Botulism in the ICU: Nursing care plan

Enferm

Intensiva.

2018;29(2):86---93

www.elsevier.es/ei

CASE

REPORT

Botulism

in

the

ICU:

Nursing

care

plan

夽

G.

Zariquiey-Esteva

(RN)

a,∗

,

D.

Galeote-Cózar

(RN)

a

,

P.

Santa-Candela

(RN)

b

,

A.

Castanera-Duro

(MSN)

c,d

a

UCI,

Hospital

Universitari

Dr.

Josep

Trueta

de

Girona,

Spain

b

Servei

de

Cirurgia

i

Traumatologia,

Hospital

de

Figueres,

Girona,

Spain

c

Unitat

de

Reanimació,

Hospital

Universitari

Dr.

Josep

Trueta

de

Girona,

Spain

d

Departament

d’Infermeria,

Universitat

de

Girona,

Spain

KEYWORDS

Botulism;

Nerve

block;

Critical

care;

Nursing

care

Abstract

Introduction

and

case

evaluation:

Botulism

is

a

rare

disease

in

Europe,

caused

by

the

bacterium

Clostridium

botulinum,

notiﬁable,

non-transmissible

person-to-person

and

potentially

fatal

(between

5%

and

10%)

if

not

treated

quickly.

The

favorable

opinion

of

the

Clinical

Research

Ethics

Committee

was

obtained.

We

present

the

nursing

care

plan

of

a

49-year-old

man

with

a

diagnosis

of

bacterial

intoxication

caused

by

Clostridium

botulinum,

secondary

to

ingestion

of

beans

in

poor

condition,

who

was

admitted

to

the

ICU

for

a

total

of

35

days.

Diagnosis

and

planning: Holistic

nursing

evaluation

during

the

ﬁrst

24

h,

with

prioritisation

of

the

systems

that

were

deteriorating

fastest:

neurological

and

respiratory.

Nine

diagnoses

were

prioritised

according

to

the

NANDA

taxonomy:

risk

for

allergy

response,

ineffective

breathing

pattern,

impaired

oral

mucous

membrane,

impaired

physical

mobility,

risk

for

disuse

syndrome,

risk

for

dysfunctional

gastrointestinal

motility,

impaired

urinary

elimination,

risk

for

acute

confusion

and

risk

for

caregiver

role

strain.

Discussion:

The

nursing

care

plan,

standardised

and

organised

with

the

NANDA

taxonomy

and

prioritised

with

the

outcome-present

state-test

(OPT)

model,

guaranteed

the

best

care

based

on

evidence,

as

the

NOC

scores

improvement

demonstrated.

It

was

impossible

to

compare

the

nursing

intervention

with

other

case

reports.

©

2017

Sociedad

Espa

˜

nola

de

Enfermer

´

ıa

Intensiva

y

Unidades

Coronarias

(SEEIUC).

Published

by

Elsevier

Espa

˜

na,

S.L.U.

All

rights

reserved.

DOI

of

original

article:

https://doi.org/10.1016/j.enﬁ.2017.07.003

夽

Please

cite

this

article

as:

Zariquiey-Esteva

G,

Galeote-Cózar

D,

Santa-Candela

P,

Castanera-Duro

A.

Botulismo

en

la

UCI:

proceso

de

cuidados.

Enferm

Intensiva.

2018;29:86---93.

∗

Corresponding

author.

E-mail

address:

gzariquiey[email protected]

(G.

Zariquiey-Esteva).

2529-9840/©

2017

Sociedad

Espa

˜

nola

de

Enfermer

´

ıa

Intensiva

y

Unidades

Coronarias

(SEEIUC).

Published

by

Elsevier

Espa

˜

na,

S.L.U.

All

rights

reserved.

Botulism

in

the

ICU:

Nursing

care

plan

87

PALABRAS

CLAVE

Botulismo;

Bloqueo

nervioso;

Cuidados

críticos;

Atención

de

Enfermería

Botulismo

en

la

UCI:

proceso

de

cuidados

Resumen

Introducción

y

valoración

del

caso:

El

botulismo

es

una

enfermedad

poco

frecuente

en

Europa,

causada

por

la

bacteria

Clostridium

botulinum,

de

declaración

obligatoria,

no

transmisible

de

persona

a

persona

y

potencialmente

mortal

(entre

un

5

y

10%)

si

no

se

trata

rápidamente.

Se

obtuvo

el

dictamen

favorable

del

Comité

de

Ética

de

Investigación

Clínica.

Se

presenta

el

proceso

de

cuidados

enfermero

de

un

varón

de

49

a

˜

nos

con

diagnóstico

de

intoxicación

bacteriana

por

Clostridium

botulinum,

secundario

a

la

ingesta

de

alubias

en

mal

estado,

que

estuvo

ingresado

en

la

UCI

un

total

de

35

días.

