The purpose of this essay is to assess and analyze two main nursing priorities in relation to a selected case study (Appendix 1) of Mr. Kumar. A 65-year-old male exhibiting signs of acute Chronic Obstructive Pulmonary Disease (COPD). He also has a history of Myocardial Infarction (MI). Based on the scenario, the two chosen nursing priorities are ineffective gas exchange and reduced cardiac output. A care plan (Appendix 2) has been formulated characterizing the problems by etiology and symptoms (PES). It will also assess the care needed, plan and set specific, measurable, achievable, relevant, timely (SMART) goals to facilitate interventions. Interventions will be associated with rationales to best understand the effects of the steps implemented in the patient’s recovery process.
Due to the acuteness of Mr. Kumar’s condition, the most appropriate framework to use is the ABCDE approach as suggested by Dougherty and Lister (Royal Marsden Handbook, 2015). This process assesses the airways, breathing, circulation, disabilities and everything else. This also adopts the Look, listen, feel approach to providing both objective and subjective data which is acquired quickly and yet comprehensive enough to form a foundation for care to be initiated. It also serves as a guide to analyzing and evaluating care in order to monitor its effectiveness for the patient (Higginson et al, 2011). It will consider the collation of data to provide a recognition pathway and therefore will be adopting and exploring the implementation of the national early warning score to ascertain the right interventions for Mr. Kumar.
The ABCDE tool is designed to aid in the detection of deterioration in its early stages and to manage any possible complications. Nevertheless, a holistic approach needs to be applied and should be based on priority. Therefore, other frameworks such as that of Roper, Logan and Tierney (1998) which explores the activities of living such as eating, drinking, mobility and more may be appropriate after the acute onset is managed effectively and can aid in supporting recovery.
The essay will also explore the pathophysiology of both COPD and AF to understand how it presents clinically. Also to facilitate understanding the rationale behind both medical and nursing interventions implemented.
There will be a discussion on the various management options for both conditions. These include medication, nutrition and lifestyle choices. The essay will take into consideration all healthcare professionals who will be involved in implementing the various levels of care and the roles in doing so. These include nurses, consultants, physiotherapist, dietitian, clinical psychologists and specialist healthcare professionals who will provide a multidisciplinary approach to the care provided (Burton et al, 2015).
COPD is an umbrella term which comprises of three main conditions. These are chronic bronchitis, chronic asthma, and emphysema (McIvor et al, 2011). The condition can be present in one or more forms in one person. The most common of which are chronic bronchitis and emphysema.
Chronic bronchitis presents as a continuous mucous cough and lasts for more than three months within a two-year period caused by irritants such as smoke, dust and environmental pollution embedding into the respiratory tract and causing inflammation (Marieb et al, 2014). Emphysema on the other hand, results from permanent damage to the air sacs (alveoli) in the lungs which cause your airways to become narrower, impairing normal breathing. There is an evident use of accessory muscles when the patient is breathing due to this, which causes exhaustion (Bostock- Cox, 2013).
Symptoms of COPD include wheezing (usually when the patient is breathing out), dyspnea (difficulty breathing)…..
Mr. Kumar has been a smoker since his teens and will have been experiencing the effects of the damage gradually until its acute onset. As a consequence, he has developed type 2 respiratory failure as his lungs air not able to facilitate effective ventilation. Damages to the alveoli walls are irreversible as it is permanent and therefore there is no cure available for COPD (Zammit et al, 2010). However, there are a variety of treatments options available to help manage the condition, improve a patient’s symptoms and quality of life (Zammit et al, 2010).
The initial nursing problem focusses on Mr. Kumar’s impaired breathing as evidenced by his low Oxygen saturation at 75% and tachypnea at 28 breaths per minute. This places him at high risk of inadequate oxygen inhalation and may result in hypoxemia or hypoxia (Zammit et al, 2010)
In order to manage the reduced oxygen intake, oxygen therapy is implemented. Increasing the amount of oxygen that Mr. Kumar is inhaling is important for his breathing. However, care should be taken when administering high-flow oxygen to patients with COPD (Dougherty et al, 2015). This is because the carbon dioxide is not able to release effectively due to lack of an appropriate exchange channel and may result in the patient retaining carbon dioxide. A term known as hypercapnia (Moore, 2013).
