Diagnosis: Right-Sided Pneumonia Leading to Acute Respiratory Failure - Essay Example

? Diagnosis: Right-Sided Pneumonia Leading to Acute Respiratory Failure Diagnosis: Right-Sided Pneumonia Leading to Acute Respiratory Failure Question 1 Two days after Mr. Bukowski’s operation on the fractured right neck of femur, four key pieces of assessment data supporting the diagnosis of acute respiratory failure were observed. These includes abnormal respiration pattern, auscultation of breath sounds, measurement of arterial blood gases, and chest X-ray (CXR). The first key assessment data and the most observable symptom in the case of Mr. Bukowski is abnormal respiration pattern. The sympathetic nervous system is being stimulated by the increased carbon dioxide in the arterial blood, leading to increased heart rate and respiratory rate that helps the body to compensate for the hypercapnia and hypoxia (Smyth, 2005, 72). This is demonstrated by the elevated respiratory rate of Mr. Bukowski two days after the operation which is 28 breaths per minute and the observance of deep and labored breathing pattern. There is indication that he has been experiencing limited chest expansion as evidenced by intercostal muscle recession thus, indicating also his right lung has collapsed and will not received enough ventilation (Higgins & Guest, 2008, 24). The abnormal respiration pattern characterized by increased respiratory effort and collapsed of the right lung supports his diagnosis of Acute Respiratory Failure. In Mr. Bukowski’s case auscultation of breath sounds is the second key assessment data needed to support the diagnosis of acute respiratory failure. Kaynar & Shama (2010) indicate that the most common reason for respiratory failure is the mismatch in the ventilation/perfusion (V/Q) (n.p). Mr. Bukowski was diagnosed with pneumonia and includes physical findings such as crackles, rales, decreased intensity of breathing sounds and presence of rhonchi breathing sounds, and used of accessory muscles during respiration. The presence of course crackles will lead to V/Q mismatch because course crackles in pneumonia indicate that he has existing secretions in the airway (Shackell & Gillespie, 2009, 18). Therefore, the contributing cause of respiratory failure in Mr. his case is diminished ventilation secondary to the presence of crackles and diminished entry sounds as revealed during the assessment process. The third key assessment data and the most definite indicator of acute respiratory failure is the measurement of arterial blood gases (ABG). Acute respiratory failure is a state in which the respiratory system fails to perform the gas exchange function (Lightower, Vedzicha, Elliott & Ram, 2003, 185).The body fails to excrete carbon dioxide which leads to hypercapnea, a condition where the partial pressure of carbon dioxide (PaCO2) is more than 45mmHg (Delerme & Ray, 2008, 252; Mueller, 2008, 787). The retention of carbon dioxide in the body (hypercapnia) contributes to the respiratory acidosis of clients with respiratory failure thus, categorized as Type 2 respiratory failure (Smyth, 2005, 72). The ABGs measurement of Mr. Bukowski reveal a PaCO2 level of 54mmHg and a pH of 7.30. The increased of PaCO2 level above the normal range indicates that he is having hypercapnia and pH level below the normal range (7.35-7.45) indicate also respiratory acidosis. Meanwhile, it is not only retention of carbon dioxide gases that contributes to respiratory failure but the limitation of gas exchange such as oxygen as well (also called arterial hypoxemia) (Kaynar and Shama, 2010, n.p.). Progressive diffusion barrier and V/Q mismatch, also called alveolar hypoventilation, caused the arterial hypoxemia in patients with acute respiratory failure (Levy, 2005, 548). Arterial blood gases measurements of Mr. Bukowski revealed a low partial pressure of oxygen (PaO2) level of 58mmHg and low oxygen saturation (SaO2) level of 89%. The normal PaO2 level is between 80mmHg to 100mmHg while SaO2 level 95%-98%. Even with oxygen administration of 6L/min via Hudson mask, ABGs remain in respective values. The results of the arterial blood gases measurements of Mr. Bukowski significantly support the diagnosis of acute respiratory failure as manifested by hypoventilation. The Chest X-ray is the last key pieces of assessment data and the visual evidence of acute respiratory failure. Mr. Bukowski has right-sided basal consolidation and collapse, as observed in the chest x-ray result. In unclear pneumonia cases, chest x-ray is considered as an important tool for determining air-space consolidation or air trapping in one or more segments of the lung (Vilar et al, 2004, 102). Mr. Bukowski’s chest x-ray result indicates that he has pneumonia leading to acute respiratory failure and that health practitioners can infer that extreme V/Q mismatch called shunt are present due to the observed collapse area of the lungs. Meaning, alveoli are obstructed (atelectasis) and cannot supply oxygen to the pulmonary capillaries (Borges et al, 2006, 268; Kaynar and Shama, 2010, n.p.). Therefore, aside from ABG results, Chest X-ray is also a significant indicator of acute respiratory failure. Question 2 Patients with infection are often prescribed with broad-spectrum antibiotics to avoid the possibility of resistance and administration of wrong antibiotic treatment. The traditional antibiotic therapy of