Contemporary Medical-Surgical Nursing - Essay Example

The rationale for nursing interventions s of affiliation Case Mr. Parietal Pleura who was admitted with a pneumothorax has a chest tube inserted attached to an UWSD. The S/S of a pneumothorax, namely chest pain, shortness of breath, absent or diminished breath sounds, are all that is required to confirm a diagnosis of pneumothorax. 1.  When a patient has a chest tube attached to a UWSD the only assessment required is swinging, bubbling, draining, TPR and BP. Rationale The rationale of assessment of a patient with a chest tube is to ensure the swinging, bubbling, the draining and the vital signs are within the accepted normal. However, these are not the only assessed in a patient with a chest tube. The others assessed in this patient include the temperature, heart rate, respiration rate and blood pressure to check for infection and any abnormality that may arise. On the other hand, the saturation levels of oxygen in the blood, breath sounds, and capillary refill are checked to ensure that the patient receives adequate bloo oxygenation (Daniels and Nicoll, 2011, p. 345). Depending on the condition of the patient, monitoring should be either continuous or intermittently. Bubbling and swinging are assessed with the patient’s respiration. In normal respiration, the fluid within the tube rises with inspiration and falls with expiration (Paul and Williams, 2009 p.45). Absence indicates that the tube is blocked, or it is out of the pleural space. Intermittent bubbling in the water seal chamber shows an air leak when the patient coughs or exhales. Continuous bubbling indicates air leak between the patient and the drain. Volume, color and consistency of the drainage are monitored (Smeltzer et al., 2010, p. 234). The drain insertion site is also assessed for signs of infection and inflammation. The sutures are checked if they are intact and secure and that the dressing is clean and intact (Smeltzer et al., 2010 p. 252). 2.  Chest tubes should only be clamped during patient transfer. Rationale The rationale for clamping the chest drain is to reduce the risk of tension pneumothorax. Smeltzer et al., (2010 p. 252) recommend disconnection of the chest drain in the case of sunction or the patient are ambulant. However, during the transport, the chamber should be kept below the patient’s chest level to enable draining (Smeltzer et al., 2010, p. 123). This allows gravity drainage and prevents backflow of fluid. However, Paul and Williams (2009, p. 13) suggest that clamping can also be done when the drainage bottle requires a replacement or to locate any air leak in the drainage system. Therefore, the suggestion that chest drains should only be removed when the patient is to be moved is false. If the water in the chest tube was—swinging but not bubbling or draining it means the air has been removed from the pleural space but that the pneumothorax has not resolved. When bubbling initially stops this should be further assessed by instructing the patient to cough. When monitoring for the patient with chest pneumothorax the bubbling shows the presence of air in the chest therefore, if there is no bubbling or draining it shows that air in the pleural space has been removed (Stewart et al., 1998, p. 345). On the other hand, swinging of the fluid in the chest tube diminishes shows that pneumothorax has resolved. Clamping a chest drain tube has the potential to cause a tension pneumothorax and circulatory collapse Rationale The rationale for this is that, the clamping a chest drain tube increases the risk of a tension pneumothorax since it allows air from the alveoli to enter the pleural space leaving it without exit route (Paul and Williams, 2009, p. 1044). Therefore, air builds up, causing a mediastinal shift towards the unaffected lung leading to compression of the vena cava. This then may lead to shock and circulatory collapse, which are fatal to the patient. Case II The management of Mr. Cushing, who is at risk for IICP (Increased Intracranial pressure), includes: Pts. at risk of IICP should usually have the head of bed (60º) elevated with head midline. The 60-degree position needs to be increased or decreased depending on patient response and need to maintain CPP. In addition, hypotension should be prevented Rationale When nursing the patients with the risk of developing increased intracranial pressure, it is appropriate to nurse