Nursing Care Plan: Patient with Respiratory Problem

Respiratory Problem

Nursing Care Plan: Patient with Respiratory Problem

Instructions:-

Task 1: Understanding nursing problems

After handover you consider and plan the nursing care that Neville requires today. You recognise that there are 5 key nursing problems for Neville today:

  • Ineffective airway clearance
  • Impaired gas exchange
  • Risk of impaired ventilation
  • Imbalanced nutrition: less than body requirements
  • Risk for infection

In grammatically correct sentences and topic paragraphs and using current, reliable evidence for practice

  • Explain the specific underlying cause/s (aetiology) or reason/s for each of the nursing problems above.

(300 words, 10 marks)

Task 2: Care planning

In addition to the nursing problems above, you also recognise that Neville requires fundamental nursing care today and your role and responsibility as the nurse caring for Neville today is to keep him:

  • Safe
  • Clean and dressed
  • Warm and comfortable
  • Fed
  • Hydrated
  • Rested
  • Mobile
  • Toileted

Based solely on the handover you have received select five (5) fundamentals of care from the list above and develop a plan of care for each one identifying:

  • The related nursing problem
  • The underlying cause or reason (ie, what the problem is related to)
  • Goal of care
  • Specific bedside nursing interventions you will do
  • The rationales for your nursing interventions and actions
  • Indicators that your plan is working

Information is to be in dot point form on the nursing care plan template on the required Assessment 1 template.

(800 words, 30 marks)

Task 3: Medication management

Three important aspects of medication management by registered nurses is for the nurse to understand why a patient has been prescribed specific medications, the nursing responsibilities associate with administering each medication and how to monitor the patient to ensure they are responding to prescribed medications as they should.

In grammatically correct sentences and topic paragraphs and using current, reliable evidence for practice,

  • Briefly explain why Neville has been prescribed:
    • Oral prednisone
    • ipratropium bromide via nebuliser
    • Oral amoxicillin

AND

·         Identify and explain

  • The specific nursing responsibilities associated with administering each medication and monitoring Neville for expected, side and adverse effects

(350 words, 10 marks)

Task 4: Patient teaching

During Neville’s hospital admission, it is part of the nurse’s role to review his current knowledge and understanding related to his condition and to update or provide new information.

Topics that need review/updating or new information are:

  • How to effectively use a metered dose inhaler (MDI) and spacer
  • Why he needs to stop smoking
  • Early indicators that his COPD is deteriorating that require medical review
  • Promoting adequate nutritional intake to meet his metabolic needs
  • Energy conservation strategies

Select one (1) of the topics above and, in grammatically correct sentences and topic paragraphs,

  • Identify the specific information you will need to explain to Neville about the topic

AND

  • Explain
    • Why the topic is an important aspect of Neville’s care
    • How you will ensure that Neville knows and understand why it is important and, if appropriate to the topic, what he needs to do

(250 words, 5 marks)

Task 5: Clinical judgement and handover

There are two (2) parts to Task 5.

Part A:

When you come back from your meal break, a colleague tells you that they have given Neville a prn salbutamol nebuliser as he requested it because he was short of breath.

The first thing you do is to check on Neville to find out if his breathing is more comfortable now. On checking Neville you notice:

Neville is

  • Restless, anxious and mumbling incoherently
  • Plucking randomly at his bed linen
  • Dyspnoeic and, his
  • Skin is flushed and diaphoretic and
  • Nasal prong oxygen is still in place

On further assessment you find:

  • Oxygen saturations are now 98% on nasal prong oxygen @ 2L/min
  • Heart rate elevated to 110 beats/minute
  • Respiratory rate has dropped to 8-10 breaths/minute
  • The nebuliser mask and tubing is connected to the oxygen outlet

In grammatically correct sentences and topic paragraphs,

·         Identify

  • What you think is happening
    • Your immediate nursing actions and interventions
    • The reason for your actions and interventions

Part B:

An important legal requirement of nursing practice is to effectively and succinctly communicate relevant information, actions and outcomes related to patient care and provide an accurate reflection of the health status of the patient, their responses to care and the patient’s perspective.

