NSG1204 Nursing Skills II

Based on the client, family and main caregiver assessment,

• identify one problem

Ineffective airway clearance

• provide evidences to explain and justify problem identified

Evidenced by increased sputum production, decreased effort tolerance to activity engagement.

Decreased partial pressure of arterial oxygen Pao2 – Decreased ventilatory response to hypoxia and hypercapnia.

• Problem identified is relevant and focused.
• Precise, focused and clear explanation of the problem identified.
• Justifications used are clearly explained with impact

Discussion of management plan

Based on the problem identified,

• provide relevant and clear explanation on the management plan
• show evidence of in depth knowledge and research
• show evidence of critical analysis and application
• Management plan is explained with great clarity and relevance.
• Advanced understanding of the problem / concept and its significance.
• Critical deliberations on its management plan and application.
• Insightful thoughts on the significance of management plan to the outcomes.

Scenario

The case involved a woman who in this case will be referred to as Madam P for confidentiality purposes. Madam P was a Sri Lankan female and was 98 years old. She presented herself with a current problem of pneumonia. On further interview about her past medical history, it was established that she had suffered from an Ischemic Heart Disease (IHD) and an Echocardiogram had been done back in 2017.The ejection fraction in this case was found to be at 60%.She also suffered osteoporosis which was due to vitamin deficiency back in May 2018.The calcium levels in this case were 29.A spinal stenosis and an L3 vertebroplasty was conducted back in 2009.The patient also suffered from recurrent falls. A Left neck of femur fracture was done back in 2008 as well as the T6 fracture. Conservative management was however done and it had a good recovery. The Right intertrochanteric fracture was also done in 2014 and a dynamic hip screw insertion was done. Madam P also suffered from hearing impairments especially of the right year a year ago and impacted wax was inserted. She was also diagnosed with diabetes mellitus 20 years ago. The HbA1c results were at 7% in March 2018.She also suffered from high blood pressure 20 years ago. Madam P has also previously suffered from Bronchiectasis and she suffered from asthma when she was 20 years old. Urge incontinence was also diagnosed 5 years ago and finally, a CA colon with hemicolectomy was done in the year 1979.

Identification Of The Problem

During the assessment, there were different problems identified. However, the one that was more significant in this case was ineffective airway clearance .According to research, pneumonia is a condition in which the air sacs of both lungs become inflamed (Hadwin, 2006). They later become filled with fluids or pus and this leads to cough characterized by phlegm or pus and difficulty breathing. Pneumonia can be caused by different agents that include viruses, bacteria or the fungi. The common signs and symptoms for the infection include shortness of breath, fatigue, chest pains whenever someone breath or cough and cough characterized by phlegm (De Sousa, Lopes, & Da Silva, 2014). The underlying condition however is ineffective airway clearance due to the accumulation of fluids in the air sacs. The management plan therefore focuses on how to correct or control ineffective airway clearance.

Management Plan For Ineffective Airway Clearance

There are different goals when drawing up a management plan for an ineffective airway clearance. Some of the objectives include the patient to maintain a clear and open airways and this can be seen by clear or normal breath sounds, a normal rate and depth of the aspirations (Karaca, 2017). The patient is also expected to demonstrate an increased rate in air exchange. The patient is also supposed to be able to classify methods that can enhance removal of different secretions .The patient should as well be able to note the significance of different changes in the color, character, amount and the odor of the sputum (Castellan, Sluga, Spina, & Sanson, 2016). The final goal of the management plan is to ensure that the patient identifies and avoids risk factors for ineffective airway clearance.

The initial step in the management plan for ineffective airway clearance is teaching the patient about the best ways to breathe and cough. This includes telling the patient to take deep breaths, holding the breath for about 2 seconds and then coughing two or three times consecutively (Beltrão et al., 2015). The objective of this plan is to ensure that secretions are removed. The best way to remove secretions is through coughing and therefore the patient has to get it right. Besides coughing, deep breathing is used to promote oxygenation before there is controlled coughing. Fever is one of the signs and symptoms of ineffective airway clearance. In this case, the nursing interventions is through regular checking of temperature by using a thermometer .Incase there is extreme temperature readings, the patient should report to the clinician in charge.