Diagnósticos

y

planiﬁcación: Valoración

enfermera

de

forma

holística

durante

las

primeras

24

h,

con

priorización

de

los

sistemas

que

presentaron

un

deterioro

más

rápido:

el

neurológico

y

el

respiratorio.

Se

priorizaron

9

diagnósticos

según

la

taxonomía

NANDA:

riesgo

de

respuesta

alérgica,

patrón

respiratorio

ineﬁcaz,

deterioro

de

la

mucosa

oral,

deterioro

de

la

movilidad

física,

riesgo

de

síndrome

de

desuso,

riesgo

de

motilidad

gastrointestinal

disfuncional,

deterioro

de

la

eliminación

urinaria,

riesgo

de

confusión

aguda

y

riesgo

de

cansancio

del

rol

del

cuidador.

Discusión:

El

proceso

de

cuidados

enfermero,

estandarizado

y

organizado

con

la

taxonomía

NANDA

y

priorizado

con

el

método

sistemático

AREA,

garantizó

los

mejores

cuidados

basados

en

la

evidencia

y

prueba

de

ello

fue

la

mejoría

de

las

puntuaciones

de

los

indicadores

de

resultado

NOC.

Resultó

imposible

comparar

la

actuación

enfermera

con

la

de

otros

casos

documentados.

©

2017

Sociedad

Espa

˜

nola

de

Enfermer

´

ıa

Intensiva

y

Unidades

Coronarias

(SEEIUC).

Publicado

por

Elsevier

Espa

˜

na,

S.L.U.

Todos

los

derechos

reservados.

Introduction

Botulism

is

a

disease

caused

by

Clostridium

botulinum,

an

anaerobic

gram-positive

bacillus

formed

by

spores

that

produce

a

powerful

neurotoxin.

1

It

is

notiﬁable,

not

trans-

missible

person-to-person

and

potentially

fatal

(between

5%

and

10%)

if

it

is

not

treated

promptly.

2

The

spores

produced

by

the

C.

botulinum

bacteria,

which

have

been

found

in

green

beans,

spinach,

mush-

rooms,

ham,

sausages,

tinned

tuna

and

ﬁsh

(fermented,

salted

and

smoked

2

),

germinate

in

anaerobic

environments,

and

when

they

grow

in

certain

environmental

conditions

create

neurotoxins.

1,2

They

are

heat

resistant

(they

can

survive

at

more

than

100

◦

C

for

5

h

or

more,

but

if

they

are

exposed

to

120

◦

C

for

5

min

they

are

destroyed

1

).

They

do

not

develop

in

acid

media

(although

a

pH

<

4.6

will

not

degrade

an

already

existing

neurotoxin

1

)

and

a

low

temperature

and

salt

content

can

prevent

their

growth.

2

C.

botulinum

is

found

all

over

the

world

and

its

growth

depends

on

environmental

factors.

3

Van

Ermengem

isolated

the

bacteria

in

1897

from

a

badly-cured

ham.

Leuchs,

in

1910,

demonstrated

that

2

strains

of

C.

botulinum

would

produce

toxins

with

different

antigenicities

and

in

1919

Burke

named

them

as

type

A

and

B,

thus

establishing

their

current

alphabetical

designations.

Subsequently,

5

further

types

of

toxins

were

discovered

(C,

D,

E,

F

and

G),

some

with

dual

toxicities.

4

Types

A,

B,

E

and

occasionally

F

can

cause

human

botulism;

A

is

used

cosmetically.

1 --- 3

There

are

6

types

of

human

botulism

1,2

:

food-borne

(through

ingestion

of

foods

contaminated

during

their

prepa-

ration,

processing

or

packaging

1 --- 3

),

infant

(through

ingestion

of

the

spores

that

colonise

the

intestinal

tract

and

release

the

toxin

1 --- 3

),

wound

(generally

due

to

injection

of

black

tar

heroin

1 --- 3

),

adult

intestinal

colonisation

(the

toxin

is

produced

in

vivo

in

the

infected

intestinal

tract

1

),

inhala-

tion

(very

rare,

as

an

act

of

bioterrorism

1,2

)

and

iatrogenic

(through

incorrect

treatment

1

).

Between

2007

and

2015,

cases

of

food

botulism

were

notiﬁed

in

some

countries

in

Europe

and

North

America.

According

to

the

World

Health

Organisation,

approximately

35%

were

serious,

with

a

mortality

rate

of

15%,

and

the

disease

lasted

from

5

to

180

days.

The

age

mode

was

50

(min-

imum

age

of

4

and

maximum

of

88)

and

48%

were

males.

