NUR250 Medical Surgical Nursing

Explain the specific underlying cause/s (aetiology) or reason/s for each of the nursing problems above.Briefly explain why Neville has been prescribed:
o Oral prednisone
o ipratropium bromide via nebuliser
o Oral amoxicillin

Identify and explain
o The specific nursing responsibilities associated with administering each medication and monitoring Neville for expected, side and adverse effects 

 

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

 

Identify the specific information you will need to explain to Neville about the topic Explain
o Why the topic is an important aspect of Neville’s care
o How you will ensure that Neville knows and understand why it is important and, if appropriate to the topic, what he needs to do.

Based on the case study  the identified nursing problems are:

• Ineffective airway clearance-It is evident from cough and increased sputum production, which  led to severe obstruction in pulmonary path. Increased difficulty in breathing even after admissionwas due to ineffective airway clearance (Burt & Corbridge, 2013),
• Impaired gaseous exchange- occurs due to incomplete release of carbon dioxide or excess oxygenation at the alveolar-capillary Nivelle had pulmonary obstruction and increased sputum production due to which he had poor gaseous exchange. Due to excess trapped air the patient suffered shortness of breath and dysapnoea. This condition also made him tachycardic and elevated his blood pressure(Kim & Criner, 2013).
• Risk of impaired ventilation- Due to impaired gaseous exchange, Nivelle is at higher risk for perfusion inequality(Matkovic & Miravitlles, 2013). He was suffering from cold and the preventive medications did not seem to relieve the symptoms. Nivelle remains tachycardic with high blood pressure. Due to persistent shortness of breath on mild exertion, his nasal prong oxygen remains in place as his oxygen saturation level was below 90%. 
• Imbalanced nutrition-The patient is experiencing acute respiratory distress. In addition, current medication, dyspnoea, and increased sputum production had increased the risk of anorectic conditions. The patient is having poor diet due to pulmonary obstruction and shortness of breath on exertion even after admission.Nivelle, is having poor diet due to this condition and his body is not meeting its basic metabolic requirements adequately. He was ordered to push oral fluids and had high requirement of protein and carbohydrates. Consequently, it led to nutritional imbalance (Hsieh et al., 2016).
• Risk for infection-Being COPD patient, Nivelle’s innate immune system is very weak. This impaired immune system makes him highly vulnerable to infection in respiratory tract. Due to inadequate first line of defence the patient has reduced ciliary secretions increasing the susceptibility of bacterial colonisation (Matkovic & Miravitlles, 2013). Further, malnutrition added to this vulnerability and acute exacerbations. 

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

 Medication management 

Neville is administered with oral prednisone. This medicine has anti-inflammatory effect.  It is a glucorticoid and has been found effective in enhancing the lung function. It may reduce repeated admission of Nevelle. The medicines administered to Nevelle  is ensured that they are cost effective and are affordable by the family members. It is also effective to minimise the allergic reactions and immune disorders. However, the medication has contraindication that the patient may be hypersensitive to this drug (Abroug et al., 2014). It is the responsibility of the nurse to ensure patient safety. Hence, the side effects will be regularly monitored which include heartburn, depression, sore throat, increased sweating, thirst and acne. While administering this medicine, the patient and his family will be informed about the necessary diet modification and exercise program to improve the symptoms more quickly (Spencer & Hanania, 2013). 

Ipratropium bromide as nebuliser is used to control and reduce shortness of breath due to COPD. This drug helps the airways to open up so that the obstruction is cleared. It helps in muscle relaxation by inhibiting the effect of acetylcholine and inducing the cholinergic effect (Obeidat et al., 2016). The side effect of the medication include constipation, dryness of mouth, or and sudden worsening of breathing. Prior to administering this medicine it will be ensured that the patient is not allergic as this drug has the potential to interact with non-prescription drugs. Moreover, this medicine needs to be administered regularly for effective results. 

Oral amoxicillin is administered as Nevile is highly susceptible to bacterial infection in current situation. This medication needs intake of plenty of fluids. The patient will be educated about the contraindications such as gastrointestinal pain, irritation of eyes, nausea and vomiting which may occur as side effects of oral amoxicillin. There are adverse effects if used for prolonged period. This drug is found to have interactions and hence will be closely monitored (Brusse-Keizer et al., 2015).

While administering this medication it will be ensured that appropriated dosage will be given as recommended by the physician and take the approval of the doctor prior to change of dosage as a part of professional communication (Scotten et al., 2015).

Patient teaching 

Neville requires a nurse led education program on smoking cessation. Health literacy is essential for patients to better manage their illness (Kawayama et al., 2016). Nevelle is required to be explained on how smoking exacerbates the COPD symptoms. Smoking increases severity of airway obstruction. Smoking destroys the air sacs and the inner lining of the lungs along with inflammation (Sewell et al., 2014). Increased trapped air increases respiratory distress due to increased sputum production and thickening of airways. It eventually worsens coughing and exacerbations to an extent that may impair his mobility. Even mild exertion may lead to difficulty in breathing. Neville can be educated by means of videos and providing other educating materials illuminating on deteriorating quality of life  due to COPD and how smoking decreases the rate of survival (Stellefson et al., 2014). Thus, smoking cessation is an important aspect of Neville’s care. 

