Mahalakshmi. B 1* , Lucy Grace.T 2
1 Nursing Superintendent, Kauvery Hospital, Tennur, Trichy, India
2 Nurse Educator, Kauvery Hospital, Tennur, Trichy, India
*Correspondence: +91 93613 88804; maha@kauveryhospital.com
We nurses hand-hold a patient on a long walk down a dark COVID road
Background
Every patient’s story and outcome are their own. Here, we share a patient’s story to illustrate how our nursing team impacted her life, how her story impacted ours. An incorrect diagnosis would have almost inevitably lead to an incorrect treatment. So, coordinated activity, open communication, and encouragement to voice concerns are all part of the dynamic that needs to drive such situations so patients will attain the best possible outcomes. In this article, we describe our journey with a patient who was treated in our hospital over three months, and emerged without any complications of a long stay at a hospital.
Case Presentation
A 39 years-old-young female was apparently normal till two days earlier, and then developed loss of appetite for 2 days.
On 26.05.2021, patient developed breathlessness and was found to be in an unconscious state since evening. She was taken to a GH, was treated at outpatient department and then referred to us for further management.
On arrival patient was unresponsive, no limb movements, PR:82b/mt, RR:46/mt, BP:180/100mmhg, GCS: E2V1M1. Room air saturation was 93% and was put on Non-Rebreathing Mask (NRBM).
CT chest done on 27.05.2021 revealed peripheral ground glass densities in both lung fields- consolidation with fibrosis in bilateral lower lobes, probable covid-19, CTSS:25/40
Patient was admitted in covid critical care unit and was intubated with 7.5 ET tube and put on ventilator support with FiO2 100%.
CT brain on 27.05.2021: Hyper dense venous sinuses with hypo-density in the left temporal cortex
CT brain on 31.05.2021 revealed Multifocal hemorrhagic infarct, with mass effect.
Neurologist opinion obtained; Mannitol, Midazolam and Fentanyl infusion at 2ml/hr. Patient was a known case of hypothyroidism and hypertension. Necessary investigations were sent. FiO2 was slowly tapered to 40%.
Repeat CT brain done on 09.06.2021 revealed extensive white matter edema in left temporo- occipital and bilateral parietal region with mass effect, and orders carried out.
Repeat CT chest was done on the same day; it revealed ground glass densities in both lungs with consolidation in right lower lobe and fibrotic changes in bilateral lower lobes, covid pneumonia in resolution.
Patient had hyponatremia for which correction done accordingly.
On 10.06.2021, IgG for Covid -19 was positive and as per pulmonologist opinion, patient was shifted to non-covid critical care.
On 11.06.2021 at 8.45 am patient had bradycardia, CPR started as per ACLS protocol and 1mg adrenaline IV given. After 3 mints of CPR, patient was reverted.
On 13.06.2021, due to increased endotracheal secretions, ENT opinion obtained regarding tracheostomy. On 14.06.2021 tracheotomy was done. Patient was on tracheotomy tube with ventilator support and vitals monitored continuously.
MRI Brain done on 16.06.2021 revealed resolving haemorrhagic infarct bilateral parietal regions; compared with previous scan mass effect had reduced.
Patient had loss of vision in both eyes. Ophthalmologist opinion obtained and orders carried out.
Bilateral lower limbs Venous Doppler study report on 18.06.2021: Normal venous doppler study of bilateral lower limbs No obvious E/O deep venous thrombosis
The patient was on anticoagulant and antibiotics.
On 19.06.2021 patient was weaned off from ventilator and was kept in room air and on treatment with antibiotics, anticoagulants and steroids.
On 21.06.2021 increased tinea glutealis, increased gluteal erythema with pus discharge noticed.
Dermatologist opinion obtained on 21.06.2021 and carried out the order.
Urine culture and sensitivity and tracheal secretion culture and sensitivity sent.
Psychiatrist opinion were obtained for the long stay in the hospital. Then patient was shifted to a room on 23.06.2021.
Patient’s GCS improved and she was responding to commands. Regular physiotherapy was given on a daily basis.
On 28.06.2021, patient showed good improvement, she was able to move all limbs. Anaesthetist opinion was obtained and tracheostomy was changed to metal.
On 05.07.2021, Patient showed good progress, vitals were stable, general condition was good and she was responding well.
ENT opinion obtained regarding tracheostomy tube and as advised by him decannulation was done and was instructed to review after 2-3 weeks. Hence patient was discharged with instructions for the care at home.
Final Diagnosis
So, the final diagnosis was Covid-19 Pneumonia, Cerebral Venous Thrombosis and loss of vision in both eyes, and with history of hypertension and hypothyroidism.
Medications:
- Tab. Eliquis 2.5mg RT 1-0-1 x 10 days
- Tab. Pantocid 40mg RT 1-0-0 x 10 days
- Tab. Nootrophil 800mg RT 1-1-1 x 10 days
- Tab. Levipil 1gm RT 1-0-1 x 10 days Page 3 of 4
- Tab. Epsolin 100mg RT 1-1-1 x 10 days
- Tab. Ivabrad 5mg RT 1-0-1 x 10 days
- Tab. Dulcolux 5mg RT 0-0-1 x 10 days
- Cap. Becosules RT 1-0-0 x 10 days
- Syp. Ascoril D 10ml RT 1-1-1 x 10 days
- Tab. Megapen 500mg RT 1-0-1 x 4 days
- Refresh eye drops 1-1-1-1-1
Nursing Management
Nursing care is one of the major components of healthcare services. Through evidence-based practice, nurses have improved the nursing care they deliver to the patients. Nurses spend far more time with a patient than anyone else in a facility, providing bedside services, comfort, and often provide explanations of what was involved in care. That means they play an out-sized role in providing patient-centered care.
This case was a good example of evidence-based practice of nursing care. This patient had stayed in the hospital for more than 3months, nurses had given the best possible nursing care right from admission till patient discharge. There were many examples of best practice of nursing care as there were no pressure injuries, no VAP, no CLABSI, no CAUTI reported throughout the hospital stay of 3 months.
Our nurses had given the best quality of nursing care through alleviation of symptos, appropriate and timely, reduced the intensity and frequency of acute exacerbations of the disease and enhanced psycho social wellbeing of the patient.
They gave emotional and psychological support to the patients’ family members also. Nurses played the major role in providing multi-disciplinary care to the patient with proper communication and coordination with other team members. Thus, the patient health improved and she attained possible best outcome under the extenuating circumstances
Conclusion
This case demonstrates how all members of the healthcare team need to be involved in arriving at a correct diagnosis and management plan. Doctors, nurses and medical technicians all bear responsibility for carrying out the duties pertaining to their particular discipline and sharing their findings with all team members. As per the doctors’ orders, all investigations and treatment were carried out, along with the best possible nursing care. Patient showed good progresss and with the best possible outcome; hence discharged with instructions for care at home.
Ms. B. Mahalakshmi
Nursing Superintendent
Ms. T. Lucy Grace
Nurse Educator