CNA252 Professional Practice 12

Kobi Monterey has grown up with asthma.  Diagnosed at a very young age, he has been very diligent in knowing what triggers his asthma resulting in Kobi experiencing few episodes in recent years. Apart from his asthma, Kobi is a fit and well 25-year-old.  However, this week Kobi has not been feeling well over the past few days and his father brought him to the emergency department this morning after Kobi experienced an asthma attack whilst at work. Kobi is quite distressed and breathing rapidly with a notable wheeze on expiration. He is unable to talk to you in full sentences, states he has a tight feeling in his chest and a continuous cough. You notice that his lips are cyanosed and he appears pale and sweaty.

Review the existing documentation;

Social History

Kobi is a keen cyclist and rides his bike about 3 times a week with a local cycling group to which he belongs. He enjoys the social activities and has a good work-life balance. Kobi works as a carpenter with his father. He has aspirations of starting his own carpentry business and is feeling positive about his future. Kobi is often working in enclosed spaces exposed to fine wood dust particles, although he complies with all the necessary workplace health and safety regulations.

Medication Use:

Kobi indicates that he has needed to use his puffer more than usual and ceased using the preventer some time ago. When he runs out of his Ventolin puffer, he orders replacements online that are delivered to his home address for convenience. With such a busy schedule, Kobi has found it difficult to find time to schedule an appointment with his GP.

Recall:

Before you continue with this assignment you should recall and apply your existing knowledge to the above situation to ensure you have a broad understanding of what is/may be occurring.

Process information

In the following table, list the data that you consider to be normal/abnormal (not included in word count)

• Relate: cluster cues by identifying relationships between them.

•      Infer: make deductions as to why a cue, or a cluster of cues may be considered abnormal in this context. Justify by referring to appropriate anatomy, physiology and pathophysiology.

Refer to Levett-Jones (2018) Clinical Reasoning p7.

• Based on your interpretation of all the information/cues presented, form and justify an overall opinion on what may be happening

Kobi’s current health condition can be accredited to the fact that he is suffering from occupational asthma. The condition encompasses health ailment that occurs due to exposure to certain substances such as, dust, gases, or chemical fumes, to which a person is sensitive, thereby leading to immunological response or allergy (Levett-Jones 2013). An analysis of the case study suggests that Kobi had been a patient of asthma since his childhood. Presence of smaller airways in children, when compared to their adult counterparts often results in this condition that significantly attributes to tightness in the chest, coughing, wheezing and troube in breathing. These are in accordance with the subjective and objective symptoms reported by Kobi.

Wheezing sounds can be attributed to the reduction in the diameter of the airways located in the lungs, thus making them constricted or narrowed. Furthermore, presence of bluish colouration in his lips represent an absence of oxygen in the bloodstream, which in turn is indicative of presence of an abnormal type of haemoglobin.

His work as a carpenter with his father acted as an occupational trigger that led to the sudden onset of asthma attack, thereby tightening the muscles that are located around the airways, a process referred to as bronchospasm (Strong and Chang 2014). This in turn resulted in swelling or inflammation and subsequent development of thicker mucus. Hence, it can be suggested that there is an immediate need to effectively manage the asthma attack episode, in order to enhance his overall health and wellbeing.

Explain what may happen to your patient if no action is taken

Without any proper action, episodes of asthma attack, as the one experienced by Kobi have the probability of being potentially life-threatening. Unmanaged asthma would result in sleep deprivation in the patient over time, thus impeding his ability to conduct activities of daily living (Tarlo and Lemiere 2014). It is also associated with the onset of fatigue and permanent problems with the airways located in the lungs of the affected person. It might also result in several psychological problems such a, anxiety, stress and depression, thus increased hospital visits. If not managed immediately, the condition might also result in collapse of a portion of the lungs, and subsequent respiratory failure, thus causing death.

Identify the Problem/s

List in order of priority at least two key nursing problems (not included in word count)

• Management of asthma- This condition encompasses the unexpected deterioration of asthma symptoms triggered by the constriction of muscles located near the respiratory airways (bronchospasm). During asthma attack, linings of the airways get swollen or reddened, thereby producing mucus that is thicker and more in amount than normal. Hence, the primary goal would to be to effectively prevent and/or manage the wheezing, troubled breathing, coughing, and chest tightness (El et al. 2016).

• Treatment of lip cyanosis- Bluish colouration of the lips are a sign of reduced oxygen supply in the bloodstream.  Poor circulation of oxygen in the blood leads to bluish staining of the skin. Inflammation of the lungs have resulted in fluid accumulation, which in turn has reduced the circulating oxygen supply. An analysis of the case scenario identifies the need of managing central cyanosis that can eventually affect the chest and tongue as well.

Establish Goal & Take Action

For your highest priority nursing problem: (300 words)

• Establish one goal

• List the related FOUR (4) actions you would undertake to achieve that goal.  Your actions should include ONE (1) skill only from the following list; 1) 12 Lead ECG and interpretation, 2) Venipuncture and sample handling, 3) Oxygen therapy, 4) Pulse oximetry.

