 2 his vasopressin was discontinues and his Levophed

was titrated at 6mcg/min to maintain his systolic BP above 80mmHg. Although his BP did not

stay at a sustained low value, this outcome was not met because of his instability.

During assessment, DW was arousable to gentle shaking and speech, and was able to

follow commands on day 1, and when asked questions about his location he nodded yes that he

was in a hospital and when asked if the year was 2001 he nodded “yes”, indicating a decreased

awareness of time. Day two, DW had a Glasgow Coma Scale rating of 10 and his pupils

remained equal and responsive to light, but he was less easily arousable. This outcome was

partially met and his level of consciousness should continue to be monitored closely and perhaps

sedation vacations should be provided for longer periods, if tolerated, to get a better baseline

assessment.


DW was mechanically ventilated with a 7 ½ endotracheal tube and the vent setting was

on PCMV at 20 bpm with an oxygenation of 60% and a PEEP of 5. He maintained O2 saturation

levels >93% the entire shift and therefore this outcome was met.

DW remains on DVT prophylaxis and assessment indicate no suspicion of lower leg

clotting: there were no reddened areas and the temperature of the legs was generalized and

somewhat cool. This outcome was met.

On day 1 with the patient, lab values indicated that his BUN was 37 and his Cr was 5,

already high, but it increased even further on day 2 to a BUN of 43 and a Cr of 5.8. Dialysis was

being held at this point because his dialysis fistula/port was being used for vasopressors to

stabilize his blood pressure, which remained very low (with a systolic pressure dipping into the

low 60’s) without vasopressors. The plan of care on day 2 included the placement of a new

subclavian IV for his vasopressors so that dialysis treatment could begin again and hopefully

decrease not only his BUN/Cr levels, but also his phosphorus levels, which were up to 5.9 on day

2. DW’s family chose not to insert a PEG tube and therefore his NG tube feedings were resumed

at 10 ml/hr and he had hypoactive bowel sounds. This outcome was partially met.


Skin assessments were performed at the beginning of the shift and when the patient was

cleaned, turned and repositioned. DW’s skin was intact on his face and his trunk and was clean

and dry in his groin area. The dressing on the RUE wounds was clean, dry and intact. The

incision on his left thigh was intact with no redness or drainage. His legs were cool, shiny and

discolored a bluish purple bilaterally from the knees to the ankles. The right index finger

amputation site was clean and dry with no redness or drainage. Upon turning the patient, the skin

on his back showed no evidence or breakdown and his sacral dressing was intact.


The patients RUE wounds were assessed and a small amount of tan, greenish drainage

with a slight odor was seen and the tissue looked necrotic and red. The patient’s axillary wound

measured 25 x 10 x 4.5 cm and his right antecubital wound measured 1.8 x 7.5 x 3 cm during the

dressing change on April 10. Both wounds measured larger than when assessed on April 5. The

wounds were cleaned using sterile water and dressed with polymem silver and gauze. His skin is

not improving and seems to be declining so this outcome was not met.

Conclusion

This case study is an example of the difficult and often distressing health situations that

critical care nurses encounter. Some interventions that pertain to adequate tissue perfusion and

skin integrity may not be applicable to DW because of his advanced disease state. For example,

adequate fluids need to be provided to him, but if nurses continue to give IV fluids and he is

anuriac, the fluid will accumulate, causing potential edema, decreased cardiac output and

pulmonary edema. One monitoring technique for peripheral tissue perfusion is comparison

assessments of bilateral blood pressures, which is not a realistic assessment tool for DW, who

has a massive wound on this RUE. To complicate matters further, DW is on vasopressors

(vasopressin, midodrine and norepinephrine) through his dialysis port and vasopressors constrict

peripheral vessels which is in direct conflict with trying to get blood to his periphery, but cost

benefit analysis and critical thinking allows nurses to understand that his periphery doesn’t

matter if his heart is not beating and if there is a low blood pressure, his tissues still won’t be

getting perfused. This case was extremely complicated and a great lesson in contradicting

interventions done just to keep a patient alive. It is also a very interesting case to observe and

think about the difference between prolonging life with the expectation that the patient will

recover and preventing the death of a patient that will never recover.


References

CPM Resource Center. (2012). Skin integrity impairment, risk/actual. Elsevier.

CPM Resource Center. (2012). Tissue perfusion, ineffective peripheral. Elsevier.

Gulanick, M., Myers, J.L. (2011). Nursing care plans: Diagnosis, interventions, and outcomes.

St. Louis, MO: Elsevier Mosby

Hubbard, J., Markel, K., Bendick, P., & Long, G. (2009). Distal revascularization-interval

ligation (DRIL) for the treatment of dialysis access steal phenomenon. Journal of

Diagnostic Medical Sonography, 25(6), 316-324. doi:10.1177/8546479309347802

Ignatavicius, D.D., Workman, M.L. (2013). Medical-surgical nursing: Patient-centered

collaborative care. St. Louis, MO: Elsevier Saunders.

Johnson, B. M., & Webber, P. B. (2010). An introduction to theory and reasoning in nursing.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Kaitani, T., Tokunaga, K., Matsui, N., & Sanada, H. (2010). Risk factors related to the

development of pressure ulcers in the critical care setting. Journal of Clinical

Nursing, 19(3-4), 414-421. doi:10.1111/j.1365-2702.2009.03047.x

Raml, N. M. (2012). Irreversible sequela in an arterial venous fistula with steal syndrome: A case

study. Journal of Vascular Nursing, 30(3), 94-97. doi:10.1016/j.jvn.2012.02.001

Reifsnyder, T., & Arnaoutakis, G. (2010). Arterial Pressure Gradient of Upper Extremity

Arteriovenous Access Steal Syndrome: Treatment Implications. Vascular &

Endovascular Surgery, 44(8), 650-653. doi:10.1177/1538574410376450

Santos, F., de Melo, R., & Lopes, M. (2010). Characterization of health status with regard to

tissue integrity and tissue perfusion in patients with venous ulcers according to the


nursing outcomes classification. Journal of Vascular Nursing, 28(1), 14-20.

doi:10.1016/j.jvn.2009.11.001

Saunders (2013). Nursing drug handbook. St. Louis, MO: Elsevier Saunders

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