Autism and Accommodations in Higher Education: Insights from the Autism Community

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Interdisciplinary Care

Background Information Summary

Client initials: IA	Age: 55	Gender: Female	Primary Language N/A
Allergies: NKA
Code status: Full	Wt: 74 kg	Ht: 160 cm	BMI: 28.9
Admit date: 09/16/20	Hospital Day # 09/16/20
Isolation Y No Indication: Medical condition is not contagious.	Bleeding Precautions Yes N Indication: The patient has had an exploratory laparotomy secondary to MVA.	Fall Risk Yes N Aspiration Risk Yes N
Admitting diagnosis/symptoms (chief complaint upon admission): Motor vehicle accident (MVA)

Current medical diagnoses: Acute Respiratory Distress Syndrome (post SICU).
Summary of hospitalization to date: IA was admitted into the SICU at 0740 after she had an emergency exploratory laparotomy at 0545. She was involved in a motor vehicle accident that fractured her left humerus. She is on mechanical ventilation and her peripheral IV was replaced with a pulmonary catheter. Assessment findings from the previous nurse showed that she was tachycardic, bilateral pulmonary contusions, hypoactive bowel sounds, pale, calmy skin, and bloody drainage from the urinary catheter. She is currently in the SICU for a post-operation observation, and the initial shift assessment will be done shortly.
PMH/PSH: Unknown
Social history (ethnicity, occupation, marital status, family support, living situation): Social history unknown. The patient has emergency contact information for next-of-kin on file.

Relevant Medical ORDERS

VS frequency: Hourly
Diet: NPO (Nasogastric tube to low wall suction).	Blood sugars frequency: On admission to ICU.
Activity order: Bedrest
Oxygen order: Intubated (Ventilator settings: A/C mode, RR 10, Vt 600, FiO2 70%, PEEP 10 cm).	Respiratory Tx: The client is intubated via A/C mode. FiO2 was increased from 70% to 80% after initial lab results.
Dressing changes: The RN should assess and apply a dry sterile wound dressing on the abdomen daily.
Other relevant orders: Foley, NG tube, I/O, Chest X-ray, ECG, Daily weighing, BG, CBC, Electrolytes, BUN, Creatinine, Magnesium, Calcium, Glucose, PTT, PT, INR, Lactic Acid level.

Assessment and Analysis

Physical Assessment Findings	Analysis of Findings (Explain significance related to current diagnosis and/or PMH.)
Vital signs: I: Temp 36.0 C, HR 120, RR 10 on MV, BP 80/50, SPO2 80% on 70% Fio2, pain 2/10 O: Temp 38.0 C, HR 130, RR 10 on MV, BP 80/50, SPO2 80% on 80% Fio2, pain 2/10	The patient is experiencing tachycardia and hypotension despite fluid resuscitation, which may indicate that the patient is losing fluid somewhere. Also, the patient’s temperature, oxygen saturation, and RR are not improving with intubation. These are classic signs of ARDS. Therefore, a thorough assessment and prompt intervention should be done to prevent further deterioration.
Neurological/Sensory: The client appears anxious and no longer responds to commands. She opens her eyes only when her name is called.	The client’s neurological status has deteriorated because she is not having adequate perfusion.
Cardiovascular: Sinus tachycardia and hypotension.	Tachycardia is a compensatory mechanism the heart uses to respond to hemodynamic changes. The patient will experience hypotension if there is a volume deficit.
Respiratory: Crackles are heard in all lung fields.	Crackles are heard if there is fluid in the lungs. The patient had a bilateral pulmonary contusion, which may allow fluids to buildup in the alveoli sacs.
Gastrointestinal & Nutrition: Hypoactive bowel sounds are heard in all quadrants and the patient was NPO.	Hypoactive bowel sounds were heard because the patient is post-op. Also, the patient is NPO and immobile.
Musculoskeletal: On initial assessment, the patient was able to grasp and release with the right hand and was able to wiggle the fingers on the left hand on command. However, there is no assessment data for the ongoing assessment.	The patient was involved in a motor vehicle accident. A musculoskeletal assessment was done to assess for peripheral perfusion.
Genitourinary/Reproductive: Urine output remained at 15 mL/hour via a urinary catheter after a 500 mL NS IV bolus was administered.	Decreased urine output is a classic sign of hypovolemic shock and kidney failure. BUN and creatinine levels should be assessed to rule out kidney failure.
Integumentary (including incisions and drains): Skin remained cold, pale, and dry.	A pale, cool, skin is a compensatory mechanism of shock in stages 1 and 2. Fluid resuscitation is needed to prevent further deterioration.
IV Assessment: 500 mL NS IV bolus via the pulmonary artery catheter.	The client’s BP is not improving with previous intervention. She should receive a bolus to maintain adequate tissue perfusion and to prevent organ damage.
Pain: 2/10	PQRST pain questionnaire was not done because the patient was unable to speak.
Psychosocial: Psychosocial history unknown. Next-of-kin is on file.	The next-of-kin was needed because the client’s condition was not improving despite the interventions. A decision must be made, whether to discontinue the client from life support or not.

