High-Acuity Nursing Care & Interprofessional Management (ICU Case Studies: Rudolf, Oliver, Eddie)

Question 1. AG Assessment and Prioritised Nursing Care for Rudolf (ICU Admission)

Answer. As the ICU nurse who is dealing with Rudolf after emergency endoscopy, massive gastrointestinal haemorrhage, and after-cardiac arrest resuscitation, a well-organised A-G assessment model allows for the identification of the life-threatening priorities within the shortest period possible, as well as to base the clinical reasoning on evidence in the high-acuity care setting.
A Airway
After six minutes of CPR, Rudolf is intubated when he returns to spontaneous circulation (ROSC). The urgency of the nursing care is to ensure the presence of endotracheal tubes, their accuracy, depth, cuff pressure, and airway security. Since Rudolf cannot control his GCS of 3, and he does not have protective reflexes, it is essential to ensure that the airways remain open to avoid aspiration, which will result in additional hypoxic damage (RCA, 2021).
B Breathing
Rudolf is kept on mechanical ventilation with less sedation (propofol). Nursing assessment involves respiratory rate/chest expansion/ventilator synchrony/ oxygen saturation/ arterial blood gas (ABG) interpretation. He first had evolved mixed metabolic and respiratory acidosis, as is the case, in hypoventilation and accumulated lactic acid under cardiac arrest. Continuous ABG monitoring serves as an aid to optimise the ventilation and supply of oxygen to prevent additional cerebral damage (Marino, 2014).
C Circulation
Circulatory compromise has a priority because of the acute blood loss, warfarin anticoagulation, and is necessary because of the necessity of the noradrenaline infusion because of hypotension. Nursing care is aimed at sustained invasive blood pressure level monitoring, using an arterial line, central venous pressure monitoring, urine output monitoring, using IDC, and peripheral perfusion. It is also necessary to protect cerebral and end-organ perfusion by ensuring a sufficient mean arterial pressure (Rhodes et al., 2017).
D Disability
Neurological examination shows fixed and large pupils, absent cranial nerve reflexes, no spontaneous breathing, and a GCS of 3, which is an indication of severe hypoxic-ischaemic brain damage. The significant role in prognostication and the discussions of the future goals of care requires serial neurological observations and documentation (ANZICS, 2020).
E Exposure
Full exposure assessment is associated with temperature control (warming blanket is applied), ongoing bleeding examination, pressure injury potential, as well as issues with the device. The old age, lack of mobility, vasopressor treatment, and life-threatening condition of Rudolf put him at a high risk of skin tears and poor thermoregulation.
F Fluids
Close observation of the fluid balance is indicated through haemorrhage, vasopressor, and high urea and creatinine, and acute kidney injury is suspected. IV fluids should be well counterbalanced to maintain perfusion but not fluid overload (Kellum et al., 2021).
G Goals of Care
Even though the full supportive treatment is still present at this stage, the early identification of the poor neurological prognosis will make possible preparation of the discussions concerning the treatment futility, so that care will not be contradictory to the values and dignity of Rudolf.

Answer 2 Interprofessional Referrals Supporting Evolving Goals of Care
With the changing clinical picture of the case of the patient Rudolf, indicating the occurrence of an irreversible neurological damage, interprofessional collaboration is critical in providing both Rudolf and his wife with ethical, compassion emergent, and person-centred care.
Palliative Care Team
Proper referral to the palliative care service should be done early, but still with ICU treatment. Palliative clinicians help to manage symptoms, discuss the issue of futility in treatment complexly, and make the transition between life-sustaining treatment and comfort-oriented care (WHO, 2020).
Social Work
It is essential to refer to social work to help the wife of Rudolf, who is going through a state of distress, uncertainty, and anticipatory grief. Social workers offer emotional support, counselling, advocacy and help in making decisions, which is especially necessary in the condition of the lack of children, depending on community networks.
Pastoral / Spiritual Care
Spiritual care service helps Rudolf's wife to deal with cultural, spiritual, and existential issues. It is especially applicable considering that Rudolf has close relations with the community, and this support has been found to enhance family coping with end-of-life care (Curtis et al., 2016).
Organ and Tissue Donation Service
Rudolf is a registered donor, and thus, it is important to be referred to the DonateLife / organ and tissue donation coordinators at an early age. Such professionals evaluate medical appropriateness, facilitate ethical consent procedures, and make sure that deliberations of donation are distinctly maintained to the choice of withdrawal-of-treatment (ANZICS, 2021).
Neurology / Neurocritical Care
Sometimes neurology consultation aids in the formal evaluation of brain death by establishing legal and clinical standards. This will give clarity to the family and facilitate evidence-based communication.
Nursing Role
This is because the ICU nurse is the coordinator of care, supporter of the earlier wishes of Rudolf, and a consistent informer, as well as a consistent supportive figure to his wife. Dignity, trust, and person-centred decision-making in end-of-life care principally lie in nursing advocacy (Aitken et al., 2024).