Once Neville’s condition has been stabilised, the doctors arrange to transfer Neville to the High Dependency Unit for bipap and closer monitoring.

Using the ISBAR format, information from the handover you initially received and the additional information above:

  • Write a handover that clearly and succinctly outlines the important information the high dependency unit needs to know about Neville

Your handover must:

  • Demonstrate person-centred care
  • Adhere to the legal and professional standards for documentation
  • Be in appropriate professional language
  • Contain NO abbreviations or nursing jargon

(Part A and B: 300 words, 10 marks)

Solution

Nursing Care Plan: Patient with Respiratory Problem

Task 1: Understanding nursing problems

Notably, Neville has a respiratory failure characterized by an ineffective airway clearance, impaired gas exchange, higher risks of impaired ventilation, an imbalanced nutrition and risk of infection. This section will outline the possible aetiology of Neville’s problems in relation to available literature. First, Neville experiences depict an infective airway clearance that is evidently triggered by inflammation caused on the airways due to smoking (Pascoal et al., 2016). Furthermore, the salient characteristic of the chronic pulmonary disease has long been associated with ineffective airway clearance(Olsson et al., 2011). Additionally, increases in sputum production can block the airway making it difficult for airway clearance(Rubin, 2014).

Second, Neville is experiencing ineffective gas exchange as a result of limited air intake triggered by the ineffective air clearance. As such, it is evident that for a normal human being to have an effective gas exchange, the concentration of oxygen and carbon dioxide must be maintained at the alveoli and the pulmonary capillaries. Therefore, Neville has an impaired gas exchange as a result of inflammation due to excessive smoking that damages alveoli and capillaries (Gläser et al., 2010). Third, Neville is likely to experience impaired ventilation due to ineffective gas exchange and/or depletion alveoli caused by the inflammation from smoking. According to Vasankari, Pietinalho, Lertola, Junnila, and Liippo, (2011), it is evident that individuals who smoke are likely to develop the chronic pulmonary disease in their lifetime. As a salient symptom of COPD, impaired ventilation can be as a result of smoking which blocks the airways with substances such as tar (Petersson & Glenny, 2014).

 Also, Neville exhibits an impaired nutrition that is less than what his body requires. According to Itoh, Tsuji, Nemoto, Nakamura, and Aoshiba (2013), it is stipulated the being underweight is a salient sign of COPD. Patients with COPD tend to be malnourished due to cachexia triggered by decreased oral intake, effects associated with increased workflow of breathing, and effects of chronic systemic inflammation(Benton, Wagner, & Alexander, 2010). For Neville, these conditions are as a result of excessive smoking. Last, Neville is likely to develop further infection since the organs, such as the nasal cavity, pulmonary capillaries, and alveoli, are inflamed as a result of smoking, exposing the regions for infection.