The patient’s understanding of the topic will be confirmed once he complains of unable to restrain from smoking. This is first step of taking initiative to cease smoking. It indicates that the patient had understood the consequences of smoking and decreasing life expectancy. The patient can be referred to motivational interviewing and regular counselling sessions to ensure smoking cessation. It will help Neville to stay firm in his decision. Cognitive behavioural therapy, rehabilitation and psychoanalytical approaches have been successful in preventing people from smoking, alcohol abuse and other addictions (Krishnan-Sarin et al., 2013). Since Neville’s wife is supportive, she must be educated on the adverse effects of illness, necessity of on time medication, and lifestyle modification needed for her husband.

Clinical judgement and handover

 In this situation it appears that Neville is experiencing the side effects of administered salbutamol nebuliser. It was prescribed due to elevated blood pressure and tachycardia. However, this medication was not justified due to contraindication that it is not administered when patient is having tachyarrhythmias (Albertson et al., 2013). The patient was not aware of it and he was given salbutamol nebuliser on his request. He is currently administered with oral prednisone, ipratropium bromide, and oral amoxicillin. 

The nursing interventions in this situation (Jellington et al., 2016) are-

• Assessment of lungs sound and vital signs- to ensure proper functioning of lungs
• Check ECG and pulse rythm- Since patient already had high blood pressure and tachycardic
• Increase brightness of light in room and rise bed rails-to reduce restlessness in patient and provide comfortable breathing
• Monitor auscultation of the lungs to identify bronchospasms 

Identify-

• Registered nurse appointed to care for patients with pulmonary disorders
• Nivelle is a 62 year old man admitted with established COPD
• Patient had history of excessive smoking

 Situation-

• Improvement in upper respiratory symptoms
• Shortness of breath and dyspnea
• Tachycardia
• High blood pressure
• Malnutrition
• Nnasal prong remains in place
• Currently administered with oral prednisone, ipratropium bromide, and oral amoxicillin

 Patient was admitted with worsening dyspnoea, cough and increased sputum production

• Excessive smoking history
• Persistent cough and cold
• Low respiratory rate
• Shortness of breath on exertion
• Unable to take more than few steps before rest
• Tachycardia and high blood pressure

 Agreed plan-

The patient has established moderate chronic obstructive pulmonary disorder (COPD)

• Continue nasal prong oxygen @ 2L/min
• Maintain oxygen saturation between 88-92%
• spirometry before and after nebulisers
• Diet to prevent malnutrition
• Continue with current medication
• Administer Pneumococcal and flu vaccines prior to discharge

 Read Back- 

Patient and family needs must follow up with attending physician and registered nurse for optimising treatment. A healthy lifestyle modification in addition to smoking cessation is required (Scotten et al., 2015).

References

Abroug, F., Ouanes-Besbes, L., Fkih-Hassen, M., Ouanes, I., Ayed, S., Dachraoui, F., ... & ElAtrous, S. (2014). Prednisone in COPD exacerbation requiring ventilatory support: an open-label randomised evaluation. European Respiratory Journal, 43(3), 717-724.

Albertson, T. E., Schivo, M., Zeki, A. A., Louie, S., Sutter, M. E., Avdalovic, M., & Chan, A. L. (2013). The pharmacological approach to the elderly COPD patient. Drugs & aging, 30(7), 479-502.

Bailey, P. H., Boyles, C. M., Cloutier, J. D., Bartlett, A., Goodridge, D., Manji, M., & Dusek, B. (2012). Best practice in nursing care of dyspnea: The 6th vital sign in individuals with COPD. Journal of Nursing Education and Practice, 3(1), 108.

Brien, S. B., Lewith, G. T., & Thomas, M. (2016). Patient coping strategies in COPD across disease severity and quality of life: a qualitative study. NPJ Primary Care Respiratory Medicine, 26, 16051.

Brusse-Keizer, M., VanderValk, P., Hendrix, R., Kerstjens, H., & van der Palen, J. (2014). Necessity of amoxicillin clavulanic acid in addition to prednisolone in mild-to-moderate COPD exacerbations. BMJ open respiratory research, 1(1), e000052.

Burt, L., & Corbridge, S. (2013). COPD exacerbations. AJN The American Journal of Nursing, 113(2), 34-43.

Corrado, A., Renda, T., & Bertini, S. (2016). Long-term oxygen therapy in COPD: evidences and open questions of current indications. Monaldi Archives for Chest Disease, 73(1).

Disler, R. T., Inglis, S. C., & Davidson, P. M. (2013). Non?pharmacological management interventions for COPD: an overview of Cochrane systematic reviews. The Cochrane Library.