Laboratory Tests (relevant admission and current labs)

Date	Lab Test	Abnormal Lab Results	Normal Range	Rationale for performing test.	Relationship between/among test results with client’s condition.
09/16/20	WBC	14,000	4000-10,000	Hyperthermia	An increased number of WBC will possibly indicate an infection.
09/16/20	HGB	10	14 - 18	Decreased oxygen saturation despite ventilated.	Refractory hypoxemia is a typical finding in ARDS patients.
09/16/20	HCT	30	36 - 52	Decreased oxygen saturation despite ventilated.	Hypoxemia is a typical finding in ARDS patients.
09/16/20	PH	7.32	7.35 - 7.45	The client is intubated, and crackles were heard in all lung fields.	Fluid buildup in the lungs can lead to respiratory depression.
09/16/20	PaCO2	40	35 - 45	The client is intubated, and crackles were heard in all lung fields.	PaCO2 is within the normal limit, which can indicate compensation.
09/16/20	PaO2	64	83 - 102	The client is intubated, and crackles were heard in all lung fields.	Moderate infiltrates throughout lung fields can allow fluids to buildup in the alveoli, which can precipitate ARDS and refractory hypoxemia despite intubation.
09/16/20	HCO3	19	22 - 28	Decreased urine output.	Metabolic acidosis can indicate kidney failure.
09/16/20	SaO2	86	94 - 100	Hypotension	Decreased oxygen saturation can indicate hypoxemia.

Diagnostic Tests (x-rays, CT scans, endoscopies, etc.

Date

Test

Reason for test

Results/Findings

Analysis of relationship between diagnosis test and client’s condition

09/16/20

X-Ray

The patient has crackles and pulmonary contusion secondary to MVA.

Moderate infiltrates throughout lung fields.

Infiltrates throughout lung fields can precipitate ARDS.

09/16/20

ECG

Elevated HR.

Sinus tachycardia

The patient is tachycardic, monitoring the heart rhythms will prevent severe life-threatening dysrhythmias.

Medications

Trade Name	Generic Name	Medication Classification	Therapeutic Use	Major adverse effects	Time dosage	Route of administration	Nursing Consideration
Flagyl	Metronidazole	Nitroimidazole/ Antibiotics	Infection	thrombocytopenia	500 mg IV piggyback every 6 hours	IV	Monitor for bleeding.
Cipro XR	Ciprofloxacin	Quinolones	Infection	Tendonitis, prolong QT interval	400 mg IV piggyback every 12 hours.	IV	Monitor ECG for dysrhythmias.
MorphaBond	Morphine	Opioid	Pain management	Respiratory depression	2 mg IV push every hour prn pain.	IV	Monitor for respiratory depression.
Medrol	Methylprednisolone	Glucocorticoid	inflammation	Hyperglycemia, hypertension, hypokalemia.	125 mg IV every 6 hours	IV	Monitor potassium, sodium, and sugar levels.
Protonix	Pantoprazole	Proton-pump inhibitor	GERD	GI tract infections	40 mg IV piggyback daily	IV	Monitor for infection.
Primaxin	Imipenem	Carbapenem	Infection	seizures	500 mg IV piggyback every 6 hours	IV	Seizure precautions
Lipitor	Atorvastatin	HMG-CoA reductase inhibitors	Hypercholesteremia	rhabdomyolysis	20 mg daily v	NGT	Monitor BUN and creatine levels.

(Davis, 2020)

Nursing Diagnoses

Nursing Diagnosis #1: Deficit fluid volume.

R/T: chest trauma/bleeding

AEB: Tachycardia, hypotension, decreased urine output (15 mL/hr).

