Respiratory System - Case Study Example

Case Study Student’s Name Institutional affiliation Case Study After seeking the patient's or a guardian's approval to proceed with the investigations, the extended care paramedic (ECP) shall begin a systematic examination of the patient. ECP serves to reduce the number of patients being referred or transported to hospitals limiting such events to cases beyond the scope of ECP (Finn et al., 2013). The respiratory system forms part of the critical elements envisaged in the prioritization of investigations and interventions for a paramedic attending to any patient under the ABC rule (Curtis & Ramsden, 2011). Systematic Respiratory Assessment The paramedics shall secure the patient in a well-lit, warm, quiet room and ensure that the privacy of the patient is withheld by covering the chest and breast area when not examining the anterior thorax. The patient shall be familiarised on the possible movements of their breast to facilitate percussion, palpation and auscultation of this field (Jarvis, 2012). Before the assessment is begun, the patient shall be taught the appropriate sitting position and breathing technique during auscultation of the patient's posterior thorax. This includes slightly hunching forward with arms crossed over the chest to maximize chest area open for assessment. Breathing shall be deeply and silently with slow inhalation and exhalation via an open mouth (Ali & Moore-Gillon, 2012). The sequence of examination shall begin with inspection, then palpation and percussion before finalizing with auscultation. Inspection Inspection is aimed at examining the respiration pattern, the skin, and the symmetry, integrity and configuration of the thorax (Ali & Moore-Gillon, 2012). Inspecting the skin shall reveal information regarding the patient’s overall nutritional state. Thoracic configuration. The patient shall be used as her own control to ascertain if there are any overt asymmetry when examining paired body parts. The anteroposterior diameter whose size ratio to the transverse diameter ranges from about 1:2 to 5:7 shall be examined for abnormalities. Appearance of a barrel chest – horizontal ribs and prominent sternal angle shall be indicative of various causes of this deformity that include asthma, panbronchiolitis, COPD, emphysema, chronic bronchitis and silicosis (Anthony, Singham, Soans & Tyler, 2009; Jarvis, 2012). Other areas to observe on the thorax include any non-uniformity in retraction of the thorax, chicken chest or any spinal deformities such as kyphosis and lordosis (Ali & Moore-Gillon, 2012). Respiration pattern. This pattern shall be essential in identifying any labored breathing by observing the movement of neck muscles such as the sternocleidomastoid and trapezius that are abnormally used as accessory muscles of respiration (Duff, 2007). During inspiration, retraction of the intercostal spaces may be indicative of air inflow hindrance while if expiration takes an excessively long time, it may be indicative of an outflow impedance (Jarvis, 2012). Normally, the respiratory rate of a resting normal adult is between 12 to 20 breaths/min with a pattern that is regular and unlabored. At a rate of at least 24 breaths/min, the pattern is labelled tachypnea while at a rate of at most 9 breaths/min, it is identified as bradypnoea (Ali & Moore-Gillon, 2012). Tachypnea may present in patients with lung or heart diseases, in anemic or anxious patients or after exercise or exertion (Cretikos et al., 2008). Palpation. This is done to expand the assessment of the abnormalities after observation or as implied by the health history. Areas assessed include the skin and its subcutaneous tissues and structures, the expansion of the thorax, the position of the trachea and the tactile fremitus (Ali & Moore-Gillon, 2012). The latter may be pathologically decreased over lung areas of pleural effusion and enhanced over lung areas with consolidation (Jarvis, 2012; Duff, 2007). The posterior chest, left and right lateral chest and the anterior chest shall be palpated. Assessment of thoracic expansion. This evaluation shall be from the anterior chest or the posterior aspect of the chest. The extent of thoracic expansion and the symmetry shall be felt and ascertained during quiet and deep