Pathophysiology of Acute Pulmonary Oedema - Essay Example

Complex Care Nursing Pathophysiology of Acute Pulmonary Oedema The signs and symptoms which Mr. Smith is experiencing are very much related to his acute pulmonary oedema. In this disease, fluid from the pulmonary capillaries would leak into the pulmonary interstitial space and the alveoli air spaces (Caterino and Kahan, 2003). The fluid accumulates mostly because of the heart’s difficulty in pumping blood to the different part of the body. Excess fluid then leaks into alveoli and negatively impacts on the oxygenation process of the cells (Greaves, et.al., 2006). Due to accumulated lung fluid, lung stiffness sets in, thereby causing Mr. Smith’s dyspnoea; it also prompts him to use of his accessory muscles in breathing. Because of the lung’s diminished capacity to oxygenate blood, haemoglobin is circulated without being adequately oxygenated; in effect, this causes shortness of breath and cyanosis in the patient (Hannon, Pooler, and Porth, 2009). With more oedema, oxygen supply to the brain decreases and this causes disorientation and altered cognition in the patient (Hannon, Pooler, and Porth, 2009). Dyspnoea manifests with decreased oxygen supply and lung stiffness. The air moving into the alveolar field causes the crepitations and crackles heard upon lung auscultation (Hannon, Pooler, and Porth, 2009). With the fluid moving through the larger air paths, the crepitations and crackles become louder. Mr. Smith’s dyspnoea, as was discussed, is caused by the accumulation of fluid in the lungs. “Excessive secretions and inability to clear such secretions can compromise airways and increase airway resistance” (Ali, et.al., 2009, p. 2). In physically separating the alveoli from the pulmonary capillary vessels, the swelling or oedema would interrupt the carbon dioxide and oxygen exchange. In effect, there is lesser space in the lungs for slow and deep breaths; as a result, the patient’s dyspnoea manifests with rapid and shallow respiration (American Academy of Orthopaedic Surgeons, 2006). This difficulty in breathing causes the patient to exert more effort in breathing and in lung filling – hence the increased use of accessory muscles in breathing. His decreased oxygen saturation is primarily caused by the decreased oxygen being carried and circulated to the different cells of the body. Due to decreased volume of oxygen taken in by the lungs and due to the decreased capacity of the alveoli to exchange carbon dioxide for oxygen, the oxygen saturation of the cells is compromised and is detected by the pulse oximeter as lower O2 saturation. The patient’s anxiety is triggered by his above symptoms. His difficulty in breathing and other symptoms like his pink-tinged sputum all trigger his anxiety. As his pulmonary oedema becomes worse, his anxiety is also bound to increase. As his anxiety increases, the more that he will seem confused, and later, stuporous (Smeltzer, et.al., 2009). Five core nursing interventions 1. Monitor vital signs every 10 to 15 minutes This is a crucial intervention on the part of Mr. Smith because vital signs are the best parameters of a patient’s condition. It is an essential part of client’s care and it often forms the basis for identifying issues and planning interventions (Timby, 2008). In Mr. Smith’s case, it is possible to evaluate the worsening or the improvement of his condition through vital signs monitoring. Since Mr. Smith is a critical care patient, his vital signs are not stable and are expected to abruptly change. It is therefore important to monitor his vital signs at closer intervals (Jeremias and Brown, 2009). Such monitoring would assist in detecting abrupt changes in the patient’s vital signs. In such case, adjustments in the patient’s medication and interventions may be made accordingly and as each incident unfolds. Mr. Smith’s condition is critical and is bound to change based on each intervention implemented on his behalf. It is therefore important to check on his vital signs and to evaluate the presence or absence of changes as each intervention is carried out. Vital signs monitoring is a routine aspect of nursing care (Iyer, 2001). Its importance in the nursing practice is very much routine as it helps determine the patient’s stability. 2. Place the patient in a high Fowler’s position This position would help ease the patient’s breathing and would improve his lung-filling capacity. High Fowler’s position is a variation of the semi-Fowler’s position, but where the latter raises the patient at a 30 degree angle from a horizontal position, the former raises the patient at a 90 degree angle (Hegner and Needham, 2001). This position is actually for many patients who have difficulty breathing. Timby (2008) discusses that unless contraindicated by their condition, patients with decreased oxygenation can be placed in a high Fowler’s position. Such position “eases breathing by allowing the abdominal muscles to descend away from the diaphragm. As a result, the lungs have the potential to fill with a greater volume of air” (Timby, 2008, p. 462). In the case of Mr. Smith, positioning him in the high Fowler’s position would help ease his breathing and increase his oxygen intake. The importance of positioning in a high Fowler’s position was highlighted in a paper by Burns (1994). Their paper sought to establish the body position which optimizes breathing patterns in spontaneously breathing intubated patients with large abdomen. The authors covered nineteen intubated