Solved: Jim Case Study

In this essay, you will draw on the knowledge and skills acquired during previous study, in particular your previous research unit (what is the best available evidence? What is high level evidence?)

In this assessment task you will undertake a review of the literature to explore and provide critique of the evidence base surrounding the care of aspects of CVAD management.

There are numerous complications which can occur, however for the purposes of this assessment task we are only focusing on three complications. The case study provides you with a background to Jim and his journey, however it does not provide information on the complications themselves, these were complications encountered by Jim during his admission.

In other words the case study allows you to collect cues about Jim, for example the type of CVAD, his BMI etc. The complications you are focusing on include: CVAD associated bloodstream infection (prevention) Occlusion (prevention and management) Local skin irritation (prevention)

To start your essay, you need to source literature on these three (3) complications and then decide what is the best available evidence, you can then apply these to the context of Jim and his journey. Helpful Hints and Tips This is an essay, therefore, it requires an essay structure, it must have an introduction, body and conclusion.

The essay is to be written in the third person (not first person). You must reference all sources and use Harvard referencing (as a final year student you will be marked down for poor referencing). You may use headings, but please ensure they do not disrupt the flow of your paper.

You have a degree of creative license when applying the evidence to Jim - that is, you dont have every detail relating to his case (this level of detail would take you forever to read and this is not the purpose of this assessment), for example you might read something which says that IV potassium can cause occlusion of CVADs (Im making this up), it is probably feasible that this may have happened in ICU, however if you read that a particular chemotherapy drug causes high rates of occlusion, then we can safely acknowledge that this is not an issue for Jim as he does not have cancer and is therefore not relevant.

Please ensure you have read the Rubric for this assessment task.

Case study

Jim Karas was born on the 7th of July 1949 in Kavala, Greece. The youngest of six children, Jim described his upbringing as ideal and he was very close to his parents and enjoyed school. At the age of 17, Jim met Amara and they married a year later. Jim’s father encouraged him to move to Australia to work for his uncle who had emigrated 20 years previously.

Although somewhat reluctant, Jim thought Australia sounded exciting and thought it would be a great start for both he and Amara. Amara was not as keen to move but wanted to do what would make Jim happy. They arrived in Australia in 1969 and were excited to find they were expecting their first child (George was born in 1970, followed by a daughter Angela in 1971).

Jim was overjoyed to be a father and while still working for his Uncle started to explore the idea of starting his own smallgoods business. This happened quite quickly when a nearby shop became vacant. Jim wanted to work close to home as he was worried about Amara, since arriving in Australia she had only made a few friends in the Greek community and only spoke one or two words of English.

Jim tried to encourage her to learn English but each time she became frustrated. Jim recalls that Amara cried frequently after the children were born - he felt it was because she was homesick. While he was concerned about his wife, he felt that they needed to remain in Australia as his small business was becoming hugely successful, customers would travel long distances to buy his smallgoods.

He worked hard, sometimes over 80 hours per week. He was well known in the community as a happy, hard-working and very likable man. His hospitality was well known and the family home was host to many memorable events and parties. Amara was an excellent cook and no-one ever went hungry, although she preferred to stay in the kitchen cooking and washing up, while Jim entertained the guests with his stories and singing. Amara discovered in 1979 that she was pregnant again, although shocked she was excited; however the baby boy was stillborn at full term. Amara felt deep sadness and a sense of failure, she lost her appetite (and as a result lost a significant amount of weight) and started smoking heavily (60 cigarettes per day). She rarely left the house.

Jim said little and instead worked harder and spent the remainder of his time in his shed, working on old cars. In 1990 after dropping out of university George decided to work for his father – for Jim this was a defining moment as he now had a family business – this had been his dream and to celebrate he had the front of the shop repainted with “Karas & Son Family Butchery”. Jim was content and his daughter completed her education and was awarded a Bachelor of Science and worked for a number of years as a research assistant.

Angela started a family with her partner Clare. Angela gave birth to Thomas in 2005 and started to notice he was ‘different to other children’ at around the age of two. Thomas was diagnosed with ASD. Clare left shortly after his diagnosis and returned to work in the west. Jim subdivided his very large block and built a house for Angela and Thomas next door. It was around this time that Amara’s health started to deteriorate. Jim spent more time at home helping both Amara and Angela.

George took over the running of the business and convinced his father to expand the business by buying second shop. Jim was incredibly proud and told everyone what a good business head his son had. However, Jim was unaware that George had a gambling problem and was taking large sums of money from the business.

In 2008 during the global financial crisis, George left Australia and Jim and Amara have not heard from him despite their efforts to trace and contact him. Due to the debts that George accumulated in Jim’s name, he lost the business and almost lost his family home. Jim now cares for Amara full-time, she has COPD and heart failure. Jim now cooks, cleans and provides Amara’s personal care. He has declined all offers of assistance from healthcare providers, family and friends, as it is “his job to care for his wife not a stranger”.

Jim had planned a retirement in which they could both travel and enjoy their children and grandchildren – Jim had saved hard for retirement but the debts from the business took all of their savings and they now rely solely on the pension. Amara has not left the house in over a year. The financial struggles, losing contact with his son and caring for his wife have taken an emotional toll on Jim.

In June of this year, Angela saw the lights on in her father’s shed and thought she would go and have a chat as her father seemed quite down in the past few months. As she approached the shed she saw him sitting in his beloved 1962 EJ Holden, at first she thought he was sleeping but something didn’t seem right, when she opened the car door she found Jim unresponsive and ran inside to call 000. When the ambulance arrived, Jim was not responsive.

