NSB231 Integrated Nursing Practice 2 On Campus

George Williamson is a 72 year old man who is a lifelong smoker. 10 years ago, George was diagnosed with COPD however he has continued to smoke with this diagnosis. George has been prescribed Salbutamol; a short acting bronchodilator (SAB) to use on a PRN basis as well as an inhaled steroid which he is supposed to use twice a day.

Today you are seeing George and his granddaughter (who is his primary carer) in the respiratory outpatient’s clinic.George’s granddaughter reports that she doesn’t think that George is using his SAB inhaler correctly and often forgets to take his steroid inhaler. She says that he is too stubborn to listen to any advice on the matter. She also comments that his exercise tolerance is decreasing, and he now spends almost all of his time lying in a reclining chair at home. She is worried that his sedentary lifestyle and lack of movement may cause other health issues.

On examination, George’s wheeze is audible without use of a stethoscope. His Spo2 is 93% on room air. He is pursed lip breathing and leans forward in his chair. His spirometry results show and FEV1 of 36%. In clinic 6 months ago, his FEV1 was 42% and his Spo2 remains stable since his last clinic visit. His blood pressure is 125/60 with a pulse rate of 84. He states that his bowels feel “blocked up” and he can’t be bothered going out or doing jobs round the house anymore. He wants to know “when will this all go away and I’ll be better?”

Introduction

Clinical reasoning cycle is one of the essential processes in healthcare, which helps the nurses and health care practitioners to collect indications, process the data collected from the patient and analyze the problem to plan treatment interventions. A nurse who practices this approach provides a better treatment that reaches the positive outcome of the proposed intervention, thereby increasing patient safety and person-centered care (Leoni-Scheiber et al., 2019,pg-1274). The patient in the case study is an older adult of age 72years who already had a history of chronic obstructive pulmonary disease (COPD). He is a lifelong smoker and has a sedentary lifestyle. The emergency assessment of the patient states that he was having a wheezing sound while breathing and had a Spo2 level of 93%, which was stable last 6 months ago. The blood pressure of the patient was also high, which is 125/60 beats per minute, with an elevated pulse rate of 84. The two problems that can be identified due to the assessment and vital signs of the patient are the development of asthma and hypertension due to inadequate blood oxygen supply into the heart (Ferguson et al., 2014,pg-680). The primary of the below paper is to discuss the pathophysiology of the disease concerning the symptoms of the patient and to plan nursing interventions for resolving this state to get a better result.

Discussio:Problem 1- Asthma

Pathophysiology

Asthma is an allergic reaction of the body in response to specific allergens. It is regarded as a chronic inflammatory disorder of the lung’s airways. The inflammation is associated with the hyper-responsiveness of the lung airways that results in a recurrent episode of wheezing sound while breathing, chest tightness, and breathlessness. These lead to the airway obstruction in the lung pathway (Quirt et al., 2018,pg-50). It can be caused due to indoor and outdoor allergens, smoking and environmental tobacco, respiratory illness, and even an unhealthy lifestyle (Chabra & Gupta, 2019). The smooth muscle mass in the lungs increases in a drastic amount, which results in severe bronchospasm during an exacerbation, the mucus secretion, is also increasing due to chronic inflammation in the lungs. All these changes overall reduce the elasticity of the airway wall of the lungs. Bronchoconstriction is the main dominant factor in the pathophysiology of asthma. The clinical symptoms are mostly due to airway tightening and a succeeding intrusion with the airflow. During acute exacerbations of asthma, bronchoconstriction occurs fast to slim the air route within the lungs in reaction to a variety of stimuli, including irritants. The allergens result in the secretion of mediators like tryptase, prostaglandins, leukotriene, and histamine from the mast cells from IgE-dependent release. All these directly contracts the airways of the lungs. Stress in the body also results in airflow obstruction which is one factor in this disease. This generates the secretion of pro-inflammatory cytokines in the body and results in inflammation (Castillo, Peters & Busse, 2017, pg-922). Airway remodeling is a mechanism of the body which is common among the patient with chronic respiratory diseases. This develops permanent structural changes in the lung airways and more progression results in loss of lung function. This increases airway obstruction, responsiveness and lead to the patient in responding less to the treatment. The changes includes thickening or tightening of subepithelial fibrosis, airway smooth muscle, basement membrane, blood vessel proliferation, hyper secretion and hyper plasia (Fehrenbach, Wagner & Wegmann, 2017,pg-560). The airway hyper responsiveness results due to inflammation, dysfunctional neuroregulation   and structural changes. The untreated condition results in the development of edema.