5

In

Spain,

according

to

the

Carlos

III

Health

Institute,

the

autonomous

communities

with

the

highest

incidence

of

food

botulism

were

Castile

and

Leon,

Andalusia

and

Madrid,

with

20,

15

and

10

cases,

respectively,

although

they

do

not

spec-

ify

the

severity.

6

In

food

botulism

the

neurotoxins,

created

by

the

diges-

tive

enzymes

after

C.

botulinum

has

been

ingested,

pass

into

the

blood

stream

and

interrupt

the

release

of

acetylcholine,

causing

a

nerve

block

1,2

and

descending

ﬂaccid

paralysis

develops

in

the

motor

and

autonomic

nerves.

2

Symptoms

appear

between

12

and

36

h

after

ingestion

and

are

prin-

cipally

neurological

2

and

gastrointestinal

1,2

:

fatigue,

2

neck

muscle,

2

respiratory

muscle

1,2

and

lower

limb

weakness,

2

vertigo,

2

blurred

vision,

1,2

diplopia,

1

drooping

eyelids,

1

photophobia,

3

symmetric

cranial

neuropathy

2

(speech

and

swallowing

difﬁculty

and

dry

mouth),

vomiting,

diarrhoea,

constipation

and

abdominal

inﬂammation.

2

Diagnosis

is

based

on

clinical

history,

physical

examination

1

and

conﬁrmed

by

samples

(faeces

or

wound,

blood

or

food

2,3

).

There

will

be

no

alterations

in

consciousness

1

or

haemodynamic

alterations,

fever

or

sensory

deﬁcit.

2

Differential

diagnosis

will

consider

88

G.

Zariquiey-Esteva

et

al.

Figure

1

Time

frame

of

progress

from

ingestion

until

discharge

home.

Guillain-Barré

syndrome,

1,2

myasthenia

gravis

1,2

and

cerebral

vascular

accident.

2

Treatment

consists

of

administering

the

botulin

antitoxin

as

promptly

as

possible,

1 --- 3

monitoring

for

signs

of

hypersen-

sitivity

because

it

is

equine-derived,

1

and

overcoming

the

neuromuscular

complications

caused

by

the

poisoning

(respi-

ratory

failure

is

the

primary

cause

of

death

1

).

Antibiotherapy

is

only

indicated

for

wound

botulism.

1 --- 3

Description

of

the

case

A

49-year-old

male,

1.72

m

tall,

weighing

75.9

kg

(body

mass

index

25.66

kg/m

2

).

Allergic

to

pyrazolones,

active

smoker

(1

pack/day).

No

medical

history.

Self-employed

(Barthel

Index

100).

The

patient

attended

his

regional

hospital

with

dizziness,

blurred

vision,

unstable

gait

and

frontal

headache,

of

4-h

onset.

He

mentioned

having

eaten

an

uncertain

amount

of

beans

in

poor

condition

14

h

previously.

On

examination

his

blood

pressure

(BP)

was

160/100

mmHg.

After

3

h

he

was

discharged

diagnosed

with

bacterial

food

poisoning

(Interna-

tional

Classiﬁcation

of

Disease

[ICD]

005.9).

Fig.

1

shows

the

time

frame

of

the

progression

of

the

disease

from

ingestion

to

discharge.

He

attended

the

emergency

apartment

again

with

droop-

ing

eyelids

in

addition

to

the

abovementioned

symptoms.

The

patient

had

a

dry

mouth,

mydriatic

pupils

with

slow

photomotor

reﬂex,

bilateral

drooping

eyelids,

and

full

loss

of

eye

motion.

BP

156/99

mmHg.

Arterial

blood

gases

(ABG):

SaO

2

96.6%,

pO

2

78.7

mmHg.

There

were

no

alterations

in

consciousness,

cutaneo-plantar

and

osteotendinous

reﬂexes

or

on

the

electrocardiogram.

The

patient

was

transferred

to

the

emergency

depart-

ment

of

the

provincial

hospital

with

suspected

C.

botulinum

food

poisoning

(ICD

005.1).

The

patient

now

had

mild

dysarthria

in

addition

to

his

BP

139/98

mmHg.

ABG:

SaO

2

96.4%,

pCO

2

34

mmHg,

pO

2

82

mmHg.

Peak

expiratory

ﬂow

(PEF,

indicator

of

lung

func-

tion,

measured

by

spirometer)

450

l/min

(expected

value

for

his

height,

age

and

sex:

601

±

48

l/min

7

).

Oxygen

ther-

apy

was

started

through

nasal

cannula

and

3

h

later

he

was

admitted

to

the

intensive

care

unit

(ICU).