Communication is key in establishing a patient’s physiological status as it can be used gain data to (Carrier, 2016). Speaking to Mr. Kumar is a good way of assessing airway patency as his response or lack of response will aid in determining any possible obstruction. Keeping him engaged and conversing can help maintain a patent airway as well as aid orientation. As he may be in an unfamiliar surroundings, he may feel a bit anxious and this can be evident in his breathing pattern· Using therapeutic methods such as the tone and rate at which you speak can aid in but understanding as relaxation.
Listen to sounds of possible obstruction such as gasping and choking sounds as well chest sounds. Encourage Mr. Kumar to perform breathing exercises and to cough up mucus which may build up to prevent fluid retention in the lungs. This could cause chest infection if it is retained in the lungs for long periods of time (Tait et al, 2013). Also to aid in facilitation of oxygen intake, he should be assisted or encouraged to position himself comfortably, ideally in an upright position. This aids in preventing Mr. Kumar being in either the same position for long periods of time or restricting him to limited positions. This aids in reducing anxiety as the patient will feel valued as care is provided specific to their immediate needs.
Assess and monitor respirations and breathing sounds, noting rate, depth and sounds such as stridor, crackles, wheezing. Also note the use of accessory muscles. This needs to be assessed every 30 minutes within the first 2 hours then hourly. After which, this should be assessed every 4 hours if there is notable improvement in patient’s breathing pattern. This is required not only to establish a baseline for future compares but also to monitor the efficacy of interventions.
Arterial blood gases (ABGs) should be assessed within 1 hour after oxygen therapy to determine the effectiveness of the oxygen being administered. This should be assessed alongside respiratory rate in in order to detect early signs of respiratory failure (British Thoracic Society/ Intensive Care Society, 2016).
Administration of pulmonary toilet (turning, chest physiotherapy with the help of the physiotherapist as well as prescribed medications such as nebulisers to promote expansion of the lungs, eliminate secretions from the lungs and strengthen the respiratory muscles (Tait et al, 2013).
Upon discharge, Mr. Kumar should be referred to a dietician who can help him to eat the well in order to prevent infections and also to keep his lungs healthy. It would be difficult to be active if overweight it will take a lot of effort to do so. However, some people with COPD can lose too much weight because eating can make them feel breathless, or it becomes more difficult to shop and prepare meals (Bates and Bates, 2011). Therefore, providing resources and ways to shop healthily can not only reduce physical and financial strain but can facilitate in continuous effective recovery when he is discharged.
An assessment of the peripheral pulses and warmth and color of extremities should be done in order to detect and changes that may show signs of inadequate oxygen intake and to reverse compromised ventilation. Findings needs to be discussed with consultant in order for suggested interventions to be implemented.
Encourage slow, pursed-lip breathing. Pursed-lip breathing decreases the respiratory rate, increases tidal volume, decreases PaCO2, and increases PaO2, all of which help reduce dyspnea (Higgins et al, 2011). This enables not only the required amount of oxygen at the time to be inhaled but for the patient to be relaxed and inhale at a pace that suits him. This combined with abdominal breathing and abdominal muscle exercises can reduce the pressure on the diaphragm and facilitate the movement of respiratory fluids.
Administer humidified oxygen therapy as prescribed. Long periods of oxygen administration can be very drying and may cause discomfort to the patient. Therefore, to prevent this occurring water for humidification is used and pass through to form a vapor which is inhaled by patient (Tait et al, 2013).
Closely monitor response to oxygen therapy, including skin color, oxygen saturation, sputum consistency, and respiratory drive. Ask patient to provide a sputum sample which can be analyzed for infection
A Peak Flow measurement should be obtained before and after nebulizers are administer in order measure the effects on the expansion of the lungs. Where it proves ineffective, this may need to be titrated to facilitate Mr. Kumar’s care needs. Ensure mouth care is provided after use of nebulisers and oxygen therapy in order to reduce further dryness in the mouth and retention of mucus in the mouth (Tait et al, 2013).
The second nursing priority to consider is reduced cardiac output. Mr. Kumar has been diagnosed with Atrial Fibrillation (AF), which is a condition that falls under abnormal cardiac rhythms. It is characterised by rapid and irregular heartbeats and often occurs as brief moments of abnormal beating. Overtime, it prolongs and becomes consistent as it can be triggered or elevated by associated symptoms and lifestyle choices. He also has a past medical history of myocardial infarction.