The patient in the case study was having symptoms such as wheezing sound, spo2 93%, spirometry result of FEV1, 36%, which was 42% during the last check-up. The patient was already suffering from chronic pulmonary obstructive disease and a sedentary lifestyle. He is a regular smoker and does not follow medication properly. The physical activity of the patient was also reduced. The average level of forced expiratory volume (FEV1) is 80% to 100% and the patient had 36% which means there is an obstruction in the airflow due to structural changes in the lungs along with the inflammation, which means the patient, had bronchoconstriction. The patient is a regular smoker, which serves as an allergen to the lungs for the development of asthma and inflammation by stimulating the pro-inflammatory mediators of the body. Wheezing sound in breathing is one of the most essential indications during asthma. It occurs due to inflammation in the lungs. The sound occurs when the air is pushed through the narrowed airways. The sound was prominent in this adult (Gonzalez-Garcia et al., 2015,pg-825). The spo2 level was 93%, which was below the normal range, that is 95%. It indicates the condition of hypoxemia that is low oxygen supply into the lungs and body cells (Sarkar, Niranjan & Banyal, 2017,pg-52). Another interpretation of this disease can be an older age. The immune system function reduces in more past ages, which results in the development of chronic infection in the body (Battaglia et al., 2016, pg-22). The patient already had COPD, which constricts the airways, and the regular consumption of cigarettes triggered in an allergic response and developed asthma. Mild Exercise is protective against asthma; the patient had a sedentary lifestyle, which exaggerated the development of this condition.  

Interventions   

The care strategy for asthma patient frequently emphases averting the hypersensitivity response, adjusting the allergens, stopping the incidence of rescindable difficulties, and preserving the airway patency. The care plan must follow all the standards of nursing practice. Here, in this case, Standard 1, Standard 2, Standard 3, Standard 6, and Standard 7 must be taken into consideration (NMBA, 2020). The plan must aim to reduce the condition of the patient by providing person-centered care and also routinely evaluating the treatment response. Person-centered care will make the patient less stubborn and adhering to the treatment. The most two crucial interventions must be assessing vital signs and prescribing drugs.

The primary goal of the plan must adequate in supplying oxygen into the lungs or help to reduce the inflammation. It can be achieved by evaluating the breathing pattern and rate, assisting the patient to maintain a comfortable position, advising him to perform coughing exercise, explaining the patient about the harmful outcomes of smoking and sedentary lifestyle, and administering drugs according to the practitioner’s guidelines or senior supervisors.   The nurse must assess the vital signs of this patient since he had a sign of hypoxemia. The nurse must effectively monitor the depth and rhythm of respiration. The anxiety level must also be assessed and try to reduce it by effective communication and by explaining the treatment plan (Baiardini et al., 2015, pg-3).  Paradoxical pulse reading must be evaluated along with the oxygen saturation rate.  Nurses must also assess the arterial blood gasses present in the patient body. The intervention must also include mild exercises, the proper position of the body, plan of rest in between physical activities, encouraging the patient to use pursed-lip breathing exhalation. The nurse must also assist the patient in consuming daily drugs as prescribed, such as short-acting beta 2 adrenergic agonist drugs, inhaled corticosteroids, and oxygen therapy (Morales et al., 2017,pg-18). Patient teaching must be another approach in reducing the symptoms in this patient. The nurse must also advise the patient in changing the lifestyle for better health outcome. The nurse must educate the patient in reducing smoking habits by different approaches such as explaining with the help of audio-visual, explaining further health risks, and also allowing the patient to interact with another ward patient for better believing the fact.

Rationale

The vital sign assessment will help in obtaining the correct blood pressure, respiratory rate, and heart rate and help in the identification of the hypercapnia, which will, in turn, rescue from developing respiratory failure.  The respiratory depth and rhythm assessment will help in identifying respiratory distress, which is common among asthma patients. The patient was already very much tensioned about the condition, which resulted in anxiety; the nurse must try to relax the patient with effectively listening to the issues and providing a calm atmosphere. The relaxation will help in dropping the condition of distress and help in reducing the restless state. Paradoxical pressure assessment will help in the early detection of respiratory failure (Van Dam & Fitzgerald, 2020). The evaluation of arterial blood gasses (ABG) will be helpful in early detection of respiratory alkalosis as the patient had a high chance of developing this state due to a lower level of oxygen supply into the lung, which is indicated, by the lower spo2 level. The rest between exercise interventions will be helpful in reducing the fatigue ness in the body by improving the supplying of oxygen into the lung. Mild exercise advising will help in reducing the inflammation by lowering the inflammatory proteins, which recovers and responds towards the Exercise by using more oxygen supply. This will be most effective for this patient as he is having lack of movements. The elevated head position will promote maximum expansion of lung and will improve the breathing pattern (Castillo et al., 2017,pg-922). The lip-pursed Exercise will help in improving the breathing pattern by allowing the entrance of new air and remove the old air from the lung (Cabral et al., 2015, pg-80). The oxygen therapy will reduce the state of hypoxia level and bring the spo2 at a reasonable level. The short-acting beta-beta-2-adrenergic agonist will help in relaxing the lining of the smooth muscles of the lungs, thereby improving the breathing pattern and also diminish the wheezing sound during breathing by clearing the air obstruction. The corticosteroids will effectively reduce mucus production from the lungs.