Task 2: Care planning

Nursing Care Plan:   Neville

Nursing problem: Risk of developing further airway clearance difficulties
Underlying cause or reason: Since the patient has COPD, further airway clearance difficulties can arise.  
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To ensure that the patient ensures patent airway during hospitalization hence making it safe for breathingDemonstrate behaviours that improve the airway clearance.     The nurse will auscultate breathing sounds and note crackles, rhonchi, and wheezes in Neville’s breathing pattern through pulmonary assessment. The nurse will ensure the patient is seated in the right position on his bed for effective breathing. The nurse has to monitor the inspiratory and expiratory ratio.The patient will have to be suctioned.        This is performed because there might be sputum in Neville’s airway that obstructs effective breathing. During oral care, coughing and restlessness might be evident, the patient has to be suctioned; not for too long    The patient breathes smoothly during hospitalisation, and no sounds are noticed during treatments.
Nursing problem: Risk of Further Bacterial or Viral Infection
Underlying cause or reason: Due to the inflammation caused by the vital parts of the lungs, pulmonary capillaries and alveoli, as well as the nasal cavity, due to excessive smoking, Neville is predisposed to other infection of the respiratory system.  
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
The nurse will ensure that the patient does not contract further respiratory infection, as such, making the patient safe from other diseases as a result of infection. This is focussed on making the patient’s airway clean and safe form infections     Detect the signs and symptoms of infections. Note the levels of dyspnoea, restlessness, distresses in respiratory process, differentiate the episodes of acute and exacerbated dyspnoea Respiratory failure can be associated with a number of infections as well as allergic reactions as well the level of chronicity of the COPD. As such, it is imperative to evaluate the level of dyspnoea that can be triggered by infections(Wedzicha, Singh, & Mackay, 2014).Also, asthma can be developed due to such infections on the respiratory tracts(Postma & Rabe, 2015).  The patient does not depict symptoms and signs of asthma.The patient does not exhibit chronic dyspnoea. The patient is safe and exhibits effective gas exchange.
Nursing problem: Risk of developing impairment of the skin related to immobility
Underlying cause or reason: Since Neville is hospitalised and bed-ridden, he might develop an impaired skin as a result of the immobility state.  
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
The nurse will make sure that the patient is rested and mobile by ensuring that:   Neville’s skin will remain intact throughout hospitalizationNeville will be free of redness of the skin and skin irritations during hospitalization.Neville will not develop any bed sores during hospitalization.   The nurse will regularly assess the skin of Neville thoroughly and apply foam dressings such as Mepilex(Henckel, Küster, Stutz, & Goesmann, 2010). The patient will be repositioned at after every two hours. The nurse will assess the patient’s pressure ulcer risk by utilizing a medical tool known as Braden Scale (Noonan, Quigley, & Curley, 2011).   Since Neville will spend most of his time in bed, he will be at the risk of developing a skin impairment or pressure ulcer(Jolley, Bunnell, & Hough, 2016).The patient is solely dependent on the nurse since he is in a chronic stage of pulmonary disease as he cannot reposition himself. Due to bed rest, the patient might develop bed sores (Saleh, Nusair, Al Zubadi, Al Shloul, & Saleh, 2011).   Neville will not develop any bed sores or skin impairments. No pressure ulcer will occur  
Nursing problem: Risk of impaired nutrition
Underlying cause or reason: Since the patient is at bed rest and has a symptom of poor oral intake, he can develop malnutrition during hospitalization.  
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
The Nurse will ensure that the patient is fed well with proper diet during hospitalization. The nurse will ensure that the patient responds well to the new diet during hospitalization     Tube feeding will be performed as the nurse, and the care technician will focus on preventing malnourished nature of Neville. Proper diet will be given to Neville such as food rich in proteins and vitamins. Since the chronic pulmonary disease is associated with malnutrition, the patient has to be fed adequately. Furthermore, COPD patients tend to have a less oral intake. Therefore tube feeding is necessary. The patient shows improvement in feeding and does not lose weight.  
Nursing problem: Unhygienic State
Underlying cause or reason: Since the patient is not able to carry out normal activity, he will be predisposed to unhygienic state.  
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To ensure the patient attends to body requirements such as going to the toilet. To ensure that the patient is able to be clean and dressed. To ensure mobility for the patient is improving.     Oral care will be performed as the nurse will ensure that the patient is clean by brushing his teeth, cleaning the gums as well as applying moisturizing cream in the patient’s mouth. Daily Bathing: With the help of a partner nurse during the shift, the nurse will ensure that the patient undergoes bathing daily. Since the patient is in a critical state, proper hygiene must be maintained through oral care and bathing.   The Proper response to oral care and daily bathing. The patient is hygienic.


