NUR 231 Evidence Based Nursing Research
Question:
Mr. Hunter’s condition continues to deteriorate. He is receiving 15 litres oxygen via the nonrebreather mask. Severe dyspnoea renders him immobile and barely able to eat. He has little appetite and is cachexic. At night, he becomes quite restless and distressed by his pain, breathlessness and cough. The palliative care team reviewed Mr. Hunter 4 days ago because he was experiencing increased pleuritic pain on inspiration. Subsequently, he was prescribed morphine 5mg (5mg/ml) solution nocté for the analgesic, cough suppressant and sedative (narcotic) effects.Yesterday evening, in handover given to the night duty nursing team, it was explained that the palliative care team had reviewed Mr. Hunter again and reduced the dose of morphine to 2-0 – 2.5mg nocté because he was becoming drowsy during the day but was easily roused and orientated once woken and maintaining oxygen saturations 92 -94%.
2.Explain why is it important to recognise an opiate-naïve patient? Discuss how the nurse can mitigate the risk of adverse effects from administration of opiate medications in the opiate-naïve patient experiencing acute pain
3.The central principles of social justice in a health care context are self-determination, equity,access and rights and, participation. How do you interpret the actions of the nurse in withholding the prescribed morphine solution (nocté) from Mr. Hunter in relation to social justice principles Discuss the potential impact on Mr. Hunter if he perceives his treatment for pain to be unfair and unjust.
Answer:
Streptococcal pneumonia is the single most pneumonia causing agent in the elderly population. The specific considerations would be to focus on the acute care of the patient and after the significant improvement; RN should focus on patient teaching. The specific considerations by the Registered Nurse (RN) for Mr. Hunter in pneumococcal pneumonia are to improve the airway patency, provide rest to conserve energy, maintain adequate nutrition, proper fluid balance and work to prevent the further complications. RN would prioritize the improvement and maintenance of the respiratory function, prevention of complications, support his recuperative process and assess for the clinical manifestations like pleuritic pain, breathlessness, cough and tachypnoea (Van Leeuwen and Bladh 2017).
Nursing considerations would be to improve the breathing pattern in the patient that is manifested due to tachypnoea. Pain management is also an important consideration as he is suffering from pleuritic pain during inspiration. Rust colored sputum is a manifestation in pneumococcal pneumonia and so there is a need to monitor the patient’s respiratory secretions and restore his normal breathing patterns. There is also a need for considering the adequate nutrition and fluid intake along with risk for infection that would help to reduce the risk for infection and further complications. The respiratory status also needs to be considered after every four hours to escalate any change in breathing pattern and hypoxemic condition as a result of decreased oxygen levels (Tabloski 2013).
Altered ventilation and diffusion are the manifestations in pneumococcal pneumonia in the patient. There is altered ventilation as there is blocking of the airflow in and out of the lungs. There are two major mechanisms involved in this process. There is narrowing or compression of the airways and there is also disruption of the neuronal transmissions that is required to stimulate the airways mechanics. The gaseous exchange or ventilation takes place in the alveoli that is located in the lower respiratory system and this is altered in Mr. Hunter. This occurs primarily because the tracheostomy or endotracheal tube is occupied by the bacteria and present around the cuff that leads to ineffective airway clearance and breathlessness occurred in the patient. There is blockage of the mechanical process in the moving airflow in and out of the lungs and there is impairment in the diffusion of the gases that passes through the membrane in each minute. There is decreased efficiency in the exchange of gases as there is narrowing or compression of the airways triggering shortness of breath and reduced lung expansion (Masoumi et al. 2016).
In diffusion, oxygen and carbon dioxide get exchanged at the alveolar capillary junctions that are dependent on the partial pressures of the oxygen and carbon dioxide. This movement of gases between the plasma, alveoli and red blood cells depending upon the partial pressures determine the oxygenation status. This is altered due to pneumonia in Mr. Hunter as there is restriction of transfer of carbon dioxide and oxygen at the alveolar capillary junction due to less surface area for the exchange manifesting hypoxemia in the patient. Due to pneumonia, the oxygen is not able to get inside the cells and carbon dioxide is unable to get out of the body through the lungs where the exchange occurs at the alveolar capillary junction. Hypoxemia condition occurs as a result of lung dysfunction in the patients with pneumonia (Sachdeva 2016).
