Mr. J is transferred to the ICU setting where he is intubated immediately for acute respiratory failure secondary to sepsis. He is unconscious. His blood pressure is 80/40 and a central venous line is placed. On intubation, the oral mucosa is friable and bleeding with evidence of massive stomatitis and esophagitis. He is treated empirically with several IV antibiotics and inotropic agents; his prognosis is poor.

Clinical Data

Mr. J is unable to speak, but within 72 hours of aggressive therapy, he begins to improve, showing conscious responses to external stimuli, although responses are limited and erratic.

Daily spontaneous breathing trials show signs of improvement and a possibility for extubation exists.

However, he begins to pull at his tubing. He has a wide-eyed fearful look as he attempts to mouth words around the endotracheal tubing. Staff can't understand Mr. J's communication attempts. He becomes intermittently lethargic then restless, reaching in space for imaginary objects.

During this time his blood pressure climbs and his heart rate peaks over 120 beats per minute. Staff attribute these vital sign changes to anxiety and tell Mr. J that he is improving. They remind him not to pull the tubing or they will have to restrain his hand.

Mr.J's care and treatment are discussed at the Care Conference with his son. Discussion centers on his mental status, communication difficulties, and ventilator weaning progress. Staff are fearful that he is in danger of harm from accidental medical treatment device (endotracheal tube/central venous line) removal and may need to be physically restrained.

Follow up Care

Mr. J's sepsis resolved, he was extubated, and his physical strength improved over several weeks. Use of physical restraint was avoided. Mr. J gradually began to sit on the side of the bed with nursing assistance and physical and occupational therapy. His pain was managed with oral solutions 15 minutes prior to activity and as assessed as necessary by the nurse. Staff worked to incorporate family participation into Mr. J's care and recovery.

Take-home points

Several important decisions were made at crucial points in time and led to the many successful outcomes experienced by Mr. J. These included increased nursing involvement in communication, early identification, care and treatment of delirium, prevention of aspiration, prevention of further deconditioning, and the decision to avoid physical restraint use. A coordinated team approach involving his son coupled with open channels of communication and consultation with other team members who knew this patient earlier in his hospital stay helped contribute to his successful recovery

Patient Outcome

Ultimately Mr. J was transferred to a sub-acute rehabilitation setting for care and treatment of reduced mobility, and to increase muscular strength, endurance, and independence in daily living.

He developed many friendships with other residents and began to transport himself, via wheelchair, to the cooking club held at the facility. Over the course of several months, he regained muscle strength and endurance in the walking program.

What assessments and interventions need to be done to evaluate other comorbidities?