respiration (Jarvis, 2012). Tactile fremitus assessment. Tactile fremitus is the vibration perceived when the thoracic wall is palpated as the patient vocalizes at low frequency (McGee, 2012). Tracheal deviation assessment. This is assessed by palpating the trachea at the suprasternal notch using the index finger. Unequal spaces bordering the trachea in the notch signifies lateral deviation of the trachea that may signify conditions such as unilateral emphysema, pleural effusion and tension pneumothorax (McGee, 2012; Jarvis, 2012) Percussion. The technique is applicable in ascertaining relative quantities of air, solid material or liquid in the underlying lung in addition to the determination of various organ positions and boundaries (Ali & Moore-Gillon, 2012). Percussion shall be done in a systematic pattern "moving from left to right and vice versa" for both the posterior and the anterior chest while avoiding bony areas. Assessment of diaphragmatic excursion may not be necessary since the patient has a normal respiratory rate (Jarvis, 2012). Auscultation. This shall be significant in assessing the patient’s breath sounds (BS) and any sound abnormality. Vesicular BS are heard on auscultation over a normal lung parenchyma. Presence of bronchovesicular BS over areas such as the peripheral lung of the patient may be indicative of an underlying pathological state. Similarly, bronchial BS heard over the parenchyma of the lungs and missing or decreased BS may be pathological (Duff, 2007). Wheezes heard on auscultation are due to air movement through narrowed lumen of the tracheobronchial tree. Pneumonia Severity Index (PSI) Class 1 PSI is a validated instrument used to stratify patients with community-acquired pneumonia (CAP) into various five classes depending on the morbidity and mortality risk (Aujesky & Fine, 2008). PSI class 1 patient is a patient with CAP aged less than 50 years, without a history of neoplastic disease, renal disease, liver disease, cerebrovascular disease or congestive heart failure. In addition, the patient’s mental status should not be altered and should have a systolic blood pressure of more than 90mmHg, a pulse of at most 125, temperature of between 350C and 400C, and a respiratory rate of at most 30/min (Jacobs, Goud & Shaikh, 2009; Aujesky & Fine, 2008). Based on the PSI, the patient can be grouped in PSI class 1. Management of the Patient ECP are allowed to ‘see and treat' patients at home, but there is a limitation on the type and condition of patients that their scope of practice allows them to manage. If the patient’s condition suddenly aggravates or after a systematic respiratory assessment, the patient is established to present with pleural effusion or airways patency suddenly deteriorates or the patient is intolerant of oral medication, the ECP may be required to transport the patient to a hospital for comprehensive assessment and management (SA Ambulance Service, 2008). ECP are allowed also to refer to an appropriate hospital or medical institution. At Silver Chain, the institution may admit the patient if she qualifies under the Silver Chain’s clinical protocol for CAP (Silver Chain, 2013). The patient may be eligible since her pneumonia is mild in PSI class 1. However, the patient may be excluded from the silver chain program if she is confirmed pregnant; if her condition exacerbates with a worsened CORB score (> 1) or PSI score of more than 3:, or her condition aggravates to necessitate the use of supplementary oxygen, or if she is identified as immunocompromised (Silver Chain, 2013). Silver Chain provides hospital-in-the-home services that allow eligible patients to be managed from their respective homes. Further investigations will be done such as pathological investigations throat swabs for examination. Treatment of the Patient ECP are allowed to treat using common oral and IV medication. Empiric treatment of the mild CAP in this patient may be by use of medicines such as oral cefuroxime 500mg taken two times a day for at least five days in addition to 500mg of oral clarithromycin 12 hourly or 200mg of oral doxycycline on the first day and 100mg on subsequent days of treatment (Maxwell, Mcintosh, Pulver & Kylie, 2005). The latter may not be used if the patient is confirmed pregnant due to the risk