Reflective Nursing in Critical Care: Account of an Intubation - Essay Example

Reflective Nursing in critical care- Account of an intubation Introduction: Scientific and social changes of the 21st century have brought a radical change in the Health care delivery system. Nursing is an important component of the health care delivery system and the role of a nurse in patient welfare has no boundaries for praise. The Nursing profession has evolved through time to establish a firm role in the medical domain based on strong ethical, moral and professional principles (Suzanne, 2004). The nursing practice has undergone a positive shift from that of a vocation to a professional status today. That is to say, nursing has a more active role to play in the health care delivery system than the past and nursing, as a profession is 'accountable' today. The patient in this case was admitted for an acute exacerbation of COPD with the complications of Atelectasis and Cor pulmonale. Chronic obstructive pulmonary disease (COPD), also known as chronic obstructive lung disease (COLD), is a term used to describe progressive lung diseases, which include emphysema, chronic bronchitis and chronic asthma.The common symptoms of COPD are progressive limitations of the airflow into and out of the lungs and shortness of breath. Emphysema and chronic bronchitis are closely related and patients with COPD may have both, which affects lung function, preventing the lungs from bringing oxygen to the body and getting rid of carbon dioxide. Atelectasis is a condition where there is a collapse of part or all of a lung by blockage of the bronchus or bronchioles or by very shallow breathing. Atelectasis can be both acute and chronic. Acute atelectasis is the recent collapse of the lung and is primarily notable only for airlessness. In chronic atelectasis, the affected area is often characterized by a complex mixture of airlessness, infection, bronchiectasis, and fibrosis. The most common cause of atelectasis is an obstruction of a large bronchus. Smaller airways also become blocked. The obstruction is caused by a plug of mucus, a tumor, or an inhaled foreign object inside the bronchus. Alternatively, the bronchus is also blocked by a tumor, enlarged lymph nodes, or a significant amount of pleural effusion or pneumothorax in the pleural space. When an airway becomes blocked, the air in the alveoli beyond the blockage is absorbed into the bloodstream, causing the alveoli to shrink and retract. The collapsed lung tissue commonly fills with blood cells, serum, and mucus and becomes infected. Acute atelectasis is a postoperative complication, especially after chest or abdominal surgery. Cor pulmonale is the failure of the right side of the heart caused by prolonged high blood pressure in the pulmonary artery and right ventricle of the heart.The left side of the heart exerts a higher level of blood pressure to pump blood to the body.Whereas, the right side pumps blood through the lungs with a lower pressure. Thus, any condition that leads to prolonged high blood pressure in the arteries or veins of the lungs causes a condition called pulmonary hypertension.This pulmonary hypertension is not tolerated by the right ventricle of the heart and thus fails to properly pump against these abnormally high pressures leading to cor pulmonale.Chronic lung diseases like COPD or other conditions like Obstructive sleep apnea,Central sleep apnea,Cystic fibrosis causing prolonged low blood oxygen can lead to cor pulmonale.The symptoms include shortness of breath,wheezing, coughing, swelling of the feet or ankles,exercise intolerance,chest discomfort, cyanosis,distension of the neck veins indicating high right-heart pressures,abnormal fluid collection in the abdomen, enlargement of the liver,swelling of the ankles and abnormal heart sounds. Nursing interventions in Critical care: Dorothea Orem (1971) defined nursing with emphasis on client's self-care needs. Self-care, according to the theory, is a learned, goal-oriented activity directed towards the self in the interest of maintaining life, health, development and well-being. Intensive Care Unit (ICU) nursing is commonly referred to as critical care nursing. Critical care nursing deals specifically with the human response to life threatening conditions. Critical care nursing is challenging due to the nature of life-threatening health situations in the ICU. Critical care nurses are often in high-stress situations, which demand complex assessments, high-intensity therapies and interventions and continuous vigilance. Nursing interventions in critical care, thus, should be based on evidence-based practice. Evidence based practice is the conscientious, explicit and judicious use of current best evidence in making decisions about the case of individual patients (Sackett, 1996). The practice of evidence-based nursing is the integration of individual clinical expertise with the best available external clinical evidence from systemic research. Individual clinical expertise is the proficiency and judgment that nurses acquire through clinical experience and practice. External clinical evidence is