He

was

given

a

ﬁrst

dose

of

the

trivalent

botulin

antitoxin

(A,

B,

E)

by

continuous

infusion

through

a

single

line,

and

for

4

h.

Nursing

assessment

During

the

ﬁrst

24

h

in

ICU

a

holistic

assessment

was

made

of

the

patient

that

highlighted

the

neurological

and

respiratory

system

alterations.

Bilateral

facial

paralysis

was

identiﬁed,

neck

muscle

alteration,

proximal

upper

limb

weakness

and

increased

dysarthria.

The

impact

of

the

neuromuscular

block

on

the

respiratory

system

required

orotracheal

intubation

and

mechanical

ventilation,

due

to

dyspnoea

and

increased

respiratory

effort.

The

PaO

2

/FiO

2

ratio,

indicator

of

pul-

monary

oxygen

diffusion

calculated

by

ABG,

considers

there

to

be

acute

lung

injury

below

300

mmHg

8

:

in

only

5

h

it

had

dropped

from

300

mmHg

to

220

mmHg

and

the

PEF

fell

from

220

l/min

to

130

l/min.

In

addition

to

the

neurological

and

respiratory

alter-

ations,

and

after

having

administered

a

total

of

2

doses

of

the

antidote,

the

patient

was

distressed

and

nauseous

(with

preserved

peristalsis).

A

nasogastric

tube

was

passed,

and

a

urinary

catheter

inserted

which

revealed

oliguria

(<400

ml/24

h)

and

a

central

jugular

venous

catheter

to

administer

vasoactive

drugs,

analgesia,

sedation

and

saline.

Over

the

subsequent

34

days,

the

patient

presented

complications

associated

with

intoxication

and

his

stay

in

ICU.

He

was

diagnosed

with

unspeciﬁed

hypotension

(ICD

458.9),

pneumonia

caused

by

other

gram-negative

bacte-

ria

(ICD

482.83),

urinary

tract

infection,

site

not

speciﬁed

(CIE

599.0)

and

paralytic

ileus

(ICD

560.1).

An

early

tra-

cheostomy

was

performed

after

7

days

to

enable

weaning

and

start

rehabilitation.

The

patient

was

in

ICU

for

a

total

of

35

days,

7

in

a

semi-

critical

unit

and

3

on

the

hospital

ward.

Diagnoses

and

care

planning

(NANDA-NOC-NIC)

The

main

problem

was

approached

by

employing

the

OPT

model

of

clinical

reasoning,

9

focussing

intervention

on

out-

comes

and

not

on

the

health

problems

identiﬁed.

The

nursing

objective

was

to

anticipate

the

problems

of

progres-

sion

of

the

patient’s

neuromuscular

paralysis

that

was

found

on

assessment.

Fig.

2

shows

the

nursing

clinical

reasoning

Botulism

in

the

ICU:

Nursing

care

plan

89

Figure

2

Nursing

clinical

reasoning

net,

according

to

the

OPT

model.

net,

as

created

by

Pesut

and

Herman

in

1999.

9

It

shows

the

main

problem,

the

nursing

diagnoses

(ND)

initially

identiﬁed

and

their

interrelations.

Note

that

9

of

them

are

those

that

eventually

formed

the

care

process

(Table

1):

these

are

the

most

important

because

if

not

resolved,

the

other

14

would

persist

(except

for

the

risk

of

allergy,

which

derived

directly

from

administration

of

the

antidote).

Table

1

combines

the

ND

(NANDA

10

),

outcomes

(NOC

10

)

and

nursing

interventions

(NIC

10

),

with

their

respective

out-

come

and

activity

indicators.

Table

2

shows

the

assessment

scales

of

the

different

outcome

indicators.

10

Assessment

of

outcomes

Bearing

in

mind

the

natural

course

of

the

disease,

out-

come

indicators

(NOC)

with

deﬁcient

scores

were

inevitable.

The

thorough

neurological

monitoring,

the

deterioration

in

breathing

over

the

ﬁrst

24

h,

the

early

tracheostomy

and

the

persistent

nursing

action

on

rehabilitation

were

noteworthy.

Discussion

The

case

we

present

conﬁrms

the

need

for

good

coordination

between

practitioners,

in

terms

of

communication,

inter-

vention

and

recording,

since

the

patient

made

good

progress

thanks

to

the

rapid

action

of

the

multidisciplinary

team.

The

nursing

care

process

comprised

a

holistic

assessment

that

ﬂagged

up

the

involvement

of

the

neurological

and

res-

piratory

systems,

and

action

based

on

strict

monitoring

of

the

course

of

the

disease

and

the

constant

moral

and

phys-

ical

support

of

the

patient.

