Nursing Care of a Critically Ill Patient - Assignment Example

Nursing Care of a Critically Ill Patient of Affiliation: Reflective essay In the nursing care of an older critically ill patient, effective assessment of the patient, correct diagnosis and subsequent care of asthmatic patient plays an important role in the recovery process (Baillie, 2005, p. 34). According to Arnold and Boggs (2003, p.25), communication between the patient and their nurse determines the care sought by the patient and that given by the nurse. This is a reflection of an event that I encountered as a nurse (Howatson-Jones, 2010, p.54). In the United Kingdom, the number of people who die from asthma is estimated at 1,140 per year. Most of these deaths have been shown to be preventable (Douglas and Elward, 2011, p.68). According to (Sheldon, 2009, p.104), about 52% of people suffering from asthma have been found to underestimate the risk of them having an asthmatic attack. Description As a nurse, I was involved in the care of a critically ill patient diagnosed with infective exacerbation Asthma (Heffner, 1991, p. 67). The patient was a 60-year-old woman who presented with shortness of breath and chest pain. The patient’s name will not be used in this reflection for confidentiality reasons and instead, the patient will be referred to as Mrs. A. In the provision of nursing care, communication plays an important role and nurses are tasked with ensuring the utilization of effective skills in communication. Communication is an effective tool in the transmission of useful information to and from the patient (s). Communication has been shown to be effective in speeding up recovery by reducing the number of complications developing from disease, reducing stress, relieving pain and alleviating the fear that patients may have regarding their condition (Arnold and Boggs, 2003, p. 52). In a study, Carpenito (2009, p.90) identified three risk behaviors that can cause an individual to get an asthma attack; an asthmatic not using their preventive inhaler as prescribed, not having an asthma action plan and an individual not paying attention to their worsening condition. In adults, asthma is diagnosed through the recognition of the characteristic symptoms the patient presents with, the signs as observed by the healthcare practitioner together with the absence of an alternative diagnosis to rule out the condition (Baillie, 2005, p. 78). The practitioner is required to carefully take the patient’s clinical history. Mrs. A’s diagnosis was done using this criterion. She presented with chest pain accompanied by shortness of breath. Peak Expiratory Flow was used as an alternative test to determine the lung flow. A diagnosis of infective exacerbation asthma was determined and she was admitted in the hospital ward as a higher dependency critically ill patient. According to Baillie (2005, p. 82), as a nurse I was charged with the professional responsibility of administering the medication prescribed for Mrs. A. it is important that a nurse has the knowledge regarding the medication prescribed as well as its possible side effects. I am also accountable for the overall care of the patient from the time he or she is admitted to his or her discharge and follow up period (Waldron, 2007, p. 34). A nurse should always be focused on ensuring the wellbeing of the patient (Baillie, 2005, p. 87). This is best done by ensuring that the needs of individual patients are identified and used as the basis for the discussion of their care both with the patient themselves and their general practitioner or specialist doctor. Mrs. A’s needs were identified; she was an elderly patient with a history of asthma. This information was used to plan her care both in the hospital and at home (Doenges, Moorhouse, and Murr, 2010, p. 43). Mrs. A was involved in deciding her action plan which was written down and she was to take home with her after she was discharged (Baillie, 2005, p. 45).It was important that Mrs. A was closely monitored because of her history of exacerbations coupled with poor lung function. Reduced lung function as compared to those previously recorded may mean two things; declining lung function or recent constriction of the bronchioles. If a patient develops airflow blockage thatis irreversible, he or she is likely to have an increased risk of having exacerbations. It is recommended that this is done by asking the patient how many times a week for example, they use their nebulizers. Alternatively, reviewing the number of times the patient refills their prescription can assess lung function. Mrs. A was to be followed up after discharge to determine her lung function and whether the medications she was on were working. Mrs. A was discharged after one week with prescription medicine to be used to manage her asthma at home. The medications prescribed were; Salbutamol 5 mg nebulizers and 500mcg Atrovent, 1.2g Benzylpenicillin, 500mg Clarithromycin and 100mg Hydrocortisone infusion (Lehne, 2007, p. 75). Additionally, she was instructed to use Peak Expiratory Flow (PEF) to measure her lung flow from home. The rationale was that an increase in PEF was best used to determine reversibility in lung flow and airflow (Lehne, 2007, p. 31). Mrs. A was also provided with information regarding the medication, its side effects and dosage. She