Respiratory system - Research Paper Example

Reflective Practice Introduction Reflective practice is essential for clinical practice because it provides a retrospective look at current clinical experience and questions the reason for doing so. It is a good way of learning and it enables the practitioner to assess, understand and learn through their experiences (Burns and Grove 1997). I have used the "What? Model of Structured Reflection of Driscoll” to analyze the case study which I would be narrating below. The reflection model is cyclical in nature and triggers questions that aid reflection so that the practitioner is on the track with the process of reflection. The parts of Driscolls model are: 1. What?: A description of the event 2. So what?: An analysis of the event 3. NOW WHAT?: Proposed actions following the event Description of the event 24 year old James was operated for unruptured acute appendicitis and then shifted to the post-operative room where I was monitoring him. I went through the medical records to see if he had any other health related issues. His past medical history was uneventful, except for the fact that he was a smoker with about 20 cigarettes per day. The patient was brought to the post-op monitoring room with a guedel airway insitu. Since his heart rate, respiratory rate, blood pressure and saturations were within normal limits I removed the airway support. 15 minutes after this was done, I noticed the patients saturations dropping down to 91- 92%. I immediately started him on 100% oxygen by mask and informed the anesthetist. I waited for the anesthetist to come and review the patient. He auscultated the patient and ordered for a chest X-ray. As we waited for the wet film of the chest X-ray, I noticed the increasing respiratory rate of the patient, the further dropping of saturations and accessory respiratory muscle usage. Gradually, he began to bring out pink frothy sputum. I called the anesthetist back who started the patient on PEEP (Positive End Expiratory Pressure) to help increase his saturations which were now decreasing further from between 80-88%. I took over from anesthetist while he reviewed the X-ray. The CCOT (Critical Care outreach Team) was informed, on whose arrival CPAP (Continuous Positive Airway Pressure) was started. The on call ICU (Intensive Care Unit) Registrar was bleeped and a decision was made to transfer him to HDU (High Dependency Unit). Upon reviewing the chest x-ray it was confirmed that during extubation, there had been some laryngospasm which had lead to pulmonary oedema of the lungs. Analysis of the event I removed the guedel airway because James was maintaining stable vital signs and saturations in room air. Sudden dip in the saturations was totally unexpected. The recovery room was quite busy and I felt out of my depth and inadequate. Seniors and other more experienced staff members were not in a position to help because they were taking care of other patients. As the anesthetist was on his way, I was wondering what could have gone wrong in my management. Postoperative complications after appendectomy are minimal. The most common complication following appendicectomy is wound infection (Lee, 2009). Some patients may develop paralytic ileus (Lee, 2009). Respiratory complications are actually unheard of. I knew that normal oxygen saturations in a healthy individual are 97% to 99% and a value of 95% also is clinically acceptable (Schutz, 2000). But below that watchful vigilance is necessary especially in a post-op patient. Hence I immediately started 100% oxygen by mask. Also, I monitored other vital signs too until the anesthetist came. There was rise in heart rate and respiratory rate. But blood pressure and perfusion remained the same. When the anesthetist came, he first auscultated the chest. Auscultation of the chest provides valuable information for a physician. Abnormal breath sounds which are marked by an unusual location, loudness, or pitch allow understanding of the pathology of the lung disease. Fine crackles are heard in fibrosis, pneumonia, and lung congestion. Wheezing sounds are heard in reactive airways, asthma, smooth muscle hypertrophy, mucous plugging and external compression (Boyars, 1997). Such and other information can be obtained by auscultation. Though I was slightly nervous, I dared to ask the anesthetist what he heard on auscultation. He said there were many crepitations all over the lung fields suggestive of congestion of lungs. He said why this congestion occurred can be decided upon reviewing chest X-ray. I auscultated the chest and heard the crepitations. I felt bad that I did not auscultate before the anesthetist did. After all, auscultation of the lungs is essential to ascertain the cause of desaturation. After sometime, I noticed rapid rise in he respiratory rate, further fall in saturations and saw the patient struggling to breathe. I also saw the patient bringing out pink frothy sputum. I re-examined the patient and found that