Interventions (3)	Expected Outcome (3 -Measurable):	Collaborative Interventions (3)
Airway management via face mask or mechanical ventilation	Oxygen saturation is between 94 – 100.	The respiratory therapist should be consulted to help with intubation.
Administer fluid as prescribed via the Pulmonary artery (PA) catheter.	Fluid resuscitation increases preload. BP is within normal limits.	The RN should assist the MD in placing the PA.
Monitor VS hourly.	Vital signs are within the patient’s baseline.	Vital signs taken by assistive personnel should be verified.

Nursing Diagnosis #2: Impaired gas exchange

R/T: fluid overload

AEB: Bilateral crackles

Interventions (3)	Expected Outcome (3 - Measurable):	Collaborative Interventions (3)
Intubate the client using the assist control mode.	Oxygen saturation is between 94 – 100.	Respiratory therapist should be contacted for assistance.
Urinary catheter to drain fluids.	Urine out is > 30 mL/hour.	Patient transporters should be informed to hang the bag below the chair or bed. Urine output is affected by gravity.
Administered diuretics if prescribed.	No crackles.	Pharmacy technicians should be contacted if the route of administration is to be changed.

Nursing Diagnosis #3: Ineffective airway clearance

R/T: Mechanical ventilation/loss of consciousness/sedation.

AEB: crackles, RR of 10.

Interventions (3)	Expected Outcome (3 - Measurable):	Collaborative Interventions (3)
Suction the client as needed.	Oxygen saturation is within normal limits.	Respiratory therapist should be consulted if hyperventilation is needed before suctioning.
Elevate the head of the bed.	The head of the bed should >30 degrees.	Techs should be informed to leave the bed elevated after vital signs are collected.
Check for kinked and dislodged lines.	Ventilation lines should be inspected and straighten to allow adequate oxygenation.	The MD should be contacted if lines are damaged or needed replacement.

Routine Nursing Management

Nurses are responsible to provide routine intervention for the patient because they are always at the bedside of the patient. The nursing process is one of the valuable tools used by nurses to deliver excellent routine nursing care. “The nursing process functions as a systematic guide to client-centered care with 5 sequential steps” (Toney-Butler & Thayer, 2020). The first step the nurse does is to assess the patient. The assessment process involves critical skills to collect subjective and objective patient data (Toney-Butler & Thayer, 2020). The second step involves writing nursing diagnoses. Nurses should follow the NANDA guidelines when writing nursing diagnosis (Toney-Butler & Thayer, 2020). The third step is developing a plan. A good plan should be achievable and time-oriented (Toney-Butler & Thayer, 2020). The fourth step is to implement the plan. This step involves utilizing nursing skills based on the care plan. The final step is to evaluate the intervention. An undesired outcome needs reevaluation of the care plan. Another routine nursing management is to monitor the patient and report any life-threatening condition to the HCP via an ISBAR. Poor communication or error communication within team members can lead to severe life-threatening injury or patient death, which are preventable (Müller, et al, 2018). To solve these barriers, communication via an ISBAR is recommended because it takes less time, comprehensive, and decreases the likelihood of error.

Interdisciplinary Care /Collaborative Management

Member of the Team	Brief description of the role & responsibilities
Primary Doctor	The MD is responsible to write the diagnosis and prescribe medications.
Primary Nurse	The nurse was responsible to provide direct bedside patient-centered-care, monitor the patient, implement the care plan, work with other team members and the family.
Tech	The tech was responsible to collect vital signs, ambulate the client, and perform ADLs tasks under the supervision of the nurse.
Respiratory therapist	RT helps to collect arterial blood, provide ventilation, and ABGs intervention.
Dietician	The dietician was responsible to recommend a therapeutic diet for the client.
Occupational therapist	The OT was responsible to provide family, work, ADLS, and community support.

Therapeutic Modalities

Nurses use different modalities or approaches to provide comfort to the patient. One such modality is repositioning the patient. Repositioning the patient frequently or according to facility protocols will help prevent pressure ulcers. One risk factor that contributes to pressure ulcers in the ICU is mechanical ventilation (Lima Serrano, et.al. 2017). Patients who are on vents are dependent on the nurses for everything. Therefore, nurses should make sure that these clients have adequate hygiene, nutrition, and repositioning. Another therapeutic modality that was utilized for this patient was tracheal suctioning. Patients who are mechanically ventilated are often sedated, which impaired their ability to clear secretions due to decreased cough reflex (Spapen, et. Al, 2017). For that reason, the nursing team provided as needed tracheal suctioning to improve oxygenation and infection prevention. Finally, oxygen therapy was another comfort measure provided to Ms. IA. The nursing team makes sure she received adequate oxygen throughout her admission into the ICU.