was also given information on how to refill or get the prescribed medication. All this was done to ensure that she understood the importance of taking her medications as well as what to expect in terms of side effects. Feelings I felt disappointed when Mrs. A was discharged before I was able write in my reflective diary. At the same time, I was glad that she was out of danger so quickly and thus she did not have to stay in the hospital longer. I was worried that given her advanced age, she may be forgetful and skip some of her medication-causing relapse in her exacerbation and consequent re admission. I was also worried that due to her advanced age, her body would not be able to effectively utilise the medication because of the possibility of her reduced metabolism and elimination. This might reduce the efficiency of medication and cause accumulation of toxic waste products in her body further disabling her metabolism and medicine utilization. It was thus important that Mrs. A was started on lower doses of the medication to be slowly increased. As a nurse it was important for me to have extensive knowledge regarding the side effects associated with the medications like nausea and drowsiness and effectively communicate this to the patient(s). I was concerned about the ability of Mrs. A to recognize the adverse side effects and seek medical care as soon as she notices this. According to Jackson, Jansen, andMangoni, (2009), the elderly may get asthma attack and be too weak to seek medical help by themselves or even reach someone to assist them. Because of her short stay in the high dependency unit, I had not managed to gather information about her living arrangements. It was difficult to establish whether she lived with someone who could be able to help her when there was an emergency (Jackson, Jansen, andMangoni, 2009, p. 101). Evaluation The diagnosis of asthma is based on a number of characteristic physical symptoms that patients present with, the signs present and the absence of a different explanation from these signs and symptoms. At the time of her diagnosis I felt that her diagnosis was carefully done taking into account her clinical history. Mrs. A had two of characteristic symptoms of asthma; breathlessness and chest pains. She was monitored according to her symptoms which was most appropriate especially for the management of asthma patients (Fitzgerald, 2001, p. 142). I felt positive when she was discharged when it was determined that the treatments received were effective in controlling the symptoms while keeping the number of exacerbations low (Fitzgerald, 2001, p. 102). However, I was worried about her ability to comply with her medication given her advanced age, which was characterized with other complications associated with digestion, metabolism, utilization and elimination of medications as well as foods (Fitzgerald, 2001). This is supported by literature on the care of elderly invalids and convalescents. I felt that as soon as she started feeling nauseous or drowsy she would likely skip some of her medications causing a relapse in her asthmatic attacks (Tabloski, 2010 p. 56). I felt positive that the communication between us –Patient and Nurse- was effective and that she understood the importance of taking her medication on time, where she could buy her medication and what to expect in terms of side effects resulting from her medication. This is clear as in the literature explaining that communication between the patient and the nurse should be effective so as to ensure that patient recovery is speed up through the reduction of complications, stress and fear as well as the relief of pain (Fitzgerald, 2001). Effective communication needs to incorporate empathy and actively involve the patient in decision making. Analysis The situation was improved by the healthcare team communicating the importance of the medication, where to get them and how to use them. This was useful information that Mrs. A required to ensure better recovery and a reduced risk of relapse due to non-compliance with medication. Her speedy recovery and subsequent discharge made it impossible for me to diarize her recovery and thus presented a challenge in my reflective exercise (Bach and Grant, 2009, p. 53). In future, I would record the journey to recovery as early as on the admission of a patient and follow them through to recovery. This is to ensure that information on living arrangements;proximity to the nearest health facility and general knowledge regarding the patients’ disease was available to the patients. I would recommend the use of alternative methods of diagnosis for example test of airflow obstruction like inflammation of the airway or the responsiveness of the airway to complement the physical symptoms and signs that the patient presents with and to eliminate the possibility of other conditions with similar symptoms like bronchitis. There is need to take and record the clinical history of the patient to rule out other causes of the symptoms. The speedy discharge in Mrs. A’s case made it impossible to determine the extent to which patient education was done (Bach and Grant, 2009, p. 63). It was difficult to ascertain patient education on inhaler use and the record keeping in PEF. It was not clear whether the patient had been discharged with a pre written PEF and a