identifying the infecting microorganism first before initiating antibiotic therapy might be fatal as delaying antibiotic therapy increases the resistance of infecting microorganisms to narrowed-spectrum antibiotics. Infection occurs when the neutrophils of the body is not sufficient enough to combat pathogenic agents (Frost, 2007, 51). In treating infection, a combination of two or more antibiotics is required as one bacterial antibiotic may not kill all pathogenic miroorganisms (Frost, 2007, 51). In an empirical study done to treat antibiotic infection, Eerden et al (2005) described that broad spectrum antibiotics are used because of the advantage of preventing antibiotic resistance (p. 672). In addition, Macleod et al (2009) have proved in their experiments that a combination of antibiotics has more curative effects on respiratory infections because Gram-positive and Gram-negative bacteria are targeted when using broad-spectrum antibiotics (p. 829). Lipman & Boots (2009) stated that a new paradigm emphasizing appropriate antibiotics and dosage in the duration of 5-7 days period must be implemented in order to reduce tolerance and that broad-spectrum antibiotic therapy must be started as soon as microbial culture has taken (p. 276). The cause of pneumonia of Mr. Bukowski is unknown. It may be from Gram-positive bacteria or Gram-negative bacteria. Therefore, initiation of two broad spectrum antibiotics, either ?-lactamase, macrolides, or quinolones must be used to treat the uninvestigated pneumonia of Mr. Bukowski. Question 3 Effective Breathing Pattern Primary interventions were used in prioritizing Mr. Bukowski’s need over the first eight hours of shift. “Primary Survey” assesses and prioritized patient’s problem in terms of airway, breathing, circulation, and disability (Brown et al, 2008, p. 1926). The priority in Mr. Bukowski’s case is breathing pattern since assessment revealed a deep, labored, and elevated respiratory rate of 28 cycles per minute and low SaO2 level of 89% despite administration of 6L of oxygen via Hudson mask. Brown et al (2008) stated that airway must be clear and free from obstructions first before attending other health problems (p. 1927). Thus, after attending airway problems, regulation of effective breathing pattern becomes the next priority. Before addressing other interventions, pain due to post-operative condition from Mr. Bukowski’s ORIF procedure must be controlled first. Staats (2003) & Morrison et al (2003) stated that pain increases oxygen demand, elevates heart rate and blood pressure due to vasoconstriction, influences mood changes, aggravates stress, and diminished movements (p. 825). Thus, pain experienced by Mr. Bukowski will only compromise respiratory mechanics and exacerbate current lung collapse, predisposing him to acute respiratory failure. The nurse must educate Mr. Bukowski of how PCA system works and must emphasize that through PCA, fear of having addiction rarely occurs for the PCA deliver only pain medications as indicated in the lockout period. Successful pain management lies on the proper use of PCA leading to controlled level of maintain that may impair respiratory condition and deep breathing exercises. However, studies revealed that use of patient-controlled analgesia such as morphine may have contributed to depression of respiratory status (Staat’s & Morrison, 2003, 825). Westerdahl et al (2005) stated that deep breathing exercise expands the alveoli of patients with atelectasis and reduces atelectasis by half-size due to the stimulation of lung expansion (p. 3482). During deep breathing exercise, intrathoracic cavity is inflated and secretions are mobilized from the lower respiratory tract to the upper respiratory tract as the diaphragm and respiratory tract moves (Fink, 2007, 1212). The diagnosis of right-sided pneumonia leading to acute respiratory failure is the most common complication after induction of general anesthesia (Carbo & Smetana, 2008, 567). Mr. Bukowski is diagnosed with right-sided pneumonia leading to respiratory failure two days after he underwent open-reduction and internal fixation (ORIF) operation of his fractured femur. As part of deep breathing exercises, Fink (2007) recommends three deep breathing maneuvers that will help expand the alveoli which includes forced expiratory technique, active cycle of breathing technique and autogenic drainage (p.1212). The forced expiratory technique is called ‘Huff Cough” and is done by doing a 1-3 second breath hold after 3-5 slow-deep breath, then a forced sigh of the word “huff” is articulated by contracting the abdominal and chest muscles during exhalation (Fink, 2007, 1213). Meanwhile, a cycle of alternate ‘huff’ forced expiratory technique and breathing control done by taking 3-4 active deep breathing and several seconds hold followed by passive relaxed breaths out is called the active cycle of breathing technique (Fink, 2007, 1214). Autogenic drainage, on the other hand, uses controlled breathing and minimal coughing to as the breaths become progressively deeper (Fink, 2007, 1216). Coughing is the process of deep breathing, closing the glottis, compressing abdominal and thoracic muscles, and explosively releasing gas as the glottis is opened (Fink, 2007, 1212). Elman & Kelly (2005) stated that coughing is a very significant exercise that provides expiratory speed of up to 500 miles/hour from tracheobronchial