them at a raised position of about 30-60 degrees. The rationale for this is that it facilitates venous blood drainage from the brain and decreasing intracranial pressure and venous pressure (Paul and Williams, 2009 p. 566). This utilizes the force of gravity. Therefore, this position this reduce the amount of pressure to reach the head as the blood volume in the head is highly reduced reducing the chances of ICP developing. At high position, the pressure becomes well distributed as a result the chances of the pressure accumulating at the head are decreased (Daniels and Nicoll, 2011 p. 455). Therefore, the 600 is adequate for the patient who is at risk for IICP. In management, it is important to manage and avoid hypotension this is because Elevated intracranial pressure masks hypotension especially hemorrhagic hypotension (Daniels and Nicoll, 2011 p.545). This will predispose the patient to shock and possible related complications. Pts. at risk of IICP must be provided with supplemental oxygen to keep O2 saturations above 92% & CO2 must be kept within normal limits. Pts. may also be administered H2 antagonists to decrease risk of GI ulcers Rationale In IICP, the pressure of blood in the brain is high (Hargrove-Huttel, 2005 p. 345). As a result, the brain is not well oxygenated. Besides, IICP is always accompanied by increase in general body blood pressure, therefore the blood do not get adequate chance to be oxygenated (Hargrove-Huttel, 2005 p. 343). Therefore, the blood supplied to the brain and other body parts is not well oxygenated. Since the brain is sensitive to low oxygen there is need to monitor the body level of oxygen to ensure that the body gets enough oxygen (Timby and Smith, 2013 p. 323). Consequently, the level of oxygen should be maintained above 92 percent concentration of oxygen. Besides, these patients need prophylaxis treatment for the ulcers (Paul and Williams, 2009 p. 343). The rationale for this is, an increase IICP the risk of developing stress ulcers is high. Therefore, treatment with H2 antagonist is appropriate to control this. However, other ant acids or ulcer prevention medications can be administered. Pts. at risk of IICP should be kept hypovolemic and serum electrolytes monitored every 2 days. Rationale It is incorrect to keep the patient at the risk of ICP hypovolemic. The rationale for this is, ICP is likely to mask hemorrhagic hypovolemia. Despite the fact that hypervolemia is a risk to increased ICP, hypovolemia is also dangerous with ICP, the nurse needs to monitor for normal blood volume. Besides, the serum osmolality should regularly be monitored to detect diabetes inside as early as possible (Baumann and Sahn, 2009 p. 345). In severe head injury polyuria and low urine osmolality could indicate hypothalamus dysfunction and can cause neurogenic fever and/or Diabetes Insipidus (DI) Rationale The rationale for this is, the hypothalamus is responsible for the production of antidiuretic hormone (ADH) needed for reabsorption of water in the kidney. Besides, it is responsible for the reabsorption of chloride and sodium ions in the kidney. In brain damage, the brain is not able to produce enough ADH, therefore, there is a lot of urine production and the urine osmolality is very low (Smelter et al., 2010 p. 453). Case III Mr. T Chemotaxis, involved in a MVA suffered head injuries, pneumothorax and multiple fractured bones. His treatment throughout admission included the insertion of chest tubes, IVT, IDC and Burr holes. His condition was considered stable by Day 3. His multiple injuries and treatment modalities have however increased his risk for Septic Shock and SIRS. When the temperature is above 38°C appropriate cultures should be obtained following the commencement of antibiotics. These may include blood cultures, wounds, IV sites, blood, urine, and sputum. Oral Panadol must be given to ensure the temperature does not continue to increase Rationale The rationale for this is, when there is elevated temperature, it suggests an infection (Smeltzer et al., 2010 p.343). There should be admission of broad-spectrum antibiotics to reduce the microbial load. It may also be necessary to perform a cultures to isolate the pathogen that is specific responsible for the infection (Macduff et al., 2010). Isolation of the pathogen is the only sure way to treat the causative agent of the infection. Since the source of the infection is not known, Macduff