The

use

of

standardised

language

(NANDA-NOC-NIC)

and

systematic

use

of

the

OPT

model

of

clinical

reasoning

enabled

the

nursing

intervention

to

be

organised

and

pri-

oritised,

ensuring

the

best

care

based

on

current

scientiﬁc

evidence.

We

found

no

literature

relating

to

the

nursing

care

of

patients

with

botulism

in

ICU;

therefore

it

is

impossible

to

compare

our

action

with

that

of

other

authors.

Ethical

responsibilities

Protection

of

people

and

animals.

The

authors

declare

that

the

research

was

carried

out

according

to

the

ethi-

cal

standards

set

by

the

responsible

human

experimentation

committee,

the

World

Medical

Association

and

the

Helsinki

Declaration.

Data

conﬁdentiality.

The

authors

declare

that

they

have

followed

the

protocols

of

their

centre

of

work

regarding

the

publication

of

patient

data.

Right

to

privacy

and

informed

consent.

The

authors

have

obtained

the

informed

consent

of

the

patients

and/or

sub-

90

G.

Zariquiey-Esteva

et

al.

Table

1

Diagnosis,

outcome

objectives,

interventions

and

nursing

activities

according

to

NANDA-NOC-NIC.

Diagnosis

(NANDA)

Outcome

objectives

(NOC)

Nursing

interventions

(NIC)

00217

Risk

for

allergy

response,

associated

with

exposure

to

allergens

(equine-derived

botulism

antitoxin)

0707

Immune

hypersensitivity

response

6680

Vital

signs

monitoring

070703

allergic

reactions

(5,

scale

n)

Monitor

blood

pressure,

pulse,

temperature

and

respiratory

status,

as

appropriate

6410

allergy

management

Identify

known

allergies

(medication,

food,

insect,

environmental)

and

usual

reaction

Monitor

patient

for

reactions

to

new

medications,

formulas,

foods,

latex

and/or

test

dyes

Monitor

the

patient

after

exposure

to

agents

known

to

cause

allergic

responses

for

signs

of

generalised

ﬂush,

angioedema,

urticaria,

paroxysmal

coughing,

severe

anxiety,

dyspnoea,

wheezing,

orthopnoea,

vomiting,

cyanosis

or

shock

3350

Respiratory

monitoring

Monitor

for

noisy

respirations

such

as

crowing

or

snoring

Monitor

rate,

rhythm,

depth

and

effort

of

respirations

00032

ineffective

breathing

pattern,

neuromuscular

impairment

and

respiratory

muscle

fatigue,

manifested

by

reduced

vital

capacity

0415

Respiratory

status

3350

Respiratory

monitoring

041503

Depth

of

inspiration

(2,

scale

b)

Monitor

oxygen

saturation

levels

continuously

in

sedated

patients

(SaO2)

per

agency

policy

and

as

indicated

041509

Pulmonary

function

tests

(1,

scale

b)

Monitor

results

of

pulmonary

function

tests,

particularly

vital

capacity,

maximal

inspiratory

force,

forced

expiratory

volume

in

1

s

(FEV1),

and

FEV

monitor

1/FVC,

as

available

Monitor

for

dyspnoea

and

events

that

improve

and

worsen

it

3320

Oxygen

therapy

Administer

supplemental

oxygen

as

ordered

Monitor

the

effectiveness

of

oxygen

therapy

(pulse

oximetry,

ABGs),

as

appropriate

0402

Respiratory

status:

gas

exchange

5820

Anxiety

reduction

040203

Dyspnoea

at

rest

(3,

scale

n)

Monitor

the

patient’s

anxiety

in

relation

for

the

need

for

oxygen

therapy

040205

Restlessness

(3,

scale

n)

040208

Partial

pressure

of

oxygen

in

arterial

blood

(PaO2)

(4,

scale

b)

0008

Fatigue:

Disruptive

Effects

3120

Airway

Insertion

and

Stabilisation

0803

Reduced

Energy

(2,

scale

n)

Assist

with

insertion

of

an

endotracheal

tube

by

gathering

necessary

intubation

and

emergency

equipment,

positioning

patient,

administering

medications

as

ordered,

and

monitoring

the

patient

for

complications

during

insertion

Instruct

patient

and

family

about

the

intubation

procedure

Monitor

mechanical

ventilator

readings,

noting

increases

in

inspiratory

pressures

and

decreases

in

tidal

volume,

as

appropriate

3180

Artiﬁcial

Airway

Management

Maintain

inﬂation

of

the

endotracheal/tracheostomy

cuff

at

15---25

mmHg

during

mechanical

ventilation

and

during

and

after

feeding

Institute

endotracheal

suctioning,

as

appropriate

Monitor

secretions

colour,

amount,

and

consistency

Institute

measures

to

prevent

spontaneous

decannulation:

secure

artiﬁcial

airway

with

tape

or

ties,

administer

sedation

and

muscle

paralysing

agent,

use

arm

restraints,

as

appropriate

00045

Impaired

oral

mucous

membrane,

reduced

salivation

and

manifested

by

dry

mouth

1100

Oral

hygiene

1730

Oral

Health

Restoration

110010

Moisture

of

oral

mucosa

and

tongue

(2,

scale

a)