The patient is also supposed to be educated on optimal positioning of himself and the how to use a pillow or hand splints whenever they are breathing. The patient is also supposed to be taught on how to use abdominal muscles for a more forceful cough as well as the utilization of both the quad and the huff techniques (Pascoal et al., 2016). Use of the incentive spirometry and finally the benefits of ambulation and frequent changing of positions are other aspects that the patient is supposed to be educated during the management plan. The objective of optimal sitting positions and the hand splits is just to increase good coughing through increasing of the abdominal pressure as well as the upward diaphragm movement (Pascoal et al., 2016). Controlled coughing methods on the other hand are important since assist in mobilizing secretions to move from smaller airways to large airways since coughing is done at different times. Finally, the aim of educating the patient on the importance of ambulation is that it promotes lung expansion and mobilizes secretions. It also lessens what is known as atelectasis.

The nurse should ensure that the patient is placed in upright position and check the patient’s position on a regular basis so as to prevent sliding down in the bed. The nurse should also perform a nasotracheal suctioning as required more so if the cough is ineffective (Avena, Da Luz Gonçalves Pedreira, Herdman, & Gutiérrez, 2015) .The rationale behind the upright positioning is to limit on the abdominal contents from pushing upwards then inhibiting the lungs from expanding. This position is known to effectively expand lungs so that there is improved gaseous exchange. Nasotracheal suctioning is on the other hand essential especially when the patient cannot cough out secretions well due to weakness or excessive mucus produced.

The procedure ought to be explained to the patient very well as well as the use of soft catheters that are well lubricated. The catheter should as well be curved at the tip. The rationale for this plan is to ensure that secretions are removed from a specific side of the lungs, either the right or the left (Borge et al., 2015). The use of a well lubricated catheter on the other hand reduces irritation and prevent trauma especially to the mucous membranes. It is also important to explain the suctioning procedure to the patient since it stimulates a cough .It should however be noted that the frequency of the suctioning should be based on the condition of the patient and not on a routine basis. This is because excessive suctioning leads to hypoxia as well as injuries to the bronchial and the lung tissue. Another important nursing intervention is the blood monitoring and this can be done by the patient themselves through the use of blood monitoring sets of equipment. Most of these equipment’s are digital and the patient is only supposed to tie the cuff and then check the pointer readings. The patient should then report any abnormalities to the nurse.

The patient should also be instructed to take several deep breaths pre and post nasotracheal suctioning and utilize supplemental oxygen. The rationale for this is that hyper oxygenation before and after suctioning limits the possibility of hypoxia. The nurse also should stop suctioning and provide supplemental oxygen whenever the patient experience bradycardia as well as the increase in ventricular ectopy (De Sousa et al., 2016). The aim of this intervention by the nurse is to improve on the oxygen saturation so as to reduce any possible complications. To effectively monitor hypoxia, the nurse should educate the patient on how to use the pulse oximeter. This is an equipment used to estimate hypoxia. It uses arterial blood. The patient should therefore report any abnormalities of hypoxia to the clinician in charge.

Humidified oxygen should be maintained as prescribed to the patient and the patient should be encouraged to increase the level of fluid intake to approximately 3 liters a day and this should be within the limits of the cardiac reserve and the renal function. The nurse should also ensure that the patient adheres to the prescribed medications that include antibiotics, mucolytic agents, the bronchodilators and finally the expectorants. Both the effectiveness and the side effects of the drugs should be noted as well .The rationale for this plan is to ensure that secretions in the airways are eliminated so as to reduce airway resistance. An increase in the intake of fluids on the other hand is to minimize on the drying of the mucosal lining and maximize the ciliary action so as to move the secretions. Humidified oxygen on the other hand reduce the thickness of the fluids and assists in their removal. The nurse should also teach the patient how to use Portable home oxygen. This is an equipment that is plugged on electricity outlet .It then takes in oxygen from the environment, compresses the air, removes oxygen and finally deliver pure and humidified oxygen via the nasal cannula to corrective ineffective breathing.