Task 3: Medication management

Oral prednisone

Neville was prescribed a corticosteroid known as oral prednisone since it is meant to treat conditions such as arthritis, blood disorders, breathing problems, allergies of the skin, and eye problems(Abroug et al., 2014).  Additionally, Abroug et al. (2014) suggest that the oral prednisone can be effective in airway ventilation clearance which is a problem that Neville experiences. As such, it triggers the body’s immune system response to diseases to decrease so as to minimize swelling and allergic reactions as well as infections for the case of Neville. The role of the nurse in administering oral prednisone is to ensure that the patient takes the medication by mouth accompanied simultaneously with milk or food so as to prevent stomach discomfort. Also, the nurse must ensure that the patient takes the medication as scheduled by the physician. Also, the nurse must assess the patient’s reaction to the Oral prednisone so that he/she can inform the doctor if the dose has to be reduced due to the drug’s side effects.

 Ipratropium Bromide via Nebuliser

Since the patient has a respiratory failure, wheezes and dyspnoea are evident. As such, Ipratropium Bromide was administered so as to control as well as prevent the wheezing and dyspnoea that is triggered by COPD(Ferguson, Ghafouri, Dai, & Dunn, 2013). This medication works by relaxing the muscles within the airways that consequently open up the airway for effective breathing for patients with COPD (Ferguson et al., 2013). The role of a nurse, in this case, is to ensure that the patient uses the medication in the correct manner. Arguably, Ipratropium Bromide administration is through a nebuliser which changes the solution into a fine mist for better inhalation. Also, the nurse has to perform the refill of the nebuliser as well as making sure that the patient inhales the solution directly to his lungs as well as making sure that the solution does not get in contact with the eye which might cause irritation.

Oral amoxicillin

As Neville is predisposed to risk of infection, the use of oral amoxicillin comes in handy. According to Wilson et al. (2012), oral amoxicillin is used in treating a variety of bacterial infections. As such the drug stops the growth of bacteria in the body. Additionally, oral amoxicillin is used to treat stomach ulcers triggered by the bacteria H. pylori. The role of the nurse, in this case, is to ensure that patient takes the medication without the accompaniment of food as well as making sure that the patient takes the medication on schedule as postulated by the physician.

Task 4: Patient teaching: Why Neville needs to stop Smoking

 Smoking has long been associated with the development of COPD(Sears, 2015). This information is vital for Neville to be made aware of since he had an addiction to smoking. Even though he tried reducing the rate of cigarettes smoked per day, it is important to let him know that smoking is the main catalyst of his condition. First, as a nurse educator, I will gather relevant evidence-based articles as well as a book that indicates the need to advise patients to stop smoking. It is my responsibility to encourage and support Neville on his journey to stop smoking. Additionally, I would use the approach of “4As”(Cancer Research UK, 2013). This is where the nurse has to ask the patient about his smoking status and evaluate the patient’s motivation to stop, advise the patient of the benefits of smoking cessation, assist the patient by helping them to prepare for to stop smoking, and arranging a professional advice or help that offers smoking cessation services such as the I Can Quit program stipulated by the Cancer Council of Australia, available online at https://www.icanquit.com.au/.

Furthermore, I can recommend a book that talks about smoking cessation that will act as a motivational device to trigger the patient to stop smoking. A book such as Allen Carr’s The Only Way to Stop Smoking Permanently (Carr, 2014). Furthermore, I would engage with Neville by advising for a smoking cessation therapy after I have made him aware of the possible effects that come with smoking regarding the quality of life.