Most individuals may experience symptoms of AF without it impacting on their life (Doyle, M et al, 2013). It is a type of supra ventricular tachycardia. This means that it originates at or above the atrioventricular node.
AF is associated with an increased risk of heart failure, dementia as well as stroke. Other risk factors include elevated blood pressure (hypertension), valvular heart disease, coronary artery disease, cardiomyopathy, and congenital heart disease (Doyle, M et al, 2013).
Lung-related risk factors include COPD, obesity, and sleep apnea. Lifestyle factors may impact on the risk of developing the disease. This may include excessive intake of alcohol, thyrotoxicosis (overactive thyroid gland) and diabetes mellitus. However, half of the cases are not associated with one of these risks (NICE, 2014).
Individuals may experience heart palpitations (being aware of your heartbeat), fainting or dizziness, shortness of breath, tiredness or even chest pain occasionally.
The primary nursing assessment is always ‘Look, Listen, Feel, Measure. This combined with the ABCDE approach, which is systematic and priority-driven approach in acute situations. It provides a quick, yet detailed method for providing preliminary results for timely and appropriate interventions to be implemented (Tait et al, 2013).
Monitor blood pressure, apical pulse, and peripheral pulses. These are clinical indicators of the adequacy of cardiac output. Monitoring enables early detection/treatment of decompensation (Jarman, 2007 ). Connecting the patient to cardiac monitor can help detect cardiac patterns. Dysrhythmias are common in patient with rheumatic heart disease (NICE, 2014). Atrial dysrhythmia is most common, due to increased atrial pressures and volumes. Conduction abnormalities also occur with aortic valve disease because of decreased coronary artery perfusion.
Encourage Mr. Kumar to rest with his head elevated to 45 degrees in order to reduce blood volume returning to the heart and therefore increasing oxygenation as well as decreasing dyspnoea, and may reduce cardiac strain.
Restrict fluid intake to prevent fluid overload to the heart and enable effective cardiac function.
Look at your patient, taking into consideration their physical appearance. Initial observation always begins with this. Look out for signs of distress, anxiety, the way they are dressed. All this can aid in painting a picture as to what might be wrong with the patient (Adam et al, 2011). Observe the patient’s skin colour, condition and turgor.
Listen for breath sounds and any irregularities is rhythm. Listen to what the patient says in relation to how their condition makes them feel. This may have an impact on how care is delivered, by ensuring it is individualized (Adam et al, 2011).
Feel patient’s pulse to check for any irregularities with rhythm, depth and rate. This can determine foundations for the right interventions to be put in place. Feel the skin of the patient. In assessing a patient rapidly, any changes in cardiac activity can be observed on the skin and change in heart rate (Doyle et al, 2013).
Mr. Kumar’s blood pressure, apical pulse, and peripheral pulses should be monitored to as these are early clinical indicators of the adequacy of cardiac output. Connect patient to cardiac monitor. Dysrhythmias are common in patient with rheumatic heart disease. Atrial dysrhythmia is most common, due to increased atrial pressures and volumes. Conduction abnormalities also occur with aortic valve disease because of decreased coronary artery perfusion (Peate et al, 2016).
Promote bed rest with head of the bed elevated to 45 degrees. Reduces blood volume returning to the heart (preload), which increases oxygenation, decreases dyspnea, and may reduce cardiac strain (Burton, 2015).
Restrict fluid intake to prevent fluid overload to the heart and enable effective cardiac function.
Involve the patient and their family in the care process by asking their input. Assessment should be based on collective information which are both subjective and objective. It is important to gain accurate information from both patients as well as their family members to enable the appropriate care to be implemented (NICE, 2014)
Conclusion
The treatments and nursing interventions provided to Mr. Kumar are that which may facilitate effective recovery.
In order to ensure that these are effective, continuous monitoring should be maintained. And if there are any deviations, to be escalated to relevant healthcare teams.
On discharge, it may be beneficial to refer Mr. Kumar to a home health department for a nursing follow-up for the first couple of weeks to enable continuous care is being implement and to also monitor compliance of advice and medication given to him.
As Mr. Kumar lives on his own, he may require some help so referring him to social services and providing a package of care which may suite his needs such as dietary and care needs can aid in care being managed effectively and reduced risk of readmission.
Therefore, assessment should be thorough in order to determine all care needs even if it is not immediate.