symptom based action plan necessary for her to re adjust their medical therapy within the new context and within the medical recommendations (Doenges, Moorhouse, and Murr, 2010, p. 35). Patient education and the above measures have been shown to be effective in the reduction of recurrence, morbidity resulting from unmonitored exacerbation. It was also not clear what caused the exacerbation, which made it difficult to determine the future actions by the patient aimed at reducing future emergency complications. According to Doenges, Moorhouse, and Murr (2010, p. 64), it was important to plan follow up activities prior to discharge followed by the patient being provided with an asthma action plan to enable the prevention of asthma attack relapse, facilitating treatment and speeding up patient healthcare seeking time in case of an asthmatic attack. I felt that treatment follow up should have been planned 2 days prior to her discharge either by her general practitioner or nurse. Follow up should be planned together with the asthma specialist nurse or a respiratory expert. Conclusion I followed the care of critically ill patients’ protocols in the diagnosis and subsequent admission of Mrs. A (Chau et al., 2010,p. 82). This included the use of the symptoms she presented with together with an alternative method – Peak Expiratory Flow- to rule out other conditions with similar symptoms as asthma. I used her clinical history to further rule out other conditions and affirm the diagnosis. In retrospect, this served to conclusively make the correct diagnosis and speed up the treatment and recovery. This reduced the hospital admission time and improved her treatment outcome. However, I realize that the use of a spirometer, which is now widely available, would be more appropriate and preferable to the taking of the Peak Expiratory Flow (Douglas andElward, 2011, p. 49). This is because spirometers allow for clearer identification of the obstruction of airflow and makes it easy to get the results. But the spirometer was not available at the time hence I made do with the PEF monitor. I applied the use of a stepwise process in the reduction of symptoms to improve Peak Expiratory Flow by starting medication and therapy at a level that facilitated this (Chau et al., 2010). Mrs. A was started on medication at the initial severity and attack. This was done to ensure that the asthma was under control and her recovery was maintained by increasing treatment when necessary and reducing when control had been achieved. I checked and confirmed whether Mrs. A was currently or had previously been on another or the same therapy, the inhaler type she had been using and the trigger factors that needed to be eliminated. The aim of asthma medical care is the management of the disease (Dewit, 2009, p. 31). Like any other medicine, asthma medicines have side effects and some patients may want to strike a balance between the management of their symptoms and the potential side effects or the inconvenience associated with taking their medication (Douglas andElward, 2011, p. 64). It is the nurses’ duty to assist patients in balancing these in order to achieve the perfect level of control. I ensured that the patient was discharged with an asthma action plan and her own peak flow monitor to manage her symptoms (Bach and Grant, 2009, p. 37). Charged with patient education regarding the use of the peak expiratory flow and how to correctly record their readings, I educated her on the best technique. I also checked her inhaler technique as well as her compliance to reduce the chance of relapse and consequent readmission. I ensured that she knew her dosages, where and how to purchase her medication, and when and how to seek medical help in case of relapse (Dewit, 2009, p. 92). I realized that I should have explained to her that the action plan could reduce hospitalizations and deaths resulting from asthmatic attacks. In retrospect, I am confident in my ability to perform a successful assessment. When presented with the same situation(s) in future I will apply the newly acquired knowledge and experience gained in the care of critically ill patients to therapeutically manage asthmatic elderly patients. Asthma care requires that the nurse or attending physician takes a careful clinical history of the patient to determine what causes the exacerbation and to provide possible actions that the patient should be advised to take to minimize or prevent future occurrences and the possibility of increased morbidity (Bach and Grant, 2009, p. 64). Action Plan In future, I will ensure that I start keeping my reflective diary early on in the management of a critically ill patient under my care. I will undertake trainings and workshops to improve on my communication skills, as communication is important in the care of critically ill patients. Communication should be two sided and engage the patient and at the same time be empathetic (Arnold and Boggs, 2003, p.78). I will sharpen my listening skills, my ability to respond to the patient’s concerns and I will allocate sufficient time for effective communication with my patient(s) (Arnold and Boggs, 2003, p. 32). I have learnt that the physical signs and symptoms that patients present with are not enough to effectively make the right diagnosis (Dewit, 2009, p. 32). There is need to use