Clinical Encounter Analysis

CNA344: Becoming an RN: Practice consolidation

Practice Portfolio of Evidence PART B: Clinical Encounter Analysis

Consider the patient situation/context (@150 words) Provide an overview of the encounter.  What happened, how it occurred, what was it that alerted you to that fact that you needed to take action in the encounter.	During the formative assessment of placement, I cared for Mr. JP, a 30-year-old man who has schizophrenia, in the emergency department. The man was in a coma and shock by the time he was transferred to the emergency room. The patient did not look well on arrival. I informed the nurse to run several quick tests on the patient’s PB, temperature, and respiratory rate.  The patient’s blood pressure (bp) was 57/30 mm/Hg, with a body temperature reading of 35.80 C and 42/minute respiratory rate. The rate of the heartbeat was 34 bpm (beats per minute), while the “Glasgow Coma Scale” score read (E1V1M1) 3. The team administered a fluid resuscitation to him by inducing a catecholamine infusion. However, after fluid resuscitation temporarily lowered the patient’s PB 72/29 mm/Hg only to begin improving and becoming stable after the team started vasopressin.  The team quickly performed intubation due to coma and shock (Busse, McCurdy, Ali, Hall, Chen & Ostermann, 2017). The patient confessed to injecting a significant amount of risperidone and was diagnosed with an overdose. The team concluded that the unexpected hypotension or drop in blood pressure due to catecholamine infusion was because of the α-adrenergic blockade influence of risperidone.
Review (@150 words) What key information was already available to you and how did this influence your thinking? (eg: handover, history, charts, result of test, assessments, medical orders  etc.).                                     Gather(@150 words) What was the new information you gathered from the additional assessment? Dot points are acceptable for this section                   Recall(@200 words) Recall and apply your existing knowledge to the above situation to ensure you have a broad understanding of what is/may be occurring before proceeding with the rest of the cycle.   What was telling you that the encounter was presenting you with a problem that required resolution?   Use scholarly, evidence-based literature/clinical guidelines and/or policy/NSQHS materials to substantiate your discussion	Review: The following were vital observations when Mr. JP was admitted to hospital; Blood pressure (bp) 58/30 mm/Hg, Body temperature 35.70 C, Respiratory rate 41/minute, Heartbeat rate 34 bpm, The concentration of risperidone in the patient’s blood sample during the admission was 398 ng/ml, much higher than the recommended therapeutic range of “20 ng/ml to 60 ng/ml.” This level decreased to 3.60 ng/ml on the second day. The team consequently diagnosed risperidone overdose. As such, the team defined the first clinical case of “catecholamine reversal.” It was stressed that in the events of unexpected hypotension or a drop in blood pressure due to catecholamine infusion, we should examine the potential use of α-adrenergic antagonists. Vasopressin is administered in such a case.
	Relevant medications (where relevant): (not included in word count)
	Gather: Before the central venous line insertion, the team cautiously introduced dopamine infusions at 6 μg/kg/minute, adjusting to 12 μg/kg/minute. The infusions gradually worsened the patient’s hypotension to 72/29 mm/Hg. The central nervous insertion line was done after 60 minutes, followed by the initiation of noradrenaline infusion at 0.1 μg/kg/minute, which was then adjusted to 0.2 μg/kg/minute. After 1 hour and 30 minutes, the team initiated dobutamine at 4 μg/kg/minute. The patient’s bp suddenly dropped to 60/39 mmHg. The head calculated tomography, point of care sonography, enhanced chest-abdominal calculated tomography, and laboratory data did not reveal the cause of the hypotension or coma (Busse, McCurdy, Ali, Hall, Chen & Ostermann, 2017). The patient’s systemic “SVRI (systemic vascular resistance index)” was extremely low at 432 dynes/s/cm/m2, far from the acceptable range of 1970-2400 dynes/s/cm/m2. As such, we suspected that unknown “distributive shock refractory” to catecholamine infusion. Hence, besides the catecholamine infusion, we also administered vasopressin at 2.5 U/hour 2 hours 30 minutes after arrival. As a result, the patient’s BP significantly improved 134/45 mmHg.
	Recall:   From my previous studies and experiments with animals, I have learned that inducing adrenaline concurrently with α-adrenergic blockade provokes a decline in blood pressure, a condition known as adrenaline reversal. For the patient, Mr. JP, the infusion of catecholamine under the “α-adrenergic blockade effect” caused by risperidone was probably the cause for the drop in Bp in the similar mechanism called the “catecholamine reversal.” This informed our decision to use vasopressin. In adrenaline reversal, the patient must be given a medication that acts in the opposite direction to balance the pressure. Since the vasopressin acts differently from catecholamine (Busse, McCurdy, Ali, Hall, Chen & Ostermann, 2017), the team recommended maintaining the patient’s blood pressure. Catecholamine is used frequently to support circulation. The catecholamine agents vary in effect depending on the receptor. The action of catecholamine on -adrenergic receptors enhances peripheral vasoconstriction. On the other hand, catecholamine’s action on the β1-adrenergic receptor promotes inotropic and chronotropic effects while increasing vasodilation on β2-adrenergic receptors. Catecholamine agents such as dopamine and noradrenaline are the ones commonly used in distributive shocks, including septic shock, to enhance vasoconstriction as they affect α-adrenergic receptors. Nevertheless, the catecholamine agents result in unexpected hypotension in some cases (Bhattarai, Junjappa, Handigund, Kim & Chae, 2018). The case of our patient, Mr. JP, is an instance of unexpected hypotension resulting from catecholamine agent infusion.
Process Information(@400 words) Interpret, relate, and infer from the information gathered to demonstrate an overall understanding of the clinical encounter to determine the two main nursing problems.                                                                                   Predict (@100 words)   What could/would have happened in your encounter if you were to have taken NO action and why?   