Clinical Placement Case Study: Nursing Management Of Acutely Ill Patients

Assessing Pathophysiology and Identifying Nursing Problems

While on clinical placement a case study is to be conducted of an acutely ill patient whom the student is caring for at their placement venue. This patient could be in accident and emergency, intensive care, operating theatre or recovery room, or a patient on a medical or surgical ward who is post major surgery or has a complex medical condition. The condition may be a chronic illness that has caused an acute hospital admission. Note: The patient does NOT necessarily have to be critically ill or requiring a rapid response call.

1. Assessment findings and abnormalities are to be discussed in relation to the underlying pathophysiology of the causal disease process or processes

Note: Pathophysiology means changes in physiological function related to disease; it does NOT relate only to blood test results.                                           

2. From the assessment identify the three (3) highest priority nursing problems or potential problems relevant at the time of the assessment and your nursing goal/goals for each, including set measureable outcome criteria.                                

3. Discuss a plan of nursing care for the patient at the time you are caring for them that addresses the identified nursing problems. The planned nursing interventions should be detailed and supported by rationales and reference to nursing research and best practice literature. They may include nursing management of ordered medical therapies, such as medication and fluid management.                              

4. The patient’s outcome should be evaluated in relation to the set nursing goals. This evaluation should be a realistic discussion of the patient’s progress towards the set goals during the time that you were involved in the patient’s care.

1. Condition of patient comprise of three main complaints, which are (Combes, 2012):

• Increase breathing work
• Chest tightness and congestion
• Feeling inadequate air supply, that not getting adequate oxygen

The condition mainly links with the impaired venous return and endothelial dysfunction. The respiratory system fails in performing either efficient gas exchange, with (i) oxygenation of mixed venous blood or (ii) elimination of carbon dioxide. In other words, the condition refers to lowering of pO₂ or increase of pCO₂ in comparison to barometric pressure. The pathophysiology hence associated with any of the following region (Markou, Myrianthefs & Baltopoulos, 2004):

• Lowering fraction of inspired oxygen
• Hypoventilation
• Mismatch in ventilation-perfusion, which results in a change of respiratory pattern
• Problem with respect to shunt functioning
• Impairment of diffusion
• Desaturation condition for mixed venous return

The result of these altered physiological functioning reflects in, obstructive diseases such as emphysema or bronchiectasis. Likewise, interstitial lung diseases are also concerned in such cases. Diminishing of cardiac output also contributes to making the lung perfusion poor with acute pulmonary emboli. It is also important to note that often acute pulmonary hypertension with less perfusion of non-gravity dependent lung is linked to the pathophysiology (Force, 2012).

Impaired diffusion links with the impairment of partial tension between alveolus and erythrocytes. In a normal patient, this is achieved with respect to the transaction of red blood cells to one-third of the length of the capillary. Hence the equilibration with respect to CO­₂ will be rapider, and thus the diffusion across the capillary membrane becomes 20 times faster with for the O₂. Reduction of permeability of gas or thickening of alveolar-capillary is also linked in such cases. These conditions are often referred to as Alveolar- capillary block. Limitation of diffusion often offers inefficiency in gas-exchange and that the oxygen desaturation becomes common (Sun, Wei & Liu, 2015).

Planning Nursing Care and Nursing Interventions

Low cardiac output in such condition also contributes to desaturation of mixed blood, where concentration of hemoglobin becomes less. On the contrary, the oxygen consumption by the peripheral tissues also increases. pO₂ remains unaffected in this condition, only if there is access to ventilated alveoli and oxygenation of the mixed venous blood. In the present case, the patient has abnormal V-Q or shunt functioning. Hence, the deterioration of gas exchange becomes common and reflects in terms of venous desaturation with respect to pO₂.