patients with abdominal distention, ascites, or obesity who were on continuous positive airway pressure. Their breathing was monitored at 0 degrees, 45 degrees, 90 degrees positions and at the reverse Trendelenburg position. The study revealed that the positioning patients at a 45 degree angle resulted in a lower respiratory rate than the 90 degrees position (Burns, 1994). The author highlighted the importance of easing spontaneous breathing among patients in order to facilitate eventual weaning off of mechanical ventilation and oxygen therapy. In the case of Mr. Smith therefore, carrying out and choosing the right intervention which would help ease his breathing is an important step in his recovery and his regaining spontaneous breathing. The high Fowler’s position is a useful tool in easing the patient’s breathing because it helps facilitate gas exchange (Springhouse, 2004). Oxygenation is an important goal for Mr. Smith because his blood pressure may increase as a response to decreased oxygenation (White, 2005). Considering the fact that Mr. Smith already had a stroke, it is important to avoid another stroke. Patient positioning is a simple process which helps prevent such an occurrence. The importance of placing the patient having difficulty breathing in a sitting position was supported in the study by Sullivan (1999) where he sought to present a case of unilateral pulmonary oedema after upper airway obstruction. His study assessed a 21 year old male to whom anaesthesia was induced with propofol and isoflurane. The patient had an episode of upper airway obstruction after being placed in a lateral position. He was placed on oxygen therapy to improve his oxygenation after he registered with decreased oxygen saturation (Sullivan, 1999). The chest x-ray indicated oedema in the patient’s lungs. Treatment included positioning of the patient in a sitting position and supplemental oxygen. After a few hours, the patient’s situation resolved. The importance of patient positioning among patients with pulmonary oedema and obstruction was highlighted in this case. It brings more support for the patient intervention in Mr. Smith’s case. 3. Teach patient to take slow deep breaths This intervention is about taking each breath slowly and deeply in order to increase oxygenation. This is also known as diaphragmatic breathing because it involves expanding the diaphragm and the abdomen as one inhales and then expanding the chest (Silberman, 2009). In this process, Mr. Smith must be taught how to take slow deep breaths. Mr. Smith would be instructed to inhale slowly, letting the abdomen expand in the process. This process would allow the lungs to fill up with oxygen. Instructing the patient to count to ten as he breathes in and out would help make the process easier to consistently apply (Silberman, 2009). First, Mr. Smith can be instructed to sit up in bed in a high-Fowler’s position. Then he would be asked to place one hand on his chest and one hand on his abdomen. He would then be instructed to breathe in through his nose, then exhale through his nose, and then repeat the process slowly (Silberman, 2009). He would be asked to feel his abdomen and his chest rise and fall with each breath. The nurse would also instruct Mr. Smith to slowly inhale and pause for a few seconds before inhaling. Then he should practice this process. He would later be asked to count to ten while inhaling and another ten while exhaling (Silberman, 2009). This process can be repeated and practiced by Mr. Smith. The importance of slow deep breathing in pulmonary affectations was highlighted in the study by Thomas and McIntosh (1994) where the authors set out to assess the conflicting body of literature on the efficacy of incentive spirometry, intermittent positive pressure breathing and deep breathing exercises in the prevention of postoperative pulmonary complications among patients undergoing abdominal surgery. The study revealed that the use of incentive spirometry and deep breathing exercises appeared to be more effective than any other intervention in preventing pulmonary complications among patients undergoing abdominal surgery (Thomas and McIntosh, 1994). In effect, this study presented strong support for the use of deep breathing exercises in the management of breathing difficulties among patients with pulmonary issues. It is an easy enough process to teach and to advocate for the patient because it is not invasive, nor is it a complicated process to carry out. 4. Closely monitor input and output including insensible losses from diaphoresis and perspiration (Swearingen, 2003) Normally, fluid input should match the amount excreted by the body through urine, sweat, and the air (Moonie, 2000). In instances when there is an imbalance in the patient’s input and output, different affectations and symptoms may manifest. In the case of Mr. Smith, he is already manifesting such an imbalance as shown by his pulmonary oedema. Patients like him have to have their input and output regularly charted for monitoring (Moonie, 2000). In instances when the input is greater than the output, this would mean that fluid is gathering somewhere in the body. Excess fluid in the body puts a strain on the heart and causes the oedema or swelling. This is very much true in the case of Mr. Smith. In instances when the output is greater than the input, dehydration is the resultant condition (Moonie, 2000). In these instances, the organs do not and cannot function at their prime condition. In patients whose fluid input and output is already compromised, it is important to monitor their condition for possible deterioration or improvements. Adjustments in Mr. Smith’s treatment may be needed in order to reduce imbalance and restore homeostasis. 