Ghosh, A., Boucher, R. C., & Tarran, R. (2015). Airway hydration and COPD. Cellular and molecular life sciences, 72(19), 3637-3652.

Hsieh, M. J., Yang, T. M., & Tsai, Y. H. (2016). Nutritional supplementation in patients with chronic obstructive pulmonary disease. Journal of the Formosan Medical Association, 115(8), 595-601.

Ignatova, G. L., & Antonov, V. N. (2017). Impact of vaccination on the course of bronchial and systemic inflammation in patients with COPD and CHD. Terapevticheskii arkhiv, 89(3), 29.

Jellington, M. O., Sørensen, E. E., & Overgaard, D. (2016). Nursing challenges in relieving dyspnoea experienced by patients with COPD during hospitalization.

Kawayama, T., Kinoshita, T., Matsunaga, K., Kobayashi, A., Hayamizu, T., Johnson, M., & Hoshino, T. (2016). Responsiveness of blood and sputum inflammatory cells in Japanese COPD patients, non-COPD smoking controls, and non-COPD nonsmoking controls. International journal of chronic obstructive pulmonary disease, 11, 295.

Kim, V., & Criner, G. J. (2013). Chronic bronchitis and chronic obstructive pulmonary disease. American journal of respiratory and critical care medicine, 187(3), 228-237.

Krishnan-Sarin, S., Cavallo, D. A., Cooney, J. L., Schepis, T. S., Kong, G., Liss, T. B., ... & Rounsaville, B. J. (2013). An exploratory randomized controlled trial of a novel high-school-based smoking cessation intervention for adolescent smokers using abstinence–contingent incentives and cognitive behavioral therapy. Drug and alcohol dependence, 132(1), 346-351.

Matkovic, Z., & Miravitlles, M. (2013). Chronic bronchial infection in COPD. Is there an infective phenotype?. Respiratory medicine, 107(1), 10-22.

Melo, E. M., Albuquerque, M. P., & Aragão, R. M. (2012). Nursing diagnosis prevalence in patients at an intensive care unit of a public hospital. Revista de enfermagem UFPE on line-ISSN: 1981-8963, 6(6), 1361-1368.

Miguel Padilha, J., Sousa, A. P., & Pereira, F. M. (2016). Participatory action research: A strategy for improving self-care management in chronic obstructive pulmonary disease patients. Action Research, 14(3), 240-256.

Obeidat, M. E., Fishbane, N., Hansel, N. N., Rafaels, N., Mathias, R. A., Ruczinski, I., ... & Sin, D. D. (2016). Age, Sex And Genetic Factors Are Associated With Response To Ipratropium Among Individuals With Mild COPD In The Lung Health Study. In B58. BIG AND BIGGER (DATA): OMICS AND BIOMARKERS OF COPD AND OTHER CHRONIC LUNG DISEASES (pp. A4074-A4074). American Thoracic Society.

Omachi, T. A., Sarkar, U., Yelin, E. H., Blanc, P. D., & Katz, P. P. (2013). Lower health literacy is associated with poorer health status and outcomes in chronic obstructive pulmonary disease. Journal of general internal medicine, 28(1), 74-81.

Rutten, E. P., Lenaerts, K., Buurman, W. A., & Wouters, E. F. (2014). Disturbed intestinal integrity in patients with COPD: effects of activities of daily living. Chest, 145(2), 245-252.

Scotten, M., Manos, E. L., Malicoat, A., & Paolo, A. M. (2015). Minding the gap: Interprofessional communication during inpatient and post discharge chasm care. Patient education and counseling, 98(7), 895-900.

Sewell, L., Mitchell-Issitt, C., Barley, K., Chebbout, C., Msimanga, S., Clinch, L., ... & Singh, S. J. (2014). S84 Is There A Relationship Between Acceptance Of Referral To Smoking Cessation Services Or Pulmonary Rehabilitation And Readmission Rates For Patients With Copd?.

Spencer, P., & Hanania, N. A. (2013). Optimizing safety of COPD treatments: role of the nurse practitioner. Journal of multidisciplinary healthcare, 6(53-63).

Stellefson, M., Chaney, B., Ochipa, K., Chaney, D., Haider, Z., Hanik, B., ... & Bernhardt, J. M. (2014). YouTube as a source of chronic obstructive pulmonary disease patient education: a social media content analysis. Chronic respiratory disease, 11(2), 61-71.

Tønnesen, P. (2013). Smoking cessation and COPD. European Respiratory Review, 22(127), 37-43.

Uronis, H. E., Ekström, M. P., Currow, D. C., McCrory, D. C., Samsa, G. P., & Abernethy, A. P. (2015). Oxygen for relief of dyspnoea in people with chronic obstructive pulmonary disease who would not qualify for home oxygen: a systematic review and meta-analysis. Thorax, 70(5), 492-494.