2. The first challenge is to rectify the condition of respiratory failure. Increase of work for breathing is the main requirement for this condition in COPD. The increase in breathing work is a reflection of increased airway obstruction and resistive load. Natural exacerbation with increase in breath shortness, and the presence of sputum production is common in such scenario. The management of such condition can be rectified with respect to use of inhalation of corticosteroids, β2 agonist (Lim, 2012).

Another problem is infection in the patient since there is fever in the patient, thus infection chances are more, that can further lead to impairment in lung functioning. Such complication can be managed with optimum use of antibiotics, which will combat the fever condition. Apart from that, antibiotics are also helpful in controlling the sputum production and preventing various kind of disability.

Impairment in circulation is also one of the challenges to nurses, for health restoration and care management. The mainstream symptom associated with this is acute pulmonary edema. Management is possible with supplementation of oxygen and non-invasive ventilation (Sun, Wei & Liu, 2015).

3. Clinical manifestation of the patient with presented symptoms and complications, largely dependent on the underlying pathophysiology and its associated consequences. The condition of the patient demonstrates labored respiration which also includes tachypnea, tachycardia, and tremulousness. Speech, in this case, will also be broken into two to three-word sentences. The immediate requirement for patient care is intubation and positive pressure ventilation. The impedance in cardiopulmonary arrest demands for an immediate intervention for which delay may cause serious deterioration condition. The clinical assessment of the patient condition requires following evaluation (Lim, 2012; Force, 2012; Sun, Wei & Liu, 2015):

• Mental status – is it important to communicate with the family member (husband of the patient in this case) and identify all the information prior to admission in an emergency department. Furthermore, drowsiness, fatigue and faintness of patient should be identified for immediate measures.
• Frequency of respiration and heart rate – tachypnea and tachycardia are the measures of severity in the present case. Other terminal events linked with the situation are fall in respiratory rate and gasping, which in other words also refers to respiratory arrest. Intervention in this regard is thus important for identification of crucial care requirements. The sign of respiratory load can be assessed with respect to respiratory alterations. In such situation, the respiratory movement aligns with abdominal movement for few breaths. Afterward, the respiratory movement functions mainly in the series with the rib cage movements. Collectively, such respiratory movement is indicative of the increase in respiratory pattern.
• Pattern of respiration – shallowness in respiratory effect, which is often rapid in nature, retraction of sternal physiology and important to check. Also, use of accessory muscles in respiration and Hoover sign are crucial indicative to check in the present case. Movement of the diaphragm, which in clinical terms refers to as thoracoabdominal paradoxical movement is necessary to consider for assessment. Typically the diaphragm should move to cranial direction where the movement of the abdomen should be inward with the inspiration. Such movement is the marking that reflect proper functioning of the diaphragm with respect to the fatiguing load.
• Inspection of skin, lips, nail beds, and tongue are important. Also, the assessment of the cyanosis condition is crucial in the present case.
• Cardiovascular assessment also constitutes an important counterpart. Since tachycardia also accompanies the shortening of respiration, thus checking the pulmonary auscultation is important. Other case, if the also worthy to discuss with other health care professionals and go for assessment of cardiac auscultation.
• Sign for cor pulmonale should be identified, in this case. These include peripheral edema checking, dilated jugular veins, hepato-jugular sign, and other similar conditions.

Often these conditions are linked with several disease specific clues, which are possible to explore with the help of physical examination. The assessment for disease-specific trait should include examination for neuromuscular disorder, muscular atrophy and patient ability to breathe deeply. Often the condition of COPD is linked with hyper-expansion of thorax, deep and prolonged expiration in conjunction with pursed lip condition, wheezing, and energetic expiration which is protracted in nature.

Along with the illustrated assessment goals, it is also necessary for nurses to refer to the therapeutic target in order to improve patient condition. These include the following considerations (Combes, Bréchot, Luyt & Schmidt, 2012):

• Contribution towards the precipitation factor is important.
• It also includes the reversion of the underlying pathological condition. These includes measures for increasing the elastic load and resistive load.
• Oxygen therapy is essential to control the arterial hypoxemia. The said measure is also effective in terms of controlling the life-threatening condition of stressful breathing.
• Antibiotics and corticosteroid should be administered. The condition of the patient also includes a fever, agitation, vigorous shortening of breath, and marked reduction in oxygen consumption. Hence, these medication measurements are effective to control such situation.
• Optimization of oxygen transport is important. Such measure can be made effective using intervention related to improvement in cardiac output or transfusion of red blood cells.

