Treatment of Acute Respiratory Failure - Assignment Example

ASSESSMENT 2 - Case Study Based Assignment Q1. Four Key Pieces of Assessment Data Supporting the Diagnosis of Acute Respiratory failure In this assignment given the acuteness of the condition, a five-step Emergency Nursing Assessment Framework (EMNF) will be used to analyse the assessment data (Curtis, Murphy, Hoy, & Lewis, 2009), which would support the diagnosis of respiratory failure. This is a reasonable framework in this scenario since the events that are encountered are situational following the surgery and unexpected (Fry & Stainton, 2005). Although the presentation of need for supplemental oxygen, high respiratory rate, physical signs of labored breathings, and failure to achieve adequate oxygen saturations were evident, the cause of this was not clear in the clinical examination. There is evidence in literature that this problem may be solved through a nursing process approach where assessment of the patient, framing nursing diagnoses, care planning, care delivery, and evaluation of care may be done through a structured framework to accomplish the best results (Faucett, Ellis, Underwood, Naqvi, & Wilson, 2006). Within the nursing process, use of the stated framework has been demonstrated to be effective as a contextualised framework relevant to emergency conditions. This framework consists of 5 steps of history taking, potential red flags, clinical examination, investigations, and nursing interventions (Curtis, Murphy, Hoy, & Lewis, 2009). The inspection of his chest revealed intercostal muscle recession, and auscultation revealed diminished air entry at both bases of the lungs with crackles audible in the right base. The respiratory rate was higher than the baseline at 28 per min with deep and laboured breathing. His SpO2 was 89% on Hudson mask at 6 L of oxygen with elevation of PaCO2 to 54. All these information indicate that he was in acute respiratory failure (Delerme & Ray, 2008). The clinical picture indicates that this alteration in respiratory function has occurred over a short period of time. This patient was at baseline hypoxaemic indicated by his need for supplemental oxygen to maintain his oxygen saturations above 95%. Given his age and potential blood loss due to fractured neck of right femur this is expected, although the history does not suggest any chronic respiratory disease at the baseline (Calverley, 2003). This is an important part of history since quite frequently such patients develop acute respiratory failure superimposed on a chronic pulmonary condition such as chronic obstructive pulmonary disease, which is common in elderly men of his age (O'Malley, Marcantonio, Murkofsky, Caudry, & Buchanan, 2007). While initially 3 L of oxygen per min via nasal prongs ensured a 99% of SpO2 of 99%, postoperatively in 2 days' time, his condition deteriorated. The assessment while trying to reach a diagnosis must include an attempt to determine causes for such changes. Although high temperature of 38.5 degrees Celsius may contribute to higher rate of breathing, the laboured breathing and findings at auscultation strongly suggests respiratory failure, which is further confirmed by rise of PaCO2 to above 50 (El Solh & Ramadan, 2006). While a fall of PaO2 to below 50 is expected, given his oxygen supplementation, this may not occur always unless there is severe respiratory failure. As expected the pH is 7.30 which is less than 7.35 indicating respiratory acidosis along with oxygen destaturation indicated by SaO2 of 89%, which is below normal (Antonelli, Pennisi, & Conti, 2003). The X-ray picture confirms right sided basal consolidation and collapse, which may indicate an infective episode, which perhaps is the cause of this failure, since the other reason of overuse of PCA can be ruled out through the patient's statement. Q2. The doctor initially prescribed two antibiotics. The later appearance of fever and concomitant respiratory failure due to consolidation and right sided pleural effusion leading to collapse indicated that this infection has been acquired in the hospital. The decision regarding antibiotic administration must be very cautious, and indiscriminate use of antibiotics must be prevented (Rello, 2007). The prescription of two antibiotics seems to be legitimate due to the fact that hospital acquired infections are caused by methicillin-resistant staphylococcus aureus, which needs combination of antibiotics. If not treated early and adequately, there may be progression in respiratory pathology and may cause infection in his site of operation (Scaglione, et al., 2009), leading to complications such as osteomyelitis. Q3. Impaired gas exchange The first problem that needs to be intervened in this case is impaired gas exchange related to impaired chest wall movement and fluid in the lungs