tree to pharynx (p. 1153). Likewise, effective coughing of 80 mmHg positive pressure re-expands alveoli and expectorates secretions (Fink, 2007, 1212). Effective coughing ability is influenced by a variety of factors including use of narcotic analgesics and general anesthesia, expiratory muscle weakness, decreasing level of consciousness, and pain which stimulates movement of respiratory muscles (expiratory, abdominal, and chest muscles) (Law, 2003, 49). Deep breathing and coughing exercises will significantly improve Mr. Bukowski’s lung consolidation and collapse as effective breathing pattern and return of respiration status to normal rate and rhythm are likewise expected. Pain management through health education of proper use of PCA and performace of deep breathing and coughing exercises are very important nursing interventions that will improve his breathing pattern as successful education will enable him to perform exercises independently and to be free from worries of addiction derived from improper use of morphine. Soon after being taught, Mr. Bukowski will be able to perform deep breathing and coughing exercise and will not hesitate on pressing the button of PCA for pain management thus, effective breathing pattern are achieved brought by the expansion of the alveoli during deep breathing and coughing exercises and complication of respiratory depression from analgesia is avoided due to proper use of PCA. Circulation A life-threatening condition that must be corrected after breathing pattern is impaired circulation of oxygen gases. Insufficient oxygenation influences the metabolic (increased heart rate and blood pressure), hemodynamic and biochemical condition. Low PaO2 level to a specific part of the body such as peripheral parts will result in cyanosis and decrease capillary refill of the peripheral tissues (Smyth, 2005, 72) as demonstrated by Mr. Bukowski’s primary survey circulation data of PaO2 level of 54mmHg, SaO2 level of 89%, PaCO2 level of 58mmHg and neurovascular findings of pale, cool to touch, and edematous right leg. The nurse noticed that Mr. Bukowski is still in hypoxemia state even if 6L/min oxygen via Hudson mask is administered. State of hypoxemia is starting to be evident in the peripheral parts of the body such as the right leg which has showed signs of decrease tissue oxygenation. Thus, Mr. Bukowski needs the appropriate oxygen delivery method to treat hypoxemia and increase tissue oxygenation to the peripheral parts of the body. Likewise, NIPPV and mechanical ventilation are treatments which do not only correct hypoxemia but the presence of hypercapnia as well (Smyth, 2005, 72). If the nurse would stabilize only the breathing pattern, the non-invasive supplemental oxygen is enough to resolve hypoxemia (Smyth, 2005, 72). However, severe hypoxemia which had already impaired the peripheral parts of the body must require high flow delivery system to correct abnormal blood gases and worsening of hypoxemia (Kaynar & Shama, 2010, n.p.). Even if Mr. Bukowski already uses a low flow delivery system such as nasal prongs, supplemental oxygen is not enough to deliver the sufficient amount of oxygen needed by the body. Venturi mask and mechanical ventilation are the typically used high flow delivery oxygen system (McGloin, 2008, 48). Venturi mask is a disposable face mask that uses a special valve that brings air using the venturi principle, controls oxygen level from 21 percent up to 100 percent, and is used to deliver a controlled and safe concentration of oxygen (McGloin, 2008, 48). Non-Invasive Positive Pressure Ventilation (NIPPV) is another method of high flow oxygen delivery system. Severe hypoxemia is treated with chemical ventilation (Diaz et al, 2005, 952) and NIPPV is an effective treatment ventilation for acute respiratory patients suffering from circulatory complications (Cheung et al, 2004, 845). NIPPV provides auto positive pressure at the end of expiration to inflate the lungs, which contributes to augmentation of tidal volume, growth of transpulmonary pressure, work of breathing reduction, diaphragmatic movement, increased of functional residual capacity leading to expansion of alveoli, and stabilizing V/Q ratio (Lunghar and D’Ambrosio, 2007, 793). By decreasing the PaCO2 level, PaO2 level circulation increases and normalize the respiratory rate (Lunghar and D’Ambrosio, 2007, 795). As the circulation of blood gases improve, so as the circulation in the peripheral parts of the body. Improvement in circulation of blood gases also reduces use of accessory muscle, improves the dyspnea symptom, and improves neurovascular assessment findings. Therefore, Mr. Bukowski needs a Venturi mask or NIPPV in order to rule out hypoxemia and increase tissue oxygenation to the different parts of the body, particularly to the peripheral areas. Question 4 Nursing interventions are successful if specific evaluation parameters are met and demonstrated by the patients. In terms of breathing pattern, interventions are effective if Mr. Bukowski will have a respiration rate of 16-20 cycles per minute, free from intercostal muscle recession and labored breathing. Also, arterial blood gases such as SO2 must be above the 95% normal range. Meanwhile, evaluation parameters for circulation interventions includes neurovascular findings of both Mr. Bukowski’s legs as pink, warm to touch, with capillary refill of Read More