the relevant patient centered clinical research from the science of medicine. This includes the accuracy and precision of diagnostic tests, prognostic markers, and therapeutic, rehabilitative and preventive regimens. External evidence sometimes replaces previously accepted treatments by virtue of accuracy and safety. Evidence based medicine takes patient's perspective also into account. Hence, evidence based medicine involves a big process of question building and this process of question building takes into account Clinical findings, Aeotiology, Diagnosis, Prognosis, Therapy and Prevention of diseases. This question building process gives the idea on the most important question, the question which is encountered very often in practice and the question's relevance very often in practice and the question's relevance to the patient situation. Evidence based nursing practice is probably best understood as a decision - making framework that facilitates complex decisions across different and sometimes conflicting groups. It involves considering research and other forms of evidence on a routine basis when making health care decisions. Such decisions include choice of treatment, tests or risk management for individual patients, as well as policy decisions for large groups and populations (Baum, 2003). At a broader level, evidence based nursing practice works by providing a safe framework in which different groups can make tough decisions by safe guarding their concerns by a fair and scientifically sound process. Medical interventions of critical nurse care Intubation: People with chest deformities or neurologic conditions that cause shallow breathing benefit from mechanical devices that assist breathing, such as continuous positive airway pressure, which delivers oxygen through a nose or face mask that prevent airways collapse, even at the end of a breath. Additional respiratory support can be provided with a mechanical ventilator. Head positioning is the most important step in intubation with the neck in the flexed position over the pillow. The laryngoscope, size 3 for women and 4 for men is introduced from the right side of the mouth until epiglottis is reached. Then the tip of the blade is advanced to the base of the epiglottis, known as the vallecula. This exposes the glottis below and the vocal cords forming a triangle on each side. Behind this is the trachea, and tracheal rings are visible. The tip of the endotracheal tube is advanced through the vocal cords and once the cuff has passed through, the nurse should stop advancing (www.ccmtutorials.com/rs/intubate/in_vent5.htm). The tube is secured at this level and the cuff inflated until the air leak is abolished. Care should be taken to avoid a high cuff pressure that can necrose the tracheal mucosa causing tracheal strictures. Endotracheal intubation can be confirmed by the presence of bilateral breath sounds and end tidal carbon dioxide measurement. Drugs administration: Antibiotics are to be given for any detected infection as in chronic atelectasis, when infection is almost inevitable. Treatment of atelectasis due to deficient or ineffective surfactant is done by treating the low blood oxygen either with mechanical ventilation or positive end expiratory pressure. For Cor pulmonale, Supplemental oxygen can be administered to increase the level of oxygen in the blood. A low salt diet is recommended. Diuretics can be given to remove excess fluid from the body. Calcium channel blockers, intravenous prostacyclin, or the oral medication bosentan are frequently used to treat pulmonary hypertension. Blood thinning anticoagulants are also useful.Oxygen administration relieves symptoms and prolongs survival.Careful intervention is essential because progressive pulmonary hypertension and cor pulmonale often leads to severe fluid retention, life-threatening shortness of breath, shock, and death. Benzodiazepines are not recommended to relieve anxiety usually occurring in patients with COPD because they decrease respiratory drive and compromise lung function. An anxiolytic, buspirone, have been found to be safe in reducing anxiety in COPD patients. Dyspnea is common in individuals with chronic obstructive pulmonary disease (COPD). Respiratory assessment of the patient should include present level of dyspnea measured using a quantitative scale such as a visual analogue or numeric rating scale.Usual dyspnea is measured using a quantitative scale such as the Medical Research Council (MRC) Dyspnea Scale.The other assessments include Vital signs, Pulse oximetry , chest auscultation ,chest wall movement and shape/abnormalities, presence of peripheral edema, accessory muscle use , presence of cough and/or sputum, ability to complete a full sentence and the level of consciousness.By doing so, nurses should be able to detect stable and unstable dyspnea and acute respiratory failure (American Thoracic Society,1998). Nurses should also be able to offer nursing interventions for all levels of dyspnea including acute episodes of respiratory distress which includes acceptance of patients' self-report of present level of dyspnea ,Medications ,Controlled oxygen therapy , Secretion clearance strategies,Non-invasive and invasive ventilation modalities,Energy conserving strategies ,Relaxation techniques, Nutritional strategies and Breathing retraining strategies. It is important for the nurses to remain with patients during episodes of acute respiratory distress. Medications include Bronchodilators ,Beta 2 Agonists ,Anticholinergics and Methylxanthines,Corticosteroids , Antibiotics ,Psychotropics and Opioids (www.guidelines.gov). Nurses have to assess patients for hypoxemia/hypoxia and administer appropriate oxygen therapy for individuals for all levels of dyspnea. Continuous Positive Airway Pressure Oxygen therapy is part of any ICU and requires absolute attention. Patient safety checks includes circuit leaks; maintenance of positive pressure; adequate inspiratory airflow and not leaving the patient alone. Managing the therapy involves maintenance of the desired FIO2; level of positive airway pressure and time period for CPAP therapy, attaching CPAP machine medical air and oxygen gas lines to wall sources, preparation of humidification source, selection of prescribed FIO2 on oxygen blender, turning flow on to level above 25 litres / min., positioning of rubber securing band behind the patient's head, centred on occiput, positioning of face mask over the patient', adjusting the level of positive expiratory pressure to prescribed level, adjusting inspiratory gas flow so that minimal fluctuations are present on pressure gauge, observing and documenting respiratory rate; work of breathing and SpO2, increasing inspiratory flow if respiratory work is excessive or the patient complains of continuing dyspnoea, Maintaining continuous SpO2 monitoring with alarm function in place, maintaining humidification temperature at 36 degree C or at temperature tolerated by the patient. Patient observations include, visual check every half an hour, documentation of respiratory rate, SpO2, nausea and vomiting, monitoring pulse rate and rhythm; blood pressure; peripheral circulation and proper functioning of humidification system every hour, checking the condition of skin around and under mask and rubber securing band, documentation of condition and interventions, condition of conjunctivae every two hours, auscultation of lungs for equal air entry and palpatation of abdomen for distension every four hours. Ventilator-Associated Pneumonia is a common nosocomial infection in the ICU accounting for 13% to 18% of all nosocomial infections. Critically ill patients supported by mechanical ventilation are especially vulnerable to ventilator-associated pneumonia, leading to increased mortality and morbidity and prolonged hospital stay. Because of intubations, bacteria have direct access to the lower airways and the endotracheal tube bypasses normal filtration mechanisms and the epiglottis .The endotracheal tube serves as a route for inoculation of the bacteria such as P. aeruginosa. Infection may be even due to improper hand washing, not changing the gloves from patient to patient, and contamination of respiratory devices like nebulizers, spirometers, oxygen sensors, bag-valve mask devices, and suction catheters (Shelby Hixson, 1998). Intubation affects and alters the natural host mechanisms by reducing the cough effort, interfering the mucociliary clearance, and damaging the epithelial layer exposing the basement membrane allowing bacterial colonization. Intubation also results in increased mucus production to trap bacteria, which results in accumulation of mucus in the respiratory tract. Proper hand washing, use of fresh gloves when suctioning patients orally or through the endotracheal tube helps in reducing infections. Oral hygiene is often neglected in intubated patients. Oral care includes brushing the patient's teeth, use of solutions and mouthwash to cleanse the mouth, and periodical suctioning of oral secretions. Nasal care and proper cleansing of the nasopharynx reduces bacterial infection. For patients who have a nasogastric or nasoenteric tube, the endotracheal tube is placed nasally. Since the tubes remain for prolonged periods, secretions accumulate and crust in the nares. Thus, routine cleansing of the nose and suctioning nasopharyngeal secretions should be done and evaluated. Stagnated mucus in the lower airways serves as an excellent medium for bacterial growth, when the pathogens reach the lower airways. (Julia, 1998). Periodic turning and positioning of the patient assists in disintegration of these secretions. Use of beds that provide vibration or rotation to prevent VAP is also recommended. Suction of patients is done only during auscultation of adventitious lung sounds or other assessments. This suction mandate reduces trauma to the airways. Stagnant mucus aided by a lack of a cough reflex aids infection and hence suctioning and interventions that facilitate effective coughing are to be done periodically. General Interventions: ICU patients especially with COPD are not in a position to speak due to respiratory intubation and cognitive difficulties. In such situations, communication forms the pulse of the nursing interventions. Is