Hospital-acquired pneumonia (HAP) also called nosocomial pneumonia is caused due to any pneumonia (only bacteria) that is contracted by any patient who is admitted in a hospital for at least 48 to 72 hours. It is caused when it is spread from the external environment, any patient or staff where the source of the infection is difficult to understand. This is different from community-acquired pneumonia where the infection is contracted by an individual with little healthcare system contact. HAP patients live in long-tem healthcare facilities or make frequent visits to the hospital. Common bacteria that cause HAP are Staphylococcus aureus, P. aeruginosa, including the methicillin-resistant S aureus (MRSA), methicillin-susceptible S aureus (MSSA) and Klebsiella pneumonia. It is caused by bacteria and not by a virus (Lin et al. 2015).
CAP is the most common pneumonia type that includes bacteria, fungi, viruses and parasites. The most commonly causative organisms that causes CAP are Haemophilus influenza, Streptococcus pneumonia, atypical bacteria like Mycoplasma pneumonia, Chlamydia pneumonia, viruses and Legionella sp. The difference between HAP and Cap is that the latter is caused by viruses and bacteria both (Behnia et al. 2014).
Aspiration pneumonia is caused when an individual inhales food, saliva or stomach acid into the lungs and is a pulmonary aspiration complication. It is caused when there is defense impairment and the aspiration contents have harmful bacteria that cause the pneumonia. People with impaired coughing are not able to cough out the foreign contents and in this act, foreign materials remain in the lungs. It is caused by bacteria that generally reside in the nasal and oral pharynx. The gram-negative bacteria, Haemophilus influenza, Streptococcus pneumonia and Staphylococcus aureus are relatively virulent that produces a small inoculum that result into pneumonia. This inoculum is subtle and typically represents the aspiration pneumonia (Luna et al. 2016).
Nursing care plan for Mr. Hunter pneumonia is to provide support for the hypoxemia, impaired ventilation, adequate food and fluid intake.
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Nursing care for |
Rationale |
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Ineffective airway clearance |
It is done to clear secretions from the respiratory tract that may be caused to pleuritic pain. It would also help to maximize the expansion of lungs and improve breathing. It would also be helpful in drainage of secretions and promote aeration. |
|
Impaired gaseous exchange |
It is done to restore the deficit or excess carbon dioxide or oxygenation elimination that occurs at the alveolar capillary membrane as the patient has dyspnoea, hypoxia and restlessness (Butcher et al. 2013). |
|
Adequate nutrition |
To increase the metabolic needs that is secondary to infection and anorexia associated with the bacterial toxins. This helps to maintain the body weight with increased appetite. It would also help to replenish the lost nutrients in order to offset the hypermetabolic state of the patient. |
|
Deficit fluid intake |
This would be helpful in maintaining the appropriate parameters like good skin turgor, stable vital signs, capillary refill and moist mucous membrane. Fluid loss occurs due to mouth breathing or hyperventilation in the patient. The intake of warm fluids would also be helpful in expectoration and mobilization of the secretions. |
|
Acute pain |
Pleuritic pain due to persistent coughing and potential tissue damage anticipated with pain. Pain management would help to relief and control the pain with increase in activity tolerance, relaxation and proper rest and sleep (Torres et al. 2015). |
|
Activity intolerance |
Insufficient physiological energy to complete a desired activity as there is imbalance between supply and demand of oxygen with general weakness. The rationale is to increase the tolerance of the activity in the patient with dyspnoea absence and stable vital signs within patient’s acceptable level. |
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Risk for infection |
It is done to achieve the resolution of the infection and no further complications of secondary infection spread. It would also help to enhance the primary defenses to increase the ciliary action and respiratory secretions. It also increases the secondary defenses and decrease the immunosuppression and fight against the existing infection (Sopena et al. 2014). |
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Ineffective breathing pattern |
Improve ventilation as there is decrease in the gaseous exchange and hyperventilation. It is done to alleviate dyspnea, improve oxygenation and shortness of breath and to restore normal breathing. It would also be helpful in healthy gaseous exchange and increased absorption of oxygen in the patient (Lewis et al. 2014). |
There is a need to monitor the heart rate, oxygen saturation levels and body temperature of Mr. Hunter as he is suffering from pneumococcal pneumonia. These parameters are important to monitor in pneumonia because the low oxygen levels in blood accelerates the heart rate pushing the heart to go for abnormal rhythms and tachycardia. The high pressure in the lung blood vessels makes the heart dilate and throw electrical signals. Any kind of lung infection causes increase in the heart rate. The low oxygen levels as there is ineffective breathing pattern leading to low oxygen blood levels that makes the fast heart beta. Pneumonia can cause atrial fibrillation where there are irregular heart rhythms or atrial tachycardia fluttering the heart to beat 150beats per minute. Therefore, it is important to monitor the heart rate to restore the regular rhythm in pneumonia (Ooi and Wu 2014).