Question 3. Pharmacological Management of Oliver During the Acute Phase of Diabetic Ketoacidosis (Excluding IV Fluids)

Answer. The clinical presentation and investigations of Oliver demonstrate severe diabetic ketoacidosis (DKA), as seen by the significant hyperglycaemia (25.0 mmol/L), metabolic acidosis (pH 7.1, HCO 3 12 mmol/L), ketonaemia (3.5 mmol/L), and a compensatory respiratory alkalosis (PaCO 2 28 mmHg). The goals of pharmacological management done in the acute phase include the correction of insulin deficiency, reversal of ketosis, electrolyte imbalances, and treatment of the precipitating agent of the condition.
1. I. V. Insulin Infusion.
Indication:
Insulin treatment is critical to cure the absolute insulin deficit in Oliver, inhibit ketogenesis, and reduce blood glucose serum concentration and metabolic acidosis.
Mechanism of Action:
Insulin promotes the absorption of glucose by the cells, prevents lipolysis and hepatic ketone formation, which overturns metabolic acidosis.
Nursing Considerations:
? IV Insulin is initiated continuously as per QLD Health protocol DKA.
? There must be hourly screenings of blood glucose.
? Insulin should not be discontinued until ketones are gone and acidosis healed.
Oliver has changed his conscious state and is in severe acidosis, and close observation is necessary.
Potential Complications:
? Hypoglycaemia
? Intracellular potassium shift and hypokalaemia.
? Cerebral oedema (uncommon, but critical, particularly during rapid correction)
2. Potassium Dihydrogen Phosphate (Potassium Replacement - KH 2 PO 4)
Indication:
Total body potassium is lost because of osmotic diuresis and acidosis; although initially, Oliver can exhibit hyperkalaemia. The insulin therapy is going to cause the rapid intracellular shift of potassium that will threaten life-threatening hypokalaemia.
Mechanism of Action:
Potassium replacement replenishes the intracellular potassium reserves and promotes normal heart and neuromuscular activity.
Nursing Considerations:
? Constant monitoring of the heart is necessary.
? The level of serum potassium should also be checked periodically.
? Replacement of potassium should not be initiated when the urine production is not satisfactory.
Potential Complications:
? Cardiac arrhythmias
? Excessive replacement causes hyperkalaemia.
? Infusion-related complications
3. Phosphate Replacement
Indication:
Catabolic condition and osmotic diuresis of Oliver put him at risk of phosphate loss that could result in disability of the respiratory muscle and cardiac contractility.
Mechanism of Action:
The replacement of phosphates promotes the formation of ATP, oxygen supply, and muscle neuronal activity.
Nursing Considerations:
? Follow-up of serum phosphate.
? Watch for symptoms of hypocalcaemia.
? Use with renal manifestation.
Potential Complications:
? Hypocalcaemia
? Soft tissue calcification
? Renal dysfunction
4. Antibiotic Therapy (IV Cefazolin)
Indication:
A usual precipitating factor of DKA is infection. The risk of sepsis and suspected respiratory infection by Oliver approaches the need for early empirical antibiotic therapy.
Mechanism of Action:
Cefazolin suppresses the synthesis of bacterial cells, both of which cover the usual gram-positive organisms (Therapeutic Guidelines, 2022).
Nursing Considerations:
? Check allergic reactions.
? Get blood culture before administration.
? Also measure the reaction to the treatment and symptoms of sepsis.
Potential Complications:
? Hypersensitivity reactions
? Gastrointestinal upset
? Antimicrobial resistance