it so because nurses are the ultimate care providers after the doctors treat the patients. Various theories on practice of nursing touch upon this aspect of nursing. Non-verbal communications do occur in nurse-patient communication. The non-verbal communication includes patient directed eye gaze, affirmative head nod, smiling, learning forward, touch and instrumental touch (Wilma, 1999). If has been observed that these non-verbal communication have as tremendous impact on the patient's well being and comfort. The nurses and the patients seem to eye gaze, head nod and smile to establish a good relationship. A caring touch is an important form of non-verbal but often effective communication. If should be understood that the nurse should be able to perceive the expressions of the critically ill to provide maximum comfort. The needs of these patients can be effectively addressed only then. Cognitive impairments pose a serious barrier on the reliability of patient assessments. Effects of cognitive impairment on the reliability of such assessments has been studied recently (Phillips et. al, 1993) to explore the relationship between cognitive status and reliability of multidimensional assessment data. The studies have proved that the reliability of the patients communication and sensory ability are affected by cognitive status. Another critical issues of debate in nurse - patient relation ship with reference to critically ill patients is that the patient's contribution is always neglected. Literature reviews point out that nurses are seen to be controlling and restricting the conversations with the patients. There have been suggestions too, to train nurses on Communication skills. Assumptions have been seen as an important factor, which formed the basis of nursing communication without taking the views of the patients at all. Nurse-patient communication is not a series of isolated conversations, but a vital component of the care & comfort concept (Jarret, 1995). It is also important for the nurse to allow emotional expressions like tears, anger and frustration of the terminally ill. Allowing expressions of emotions relieves their psychological pressures. Research studies on the on the effect of information on illness in anxiety relief have shown that information to patients has an effect on the anxiety relief (Teasdele, 1993). The studies emphasize that patient anxiety can be relieved more reliably by the use of reframing and empowering interventions than by the presentation of information. Thus, use of non-verbal communication skills (NVC) to improve nursing care, especially with people who have disability has been assessed in a study (Chambers, 2003). The study outlines a nursing diagnosis of altered non-verbal communication and a new wellness diagnoses for enhanced non-verbal communication with detailed discussion on use of NVC with people with comprehension difficulties. The study stresses on the fact that nurses can be important in enhancing the non-verbal skills of the patient to help them communicate. Adding support to the view, the importance of improving communication by touch has been documented (Vortherms, 1991). The article views touch as an integral aspect of nursing care, with the language of touch including tactile symbols of duration, location, action, intensity, frequency and sensation. The article classifies touch as affectional, functional and protective. The article stress that age is not a category to decide upon touch in terms of reduced needs of touch. An examination of touch between nurse and elderly patients (McCann et. al, 1993) has shown that most nurses- patients touch interactions in a care of the elderly are instrumental in nature and expressive touches are usually given to body extremities like the forehead, arms and the legs. The gender and parts of the body touched influence the level of comfort. Conclusion: Thus, a nurse needs insight, sensitivity, effective communication skills and strategies to give what the patient needs and uphold the values of nursing care. The entire concept of care is based on communication, adaptation and recognition of the patient's needs. The ICU setting demands maximum nursing interventions and constant monitoring of the patients especially with conditions like COPD. Thus, there is also a need for specialist nurses who are experts in not only medical care but also patient care. ICU nursing is stressful and hence lots of research studies are in place to stress the importance of educating the nurses at the curriculum level on such interventions with renewed interests on communication and care aspects of nursing. The equipments in the ICU include various other instrumentations like ECG monitor, Oxygen supply, Heart lung machine etc. Most of the time, there is no coordination between the support staff and the surgeons in a theatre and this results in confusion and a reduced output on patient care. These Critical care nurses are often in high-stress situations, which demands complex assessments, high-intensity therapies and interventions and continuous vigilance. 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