Fever or elevation of body temperature is a hallmark manifestation in pneumonia. It is important to monitor the body temperature in the pneumonia patient. The bacterial or viral infection is present and fever is an adaptive response to the infection where there is increase in the body temperature in pneumonia. The increase in body temperature is a clear manifestation of the development of pathogens in the respiratory tract that is produced by the pyrogens and inability of the body to neutralize the pathological process. Fever or elevation in body temperature occurs in pneumonia as the body attempts to destroy the infection and that elevates the body temperature. When this inflammation occurs in the air sacs or alveoli in the lungs, it is an indication of the body’s attempt to fight the infection causing fever (McCaughey 2014).
Oxygen saturation levels are important to monitor as the pneumonia decreases the availability of oxygen in the blood so its timely monitoring is important. There is also decrease in breathing ability and so oxygen saturation levels are important to maintain above 92% so that there is no external oxygen supplementation. It is important to monitor the oxygen saturation levels as low levels of oxygen indicates that there is low oxygen levels entering the blood from the lungs. During the inflammation, the air sacs are filled with fluid and so the lungs become more elastic and are unable to take up oxygen into the blood and in turn, there is poor removal of carbon dioxide from the blood. This results in shortness of breath as the most common symptom of pneumonia. Therefore, it is important to maintain the oxygen saturation levels above 92% in the patients with pneumonia as below 90% is linked with morbidity and mortality (Ochoa-Gondar et al. 2014).
When a patient deny nursing care, it is important for the nurses to give appropriate information about the patient’s current condition so that the person is able to accede with the procedure. The strategy include to achieve Mr. Hunter’s agreement to continue with the oxygen supplements by proving him information about pneumonia and giving him evidence for the importance of maintenance of normal oxygen levels. The nurse should demonstrate efficient communication skills with the patient so that he agrees to listen to the implications for not using the oxygen supplements. After a while, the nurse should encourage the patient to understand what he is refusing and what would be the consequences of his refusal. Patient teaching would be the best strategy that would help to make him to learn and accept the treatment that is life threatening (Meng et al. 2015).
Empathetic listening and good communication skills are important to develop good nurse-patient relationship that would enhance trust in the treatment with no refusal. Although there are ethical issues like autonomy, self-determination and participation and treatment, the nurse have to interact with the patient so that he or she accepts the treatment (Moorhead et al. 2014).
To manage the situation, the first line of action would be to understand Mr. Hunter’s point of view to know the patient’s thinking about the entailing of the procedure. This would help the nurse to understand the underlying reason of the patient in making that decision. This opens an opportunity for the nurse to make the patient understand their condition and implications of the denial of the treatment. This would also provide a scope for the patient teaching and how the procedure would help him. The discussing of the concerns is another action that would be helpful in encouraging the patient to bring about his concerns about the procedure. The communication skills can be utilized by the nurse in making Mr. Hunter understand the implications of the procedure denial and make him accept the treatment and in the management of the situation (Kuhse, Schüklenk and Singer 2015).
The two important things that I have learned from this scenario is the identification of the specific healthcare needs and in managing ethical dilemma to develop patient centered care and care strategies that consider the specific needs of the patient. It also helped me to develop problem-solving skills and critical thinking that can be applied to decision-making and practice safe nursing in the clinical settings. This scenario also provided me an opportunity to learn the importance of clinical reasoning cycle in nursing practice. This steps in the cycle like collection of cues, processing of information that is helpful in understanding the patient situation and problem along with planning and implementation of interventions. This would also be helpful to evaluate the patient outcomes and reflect on their own learning process. It is an important tool in building excellence to deliver patient-centered care where there is capacity for critical thinking, clinical reasoning and reflective practice.
My future action plan will be to improve my critical thinking skills to make my decision-making and problem solving skills more efficiently to apply in safe nursing practice. This will also help to entail effective communication skills that would be helpful in managing the ethical dilemma that might arise during the course of nursing practice. I will also use the clinical reasoning cycle efficiently in my professional practice that would influence my experience and knowledge in using the reflective thinking as a part of learning and identification of opportunities and issues faced during nursing practice.
References
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