5. Monitor for indications of decreased cerebral perfusion like restlessness, confusion, lethargy, stupor, and coma. Neurologic evaluations of the patient’s level of consciousness are important indicators of the patient’s cerebral blood flow (Baumherger-Henry, 2005). The behavioural manifestations like restlessness, anxiety, lethargy, irritability point to decreased cerebral perfusion. There is a need to monitor the patient for the presence of these symptoms in order to ensure that timely interventions are implemented for the patient. In instances when the patient manifests these symptoms, there is a need to “reorient and institute safety precautions as necessary. Notify the health care provider of significant or continued mental status changes” (Swearingen, 2003, p. 169). It is important to refer the appearance of symptoms which indicate decreased cerebral perfusion in order to ensure that the appropriate interventions would be implemented immediately for the patient. Failing to refer the patient to the attending physician may further lead the patient to reduced and/or absent responsiveness (Caroline, 2007). Non-invasive ventilation Non-invasive ventilation is of benefit in the acute management of acute pulmonary oedema. In this procedure, the patient must be seated in a semi-recumbent position in bed and a full-face mask must be utilized for the first 24 hours; it would then be switched to a nasal cannula if such is preferred by the patient (Royal College of Physicians, 2008). Initial positive airway pressure (IPAP) at 10cm H2O and expiratory positive airway pressure of 4-5 cm H2O must be utilized. For the most part, these settings are appropriate for most patients (Royal College of Physicians, 2008). IPAP must be raised by 2-5 cm adjustments at a rate of about 5 cm H20 per 10 minutes with the usual target of 20 cm H2O or until a positive response is gained from the patient. Oxygen must therefore be made available when necessary and its flow must be adjusted in order to gain favourable saturation. The bronchodilators should also be made available when necessary at the expiration port and the face mask (Royal College of Physicians, 2008). In cases when the nasogastric tube is placed, a fine bore tube is favoured in order to reduce mask leakage. The monitoring process in applying this non-invasive method in managing acute pulmonary oedema, includes a combination of physiological remedies and clinical standards. Such standards must then be used to formulate a management plan and to assist in the decision to intubate. Staff members caring for and monitoring of patients must be adequately trained and experienced (Royal College of Physicians, 2008). Recording on the following elements must be carried out in order to formulate a management plan: baseline observations (arterial blood gas, respiratory rate, and heart rate); continuous pulse oximetry and ECG recording of the first 12 hours; repeat ABGs (after an hour of therapy and an hour after every change of setting; after 4 hours or sooner among patients not improving); frequent clinical monitoring of ill patients (every 15 minutes on the first hour; every 30 minutes in the first to fourth hour; and hourly in the 4 to 12 hour period); observations on the patient’s respiratory rate; heart rate; level of consciousness; patient comfort; chest wall movement; and accessory muscle use; patient comfort (clinical assessment mask). In considering the duration of the patient’s treatment, the patients who are benefitting from non-invasive ventilation in the first four hours of treatment must receive it for as long as is possible (Royal College of Physicians, 2008). The treatment must also last until the acute nature of the disease is resolved, which is mostly after about 3 days. In patients who have successful courses with non-invasive ventilation after the first 24 hours, a weaning plan may already be started for them (Royal College of Physicians, 2008). In this case, the non-invasive ventilation must be gradually reduced based on the patient’s clinical improvement. In a discussion by Masip (2007), the author sets forth that there is sufficient evidence which supports non invasive ventilation with CPAP or NIPSV over the usual means of oxygen therapy in relation to the reduction of intubation of patients with acute pulmonary oedema. Studies seem to indicate a better outcome in respiratory failure patients using NIPSV. Using the CPAP is favourable because not much experience is needed to carry it out and it has shown better results in the studies. It may therefore show better outcomes for most patients with APO (Masip, 2007). In effect, this study seems to indicate that using non-invasive ventilation is an effective intervention for acute pulmonary oedema. It provides for improved outcomes for Mr. Smith, giving him improved oxygenation and ultimately, better chances for survival. Works Cited Ali, J., Summer, W., Levitzky, M. (2009). Pulmonary pathophysiology: a clinical approach. USA: McGraw Hill Professional American Academy of Orthopaedic Surgeons (2006). Emergency Care And Transportation of the Sick And Injured. New Jersey: Jones & Bartlett Learning Baumberger-Henry, M. (2005). Quick Look Nursing: Fluid and Electrolytes. 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