Nursing Reflection

As a professional nurse, it is very imperative to incorporate all communication styles to meet the client’s needs. However, because nursing tasks are not considered to be done without proper documentation, communications among interdisciplinary team members were mostly done via writing. One critical component of written communication is documentation on the client’s chart. As a team member for Ms. IA, I make sure I document clearly for other team members to understand. Also, to communicate to the HCP clearly concerning the patient’s condition, an ISBAR was utilized. The patient assessment data, intervention, and recommendation were communicated to the HCP via an ISBAR format. On the other hand, communicating to the critically ill and facility members involves more than just written communication. For one thing, the patient cannot communicate verbally because she was intubated. As a result, I used the lip reading, gestures, and head nods methods to communicate with her (Ten Hoorn, 2016). These communication techniques are time-consuming, but patient comfort and safety are nursing priorities (Ten Hoorn, 2016). As for the family members, I preferred using empathy, active listening, and silence when discussing treatment plans and the patient’s condition. The impact of these styles of communication brought a positive outlook on the patient. For one, it was easy to communicate with the health care team and family members. There was a significant barrier between me and the patient. For one thing, the patient was not able to talk or use body language to communicate pain or concerns. This was challenging for me, but it is an expectation for an ICU nurse. To breach this barrier, I utilized the nursing process, and the therapeutic communication of touch to provide care for this patient. When it comes to enhancing interdisciplinary collaboration in the ICU, “coordination of care is easier when the healthcare providers are committed to working and growing as a team” (Kreimer, 2019). Teamwork is very critical in the ICU. A critically ill patient, such as IA, needs a handful of healthcare workers, such as nurses, doctors, techs, dieticians, therapists, and others, to achieve an optimum outcome. Teamwork also helps to manage critical equipment within the hospital that is short due to a high admission rate or malfunction. For example, a ventilator machine or imaging equipment can be moved around back and forth around the hospital instead of being in one unit unoccupied (Kreimer, 2019). Collaboration also helps healthcare team members to share knowledge and skills with other members. For example, a team member can volunteer to go to another unit to help fix a ventilator problem (SCCM, 2020). Finally, to be an effective member of an interdisciplinary team, I need to utilize the nursing process, therapeutic communications, and respect for the team and family members. Also, I need to provide patient-centered-care by observing the ethical principles of autonomy, beneficence, nonmaleficence, justice, veracity, and fidelity.

References

Davis, (2020). Drug Guide. Retrieved from https://www.drugguide.com/ddo/

Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W. E., & Stock, S. (2018). Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. BMJ open, 8(8), e022202. https://doi.org/10.1136/bmjopen-2018-022202

Recio-Saucedo, A., Dall'Ora, C., Maruotti, A., Ball, J., Briggs, J., Meredith, P., Redfern, O. C., Kovacs, C., Prytherch, D., Smith, G. B., & Griffiths, P. (2018). What impact does nursing care left undone have on patient outcomes? Review of the literature. Journal of clinical nursing, 27(11-12), 2248–2259. https://doi.org/10.1111/jocn.14058

Kreimer, S. (2019). Interdisciplinary Collaboration to Enhance Patient Care. Retrieved from https://www.physicianleaders.org/news/interdisciplinary-collaboration-patient-care

Lima Serrano, M., González Méndez, M. I., Carrasco Cebollero, F. M., & Lima Rodríguez, J. S. (2017). Risk factors for pressure ulcer development in Intensive Care Units: A systematic review. 41(6), 339–346. https://doi.org/10.1016/j.medin.2016.09.003

SCCM (2020). Shortage of ICU Providers Who Operate Ventilators Would Severely Limit Care During COVID-19 Outbreak. Retrieved from https://sccm.org/getattachment/About-SCCM/Media-Relations/Final-Covid19-Press-Release.pdf?lang=en-US

Spapen, H. D., De Regt, J., & Honoré, P. M. (2017). Chest physiotherapy in mechanically ventilated patients without pneumonia-a narrative review. Journal of thoracic disease, 9(1), E44–E49. https://doi.org/10.21037/jtd.2017.01.32

Ten Hoorn, S., Elbers, P. W., Girbes, A. R., & Tuinman, P. R. (2016). Communicating with conscious and mechanically ventilated critically ill patients: a systematic review. Critical care (London, England), 20(1), 333. https://doi.org/10.1186/s13054-016-1483-2

Toney-Butler TJ, Thayer JM. (2020). Nursing Process. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK499937/