the heart rate and blood pressures had further increased and the patient was pale and in altered sensorium. I immediately paged for the anesthetist. The patient was already on 100% oxygen, hence there was nothing much from my side to do. As I waited for the anaesthetist, I was tensed and felt helpless. The most common cause for pink frothy sputum is pulmonary edema. Pulmonary edema is fluid accumulation in the lungs. This fluid accumulation can occur either due to failure of the heart to remove excess fluid from the lung circulation or due to direct injury to the lungs. The former is known as cardiogenic edema (Grossman, 2009) and the latter as non-cardiogenic edema. Non-cardiogenic pulmonary edema (NPE) occurs as a result of direct or indirect pathologic insult leading to changes in the permeability of the pulmonary capillary membrane. NPE occurs in drowning, fluid over load, acute glomerulonephritis, aspiration injury, inhalation injury, allergy and hypersensitivity and adult respiratory distress syndrome (Khan, 2008). Pulmonary edema leads to impaired exchange of gas across alveoli. The main complication of pulmonary edema is hypoxia and respiratory failure. Symptoms of pulmonary edema are dyspnoea, hemoptysis, excessive perspiration, anxiety and pallor. Pink frothy sputum is a classic sign of pulmonary edema. If left untreated, pulmonary edema can lead to coma and death. Pulmonary edema can be suspected by the symptomatology and clinical findings. Auscultation of the chest reveals end-inspiratory crackles which are characteristic of pulmonary edema. Chest X-ray shows increased fluid in the alveolar walls. It helps differentiate between cardiogenic and non-cardiogenic edema. In cardiogenic edema, pleural effusion, increased vascular filling, Kerley B lines and upper lobe diversion are seen. Whereas in non-cardiogenic edema, patchy alveolar infiltrates with air bronchograms are seen. Along with chest X-ray, other investigations like arterial blood gas analysis and echocardiogram help at the arrival of the diagnosis. The anesthetist started PEEP respiration using bag and mask. He then immediately informed the CCOT after seeing the X-ray, who started the patient on CPAP. I felt bad because the cause of deterioration of the patient was NPE due to laryngospasm secondary to abrupt airway removal. I also felt bad because I could not initiate certain procedures like PEEP myself and called the CCOT before the anesthetist. All others around me were experienced and hence were confident enough to handle the situation. But nobody blamed me for the incident. I learnt quite a lot form the incident and have a fair idea of how to handle such situations next time. Everybody appreciated the fact that though I was the junior most with less experience, I acted fast and in a timely manner. This incident helped me realize my role. I learnt not to worry about what others think about my inexperience. After all, everybody starts from this stage. Also, there is always lot of help available in times of emergency from the seniors and the experts. Hence I decided to do my duty without bothering about other things. Other staff on the shift who were seniors said that I acted pretty fast even during stress and that I must have trust in myself and not be afraid to speak up. Now What? Lessons learned from James example is that Quick action is imperative in any emergency situation. Team work and communication skills help pass through times of difficulty. One important aspect I learned during this episode was that CCOT is a reliable source of help and information during emergency. Also, the next time, I would be initiating PEEP myself if necessary. Also, I will call the CCOT without waiting for other’s permission. Conclusion The reflective analysis of a clinical experience helps one acquire proper knowledge, assess the positive and negatives in the management of a case and gives scope for further improvement. References Boyars, M.C. (1997). Chest Auscultation: How to Maximize Its Diagnostic Value in Lung Disease. Emergency Clinical Guide. Retrieved on March 3rd, 2009 from http://www.anisman.com/ecg/index.asp?mainpage=chest_auscultation.htm Driscoll, J. (2000). Practising clinical supervision. Edinburgh: Balliere Tindall. Grossman, S. (2009). Congestive Heart Failure and Pulmonary Edema. Emedicine from WebMD. Retrieved on March 3rd, 2009 from http://emedicine.medscape.com/article/757999-overview Khan, A.N. (2008). Pulmonary Edema, Noncardiogenic. Emedicine from WebMD. Retrieved on March 3rd, 2009 from http://emedicine.medscape.com/article/360932-overview Lee, D. (2009). Appendicitis and Appendectomy. MedicineNet.com. Retrieved on March 3rd, 2009 from http://www.medicinenet.com/appendicitis/article.htm Schutz, S.L. (2001). Oxygen Saturation Monitoring by Pulse Oximetry. Retrieved on March 3rd, 2009 from http://72.14.235.132/search?q=cache:cavmjtMkQrIJ:www.aacn.org/WD/Practice/Docs/ch_14_PO.pdf+normal+oxygen+saturations&hl=en&ct=clnk&cd=1&gl=in Read More