of teeth discoloration (Mcintosh et al., 2005). Analgesics, antipyretics and anti-inflammatory medications shall be used to relieve the fever and inflammation or pain associated with the infection (Richards et al., 2005). Drugs such as NSAIDS shall be suitable for relieving fever, pain and inflammatory symptoms. The patient shall be advised to increase her oral fluid intake to restore any fluid lost. The patient shall be monitored clinically to ascertain an improvement of the condition after treatment. Persistent or worsening symptoms 24 to 72 hours later may necessitate a reassessment of the patient's condition (McIntosh et al., 2005). The patient shall be assured of her recovery to relieve any anxiety. In addition, she shall be advised to rest and avoid strenuous activity that may trigger an asthmatic attack that may worsen the severity of symptoms while still under treatment of CAP. Conclusion ECP are allowed to assess and treat certain patients as defined within their scope of practice. This saves time and cost of transporting patients to the emergency department (ED) for management of conditions that can be effectively managed by ECP. It also reduces congestion in the ED allowing timely and efficient management of patients presenting in the ED. CAP is one of the conditions that may be managed by ECP. To manage it, they are equipped with history taking and assessment skills to help them reach an appropriate diagnosis and then ascertain the severity of the CAP. Based on the severity scores of tools such PSI, the severity and appropriate referral or transport to ED can be provided by ECP. References Ali, F.R. & Moore-Gillon, J.C. (2012). Basic systems. Respiratory system. In M. G. Drake (Ed.), Hutchinson's clinical methods, An integrated approach to clinical practice (23rd ed., pp. 147-164). Chatswood, NSW.: Saunders Elsevier. Anthony, M.P., SIngham, S., Soans, B. & Tyler, G. (2009). Diffuse panbronchiolitis: not just an Asian disease: Australian case series and review of the literature. Biomedical Imaging and Intervention Journal, 5(4), e19-e24. Aujesky, D. & Fine, M.J. (2008). The pneumonia severity index: a decade after the initial derivation and validation. Clinical Infectious Disease, 47(suppl 3), S133-S139. Cretikos, M.A., Bellomo, R., Hillman, K., Finfer, S. & Flabouris, A. (2008). Respiratory rate: the neglected vital sign. The Medical Journal of Australia, 188(11), 657-659. Curtis, K. & Ramsden, C. (2011). Emergency and Trauma care for nurses and paramedics. Chatswood, NSW: Mosby Elsevier Australia. Duff, B. (2007). The impact of surgical ward nurses practicing respiratory assessment on positive patient outcomes. Australian Journal of Advanced Nursing, 24(4), 52-56. Finn, J.C., Fatovich, D.M., Arendts, G., Mountain, D., Tohira, H., Williams, T.A., ... Jacobs, I.G. (2013). Evidence-based paramedic models of care to reduce unnecessary emergency department attendance - feasibility and safety. BMC Emergency Medicine, 13(13), 1-6. Jacobs, S., Goud, R.S. & Shaikh, A. (2009). Pneumonia severity index: A validation and triage tool study to help confirm clinical triage decisions in the emergency department to transfer patients with community acquired pneumonia for appropriate care. Australian Critical Care, 22(11), 65-71. Jarvis, C. (2012). Jarvis's Physical examination and Health Assessment. Chatswood. NSW: Saunders Elsevier Australia. Maxwell, D.J., McIntosh, K.A., Pulver, L.K. & Easton, K.L. (2005). Empiric management of community-acquired pneumonia in Australian emergency departments. Medical Journal of Australia, 183(10), 520-524. McGee, S.R. (2012). Evidence-based physical diagnosis. Philadelphia, PA: Elsevier Saunders. Richards, D.A., Toop, L.J., Epton, M.J., Town, G.I., Dawson, R.D., Hlavac, M.C. ... Werno, A.M. (2005). Home management of mild to moderately severe community-acquired pneumonia: a randomized controlled trial. Medical Journal of Australia, 183(5), 235-238. SA Ambulance Service. (2008). Extended care paramedics. Retrieved from http://www.saambulance.com.au/LinkClick.aspx?fileticket=7dKFTy8RTL0%3d&tabid=82 Silver Chain. (2013). Clinical protocol for community-acquired pneumonia. Retrieved from http://www.silverchain.org.au/assets/WA/Health/Home-Hospital-Protocols/Clinical-Protocol-CAP-CC-CP-004.pdf Read More