Use scholarly, evidence-based literature/clinical guidelines and/or policy/NSQHS materials to substantiate your discussion	Interpret, Relate, and Infer: The patient displayed sudden hypotension when we introduced a catecholamine infusion. We associated that unexpected hypotension to the pharmacological occurrence, probably the action of catecholamine in reaction to α-adrenergic blockade effect of risperidone. Studies show that experiments with animals mask α-adrenergic effects and enhance β2-adrenergic effects when adrenaline is induced concurrently with α-adrenergic receptor-blockers (Bhattarai, Junjappa, Handigund, Kim & Chae, 2018). At the same time, vasodilation happens, and blood pressure drops. The phenomenon is referred to as “adrenaline reversal” (Busse, McCurdy, Ali, Hall, Chen & Ostermann, 2017). Cases of Adrenaline reversals have also been reported in various clinical scenarios. For instance, the paradoxical hypotension caused by adrenaline infusions has been reported in patients of a large amount of quetiapine overdose. This happens since it is known to have quetiapine α-adrenergic blockade effects (Bhattarai, Junjappa, Handigund, Kim & Chae, 2018). Our report shows that adrenaline reversal can also happen in incidences of substantial antipsychotic overdose. Some researchers recommend noradrenaline in response to hypotension under α-adrenergic blockade effects, including overdosing quetiapine (Saugel, Huber, Nierhaus, Kluge, Reuter & Wagner, 2016). Nevertheless, I differ with the idea since most animal experiments and literature reviews prove that noradrenaline can also cause a similar phenomenon, “noradrenaline reversal.” However, research shows that noradrenaline has a strong effect compared to β-adrenergic. As such, this study suggests the avoidance of noradrenaline in hypotension under α-adrenergic blockade effects is recommended (Aushev, Ripoll, Vellido, Aletti, Pinto, Herpain, & Bendjelid, 2018). The study also suggests that dobutamine and dopamine can also have β-adrenergic and α-adrenergic effects (Saugel, Huber, Nierhaus, Kluge, Reuter & Wagner, 2016). Therefore, the team suggested that catecholamine reversal could have also been caused by dobutamine and dopamine. There is a high potential that catecholamine agents besides adrenaline can as well aggravate “catecholamine reversal” (Vincent & De-Backer 2013).) when the patient uses them alongside α-adrenergic antagonists. For Mr. JP’s case, a significant quantity of catecholamine infused under the effects of “α-adrenergic blockade” could have been the cause of the hypotension since risperidone has α-adrenergic blockade effects. Vasopressin, on the one hand, improves peripheral vasoconstrictions through receptors, and is mostly adopted to maintain vasoconstriction in a distributive sock (Busse, McCurdy, Ali, Hall, Chen & Ostermann, 2017). For instance, Mr. JP’s acute hypotension remarkably improved upon the initiation of vasopressin. The phenomenon is linked to the vasopressin’s mechanism, which differs from catecholamines. The finding proves that vasopressin supports circulation in patients who have applied α-adrenergic antagonists (Bhattarai, Junjappa, Handigund, Kim & Chae, 2018). Since most “antipsychotic agents” have “α-adrenergic blockade,” this study suggests that the caregiver cautiously chooses which vasoactive agent is suitable for the patients using such drugs.
	Predict:   If we did not move swiftly to administer vasopressin, the patient’s hypotension could have worsened. The blood pressure dropped significantly to an unacceptable level. In the event a catecholamine reversal occurs, characterized by a sudden fall in BP or hypotension as a result of catecholamine infusion, the first suspect should be α-adrenergic antagonist use. In that case, you apply vasopressin, or else the patient will experience severe hypotension. Mr. JP could have experienced other complications, including organ failure, if the hypotension was not reversed. The blood vessels do not constrict adequately during a septic shock, thus hindering blood supply to other organs leading to acute hypotension and organ failure (Bosnjak, 2017), which could even lead to death if not treated swiftly.
Identify the Problem/s	List in order of priority two key nursing problems that required resolution (not included in word count)
Problem 1	Shock and coma
Problem 2	Hypotension and fluid volume deficit due to reduced circulation
Establish Goals & Take Action
(@125 words for each rationale section).  Other sections not included in word count   Work through the two nursing problems identified and establish one goal and then rationalise with scholarly, evidence-based literature/clinical guidelines and/or policy/NSQHS materials the related nursing actions you did/would undertake.	Problem 1 Goal Related nursing actions Rationale Shock and coma                     Preserve life and brain functions Effective resuscitation Assess the rate of heartbeat and depth of respiration, use of accessory muscle, and chest movement.   Shock and come are emergency medical cases that can cause brain dysfunction or even death when not responded to swiftly. Resuscitation entails rapid identification and correcting the inadequate circulation to restore brain functioning and preserve life. For instance, the shock is characterized by systemic hypoperfusion, which translates into severe dysfunction of vital body organs, including the brain. Scanning for hemodynamic parameters such as blood pressure is essential to identify and effectively respond to the cause of shock and come (Puskarich et al. 2011) and to administer appropriate treatment. Low blood pressure or high blood pressure or overdose of drugs are some of the primary agents causing coma and shock that should be scanned when the patient arrives in the hospital (Busse, McCurdy, Ali, Hall, Chen & Ostermann, 2017).   Problem 2 Goal Related nursing actions Rationale Hypotension and fluid volume deficit due to reduced circulation                       Achieve a balance in blood pressure and blood circulation The nurse measures and monitors vital signs, including blood pressure, BP and the rate of heartbeat (heart rate), HR The nurse should cross-examine the patient for prior diagnosis or current medication Refer the patient to a private nurse or home health nurse for further assistance. Fluid volume deficit or a decline in blood volume is among the causes of hypotension and tachycardia. The heart rate change in a compensation mechanism to balance the cardiac output (Busse, McCurdy, Ali, Hall, Chen & Ostermann, 2017). In many cases, the pulse tends to be slower and irregular when there is an electrolytic imbalance, hence the need to monitor both heart rate and blood pressure (Wayne, 2020)   It is also vital to engage the patient and establish the previous diagnosis or currently used medication or drugs to verify if the treatment will respond to the client effectively. It also helps to prevent potential complications caused by different antagonistic drug reactions in the body.   There are community resources that facilitate continuity of care and essential service for the recovery process in patients with schizophrenia.
Evaluate outcomes (@100 words)   Evaluate the outcomes of your clinical encounter, including the effectiveness of the care provided with supporting evidence-based literature   *Do not ‘reflect on new learning’ in this section.  This will occur in your next assessment (Part C).	During my clinical encounter, there was sufficient teamwork, as we worked together as a team with other nurses to preserve life and ensure continuous brain function for Mr. JP, one of the patients admitted to our emergency department. In the context of complicated healthcare settings such as the emergency department, effective teamwork is essential for the patient’s safety as it helps to minimize adverse effects resulting from miscommunication and misunderstanding of roles and responsibilities (Gausvik, Lautar, Miller, Pallerla & Schlaudecker, 2015). We administered vasopressin to the patient, which effectively addressed catecholamine reversal, helping to balance the blood pressure. The finding proves that vasopressin improves circulation in patients who have applied α-adrenergic antagonists (Bhattarai, Junjappa, Handigund, Kim & Chae, 2018).

