NUR250 Medical Surgical Nursing 1
Questions:
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.
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
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
- Identify and explain
The specific nursing responsibilities associated with administering each medication and monitoring Neville for expected, side and adverse effects
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 newinformation. 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
- 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
Task 5: Clinical judgement and handover
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
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
Answers:
Task 1: Understanding nursing problems
Ineffective airway clearance– Inflammation and smoking contribute to enlargement of mucus glands that are responsible for causing goblet cell metaplasia. Healthy cells are replaced by cells that secrete more mucus. In addition, inflammation that is related to COPD leads to damage to the mucociliary transport system that is responsible for effectively clearing mucus from the airways. Both the factors contribute to excess production of mucus, blocking and worsening the airflow. The patient, therefore, suffers from ineffective airway clearance.
Impaired gas exchange– Impaired gas exchange takes place due to regional inequalities of perfusion and ventilation (mismatch of VQ). The process leads to hypoxemia. In more advanced stages it leads to chronic respiratory acidosis and hypercapnia. Other factors that contribute to gas exchange disturbance are impaired function of the cardiac system and pulmonary hypertension, leading to reduced mixed venous oxygenation (Andrews et al., 2013).
Risk of impaired ventilation– The direct result of the basic inflammatory response produced by COPD is an airway remodelling. There are a number of factors that lead to such conditions- accumulation of scar tissue from damage done to the airways, peribronchial fibrosis and over-multiplication of the epithelial cells present in the lining of the airways. Parencgynal destruction has a relation with the loss of elasticity of lung tissue that is a result of the destruction of those structures that support the alveoli. This implies that the small airways can collapse at the time of exhalation as a result of which airflow is impeded, and the air is trapped in the lungs, thereby reducing lung capacity.
Imbalanced nutrition: less than body requirements– Patient suffering from COPD have altered nutritional status. Their nutritional level is less than the requirement of the body. The factors contributing to such condition are multi-faceted. Decreased oral uptake of nutrition is linked with fatigue, weakness and dyspnea; nausea; early satiety due to compression of the stomach. Nausea is felt in response to any noxious stimuli. Moreover, metabolic needs are often increased as a result of increased energy expenditure due to strenuous breathing efforts as well as persistent coughing (DeBellis & Fetterman, 2012).
Risk for infection– Patients with COPD are at more risk for infections due to the impairment of the innate immune system of the body. Inadequate primary defences, as marked by persistent secretions and decreased function of the cilia of the body, is responsible for the colonisation of the individual’s respiratory tract with microbes. In addition, the individual also suffers from an increased risk of infection from new bacterial strains that lead to acute exacerbations (Althani et al., 2013).
Task 2: Care planning
Nursing Care Plan: Neville
Note: Dot points recommended in care plan. Click and type in each cell, click enter in a cell to make it longer
A reminder that all information must be referenced
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Nursing problem: Hydration |
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Underlying cause or reason: Hydration aids in decrease of the viscocity of secretions, thereby facilitating expectoration. Fluids helps in increase of gastric distension and increases the pressure on the diaphragm |
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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The goal of care would be to maintain the adequate hydration level of the patient
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The fluid intake of the patient needs to be increased to 3000 mL per day. Tepid and warm liquids are to be given. Intake of fluids is suitable between meals. The patient is to be helped to take the fluids in case he needs assistance. The fluid needs to be taken at a state comfortable for the patient. If oral fluids are tolerated then those fluids must be given that are preferred by the student. |
Fluid intake in form of warm fluids helps in expectoration. Patients may feel weak and require assistance of taking the fluids Suitable fluid intake facilitates the body functioning to optimal level
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Statement of breathing difficulty Changes in respiration rate Abnormal breath sounds such as wheezes, crackles and rhonchi (Cox et al., 2017) |
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Nursing problem: Mobility |
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Underlying cause or reason: Patients with COPD need to be kept in an active state for keeping muscles strong and utilise less oxygen. These patients show marked deficiency in muscle quality, mass and strength along with less mobility. |
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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To promote the mobility of the patient so that movement can be increased without external support
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The patient is to be encouraged to consider muscle exercise Present a safe environment through bed rails and other items Preventive measures are to be taken against skin breakdown from prolonged immobility Help the patient to carry out daily activities of living at his own pace. The patient is to be encouraged for carrying out activities independently in a safe environment.