Monitor

condition

of

the

patient’s

mouth

(tongue,

mucous

membranes),

including

character

of

abnormalities

Administer

mouthwash

(antibacterial

solution)

Apply

lubricant

to

moisten

lips

and

oral

mucosa,

as

needed

1720

Provide

oral

care

for

unconscious

patient

using

appropriate

precautions

Encourage

and

assist

patient

to

rinse

mouth

00085

Impaired

physical

mobility

neuromuscular

involvement,

as

manifested

by

limited

ability

to

perform

gross

and

ﬁne

motor

skills

0208

Mobility

0226

Exercise

therapy:

muscle

control

020802

body

positioning

performance

(4,

scale

a)

Assist

patient

to

sitting/standing

position

for

exercise

protocol,

as

appropriate

020803

Muscle

movement

(4,

scale

a)

Encourage

the

patient

to

self-exercise

020809

Coordination

(4,

scale

a)

Monitor

the

emotional,

cardiovascular

and

functional

response

of

the

patient

to

the

exercise

protocol

Provide

positive

reinforcement

for

patient’s

efforts

in

exercise

and

physical

activity

Assist

patient

to

participate

in

stretching

exercises

when

lying,

sitting,

or

standing

Assist

patient

to

move

to

sitting

position,

stabilise

trunk

with

arms

placed

at

the

side

on

bed/chair,

and

rock

trunk

over

supporting

arm

0212

Coordinated

movement

0224

Exercise

therapy:

joint

mobility

021203

Speed

of

movement

(2,

scale

a)

Assist

patient

to

optimal

body

position

for

passive/active

joint

movement

021204

Smooth

movement

(2,

scale

a)

Perform

passive

or

assisted

range

of

movement

exercises

021205

Control

of

movement

(2,

scale

a)

Encourage

to

sit

in

bed,

on

side

of

bed,

or

in

chair

021207

Balanced

movement

(4,

scale

a)

Provide

positive

reinforcement

for

performing

joint

exercises

0210

Transfer

performance

1806

Self-care

assistance:

transfer

021001

Transfer

from

bed

to

chair

(1,

scale

a)

Determine

current

ability

of

patient

to

transfer

self

(e.g.,

mobility

level,

limitations

of

movement,

endurance,

ability

to

stand

and

bear

weight,

medical

or

orthopaedic

instability)

Botulism

in

the

ICU:

Nursing

care

plan

91

Table

1

(Continued)

Diagnosis

(NANDA) Outcome

objectives

(NOC) Nursing

interventions

(NIC)

Provide

encouragement

to

patient

as

he/she

learns

to

transfer

independently

Determine

amount

and

type

of

assistance

needed

Lift

and

move

patient

with

hoist

Evaluate

patient

at

end

of

transfer

for

proper

body

alignment,

nonocclusion

of

tubes,

wrinkled

linens,

unnecessarily

exposed

skin,

adequate

patient

level

of

comfort,

raised

side

rails,

and

call

bell

within

reach

0005

Activity

tolerance 0180

Energy

management

000502

Pulse

rate

with

activity

(5,

scale

a) Monitor

cardiorespiratory

response

to

activity

(e.g.,

tachycardia,

other

dysrhythmias,

dyspnoea,

diaphoresis,

pallor,

haemodynamic

pressures,

respiratory

rate)

000508

Respiratory

rate

with

activity

(4,

scale

a)

00040

Risk

for

disuse

syndrome,

paralysis

0204

Immobility

consequences:

physiological 5612

Teaching:

prescribe

exercise

020412

Muscle

tone

(1,

scale

a)

Inform

the

patient

of

the

purpose

for,

and

the

beneﬁts

of,

the

prescribed

exercise

Teach

the

patient

how

to

do

the

prescribed

exercise

Reinforce

information

provided

by

other

health

care

team

members,

as

appropriate

0201

Exercise

promotion:

strength

training

Collaborate

with

family

and

other

health

professionals

(e.g.,

activity

therapist,

exercise

physiologist,

occupational

therapist,

recreational

therapist,

physiotherapist)

planning,

teaching,

and

monitoring

a

muscle

training

programme

0914

Neurological

status:

Spinal

Sensory/Motor

Function

2620

Neurological

monitoring

091401

Head

and

shoulder

movement

(2,

scale

a)