Immediate target for relieving the complicated conditions in the patient include certain measure, which should be brought into care by nurse. Evidence-based nursing approach is effective in such condition, where precise measures should be adopted with through discussion. The immediate target includes:

• Bronchodilation
• Control of mucus secretion and any probable infection
• Chest wall stabilization is necessary. It will also reduce the burden of forced respiration and corresponding stress
• O₂ therapy is essential, in this case, which require critical control to meet the oxygen demand of the physiological system.
• Avoiding the drugs, which depress breathing or respiratory functioning. It is important to note that often drugs cause reversal of their effect after the t_1/2, which should be monitored by a nurse upon drug administration.

4. Nurse should monitor the criteria for the tolerance to the present condition of patient. More importantly, the below-mentioned points are also reflective of the condition for improvement in patient condition, with respect to the intervention and medication approach (Goodacre, 2014).

• Oxygenation rate should be near to the acceptable limit, which include saturated pressure of oxygen as sO₂ ≥ 90 %, with partial pressure pO₂as ≥ 60 mmHg.
• Acceptable level of ventilation include the criteria such as an increase in partial pressure of CO₂ with a level of pCO₂ ≤ 10 mmHg and that the systemic pH should decrease with a value of ≤ 0.10.
• Respiratory rate should be in a range of ≤ 35 breaths per minute (rate).
• Heart rate should be in a range of ≤ 140 beats per min with an increase of ≤ 20 % compared to baseline heart rate.
• Systolic blood pressure should be in a range of ≥ 80 – 90 mmHg and ≤ 160 – 180 mmHg. Notably, the change should be reflective of an increase of ≤ 20 % compared to baseline systolic blood pressure.
• The respiratory rate or tidal volume in respiration should be < 100 breaths per min.
• The effectiveness of the treatment and care management approach is indicative of no signs of elevated breathing or forceful respiration. These are also indicative of no thoracoabdominal paradox and no use of accessory muscle in respiration.
• Other than this, there should be no sign of distress including absence of diaphoresis and agitation.

References:

Combes, A., Bréchot, N., Luyt, C. E., & Schmidt, M. (2012). What is the niche for extracorporeal membrane oxygenation in severe acute respiratory distress syndrome? Current opinion in critical care, 18(5), 527-532.

Force, A. D. T. (2012). Acute respiratory distress syndrome. Jama, 307(23), 2526-2533.

Goodacre, S., Stevens, J. W., Pandor, A., Poku, E., Ren, S., Cantrell, A., … & Plaisance, P. (2014). Prehospital Noninvasive Ventilation for Acute Respiratory Failure: Systematic Review, Network Metaâ€Âanalysis, and Individual Patient Data Metaâ€Âanalysis. Academic Emergency Medicine, 21(9), 960-970.

Lim, W. J., Mohammed Akram, R., Carson, K. V., Mysore, S., Labiszewski, N. A., Wedzicha, J. A., … & Smith, B. J. (2012). Nonâ€Âinvasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. The Cochrane Library. Retrieved from

https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004360.pub4/full

Markou, N. K., Myrianthefs, P. M., & Baltopoulos, G. J. (2004). Respiratory failure: an overview. Critical care nursing quarterly, 27(4), 353-379.

Sun, Y. Q., Wei, Q., & Liu, Z. (2015). Efficacy of Continuous Positive Airway Pressure in the Treatment of Chronic Obstructive Pulmonary Disease Combined With Respiratory Failure. American journal of therapeutics. Retrieved from

https://europepmc.org/abstract/med/25768378