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Adds to gain of increased sense of balance along with strengthening of compensatory body parts These measures promote a safe and secure environment for moving about. Reduction in risks of falls is also achieved Prevention of skin breakdown aids in mobility The patient’s confidence would be increased and recovery would be fast
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Patient is able to work towards an optimal activity level Patient is able to pace normal activities (Bendixen et al., 2014)
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Nursing problem: Clean and dressed |
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Underlying cause or reason: Patients with COPD have increased chances of getting infections that can bring decline in the breathing symptoms. Infections are the common cause of acute exacerbations, also known as COPD flare-ups. It is therefore necessary to maintain personal hygiene for the patients and be clean and dressed. |
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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To develop good hygiene practices and habits for maintaining the health of the patient and prevent infection
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Provide privacy for bathing Provide security and safe environment in the washroom Provide adaptive equipment in case needed Educate patient about the need of maintaining hygiene Encourage hand washing practices |
Privacy supports patients to consider regular bathing and washing A safe environment ensures that the patient is not afraid of using the washroom frequently
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Patient wears clean dress and changes regularly Demonstrates optimal hygiene practices Participates in verbal or physical self-care activities
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Nursing problem: Fed |
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Underlying cause or reason: Food provides the patient’s body with nutrients. Breathing requires more amount of energy for patients with COPD. The muscles that are utilised in breathing purposes have the tendency to require almost 10 times more calories in comparison to someone who is not suffering from COPD. |
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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The provide the patient with adequate nutritional support
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A balanced diet is to be provided to the patient Assistance is to be provided for feeding It is to be ensured that the patient eats at regular intervals |
Good nutrition aids in prevention of infections Body weight is maintained for proper breathing patterns |
Restoration of body energy Ability of the patient to respond to breathing coping strategies |
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Nursing problem: Rested |
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Underlying cause or reason: Adequate periods of rest is pivotal for achieving better outcomes in COPD management. Rest enables maximal body functioning and restores the ability of the patient to carry out the daily activities of life. |
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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To provide a suitable environment for the patient to get adequate periods of rest and sleep in order to support maximal body functioning |
A calm and peaceful environment is to be provided to the patient Regular periods of rest are to be encouraged Periods of rest are to be planned in between meals and not soon after and soon before meals
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A peaceful and calm environment promotes sleep patterns Suitable periods of rest in between meals facilitates proper digestion and enhancement of body functioning |
Patient able to carry out the daily activities of life Patient achieves a positive mental and physical well being Patient is able to respond adequately to the medications and other treatment regimen (Trappenburg et al., 2011)
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Task 3: Medication management
Oral prednisone is a form of steroid that is used for the treatment of a multiple of diseases, including COPD. Prednisone is an artificially made replica of cortisone, a steroid that helps in the regulation of the body’ salt and water balance. This is used as a therapeutic option for suppressing inflammation. Oral prednisone is used widely for treatment of COPD in the case where the symptoms are worse, such as acute COPD exacerbation. In the present case, Neville is suffering from increased mucus production and therefore has been given the medication. Ipratropium bromide administrated via nebuliser is indicated for treating reversible bronchospasm related to COPD. The compound acts to treat reversible airways obstruction by bringing about the relaxation of the muscles around the airways. In the present case, it has been used for Neville for controlling and preventing symptoms such as shortness of breath due to COPD. The patient would be able to breath properly as a result. Oral amoxicillin is an antibiotic directed against the common pathogens of the human body such as Haemophilus influenza, Streptococcus pneumonia, and Moraxella catarrhalis. Exacerbations if COPD is treated with such antibiotics. For Neville, amoxicillin would help in reduction of chances of associated infection of COPD as well as manage severe exacerbations (Lehne & Rosenthal, 2014).
The number of nursing responsibilities is associated with the administration of each medicine. While administering Oral prednisone the nurse must establish a baseline and then continue monitoring of data including BP, glucose level, I&O ratio, sleep pattern. It is required to be alert to the major signs of glycemia. Withdrawal symptoms are to be monitored, including nausea, fatigue, vomiting, dizziness, hypoglycemia, myalgia, hypotension, arthralgia. While administering Ipratropium bromide, it is essential to monitor the therapeutic effectiveness that is indicated by improvement in pulmonary function after 90 minutes of administration of the drug. The patient is to be monitored for tremor in the finger, tachycardia, and symptoms of GI instability. If the patient suffers from vertigo or dizziness, the physician is to be consulted immediately. Previous hypersensitivity to amoxicillin is to be determined prior to administration of the medicine. Signs of hypersensitive reaction might include itching, wheezing and dyspnea (McCuistion et al., 2014).
Task 4: Patient teaching
Neville needs to be educated about the importance of quitting smoking as he is a regular smoker with a past history of heavy smoking. The reason behind this approach is that tobacco smoking is an important risk factor for COPD. Smoking cessation is beneficial for achieving better patient outcomes in COPD. Smoking cessation has been proven to modify the natural course of COPD. It is the most cost-effective and efficient way fo treating COPD. Smoking cessation has been indicated to slow down the decline in the forced expiratory volume of air expelled in one second. Moreover, it brings a reduction in the bacterial colonisation in the bronchi and restores recovery of the natural defences of the body (Temitayo Orisasami & Ojo, 2016).
The topic is an important aspect of the care of Neville since he smokes 10 cigarettes each day and is giving difficulty in quitting smoking. In patients who have a history of smoking, COPD is aggrevated with a range of symptoms such as chronic coughing, excessive production of sputum, expectorations and shortness of breath. Neville must be taught about the importance of quitting smoking for slowing down the progression of COPD. It would be the best approach for managing the shortness of breadth as experienced by Neville (Chiappa et al., 2013).
It is necessary to ensure that Neville knows and understands the importance of the topic. This can be achieved by engaging in an informal communication with the patient. The language and the tone must be supportive in nature so that the patient hares his concerns with the nurse and expresses any challenges faced in understanding the education imparted.