Monitor

pupillary

size,

shape,

symmetry,

and

reactivity

091405

Upper

body

strength

(2,

scale

a) Monitor

level

of

consciousness

091406

Flaccidity

(3,

scale

n) Monitor

level

of

orientation

0912

Neurological

status:

consciousness Monitor

trend

of

Glasgow

coma

scale

091201

Opens

eyes

to

external

stimuli

(1,

scale

a)

Monitor

cough

and

gag

reﬂex

91213

Delirium

(2,

scale

n)

Monitor

facial

symmetry

Monitor

EOMs

and

gaze

characteristics

Monitor

for

visual

disturbance:

diplopia,

nystagmus,

visual-ﬁeld

cuts,

blurred

vision,

visual

acuity

00197

Risk

for

dysfunctional

gastrointestinal

motility,

ingestion

of

contaminated

foods

0501

Bowel

elimination 2300

Medication

administration

050101

Elimination

pattern

(1,

scale

a) Monitor

patient

for

the

therapeutic

effect

of

the

medication

050129

Bowel

sounds

(2,

scale

a)

Document

the

administration

of

medication

and

the

patient’s

response

capacity,

per

agency

protocol

2380

Medication

management

Monitor

patient

for

the

therapeutic

effect

of

the

medication

1015

Gastrointestinal

function

1570

Vomiting

management

101501

Food

tolerance

(1,

scale

a) Measure

or

estimate

emesis

volume

101510

Amount

of

residual

gastric

aspirates

(1,

scale

a)

Ensure

effective

antiemetic

drugs

are

given

to

prevent

vomiting,

when

possible

101530

Gastric

reﬂux

(1,

scale

n)

Monitor

ﬂuid

and

electrolyte

balance

1874

Tube

care:

gastrointestinal

Check

that

the

tube

is

correctly

in

place

monitoring

for

signs

and

symptoms

of

tracheal

positioning,

checking

the

colour

and

and/or

pH

of

aspirate,

inspecting

the

oral

cavity

and/or

verify

placement

by

X-ray,

if

appropriate

Initiate

and

monitor

delivery

of

enteral

tube

feedings,

as

appropriate

per

agency

protocol

Monitor

amount,

colour,

and

consistency

of

nasogastric

output

Monitor

for

sensations

of

fullness,

nausea,

and

vomiting

Connect

tube

to

suction,

as

appropriate

1056

Enteral

tube

feeding

Check

residual

every

4 --- 6

h

for

the

ﬁrst

24

h,

then

every

8

h

during

continuous

feedings

Check

residual

before

each

intermittent

feeding

Hold

tube

feedings

if

residual

is

greater

than

150

cc

or

more

than

110---120%

of

the

of

the

hourly

rate

in

adults

1200

Total

parenteral

nutrition

administration

Encourage

a

gradual

transition

from

parenteral

to

enteral

feeding,

if

indicated

2301

Medication

response 1080

Gastrointestinal

intubation

230101

Expected

therapeutic

effects

(3,

scale

a)

Administer

medication

to

increase

peristalsis,

if

indicated

00016

Impaired

urinary

elimination,

sensory-motor

impairment,

as

manifested

by

oliguria

0503

Urinary

elimination 4120

Fluid

management

050303

Urine

amount

(2,

scale

a)

Maintain

accurate

intake

and

output

record

0601

Fluid

balance Insert

urinary

catheter,

if

appropriate

060107

24-hour

intake

and

output

balance

(3,

scale

a)

Administer

prescribed

diuretic

drugs,

if

appropriate

Administer

prescribed

I.V.

therapy

92

G.

Zariquiey-Esteva

et

al.

Table

1

(Continued)

Diagnosis

(NANDA)

Outcome

objectives

(NOC)

Nursing

interventions

(NIC)

4130

Fluid

monitoring

Determine

possible

risk

factors

for

ﬂuid

imbalance

(diuretic

therapy,

infection)

Examine

skin

turgor

by

pinching

the

skin

gently

holding

it

for

a

second

and

releasing

(skin

will

fall

back

quickly

if

patient

is

well

hydrated)

Monitor

serum

and

urine

electrolyte

values,

as

appropriate

Monitor

BP,

heart

rate,

and

respiratory

status

Keep

an

accurate

record

of

intake

and

output

(enteral

intake,

IV

intake,

antibiotics,

ﬂuids

given

with

medications,

NG

tubes,

vomit)

Monitor

colour,

quantity,

and

speciﬁc

gravity

of

urine

00173

Risk

for

acute

confusion

aguda,

0901

Cognitive

orientation

4820

Reality

orientation

---

pharmacological

agents

90101

Identiﬁes

self

(5,

scale

a)