• Provide a rationale that associates the pathophysiological and psychological principles with each selected nursing action

• Describe how you would evaluate the effectiveness of the care provided (i.e. how will you know that your actions were beneficial to the patient?).

Management of ineffective breathing pattern

Administration of oxygen therapy

Supplemental oxygen will be administered as the medical treatment for the infective patterns of breathing, as reported by Kobi. Use of a nasal cannula will facilitate this goal where oxygen will be delivered to the bloodstream, and increase its amount in the lungs (Mayfield et al. 2014). The target levels of oxygen will be approximately 94–96%.  Administration of oxygen will prevent swelling of the bronchial tubes and will also reduce cough and tachypnoea.

Kobi will demonstrate optimal breathing patterns, as observed by normal breathing rates, dyspnoea absence and relaxed breathing.

Management of ineffective breathing pattern

Administration of inhaled corticosteroids

Corticosteroids such as, fluticasone and hbudesonide will help in reducing the inflammation observed in the airways, which carry oxygen to the lungs, This in turn will help in decreasing the amount of mucus produced in the bronchial tubes, thereby reducing distress (Teach et al. 2015). Some side effects might include sore throat, mild infection in the throat and hoarse voice.

Kobi will report less symptoms of tightness in the chest, less mucus formation

Management of ineffective breathing pattern

Administration of Short-acting beta-2-adrenergic agonists

Beta-2-adrenergic agonists such as albuterol and terbutaline are a group of bronchodilators that will be administered to the patient for providing quick relief from the asthma attack. Upon activation these antagonists will being about relaxation of the smooth muscles located in the lungs, thus causing dilation of the airways and opening them (Timmer et al. 2015). This in turn will reduce the troubled breathing symptoms. However, they might lead to excessive sweating and agitation 

Hyperpolarisation of the smooth muscles located in lungs demonstrated by reduction in wheezing sounds

Asthma attack

Management of ineffective breathing pattern

Positioning the patient in semi-fowler’s position

Kobi will be assisted to lie in a supine position, after his bed is inclined at an angle of 30-45 degrees. This position will encompass keeping the foot of his bed elevated near his knees, in order to bend his legs. The position will allow loung expansion (Kuhajda et al. 2015).

Evidenced based skill assessment and reflection

Watch the video of the clinical skill performance which you have chosen from the list provided above.  Analyse and critically reflect on skill performance in the video you have chosen, using the skill checklists in (Tollefson 2016). Discuss 1 (ONE) strength and 1 (ONE) weakness that you have identified in the skill performance. Discuss in relation to the Registered Nurse Standards for Practice. (150 words)

Weakness

Reflecting on the video performance, discuss what two (2) actions you will take to address their performance in the promotion of positive health outcomes. Reflecting on the clinical reasoning cycle, how has this reinforced your professional responsibility as a beginning level practitioner and informed your future learning? (200 words)

Reference:

El, W.A., El, A.K., Bentalha, A. and El, S.K., 2016. Perthes syndrome secondary to an asthma attack: A case report in a 15-year-old child. Revue de pneumologie clinique, 72(6), pp.359-362.

Kuhajda, I., Djuric, D., Milos, K., Bijelovic, M., Milosevic, M., Ilincic, D., Ilic, M., Koledin, B., Kuhajda, D., Tsakiridis, K. and Mpakas, A., 2015. Semi-Fowler vs. lateral decubitus position for thoracoscopic sympathectomy in treatment of primary focal hyperhidrosis. Journal of thoracic disease, 7(Suppl 1), p.S5.

Levett-Jones, T (ed) 2013, Clinical reasoning: learning to think like a nurse, Pearson Australia, Frenchs Forest.

Mayfield, S., Bogossian, F., O’Malley, L. and Schibler, A., 2014. High?flow nasal cannula oxygen therapy for infants with bronchiolitis: pilot study. Journal of paediatrics and child health, 50(5), pp.373-378.

Strong, C. and Chang, L.Y., 2014. Family socioeconomic status, household tobacco smoke, and asthma attack among children below 12 years of age: gender differences. Journal of Child Health Care, 18(4), pp.388-398.

Tarlo, S.M. and Lemiere, C., 2014. Occupational asthma. New England Journal of Medicine, 370(7), pp.640-649.

Teach, S.J., Gill, M.A., Togias, A., Sorkness, C.A., Arbes Jr, S.J., Calatroni, A., Wildfire, J.J., Gergen, P.J., Cohen, R.T., Pongracic, J.A. and Kercsmar, C.M., 2015. Preseasonal treatment with either omalizumab or an inhaled corticosteroid boost to prevent fall asthma exacerbations. Journal of Allergy and Clinical Immunology, 136(6), pp.1476-1485.

Timmer, W., Moroni-Zentgraf, P., Cornelissen, P., Unseld, A., Pizzichini, E. and Buhl, R., 2015. Once-daily tiotropium Respimat® 5 μg is an efficacious 24-h bronchodilator in adults with symptomatic asthma. Respiratory medicine, 109(3), pp.329-338.