Nursing Intervention Strategy for a Critical Patient - Case Study Example

CASE: Denver changed to protect identity) is a 60 year old male who has a history of undergoing surgery for carcinoma of the colon. Despite liver metastases he has been managing well until he was diagnosed to have a pleural effusion. His breathlessness has been increasing over the past few weeks and comes to the clinic because his breathing is progressively getting worse. A chest radiograph showed a large ( 50% of the hemithorax) right pleural effusion with mediastinal shift to the contralateral side. His clinical diagnosis on presentation is Impaired Gas Exchange (IGE) which is defined as "the excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar - capillary membrane" (NANDA definition). This essay focuses on the importance of a primary intervention strategy for a patient presenting to the clinic in a critical state of hypoxia. Taking the case example of Denver, we will discuss the presenting signs and symptoms, diagnostic and assessment tools specific to the problem and its severity and the intervention strategies to provide immediate relief and prevent morbidity and mortality. Here we specifically stress on the significance of Continuous Positive Airway Pressure (CPAP) and it's rational in this particular situation along with its description and effectivity in the management of a hypoxic patient suffering from Impaired Gas Exchange. A patient with IGE has characteristic symptoms of visual disturbances, dyspnea, irritability, somnolence, restlessness and headache on awakening. Clinical manifestations may be in form of abnormal arterial blood gas levels, hypoxia; hypercapnia, tachycardia, cyanosis, abnormal skin color (pale, dusky), hypercarbia, diaphoresis, abnormal arterial pH and nasal flaring.Factors like ventilation-perfusion imbalance or alveolar-capillary membrane changes may also be related to the condition. The primary goal of the management plan would be to demonstrate improved ventilation and adequate oxygenation as evidenced by blood gas levels within normal parameters for the patient concerned maintain clear lung fields and remain free of signs of respiratory distress and verbalize understanding of oxygen supplementation and other therapeutic interventions. Suggested NIC (Nursing Intervention Classification) plans are Acid-Base Management and Airway Management. AIRWAY: Auscultate breath sounds every 1 to 2 hours. The presence of crackles and wheezes may alert the nurse to airway obstruction, which may lead to or exacerbate existing hypoxia. In severe exacerbations of chronic obstructive pulmonary disease (COPD), lung sounds may be diminished or distant with air trapping (Zampella, 2003). BREATHING: The second step would be to monitor respiratory rate, depth, and effort, including use of accessory muscles, nasal flaring, and abnormal breathing patterns. Increased respiratory rate, use of accessory muscles, nasal flaring, abdominal breathing, and a look of panic in the client's eyes may be seen with hypoxia. CIRCULATION: Monitor oxygen saturation continuously using pulse oximetry and note blood gas results for diagnostic and comparatative reference. An oxygen saturation of less than 90% (normal: 95% to 100%) or a partial pressure of oxygen of less than 80 mm Hg (normal: 80 to 100 mm Hg) indicates significant oxygenation problems (Berry and Pinard, 2002; Grap, 2002). DISABILITY (CNS DYSFUNCTION): Next, observe and assess the patient's behavior pattern and psychological status for the onset of restlessness, agitation, confusion, and extreme lethargy that may occur in later stages. Changes in behavior and mental status can be early signs of impaired gas exchange (Misasi and Keyes, 1994). In the late stages the client becomes lethargic and somnolent. EXPOSURE: Observe the skin colour and tone and look for signs of cyanosis, especially note color of the tongue and oral mucous membranes. Central cyanosis of the tongue and oral mucosa is indicative of serious hypoxia and is a medical emergency. Peripheral cyanosis in the extremities may or may not be serious (Carpenter, 1993). INTERVENTION AND RATIONALES: Ask the patient when and how the breathing started to get worse because breathlessness of sudden onset (seconds or minutes) has different causes (eg. pulmonary embolus) to those that built up over days or longer (eg. Pleural effusion). If the patient presents with unilateral lung disease, alternate semi-Fowler's position with a lateral position (with 10- to 15-degree elevation and "good lung down" for 60 to 90 minutes). This method is contraindicated for clients with pulmonary abscess or hemorrhage or interstitial emphysema. Gravity and hydrostatic pressure cause the dependent lung to become better ventilated and perfused, which increases oxygenation (Lasater-Erhard, 1995; Yeaw, 1992). If the patient presents with bilateral lung disease, position the patient in either semi-Fowler's1 or a side-lying position, which increases oxygenation as indicated by pulse oximetry (or, if the patient has a pulmonary catheter, venous oxygen saturation). Turn the patient every 2 hours. Monitor mixed venous oxygen saturation closely after turning. If it drops below 10% or fails to return to baseline promptly, turn the patient back into the supine position and evaluate oxygen status. Turning is important to prevent complications of immobility, but in critically ill clients with low hemoglobin levels or decreased cardiac output, turning on either side can result in desaturation (Winslow, 1992). Critically ill clients should be turned carefully and watched closely (Gawlinksi and Dracup, 1998). If the patient is obese or has ascites, consider positioning the patient in reverse Trendelenburg's2 position at 45 degrees for periods as tolerated. A study demonstrated that use of reverse Trendelenburg's position at 45 degrees resulted in increased tidal volumes and decreased respiratory rates in a group of intubated clients with obesity, abdominal distention, and ascites (Burns et al, 1994). If the patient presents with respiratory distress syndrome, or difficulty maintaining oxygenation, place him/her in a prone position3 with the upper thorax and pelvis supported, allowing the abdomen to protrude. Monitor oxygen saturation and turn back to supine position if desaturation occurs. Oxygenation levels have been shown to improve in the prone position, probably due to decreased shunting