alternative tests like considering the patient’s clinical history or the use of tests that determine whether there is obstruction to the airflow into the patient’s lungs. Peak expiratory flow is one such alternative test. This test measures the variability in lung flow to constantly monitor her lung airflow and volume (Moroney and Knowles, 2006, p. 56). This is a useful, easy to understand and portable test that can be carried home by the patient and used to take readings while at home. In Mrs. A’s case, she was discharged with her prescribed medication and a peak expiratory flow to monitor her lung airflow and volume. According to Moroney and Knowles (2006), peak expiratory variability normal range lies between less that 8% and less than 20% (p. 30). This value is dependent on the number of readings the patient takes per day and how well the patient is able to measure this variability. This means that it is important that the patient is properly coached on the technique she should use. According to Dewit (2009), particular features increase the chance of a patient having asthma if they have physical symptoms that include wheezing, chest pain, shortness of breath and a cough that worsens in the night or early morning or that worsens after rigorous activity and exposure to allergens. Secondly, an individual with a history of atopic disorder is likely to have asthma. Thirdly, people with a family history of asthma or atopic disorder are likely to be diagnosed with asthma. Lastly, any low lung expiratory volume that cannot be explained may mean that the patient is asthmatic (Rainbow, 1989, p. 67). I will update my skills and the knowledge that I have on the current nursing practice so as to ensure that I am able to make the right decision regarding patient care and medication. This will include the awareness of the possible side effects of the drugs prescribed to them as well follow up activities that need to be carried out (Dewit, 2009, p. 69). I will extensively involve patients under my care in their recovery by paying attention to their feelings and concerns. I will ensure that the patient is educated or re educated regarding their medication to ensure that they comply with their medications and are able to seek medical help when needed. This is because I have realized that inconsistent use of medications is the lead cause of relapse and consequent re admission in hospital. When caring for critically ill patients who are older, I will ensure that the follow up activities are rigorous to ensure medicine compliance and minimize relapse (Kim and Kollak, 2006). I realized that elderly patients are likely to forget to take their medication or may not comply when they experience side effects that may be uncomfortable with. I will ensure that I find out whether these patients have the support system they need in place and if not, I will try to establish such systems (Kim and Kollak, 2006, p. 104). I have learnt from this experience that medications for asthmatic patients should be changed depending on the current assessment and patients should be provided with an action plan that they have participated in writing with the aim of preventing relapse, ensuring that treatment is successful and decrease the time patients take to seek medical care in the future (Sully, and Dallas, 2005 p. 45). This experience has taught me that it is important to arrange for follow up activities at least 2 days before they are discharged. This should be planned by the asthma specialist nurse or the respiratory physician and scheduled weekly or monthly depending on the severity of the patient’s lung function. I have also learnt that asthmatic adults in primary care need to have their symptoms monitored regularly (Holland et al., 2010). That it is important that asthmatic patients’ symptoms are controlled with treatment to reduce the risk exacerbations. A patient with a history of poor lung function and that of exacerbations within a year is an indication of increased risk for future exacerbations for any given level of physical symptoms. Exacerbations have been shown to result from eosinophilic inflammation of the airway (Holland et al., 2010). As such a strategy that controls this infection is likely to reduce the number of exacerbations especially in institutionalized patients. Critique The reflective process was made difficult by the speedy discharge of Mrs. A and my failure to compute the reflective process in my reflective diary. In my opinion, it is important that the medical practitioner and the nurse charged with the care of critically ill geriatric patients prepare a follow up plan to ensure patients comply with their medications (Howatson-Jones, 2010, p.48). Compliance has been shown to result in better outcomes among asthma patients. References Arnold, E., & Boggs, K. U. (2003). Interpersonal relationships: professional communication skills for nurses. St. Louis, Mo, Saunders. Baillie, L. (2005). Developing practical nursing skills. London, Hodder Arnold. Bach, S., & Grant, A. (2009). Communication and Interpersonal Skills for Nurses. Exeter, Learning Matters Ltd. http://public.eblib.com/EBLPublic/PublicView.do?ptiID=680126. Carpenito, L. J. (2009). Nursing care plans & documentation: nursing diagnoses and collaborative problems. 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