Task 5: Clinical judgment and handover

Part A

Regarding the conditions of increased oxygen saturations of 98% on nasal prong at 2L/min, an elevated heart rate, and respiratory rate drop, Neville might be experiencing a COPD exacerbation. According to Anzueto (2010), COPD exacerbations are caused by interactions of the host with bacteria, viruses, and any form of environmental pollution. For Neville case, since the nebuliser and tubing are intact, it is evident that he has developed a viral infection and/or a bacterial infection that affects the functioning of the respiratory system. Heightened dyspnoea might be as a result of bacterial action on the pulmonary capillaries and alveoli. These bacteria induce the mucus hypersecretions while other cause epithelial damage during adherence that blocks the airway leading to ineffective airway clearance and impaired gas exchange(Wedzicha et al., 2014). Viral infections such as the influenza virus tend to exacerbate COPD symptoms(Matsumoto & Inoue, 2014).  As such, Neville might have contracted a virus that triggers heightened symptoms of COPD.

Part B   

I – IDENTITY

As an RN at [insert hospital name], I am calling to recommend further assessment and treatment of Patient – Neville, 62 years of age, Male.

S – SITUATION

I seek to recommend Neville to a High Dependency Unit as a result of the recent COPD exacerbations after an acute care medication. The patient indicated elevated heart rate to 110 beats/second. A drop in the respiratory rate to 8-10 breaths per second as well as oxygen saturations 98% on the nasal prong oxygen at 2L/min.

B – Background   

  • History of Smoking.
  • Diagnosed with Chronic Obstructive Pulmonary disease (COPD).
  • During admission, the patient had worsening dyspnoea, cough, and excessive sputum production.
  • He reported cold a few days ago.
  • Tachycardic and High blood pressure.
  • The patient was given medication for nasal prong oxygen @2L/min to maintain oxygen saturations, Spirometry conducted, high protein and carbohydrate diets, push oral fluids, fluid balance chart, and food chart.
  • Also, the patient was given ipratropium bromide and salbutamol nebulisers, oral prednisone, oral amoxicillin, prn paracetamol, and Coloxyl.
  • Flu and pneumococcal vaccines scheduled before discharge

A – Assessment

Regarding my assessment, Neville experiences COPD exacerbation that is characterised by elevated heart rate and high oxygen saturations of 98 % on nasal prong oxygen @2L/min. Furthermore, the patient might have contracted a bacterial or viral infection that has triggers exacerbated symptoms of COPD.

R – Requirement

I am requesting further management of the patient’s situation at the High Dependency Unit for critical care of the patient stated above. Also, I recommend the need to examine the patient’s nasal cavity of any presence to bacteria and viruses. 

References

Abroug, F., Ouanes-Besbes, L., Fkih-Hassen, M., Ouanes, I., Ayed, S., Dachraoui, F., … ElAtrous, S. (2014). Prednisone in COPD exacerbation requiring ventilatory support: An open-label randomised evaluation. European Respiratory Journal, 43(3), 717–724. https://doi.org/10.1183/09031936.00002913

Anzueto, A. (2010). Impact of exacerbations on copd. European Respiratory Review. https://doi.org/10.1183/09059180.00002610

Benton, M. J., Wagner, C. L., & Alexander, J. L. (2010). Relationship between body mass index, nutrition, strength, and function in elderly individuals with chronic obstructive pulmonary disease. Journal of Cardiopulmonary Rehabilitation and Prevention, 30(4), 260–3. https://doi.org/10.1097/HCR.0b013e3181d6f94f

Cancer Research UK. (2013). Smoking.

Carr, A. (2014). The Only Way to Stop Smoking Permanently. Penguin Books. Retrieved from https://books.google.co.ke/books?id=2gKdngEACAAJ&dq=Quit+Smoking&hl=en&sa=X&redir_esc=y

Ferguson, G. T., Ghafouri, M., Dai, L., & Dunn, L. J. (2013). COPD patient satisfaction with ipratropium bromide/albuterol delivered via respimat: A randomized, controlled study. International Journal of COPD, 8, 139–150. https://doi.org/10.2147/COPD.S38577