Task 5: Clinical judgement and handover
Part A
Prn salbutamol nebuliser is a β2-adrenergic receptor stimulating drug used for having a bronchodilator effect. Though the drug is commonly well-tolerated, the severity and the incidence of adverse side effects are due to the dosage and hypersensitivity of the patient to the drug. There are potential side effects of the medicine and lead to allergic reaction. Common side effects include sweating, restlessness, tremor, dizziness, irritation, rash, redness of skin, muscle scramp, irregular heart rhythm, hyperactive behaviour and breathing difficulty (Boskabady et al., 2010).
Suitable measures are to be implemented for improving the breathing pattern of the patient. Prn salbutamol nebuliser is to be dislodged at the earliest. Actions are to be performed for reducing anxiety and fear of the patient. This would help the patient achieve stability and reduce restlessness. Actions are to be performed for reducing pressure on the diaphragm. This would include reduction of accumulation of fluid and gas in the GI tract. Pleural effusion is to be prevented for improved breathing patterns (Sulemanji et al., 2014).
Part B
Handover for Neville-
Identification- The patient is Neville, a 62-year-old man with established chronic obstructive pulmonary disease (COPD).
Situation- The patient has been suffering from breathing difficulty after administration of prn salbutamol nebuliser.
Background- The patient has a history of smoking and had been admitted to the hospital with worsening dyspnoea, cough and increasingly purulent sputum production. The patient had been suffering from tachycardia and elevated blood pressure. Current medications are ipratropium bromide oral amoxicillin, salbutamol nebulisers, oral prednisone, prn paracetamol and colony.
Assessment- The patient is likely to be suffering from the adverse drug reactions and needs proper management plan for reducing the adverse effects. The reason for adverse effects might be an overdose of the medication.
Recommendation- The accurate dose is to be measured before administration of the medication. The patient is to be supported with strategies for effective breathing pattern.
References
Althani, A., Bushra, S., Shaath, N., & Sattar, H. A. (2013). Characterisation of winter respiratory viral infections in patients with asthma and COPD in Qatar. Archives Of Virology, 158(5), 1079-1083. doi:10.1007/s00705-012-1576-4
Andrews, J., Sathe, N. A., Krishnaswami, S., & McPheeters, M. L. (2013). Nonpharmacologic airway clearance techniques in hospitalized patients: a systematic review. Respiratory Care, 58(12), 2160-2186. doi:10.4187/respcare.02704
Bendixen, H. J., Wæhrens, E. E., Wilcke, J. T., & Sørensen, L. V. (2014). Self-reported quality of ADL task performance among patients with COPD exacerbations. Scandinavian Journal Of Occupational Therapy, 21(4), 313-320. doi:10.3109/11038128.2014.899621
Boskabady, M., Boskabady, M. H., Mansouri, F., & Shafei, M. N. (2010). Pharmacologic bronchodilation response to salbutamol in COPD patients. Indian Journal Of Medical Sciences, 64(8), 363-372. doi:10.4103/0019-5359.100339
Chiappa, S., Winn, J., Viñuela, A., Tipney, H., & Spector, T. D. (2013). A probabilistic model of biological ageing of the lungs for analysing the effects of smoking, asthma and COPD. Respiratory Research, 1460. doi:10.1186/1465-9921-14-60.
Cox, K., Macleod, S. C., Sim, C. J., Jones, A. W., & Trueman, J. (2017). Avoiding hospital admission in COPD: impact of a specialist nursing team. British Journal Of Nursing (Mark Allen Publishing), 26(3), 152-158. doi:10.12968/bjon.2017.26.3.152
DeBellis, H. F., & Fetterman, J. J. (2012). Enteral nutrition in the chronic obstructive pulmonary disease (COPD) patient. Journal Of Pharmacy Practice, 25(6), 583-585. doi:10.1177/0897190012460827
Lehne, R. A., & Rosenthal, L. (2014). Pharmacology for nursing care. Elsevier Health Sciences.
McCuistion, L. E., Kee, J. L., & Hayes, E. R. (2014). Pharmacology: A patient-centered nursing process approach. Elsevier Health Sciences.
Sulemanji, D. S., Bao, F., Jiang, Y., & Kacmarek, R. M. (2014). A unidirectional breathing pattern improves breathing efficiency in subjects with severe COPD. Respiratory Care, 59(10), 1487-1493. doi:10.4187/respcare.02899
Temitayo Orisasami, I., & Ojo, O. (2016). Evaluating the effectiveness of smoking cessation in the management of COPD. British Journal Of Nursing (Mark Allen Publishing), 25(14), 786-791. doi:10.12968/bjon.2016.25.14.786.
Trappenburg, J. A., Schaap, D., Monninkhof, E. M., Bourbeau, J., de Weert-van Oene, G. H., Verheij, T. M., & … Schrijvers, A. P. (2011). How do COPD patients respond to exacerbations?. BMC Pulmonary Medicine, 1143. doi:10.1186/1471-2466-11-43.
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