Outcome

The interventions will bring the spo2 level in 95%, the FEV1 will be between 80% to 100%, the wheezing sound will be diminished, and the patient will be stress-free and perform slight Exercise.

Problem 2-

Hypertension 

Hypertension is often a risk factor of asthma, which elevates the condition and also results in heart failure. It also exhibits three familiar pathological characters, such as inflammation, smooth muscle constriction, and muscle cell proliferation. Inflammation is associated with asthma and also results in the development of pulmonary arterial pressure due to the thickening of smooth muscle walls along with cell proliferation (Ferguson et al., 2014, pg- 680). It is due to the result of the reduction in pumping efficiency, which results in fluid accumulation in the lungs, also known as pulmonary edema. This results in breathlessness and wheezing. The condition of hypertension with asthma may result in cardiovascular disorder. The blood pressure rises due to peripheral resistance of the small arterioles, which comprises of smooth muscle (Nasreen et al., 2018,pg-36). The contraction of these smooth muscles is due to an increase in intracellular calcium contraction. The subsequent rise can also be due to the sympathetic overactivity of nerves.  The condition is associated with asthma, as it is characterized by cholinergic abnormalities, which results in cholinergic dysfunction, thereby increasing the allergic response in the body due to asthma and rising blood pressure. The patient, in this case, showed the risk of elevated blood pressure that is 125/60 mmHg, along with the rise of a pulse rate that is 84. The risk of developing this is due to lesser or forced blood flow into the body, and the oxygen level is decreased in the body due to smooth muscle proliferation. The patient is a smoker, which is a critical factor for developing this risk. The nicotine constricts the blood vessels along with the hardening of the lungs, which results in less blood flow into the lungs, and elevates the blood pressure. The untreated condition may result in a stroke. The patient also lives a sedentary lifestyle, which increases the chance of cardiovascular disease; the diet and physical inactivity hamper the systemic body circulation raises the blood pressure along with asthma symptoms (Hegde & Solomon, 2015, pg-10).

Intervention  

The nurse must assess the cardiac makers, blood cell count, and the level of electrolyte to identify the risk factors. The nurses in a regular shift must monitor the heart rhythm and the breath sound. It can be done from the heart, lungs, and any other organs. The skin colour, capillary refill time must also be tasted. The nurse must encourage the patient in adhering to a healthy diet, primarily a reduction in sodium intake. The nurse must also advise the patient to engage in self-care and also help in reducing the stress of the patient’s mind by recommending mild Exercise and even engaging in social activity. The skin and body temperature must be assessed regularly. The explanation of energy conservation techniques will also be effective in this case (Stoodley et al., 2019,pg-e55). The diet plan must be excluded from allergic food as the patient is grasped with asthma, and calorie intake must be reduced due to the risk of hypertension (Bazzano et al., 2013, pg-700). However, the patient must be allowed to choose the diet, which will feel the patient, relax, and also help in adhering to the treatment plan. Lastly, the patient must be educated with the harmful effects of smoking, and the nurses must guide rehabilitation methods to decrease the cigarette count.

Rationale

The electrolyte level assessment will be helpful in identifying the sodium, potassium level in the body, the auscultation of sounds will be useful in detection abnormality in rhythm, and stroke can be prevented. The skin colour will detect the presence of cyanosis or thrombosis in the body. The energy conservation will reduce the fatigue ness, and the patient will gain strength for movement. The relaxation therapy will reduce the stress condition, which will automatically reduce the risk of hypertension. The rehabilitation method (Nicotine therapy) will reduce the smoking intake and resolve both asthma and hypertension condition (Golechha, 2016,pg-7).

Outcome  

Blood pressure risk will be diminished. The pulse rate will be reduced. The patient will understand dietary management and involve himself in mild Exercise. The smoking consumption will also be reduced.

Conclusion

The above paper focuses on an older patient suffering from asthma and has a risk of developing hypertension. The patient developed this state due to excessive smoking and also due to the past history of the chronic pulmonary obstructive disorder. The condition can be identified by a few symptoms such as wheezing sound, spo2 93%, high pulse rate, sedentary lifestyle, and irregularity of the medicines. Asthma is a chronic inflammatory disorder that results in excessive secretion of mucus and narrowing of airways. The patient might also develop this state due to the progressive age. Hypertension occurred due to a defective supply of blood and oxygen due to the constriction of blood vessels. The paper also discusses nursing interventions for reducing both the consider, such as vital sign observations, drug therapy, change in diet, and mild exercises. Lastly, the paper discusses the outcomes of these interventions. 

References

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