References:

Aushev, A., Ripoll, V. R., Vellido, A., Aletti, F., Pinto, B. B., Herpain, A., & Bendjelid, K. (2018). Feature selection for the accurate prediction of septic and cardiogenic shock ICU mortality in the acute phase. PloS one, 13(11), e0199089.

Bhattarai, K. R., Junjappa, R., Handigund, M., Kim, H. R., & Chae, H. J. (2018). The imprint of salivary secretion in autoimmune disorders and related pathological conditions. Autoimmunity Reviews, 17(4), 376-390.

Bosnjak, A. P. (2017, January). The present and the future of the Baby-Friendly Hospital Initiative in the NICUs. In 13th World Congress of Perinatal Medicine.

Busse, L. W., McCurdy, M. T., Ali, O., Hall, A., Chen, H., & Ostermann, M. (2017). The effect of angiotensin II on blood pressure in patients with circulatory shock: a structured review of the literature. Critical Care, 21(1), 324.

Gausvik, C., Lautar, A., Miller, L., Pallerla, H., & Schlaudecker, J. (2015). Structured nursing communication on interdisciplinary acute care teams improves perceptions of safety, efficiency, understanding of care plan, and teamwork, as well as job satisfaction. Journal of multidisciplinary healthcare, 8, 33.

Puskarich, M. A., Trzeciak, S., Shapiro, N. I., Heffner, A. C., Kline, J. A., Jones, A. E., & Emergency Medicine Shock Research Network (EMSHOCKNET. (, 2011). Outcomes of patients undergoing early sepsis resuscitation for cryptic shock compared with overt shock. Resuscitation, 82(10), 1289-1293.

Saugel, B., Huber, W., Nierhaus, A., Kluge, S., Reuter, D. A., & Wagner, J. Y. (2016). Advanced hemodynamic management in patients with septic shock. BioMed research international, 2016.

Vincent, J. L., & De Backer, D. (2013). Circulatory shock. New England Journal of Medicine, 369(18), 1726-1734. Wayne, G (2020). Fluid Volume Deficit (Dehydration) Nursing Care Plan. https://nurseslabs.com/deficient-fluid-volume/