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Patient Case Study Research Essay Falls and Skin tear (Australian)

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Case Study
Lars De Jong was born on the 9th of August 1953 in Delft, Netherlands. The youngest of three children, Lars described his upbringing as ideal and he was very close to his parents and enjoyed school. At the age of 17, Lars met Isa and they married a year later. Lars’s father encouraged him to move to Australia to work for his uncle who had emigrated 20 years previously.
 
Although somewhat reluctant, Lars thought Australia sounded exciting and thought it would be a great start for both he and Isa. Isa was not as keen to move but wanted to do what would make Lars happy.
 
They arrived in Australia in 1970 and were excited to find they were expecting their first child (Finn was born in 1971, followed by a daughter Hanna in 1972).  Lars was overjoyed to be a father and while still working for his Uncle started to explore the idea of starting his own bakery. This happened quite quickly when a nearby shop became vacant.  Lars wanted to work close to home as he was worried about Isa, since arriving in Australia she had only made a few friends in the Dutch community and only spoke one or two words of English. Lars tried to encourage her to learn English but each time she became frustrated.  Lars recalls that Isa 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 pastry goods. 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. Isa was an excellent cook and no-one ever went hungry, although she preferred to stay in the kitchen cooking and washing up, while Lars entertained the guests with his stories and singing.
 
Isa discovered in 1979 that she was pregnant again, although shocked she was excited; however, the baby boy was stillborn at full term. Isa felt deep sadness and a sense of failure, she started smoking heavily (60 cigarettes per day). She rarely left the house.  Lars 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 Finn decided to work for his father – for Lars 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 “De Jong & Son Family Bakery”.  Lars was content and his daughter completed her education and was awarded a Bachelor of Education and worked for several years as a primary school teacher. Hanna started a family with her partner Mark. Hanna gave birth to Charlie in 2006. By the time Charlie was 3 years old it was noticed that he was different to other children and not reaching his milestones, after testing Charlie was diagnosed with Autism. Mark left shortly after his diagnosis and returned to his parent’s farm in the Queensland.
 
Lars subdivided his very large block and built a house for Hanna and Charlie next door. It was around this time that Isa’s health started to deteriorate.  Lars spent more time at home helping both Isa and Hanna. Finn took over the running of the business and convinced his father to expand the business by buying second shop.  Lars was incredibly proud and told everyone what a good business head his son had. However, Lars was unaware that Finn had a gambling problem and was taking large sums of money from the business. In 2008 during the global financial crisis, Finn left Australia and Lars and Isa have not heard from him despite their efforts to trace and contact him. Due to the debts that Finn accumulated in Lars’s name, he lost the business and almost lost his family home.
 
Lars now cares for Isa full-time, she has COPD, Type 2 Diabetes and difficulty walking without a frame due to her weight gain.  Lars now cooks, cleans and provides Isa’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”.  Lars had planned a retirement in which they could both travel and enjoy their children and grandchildren – Lars had saved hard for retirement but the debts from the business took all their savings and they now rely solely on the pension. Isa 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 Lars.
 
In August of this year, Hanna 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 Lars unresponsive and ran inside to call 000.
 
When the ambulance arrived, Lars was not responsive. He wasn’t 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 Hanna 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 Lars is 178 cms tall and weighs 92kgs. Hanna kept saying ‘I didn’t know what to do? How could I have saved him?’ They asked Hanna to travel to the hospital with them, but she declined, as she was worried about who would look after her mum and son Charlie.
 
On arrival at the Emergency Department (ED), Lars remained unconscious and was not breathing spontaneously. The ED Registrar, Dr Singh, intubated Lars so he could be mechanically ventilated. He was hypotensive despite 1.5 Liters of IV crystalloid, so an infusion of IV metaraminol was commenced with an aim of increasing his Mean arterial pressure greater than 65mm Hg. Lars’s hypotension continued to be an issue, so Dr Singh inserted a three-lumen central venous catheter into Lars ’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.  Lars was transferred to the intensive care unit for ongoing care and close monitoring.
 
Hanna 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 Lars was ready for visitors. It was over an hour before the nurse came to get her and during this time, Hanna imagined terrible things that could be happening to her dad. She felt guilty for worrying how she was going to manage without Lars in her life. Her mum Isa’s health was worsening, and she relied heavily on Lars for all her personal care and management of her medications. Hanna’s son Charlie is now 12 and becoming increasingly challenging in terms of behaviors related to his Autism. Since her partner left, Hanna 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 Hanna 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 Williams, spoke to Hanna about Lars’s situation. She said that Lars was stable now, but he wasn’t breathing on his own and medications were keeping his blood pressure up. Dr Williams explained that they didn’t know how long Lars 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 Lars gained consciousness over the next 24 hours.
 
Hanna had to return home to her mother and son who were being cared for by a neighbour. She wished she could contact her brother Finn. Despite everything he had done, he was still her brother and she desperately wanted to share the current pressures and responsibilities.
 
On day three, Lars regained consciousness. He opened his eyes to voice, responded to requests to move his arms/legs appropriately. He had reduced limb strength but with equal and purposeful movements.  Lars was weaned from the ventilator and extubated. Nasal prong oxygen was administered to maintain SPO2 > 93%. Lars’s blood pressure continued to be reliant on inotropes, so he remained in the ICU.
 
On the evening of day four, Lars ’s blood pressure became increasingly difficult for staff to maintain a MAP of 65 without significantly increasing his inotropic supports. His heart rate increased to 121, respirations of 28 and he was required to change to high flow nasal prong support at 40L 50%Fi02 to maintain his Sp02 >93%. When Dr Singh reviewed Lars, she noted that his urine output had been charted at 20 ml then 15mls for the last two hours. A new set of blood tests were ordered, and Dr Singh found that Lars’s creatinine was 420 umm/L, bilirubin 83 mg/dL and platelets of 90 (x10³/uL)
 
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.
 
Lars had become 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 to reassure Lars 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 Hanna visited Lars in the morning, she was very distressed, thinking that Lars had terrible brain damage. Nursing and medical staff reassured Hanna and informed her of the strategies they were putting in place to support him during this period of delirium. Hanna 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 Isa was, which surprised Hanna.
 
On day eight, Lars was no longer reliant on inotropes and was mentally alert and orientated. Lars’s CVC line and IDC were removed, and he transferred to the medical ward to continue IV antibiotics and follow up with the psychiatric team. At 0230 on day nine a loud crash was heard in Lars’s room. Nursing staff found Lars sitting on the floor beside his bed having knocked over his bedside table with a pool of blood from his L elbow down. After initial assessment it was found that Lars had not suffered a head strike or neck injury, so Lars was assisted back to bed. On examining his L elbow a large 6cm x 10cm skin tear was found. The after-hours Medical Register was contacted to review Lars and no other injuries were found. When asked how he fell Lars reported that he was trying to go to the toilet and slipped on the floor.
 
 
 
Seven days later, Hanna met with the Psychiatrist and Lars’s physician who informed her that Lars was ready for discharge.  Lars was keen to be discharged from hospital however he refused to participate in any discussions around residential care for either Isa or himself. Hanna wanted her father to return home but acknowledged that additional services were required, and Lars agreed to this request.
 

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