Address

patient

by

name

when

initiating

interaction

---

disorders

of

sleep-wake

cycle

90102

Identiﬁes

signiﬁcant

other

(5,

scale

a)

Speak

to

the

patient

in

a

distinct

manner

with

an

appropriate

pace,

volume,

and

tone

---

impaired

mobility

90103

Identiﬁes

current

space

(5,

scale

a)

90105

Identiﬁes

correct

month

(5,

scale

a)

Inform

patient

of

person,

place,

and

time,

as

needed

Engage

the

patient

in

concrete

‘‘here

and

now’’

activities

(ADL)

that

focus

on

something

outside

the

self

that

is

concrete

and

reality

oriented

5270

Emotional

support

Discuss

with

the

patient

the

emotional

experience

Make

supportive

or

empathetic

statements

6430

Chemical

restraint

Monitor

the

patient’s

response

to

the

medication

Monitor

level

of

consciousness

5820

Anxiety

reduction

Provide

factual

information

concerning

diagnosis,

treatment,

and

prognosis

Identify

when

level

of

anxiety

changes

Help

patient

identify

situations

that

precipitate

anxiety

Administer

medications

to

reduce

anxiety,

as

appropriate

7560

Visitation

facilitation

Determine

patient’s

preferences

for

visitation

and

release

of

information

Determine

the

need

to

promote

visits

by

family

and

friends

Encourage

the

family

member

to

use

touch,

as

well

as

verbal

communication,

as

appropriate

00062

Risk

for

caregiver

role

strain,

unpredictable

illness

course

(applied

to

the

family)

1803

Knowledge:

disease

process

7040

Caregiver

support

180302

Characteristics

of

speciﬁc

disease

(2,

scale

u)

Determine

caregiver’s

level

of

knowledge

180303

Cause

and

contributing

factors

(1,

scale

u)

Determine

caregiver’s

acceptance

of

role

180305

Physiological

effects

of

disease

(2,

scale

u)

Acknowledge

difﬁculties

of

caregiving

role

180307

Usual

course

of

disease

process

(2,

scale

u)

Acknowledge

dependency

of

patient

on

caregiver

(as

appropriate)

180309

Potential

complications

of

disease

(3,

scale

u)

Make

positive

statements

about

caregiver’s

effort

Provide

support

for

decisions

made

by

caregiver

Provide

information

about

patient’s

condition

in

accordance

with

patient

preferences

Identify

sources

of

respite

care

Support

caregiver

in

setting

limits

and

taking

care

of

self

Taken

from

NNNConsult.

10

Botulism

in

the

ICU:

Nursing

care

plan

93

Table

2

Likert

scales

to

assess

outcome

indicators.

Scale

a

Severely

compromised

Substantially

compromised

Moderately

compromised

Mildly

compromised

Not

compromised

Scale

b:

Severe

deviation

from

normal

range

Substantial

deviation

from

normal

range

Moderate

deviation

from

normal

range

Mild

deviation

from

normal

range

No

deviation

from

normal

range

Scale

n:

Severe

Substantial

Moderate

Mild

None

Scale

u

No

knowledge

Limited

knowledge

Moderate

knowledge

Substantial

knowledge

Extensive

knowledge

Taken

from

NNNConsult.

10

jects

referred

to

in

the

article.

This

document

is

held

by

the

corresponding

author.

Conﬂict

of

interest

The

authors

have

no

conﬂict

of

interest

to

declare.

Acknowledgements

We

would

like

to

thank

all

the

professionals

who

docu-

mented,

provided

and

contributed

towards

the

compilation

of

information.

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1.

Pegram

PS,

Stone

SM.

Botulism;

2017.

Available

at:

http://www.

uptodate.com/contents/botulism

[updated

07.03.16;

accessed

10.11.16].

2.

OMS.

Botulismo.

OMS;

2014.

Available

at:

http://www.

who.int/mediacentre/factsheets/fs270/es/

[accessed

03.11.16].

3.

Botulism.

Ames,

Iowa:

The

Center

for

Food

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&

Public

Health;

2010.

Available

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http://www.cfsph.

iastate.edu/Factsheets/pdfs/botulism.pdf

[accessed

04.11.16].

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Barash

JR,

Arnon

SS.

A

novel

strain

of

Clostridium

botulinum

that

produces

type

B

and

type

H

botulinum

toxins.

J

Infect

Dis.

2014;209:183---91.

Available

at:

https://academic.

oup.com/jid/article/209/2/183/828053/A-Novel-Strain-of-

Clostridium-botulinum-That

[accessed

03.11.16].

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WHO.

WHO

estimates

of

the

global

burden

of

foodborne

diseases.

Foodborne

disease

burden

epidemiology

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WHO;

2015.

Available

at:

http://apps.who.

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