due to infection and/or aspiration. There were both increased work of breathing and pulmonary oedema. The primary survey revealed that being a postoperative patient, he had higher chance to develop atelactasis. Following surgery, the diminished breathe sounds and absent sounds indicated his inability to ventilate his lungs sufficiently. The crackles indicated that there were fluid in the in the lungs which might have been the result of consolidation. This is highly likely that these indicated his ineffective airway clearance. Furthermore, the breathing was rapid and shallow, and intercostal muscle retraction indicated his inability to maintain adequate minute ventilation. As indicated earlier, despite supplemental oxygen, he had hypercapnia, respiratory acidosis, and diminished oxygen saturation detected through pulse oximetry (Hoo, Hakimian, & Santiago, 2000). Since the patient was not able to maintain his minute ventilation, he was retaining carbon dioxide, and blood pH showed indications of falling. Hypercapnia also was leading to his confused and motionless state. Pathophysiologically, this appeared to be the case that hypoxaemia was caused by hypercapnia, and the CO2 retained by lungs was generating bicarbonate, predisposing to acidaemia and fall in pH (Sud, Sud, Friedrich, & Adhikari, 2008). Since respiratory failure is a life-threatening situation, this needs immediate intervention. The hypercapnia appears to be incidental, and while designing intervention it must be remembered that hypoxic drive caused by hypercapnia stimulates the respiratory centre to help maintain innate breathing cycles. Oxygen therapy is ongoing at a high rate of 6L per minute, thus the continued oxygen therapy is inadequate. Since pneumonia has been identified to be the cause of his problem, and likely atelactasis in the postoperative phase has precipitated such situation, pulmonary ventilation could be an effective alternative (Antro, Merico, Urbino, & Gai, Non-invasive ventilation as a first-line treatment for acute respiratory failure: "real life" experience in the emergency department, 2005). Before attempting invasive ventilation, it has been recommended that non-invasive positive pressure ventilation can be a worthwhile option (Brochard, Mancebo, & Elliott, 2002). Since it is expected that antibiotics will start controlling the pneumonia effectively, given no other history of prior respiratory disease, positive pressure ventilation using a face mask at 10 L oxygen per minute could improve his clinical condition and parameters in arterial blood gas analysis. Since there are crackles, it is interpreted that there is congestion in the pulmonary alveolar-capillary interface leading to problems with diffusion of gases. This could be due to atelactasis and/or previous respiratory disease. Since the patient is hypertensive, a dose of diuretic could help relieve congestion and moderate the blood pressure at the same time. Administration of oxygen should attempt to maintain PaO2 at 60 mmHg with SaO2 at 90%, and a partial re-breathing mask or aerosol mask ventilation would be warranted. Since diuretics are indicated, the fluid balance must be maintained so normovolaemia is ensured, meaning the patient should neither be dehydrated nor overhydrated. In such cases, the physician must be reported early on about the status of the patient, and preparation must be made for intubation and ventilation in case such need arises. On evaluation, clinically the patient should show improvement in respiratory rate, distress in breathing, lessening if intercostal retraction, oxygen saturation would improve with less oxygen, there would be no hypercapnia indicated by a PaCO2 of below 50 mmHg, with improvement in breathe sounds, less crackles, appearance of breathe sounds in previously detected areas of absent breathe sounds, and improvement in SpO2 to above 90% and consequent arterial blood gas parameters indicating acidaemia and blood pH within 7.35 to 7.45. The second priority intervention area is the nursing diagnosis of ineffective airway clearance leading to atelactasis. This may be related to increased and/or tenacious secretions. This is a contributing factor in postoperative respiratory failure in patients who has undergone surgery under anaesthesia. In cases with pneumonia superimposed on pulmonary collapse due to atelactasis, there are reports of increased secretions. The patient has evidence of hypoxaemia at baseline, and the abrupt increase in distress and associated hypercapnia and hypoxaemia suggest possibility of this condition. Damage to alveolar-capillary membrane might have caused leakage of fluid into the pulmonary interstitial space, and the crackles may signify this. Moreover, another serious condition namely acute respiratory distress syndrome (ARDS) may be causing this, since in cases of