He wasnt breathing but the ambulance officers could feel a faint carotid pulse. They inserted an oropharyngeal airway, intravenous (IV) cannula and provided ventilation with bag/valve/mask using 100% oxygen. The ambulance officers reassured Angela who was distraught after finding her beloved father in such a terrible state.

After calling the ambulance, she had turned off the engine and pulled her dad out of the car toward fresh air – this was a difficult task as Jim is 171 cms tall and weighs 89kgs. Angela kept saying ‘I didn’t know what to do? How could I have saved him?’ They asked Angela to travel to the hospital with them, but she declined, as she was worried about who would look after her mum and son Thomas. On arrival at the Emergency Department (ED), Jim remained unconscious and was not breathing spontaneously. The ED Registrar, Dr Jaram, intubated Jim so he could be mechanically ventilated.

He was hypotensive despite 1.5 Litres of IV crystalloid, so an infusion of IV metaraminol was commenced with an aim of increasing his Mean arterial pressure greater than 65mm Hg. Jim’s hypotension continued to be an issue, so Dr Jaram inserted a three lumen central venous catheter into Jim’s right subclavian vein using surgical aseptic non touch technique (ANTT). Inotropes in the form of IV noradrenaline was commenced and titrated to maintain MAP > 65.

Jim was transferred to the intensive care unit for ongoing care and close monitoring. Angela arrived at the ED to see her father and was directed to the ICU. She was terribly frightened about how her father would be when she arrived. When she got the ICU, staff asked her to stay in the waiting room until Jim was ready for visitors. It was over an hour before the nurse came to get her and during this time, Angela imagined terrible things that could be happening to her dad. She felt guilty for worrying how she was going to manage without Jim in her life.

Her mum Amara’s health was worsening and she relied heavily on Jim for all of her personal care and management of her medications. Angela’s son Thomas is now 12 and becoming increasingly challenging in terms of behaviours related to his ASD. Since her partner left, Angela has managed everything by herself, and it was becoming increasingly challenging to juggle the responsibilities of work, her son, her home and her parents alone. She felt so guilty that her dad had come to this desperate state and she had not recognised it. When Angela finally walked into her father’s ICU room, she saw a pale, frail man who was attached to a breathing machine which made his chest rise and fall at a strangely regular rate. There were tubes everywhere, which were attached to machines delivering medications and a tube down his nose which delivered nutrition to his stomach.

The intensive care specialist Dr Prince, spoke to Angela about Jim’s situation. She said that Jim was stable at the moment but he wasn’t breathing on his own and medications were keeping his blood pressure up. Dr Prince explained that they didn’t know how long Jim had been exposed to the carbon monoxide from the car which can cause damage to the brain, and they would need to wait and see if Jim gained consciousness over the next 24 hours. Angela had to return home to her mother and son who were being cared for by a neighbour. She wished she could contact her brother George. Despite everything he had done, he was still her brother and she desperately wanted to share the current pressures and responsibilities. On day two, Jim had not regained consciousness.

He was not opening his eyes, although he was moving his limbs spontaneously but not with any purpose. Jim’s temperature was documented at 38.8 degrees Celsius, with an increased heart rate and he remained hypotensive. On assessment, the insertion site of his CVC was very red and warm. No other site of infection was found so a diagnosis of Central Line Associated Bloodstream Infection (CLABSI) was made. A swab was taken from the site as well as peripheral and central blood cultures. A new CVC was inserted into the Left internal jugular vein under strict surgical ANTT and the suspected source of the infection, the original CVC was removed.

Broad spectrum IV antibiotics were commenced and then changed when sensitivities were available. On day four, Jim regained consciousness. He opened his eyes to voice, responded to requests to move his arms/legs appropriately. He had reduced limb strength but there was equal and purposeful movements. Jim was weaned from the ventilator and extubated. Nasal prong oxygen was administered to maintain SPO2 > 93%. Jim’s blood pressure continued to be reliant on inotropes, so he remained in the ICU. Angela was relieved her dad didn’t seem to have brain damage. She tried to talk to her father about what had happened but he refused and would avoid eye contact whenever she brought the subject up. He did not ask how Amara was, which surprised Angela.

On the evening of day five, Jim suddenly became agitated and restless and persistently tried to remove tubes and lines. When he wasn’t demonstrating this behaviour, he appeared withdrawn, apathetic, avoiding conversations and eye contact. Nursing staff suspected he was experiencing delirium, and implemented non-pharmacological protocols in an attempt to reassure Jim and re-orientate to the environment.

Interventions included encouraging communication and repeated reorientation, ensuring visible daylight, consistency of nursing staff, mobilisation activities and range of motion exercises. When Angela visited Jim in the morning, she was very distressed, thinking that Jim had terrible brain damage. Nursing and medical staff reassured Angela and informed her of the strategies they were putting in place to support him during this period of delirium. During this period, Jims CVC became occluded, this was managed without having to remove the CVC. On day eight, Jim was no longer reliant on inotropes and was mentally alert and orientated.

He transferred to the medical ward to continue IV antibiotics and follow up with the psychiatric team. A few days later, Angela met with the Psychiatrist and Jim’s physician who informed her that Jim was ready for discharge. Jim was keen to be discharged from hospital however he refused to participate in any discussions around residential care for either Amara or himself. Angela wanted her father to return home but acknowledged that additional services were required and Jim agreed to this request. Jims CVC line was removed prior to discharge.