Gläser, S., Koch, B., Ittermann, T., Schäper, C., Dörr, M., Felix, S. B., … Hansen, J. E. (2010). Influence of age, sex, body size, smoking, and beta blockade on key gas exchange exercise parameters in an adult population. European Journal of Cardiovascular Prevention and Rehabilitation : Official Journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology, 17(4), 469–476. https://doi.org/10.1097/HJR.0b013e328336a124

Henckel, K., Küster, H., Stutz, L. J., & Goesmann, A. (2010). MediPlEx – a tool to combine in silico & experimental gene expression profiles of the model legume Medicago truncatula. BMC Research Notes, 3, 262. https://doi.org/10.1186/1756-0500-3-262

Itoh, M., Tsuji, T., Nemoto, K., Nakamura, H., & Aoshiba, K. (2013). Undernutrition in patients with COPD and its treatment. Nutrients. https://doi.org/10.3390/nu5041316

Jolley, S. E., Bunnell, A. E., & Hough, C. L. (2016). ICU-Acquired Weakness. Chest. https://doi.org/10.1016/j.chest.2016.03.045

Matsumoto, K., & Inoue, H. (2014). Viral infections in asthma and COPD. Respiratory Investigation. https://doi.org/10.1016/j.resinv.2013.08.005

Noonan, C., Quigley, S., & Curley, M. A. Q. (2011). Using the Braden Q Scale to Predict Pressure Ulcer Risk in Pediatric Patients. Journal of Pediatric Nursing, 26(6), 566–575. https://doi.org/10.1016/j.pedn.2010.07.006

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Pascoal, L. M., de Carvalho, J. P. A., de Sousa, V. E. C., Santos, F. D. R. P., Lima Neto, P. M., Nunes, S. F. L., & Lopes, M. V. de O. (2016). Ineffective airway clearance in adult patients after thoracic and upper abdominal surgery. Applied Nursing Research, 31, 24–28. https://doi.org/10.1016/j.apnr.2015.11.015

Petersson, J., & Glenny, R. W. (2014). Gas exchange and ventilation-perfusion relationships in the lung. European Respiratory Journal. https://doi.org/10.1183/09031936.00037014

Postma, D. S., & Rabe, K. F. (2015). The Asthma–COPD Overlap Syndrome. The New England Journal of Medicine, 373(13), 1–4. https://doi.org/10.1056/NEJMra1411863

Rubin, B. K. (2014). Secretion properties, clearance, and therapy in airway disease. Translational Respiratory Medicine, 2(6), 1–7. https://doi.org/10.1186/2213-0802-2-6

Saleh, B. S., Nusair, H., Al Zubadi, N., Al Shloul, S., & Saleh, U. (2011). The nursing rounds system: Effect of patient’s call light use, bed sores, fall and satisfaction level. International Journal of Nursing Practice, 17(3), 299–303. https://doi.org/10.1111/j.1440-172X.2011.01938.x

Sears, M. R. (2015). Smoking, asthma, chronic airflow obstruction and COPD. European Respiratory Journal, 45(3), 586–588. https://doi.org/10.1183/09031936.00231414

Vasankari, T., Pietinalho, A., Lertola, K., Junnila, S. Y., & Liippo, K. (2011). Use of spirometry and recording of smoking habits of COPD patients increased in primary health care during national COPD programme. BMC Family Practice, 12, 97. https://doi.org/10.1186/1471-2296-12-97

Wedzicha, J. A., Singh, R., & Mackay, A. J. (2014). Acute COPD exacerbations. Clinics in Chest Medicine. https://doi.org/10.1016/j.ccm.2013.11.001

Wilson, R., Anzueto, A., Miravitlles, M., Arvis, P., Alder, J., Haverstock, D., … Sethi, S. (2012). Moxifloxacin versus amoxicillin/clavulanic acid in outpatient acute exacerbations of COPD: MAESTRAL results. European Respiratory Journal, 40(1), 17–27. https://doi.org/10.1183/09031936.00090311

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