orthopaedic surgeries and pneumonia, ARDS has been reported to be the cause of such presentations. Bacterial pneumonia and fat embolism due to bone trauma are well known causes of such condition (Cheung, et al., 2004). Atelactasis leads to insufficient chest wall function, and thus the problem of ineffective airway clearance as a result of increased and tenacious secretions must be intervened as a second priority. These are indicated by diminished or absent breathe sounds or pulmonary oedema. In the first case, the patient had tachypnoea, intercostal retraction, and crackles for the second case. These indicate inability to ventilate the lungs so the atelactasis is prevented or ineffective clearance of the airway and/or accumulation of fluid in the pulmonary interstices. Thus chest physical therapy and adequate hydration to mobilize secretions would be the nursing intervention. These would improve chest wall function, prevent atelactasis, promote expulsion of secretion, and lead to clearance of airway, thus improving oxygenation (Wong, 2000). Some measures that effect better handling of secretions and prevent atelactasis are done and promoted through chest expansion. Secretion clearance is also accomplished through these measures. These are incentive spirometry, nebulisation, head of bed elevated 30 degrees, turning the patient frequently, and when able encouraging the patient to be out of bed (Morris, et al., 2008). The airway clearance is also maintained through chest physiotherapy which aids in removal of mucus. Fluid balance is also important in ensuring fluidity of tenacious secretions. Mucolytic drugs may be indicated for reduction of sputum viscosity. In order to assist removal of secretions, the patient may be suctioned as needed, specially when he is not able to cough. In the doctor orders bronchodilators for better clearance or prescribes corticosteroids to reduce airway inflammation, these would be given in such cases, to effect clearance or reduce production of secretions. It has been demonstrated that bronchodilators promote removal of secretion and ventilation. The patient would be instructed to cough and breathe deeply when able. As antibiotics would suffice to cure the causative condition, the support must be continued till the time of remission. With effective clearance of secretions, the chest examination would reveal gradual improvement in breathe sounds and crackles on auscultation. The area of pulmonary collapse would reduce, and this would contribute to improvement in gas exchange parameters reflected in the repeated measurement of arterial blood gases. The chest excursion would improve, leading to depth in currently shallow respiration, with consequent decrease in the respiratory rate. The cough reflex will increase and the sputum will be less tenacious. If such measures such as controlled cough, positive expiratory pressure valve therapy, or chest physical therapy fail to improve the atelactasis and associated respiratory failure, or if the patient becomes increasingly lethargic, cannot cough, fails to expectorate secretions, fails to cooperate with therapy, pH falls below 7.30, immediate report must be made to the physician, where a decision about ventilation may be taken to salvage the condition. Bibliography Antonelli, M., Pennisi, M., & Conti, G. (2003). New advances in the use of noninvasive ventilation for acute hypoxaemic respiratory failure. European Respiratory Journal (22), 65s - 71s. Antro, C., Merico, F., Urbino, R., & Gai, V. (2005). Non-invasive ventilation as a first-line treatment for acute respiratory failure: "real life" experience in the emergency department. Emergency Medicine Journal (22), 772 - 777. Antro, C., Merico, F., Urbino, R., & Gai, V. (2005). 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O'Malley, J. A., Marcantonio, E. R., Murkofsky, R. L., Caudry, D. J., & Buchanan, J. L. (2007). Deriving a Model of the Necessity to Hospitalize Nursing Home Residents. Research on Aging (29), 606 - 625. Rello, J. (2007). Importance of appropriate initial antibiotic therapy and de-escalation in the treatment of nosocomial pneumonia. European Respiratory Review (16), 33 - 39. Scaglione, F., Esposito, S., Leone, S., Lucini, V., Pannacci, M., Ma, L., et al. (2009). Feedback dose alteration significantly affects probability of pathogen eradication in nosocomial pneumonia. European Respiratory Journal (34), 394 - 400. Sud, S., Sud, M., Friedrich, J. O., & Adhikari, N. K. (2008). Effect of mechanical ventilation in the prone position on clinical outcomes in patients with acute hypoxemic respiratory failure: a systematic review and meta-analysis. Canadian Medical Association Journal (178), 1153 - 1161. Wong, W. P. (2000). Physical Therapy for a Patient in Acute Respiratory Failure. 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