et al., (2010 p. 23) suggests that multiple tests to be done. The blood culture is needed because of the inoculation of the drugs into the vein. Besides the blood forms the main method for the transport of the pathogens (Baumann and Strange, 1997, p. 12). Since the patient has pneumothorax, chest culture will rule out any chest infection. Similarly, the wound and IV site culture rules out the presence of the pathogens at that place. Finally, the patient since this patient has a catheter it is important to rule out any urinal infection. For this patient, it is important to lower the body temperature (Daniels and Nicoll, 2011, p. 23). Oral paracetamol has antipyretic properties. Therefore, administration of paracetamol helps to reduce this fever preventing further damage to the patient. An increase in platelets followed by a decrease in platelets could signify a risk for Disseminate Intravascular Coagulation and characterized by widespread micro-thrombi and excessive bleeding Rationale Disseminated intravascular coagulation is characterized by systemic activation of blood coagulation with generation and deposition of fibrin (Baumann and Sahn, 1990, p. 213). This leads to deposition of micro-thrombi in various organs. Thrombin generated amplifies clotting by platelet activation, enhancing its aggregation and augmenting functions in coagulation (Paul and Williams, 2009, p. 234). The continuous activation of coagulation leads to consumption and subsequent exhaustion of the platelets and other clotting factors. Compensatory mechanisms are overwhelmed. If there is reduced levels of platelets and other coagulation proteins the will be severe bleeding (Paul and Williams, 2009, p. 234). Sepsis is associated with an increased systematic capillary permeability and therefore the retention of fluid in interstitial spaces leading to hypovolemia and acute cardiogenic pulmonary edema. Rationale The rationale for this is, septic reactions travel through the vascular system to spread inflammation throughout the body. The body immune system reacts to innate immune response that results in excessive cytokine release (Paul and Williams, 2009, p. 234). Sepsis tends to develop in deregulated natural immune response. Deregulated cytokine release and nitric oxide led to vasodilation and increased systemic capillary permeability resulting to the leaking of fluid into interstitial spaces leads to hypovolemia, hypotension, and edema (Smeltzer et al., 2010 p.35). Sepsis also makes the activated endothelium porous to large molecules such as proteins leading to tissue edema. With increased pulmonary capillary pressure, decreased oncotic pressure and increased negative interstitial pressure acute cardiogenic pulmonary edema. You are to administer Mr. Chemotaxis, who has an infusion of normal saline in progress, an IV antibiotic.  It is essential prior to administering this IV antibiotic to ensure patency by administering a Normal saline flush Rationale It is incorrect to flush a patent IV line. The rationale for this is, the patient has already a running fluid, it means that the line is patent. Since the fluid is normal saline, which does not have any adverse reaction to the antibiotics it is not necessary to flush. However, in other instances where the patient has other medications running, flushing is crucial as it determines the patency of the IV line preventing wastage of the drug (Daniels and Nicoll, 2011, p. 34). References Baumann, M.H., Sahn, S.A., 1990. Medical management and therapy of broncho pleural fistulas in the mechanically ventilated patient. CHEST Journal 97, 721–728. Baumann, M.H., Strange, C., 1997. Treatment of spontaneous pneumothorax: a more aggressive approach? CHEST Journal 112, 789–804. Daniels, R., Nicoll, L., 2011. Contemporary Medical-Surgical Nursing. Engage Learning. Hargrove-Huttel, R.A., 2005. Medical-surgical Nursing. Lippincott Williams & Wilkins. Macduff, A., Arnold, A., Harvey, J., 2010. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax 65, ii18–ii31. Paul, P., Williams, B., 2009. Brunner & Siddhartha’s Textbook of Canadian Medical-surgical Nursing. Lippincott Williams & Wilkins. Smeltzer, S.C.O., Bare, B.G., Hinkle, J.L., Cheever, K.H., 2010. Brunner & Siddhartha’s Textbook of Medical-surgical Nursing. Lippincott Williams & Wilkins. Timby, B.K., Smith, N.E., 2013. Introductory Medical-Surgical Nursing. 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