The relevant nurse should coordinate with other respiratory therapists to conduct chest physiotherapy and nebulizer management as prescribed. A nebulizer should be used in case there is persistent ineffective airway clearance .A nebulizer is an equipment that converts drugs into a spray that is delivered to airways to improve breathing. Postural drainage, percussion and vibration should also be provided to the patient as ordered (Carvalho et al., 2015). Oral care should also be provided after every 4 hours. If the secretions cannot be cleared, the nurse should resort to intubation. This is because intubation facilitates the removal of tenacious and copious quantities of fluids and offers a good source for augmenting of oxygen. The rationale in oral care is to freshen up the mouth after respiratory secretions have been expelled.

References

Avena, M. J., Da Luz Gonçalves Pedreira, M., Herdman, T. H., & Gutiérrez, M. G. (2015). Respiratory Nursing Diagnoses: Presenting Evidence for Identification of the Defining Characteristics in Neonatal and Pediatric Populations. International Journal of Nursing Knowledge, 27(4), 184-192. doi:10.1111/2047-3095.12098

Beltrão, B. A., Herdman, T. H., Pascoal, L. M., Chaves, D. B., Da Silva, V. M., & De Oliveira Lopes, M. V. (2015). Ineffective breathing pattern in children and adolescents with congenital heart disease: accuracy of defining characteristics. Journal of Clinical Nursing, 24(17-18), 2505-2513. doi:10.1111/jocn.12838

Borge, C. R., Mengshoel, A. M., Omenaas, E., Moum, T., Ekman, I., Lein, M. P., … Wahl, A. K. (2015). Effects of guided deep breathing on breathlessness and the breathing pattern in chronic obstructive pulmonary disease: A double-blind randomized control study. Patient Education and Counseling, 98(2), 182-190. doi:10.1016/j.pec.2014.10.017

Carvalho, O. M., Silva, V. M., Távora, R. C., Araújo, M. V., Pinheiro, F. R., Sousa, T. M., & Lopes, M. V. (2015). Desobstrução ineficaz de vias aéreas: acurácia dos indicadores clínicos em crianças asmáticas. Revista Brasileira de Enfermagem, 68(5), 862-868. doi:10.1590/0034-7167.2015680514i

Castellan, C., Sluga, S., Spina, E., & Sanson, G. (2016). Nursing diagnoses, outcomes and interventions as measures of patient complexity and nursing care requirement in Intensive Care Unit. Journal of Advanced Nursing, 72(6), 1273-1286. doi:10.1111/jan.12913

De Sousa, V. E., Lopes, M. V., & Da Silva, V. M. (2014). Systematic review and meta-analysis of the accuracy of clinical indicators for ineffective airway clearance. Journal of Advanced Nursing, 71(3), 498-513. doi:10.1111/jan.12518

De Sousa, V. E., Pascoal, L. M., Do Nascimento, R. V., De Matos, T. F., Beltrão, B. A., Da Silva, V. M., & Lopes, M. V. (2016). Ineffective breathing pattern in cardiac postoperative patients: Diagnostic accuracy study. Applied Nursing Research, 32, 134-138. doi:10.1016/j.apnr.2016.07.005

Hadwin, P. (2006). Behavioural Change – An Evidence-based Handbook for Social and Public Health Colette J Browning Behavioural Change – An Evidence-based Handbook for Social and Public Health Shane A Thomas Elsevier 316pp £24.99 0 443 07357 0 0443073570. Nursing Standard, 20(29), 37-37. doi:10.7748/ns.20.29.37.s41

Karaca, T. (2017). Evaluation of First Year Nursing Students’ Care Plans-Nursing Diagnosis and Nursing Intervations. International Journal of Nursing Care, 5(1), 40. doi:10.5958/2320-8651.2017.00009.6

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

Pascoal, L. M., Lopes, M. V., Da Silva, V. M., Beltrão, B. A., Chaves, D. B., Herdman, T. H., … Costa, A. G. (2016). Clinical indicators of ineffective airway clearance in children with acute respiratory infection. Journal of Child Health Care, 20(3), 324-332. doi:10.1177/1367493515598648