and better perfusion of the lungs (Curley, Thompson, and Arnold, 2000; Mure et al, 1997; Vollman and Bander, 1996). If the patient is acutely dyspneic, consider having the client lean forward over a bedside table, if tolerated. Leaning forward can help decrease dyspnea, possibly because gastric pressure allows better contraction of the diaphragm (Celli, 1998). This is called the tripod position and is used during times of distress (Zampella, 2003). Assist the patient to deep breathe and perform controlled coughing. Have the patinet inhale deeply, hold the breath for several seconds, and cough two or three times with the mouth open while tightening the upper abdominal muscles as tolerated. This technique can help increase sputum clearance and decrease cough spasms (Celli, 1998). Controlled coughing uses the diaphragmatic muscles, which makes the cough more forceful and effective. Monitor the effects of sedation and analgesics on the patients respiratory pattern; use judiciously. Both analgesics and medications that cause sedation can depress respiration at times. However, these medications can be very helpful for decreasing the sympathetic nervous system discharge that accompanies hypoxia. Schedule nursing care to provide rest and minimize fatigue. The hypoxic client has limited reserves; inappropriate activity can increase hypoxia. Administer humidified oxygen through an appropriate device (e.g., nasal cannula or face mask per the physician's order); watch for onset of hypoventilation as evidenced by increased somnolence after initiating or increasing oxygen therapy. A client with chronic lung disease may need a hypoxic drive to breathe and may hypoventilate during oxygen therapy. Provide adequate fluids, within the patient's cardiac and renal reserve, to liquefy secretions. If the patient is severely debilitated from chronic respiratory disease, consider the use o a wheeled walker to help in ambulation. Use of a wheeled walker has been shown to result in significant decrease in disability, hypoxemia, and breathlessness during a 6-minute walk test (Honeyman, Barr, and Stubbing, 1996). Monitor nutritional status and refer the patient for a dietary consultation if needed. Many clients with emphysema are malnourished. Improved nutrition can help increase muscle aerobic capacity and exercise tolerance (Palange et al, 1995). Refer the COPD client to a pulmonary rehabilitation program. Pulmonary rehabilitation has been shown to relieve dyspnea and fatigue, and enhance clients' sense of control over their disease. Rehabilitation is an important component of the management of COPD (Lacasse et al, 2002). Geriatric patients like Denver require extra care. While dealing with older patients, use central nervous system depressants carefully to avoid decreasing respiration rate. An elderly client is prone to respiratory depression. Maintain low-flow oxygen therapy. An elderly client is susceptible to oxygen-induced respiratory depression and encourages the client to stop smoking. Elderly clients who stop smoking experience substantial health benefits (Foyt, 1992). Stress on the importance of not smoking and be aggressive in approach. All health care clinicians should be aggressive in helping smokers quit (Agency for Health Care Policy Research, 1996). Clinical Research: Giving up smoking can slow the course of disease, and some clients may even regain some lung function (Anthonisen et al, 1994). ROLE OF NURSES: Maintaining adequate oxygenation to promote vital organ functions represents a common challenge for the critical care nurse. Critically ill patients with impaired respiratory function may be particularly vulnerable to tissue oxygen deprivation because they have limited ability to increase oxygen delivery when oxygen demands increase. Consequently, routine nursing procedures that increase oxygen requirements may have adverse effects on tissue oxygenation. Interventions that enhance patient tolerance to nursing procedures by supporting the balance between oxygen supply and demand promote physiologic adaptation and may prevent complications associated with hypoxia such as cardiac dysrhythmias, hypotension, and cardiac arrest. Simple measures like providing company, opening the windows and helping the patient relax are seen to be effective while dealing with agitated and nervous patients (Leidy and Traver, 1996). Providing some form of entertainment like music or television also helps in distracting the patient from the distress (Cox C, 2002). In cases of lung infections antibiotics should be administered and minimum amount of oxygen should be given before it is made sure that it is safe to deliver higher levels. Also, the increased nutritional needs of an acutely ill, mechanically ventilated patient must not be overlooked as these patients are often malnourished because of an existing disease process and the hard work of breathing. Each patient requires a complete nutritional assessment to determine existing deficits (Berry and Baum, 2001). Last but not the least, help keep the patient more comfortable, maintain appropriate room temperature and minimize light and noise. This will help him rest and prepare for the intervention (Gift, Moore, and Soeken, 1992). NEED FOR CPAP: Mechanical ventilation is primarily indicated in case of respiratory failure. However, other clinical indications include a prolonged postoperative recovery, altered conscious level, and inability to protect the airway or exhaustion when the patient is likely to proceed to respiratory failure (William C, 2004). The aim of mechanical/artificial ventilation is to improve gas exchange, to reduce the work of breathing and to avoid complications while maintaining optimal conditions for recovery. Whatever the indication for respiratory support, the underlying condition of the patient must be reversible; otherwise subsequent weaning may not be possible. Respiratory failure occurs when pulmonary gas exchange is sufficiently impaired to cause hypoxemia with (Type 2) or without hypercarbia (Type 1). The causes of respiratory failure are diverse and the problem may occur due to disease at the alveolar / endothelial interface (eg pulmonary edema) or in the respiratory pump mechanism resulting in inadequate minute ventilation (eg flail segment accompanying fractured ribs). Mechanical ventilation is indicated when any of the following criteria are met: Respiratory rate = >35 or Read More