Question 4 Person-centred, high-acuity nursing care for Eddie

The presented case involves an 80-year-old male patient admitted to the surgical HDU after a complex CT procedure that necessitated a Hartmann operation, and where the patient lost a significant amount of blood (1500 mL), experienced a momentary hypotension, and showed early evidence of acute kidney injury (AKI). Nursing care should be given a priority in order to take care of urgent physiological instability, and yet be in line with the Person-Centred Nursing Framework (McCormack & McCance, 2016).
Priority 1: Perfusion and haemodynamic stability
Nursing would most urgently need to ensure proper circulation and tissue perfusion. The tachycardia (HR 107 bpm) on the border of blood pressure, decreased urine production, and low Haemoglobin (92 g/L) of Eddie are evidence of continued compensatory mechanisms to hypovolaemia. Arterial line insertion and constant cardiac monitoring make it possible to measure the blood pressure properly and identify the worsening in time. A mean arterial pressure of 65 mmHg and above is necessary to ensure renal and cerebral perfusion, regardless of Eddie being of advanced age with a history of congestive cardiac failure. The careful fluid resuscitation (250 mL regular saline two-hourly) is the reflection of good clinical judgment, as it will be in the middle between addressing hypovolaemia and fluid overload.
It goes along with the person-centred aspect of the provision of physical needs in terms of safety and comfort in a high-acuity environment (McCormack & McCance, 2016).
Priority 2: Renal defence and electrolyte balance
The increased urea and creatinine, high urine osmolality, and oliguria levels of Eddie suggest that he has early AKI, which is probably caused by hypoperfusion. Close fluid balance, weight monitoring, and repeat UECs should be used to inform the continued management. Electrolytes should be closely monitored because hyperkalaemia (K 5.3 mmol/L) can predispose a patient to cardiac arrhythmias, especially in patients with underlying cardiac disease. Prompt notification of deterioration of renal performance facilitates the prompt increase, including ICU referral and renal replacement therapy in case of necessity.
This is indicative of professional competence as well as clinical decision-making, which are fundamental requirements of person-centred practice (McCormack & McCance, 2016).
Priority 3: Timely complications identification
Continuing to test occult bleeding, ileus, or sepsis is necessary because of the situation with Eddie being abdominally distended, in pain, and experiencing recent hypotension. Repeat pathology, catalogue of stool, and prompt assessment of care aid in early detection of shortage and increase in care, such as vasoactive assistance in case the haemodynamics cannot be enhanced (Wagner et al., 2018).
Priority 4: Person-centred interaction.
In spite of the high-acuity requirements, Eddie must participate in care-related decision-making when feasible. Clarity in the explanation of the monitoring, pain management, and intervention will facilitate engagement, dignity, and shared decision-making, which are all in line with working on the values and beliefs of the person (McCormack & McCance, 2016).

References

Aitken, L., Marshall, A., & Buckley, T. (2024). Critical care nursing (5th ed.). Elsevier.
Australian and New Zealand Intensive Care Society. (2020). ANZICS statement on care and decision-making at the end of life for the critically ill. https://www.anzics.com.au
Craft, J., Gordon, C. J., Huether, S. E., McCance, K. L., & Brashers, V. L. (2020). Understanding pathophysiology (Australian & New Zealand ed., 4th ed.). Elsevier.
Kellum, J. A., Romagnani, P., Ashuntantang, G., Ronco, C., Zarbock, A., & Anders, H. J. (2021). Acute kidney injury. The Lancet, 398(10302), 129143. https://doi.org/10.1016/S0140-6736(21)00519-
Marino, P. L. (2014). The ICU book (4th ed.). Wolters Kluwer Health.
McCormack, B., & McCance, T. (2016). The person-centred practice framework. In B. McCormack & T. McCance (Eds.), Person-centred practice in nursing and healthcare: Theory and practice (2nd ed., pp. 5986). Wiley-Blackwell.
Resuscitation Council Australia. [RCA] (2021). Advanced life support guidelines. https://resus.org.au
Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R., Kumar, A., Sevransky, J. E., Sprung, C. L., Nunnally, M. E., Rochwerg, B., Rubenfeld, G. D., Angus, D. C., & Dellinger, R. P. (2017). Surviving Sepsis Campaign. Intensive Care Medicine, 43, 304377. https://doi.org/10.1007/s00134-017-4683-6
Therapeutic Guidelines Limited. (2022). Therapeutic guidelines: Antibiotic. https://www.tg.org.au
Wagner, K. D., Hardin-Pierce, M., Welsh, D., & Johnson, K. (2018). High-acuity nursing (7th ed.). Pearson.