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It also provides ll healthcare providers with a common awareness and serves as an algorithm for treatment and assessing which in turn can buy time to enable a final diagnosis and treatment plan to be made. According to the National Institute for Health and Clinical Excellence (NICE) (2007), patients may receive suboptimal care if staff do no act on clinical deterioration in a timely manner. Furthermore, failure to follow a systematic assessment in the treatment of an acutely ill patient is also another contributing factor (Resuscitation Council UK 2006).
There is however, the risk of this kind of approach being subjective as ach individual may observe, feel or hear symptoms differently. Due to the word constraint, this assignment will concentrate on the breathing assessment aspect of Dominic’s condition and also the pathophysiology of COPD and the use of oxygen (02) as treatment to alleviate his symptoms. Mr Taylor’s airway is assessed first by asking simple questions and obtaining a patient history and listening to how he responds (i. e. in full sentences or short sentences).
The questions asked should enable you to take a patient history and to assess when his new symptoms started. Also, whilst doing this task note is taken of his general appearance (such as skin colour, chest movement) and noting whether he appears to be distressed, anxious or content. As he is able to talk and has no abnormal sounds such as gurgling or snoring, he has a patent airway. Breathing is the next stage of assessment to be made in this approach. Breathing is vital for life as all cells require continuous oxygenation or they die and is essential to maintain homeostasis (Tait D et al 2013).
The purpose of the complex respiratory system is to oxygenate the blood and to remove arbon dioxide (C02) through efficient gaseous exchange (Luke P et al 2011 Marieb E (2012) states that to enable this exchange, 4 key events must occur: pulmonary ventilation; external respiration; respiratory gas transport; and internal respiration. Breathing is controlled by a multifaceted collaboration between mechanical, neural and chemotactic pathways and breathlessness can occur when there is a disturbance to them such as developing a cold caused by the Rhinovirus (common cold) (McKinney A 2012).
COPD is a disease, one of the most common in the united Kingdom (Credland N (2013) and is characterised by the limitation of airflow that is not fully reversible and is likely to become progressive in nature, therefore it is a long term condition with no cure. Gaseous exchange abnormalities result in hypoxaemia (low 02 levels) and hypercapnia (high C02 levels). Dominic’s productive cough is caused by mucus hypersecretion which is worsened by the contin uation of smoking (GOLD 2014). The assessment of respiratory function requires intelligent observation and common sense.
To assess this it is important to look, listen and feel whilst thinking of the ABCDE approach. Dominic is observed for any general signs of respiratory distress such as tachypnoea, cyanosis, use of accessory muscles and anxiousness (Jevon R 2010). Observations were made of the symmetry of his chest movement; the position of his trachea; respiratory rate, rhythm and depth; bilateral chest auscultation to listen for any signs of wheezes or crackles; palpitation to identify any areas of swelling or pain and this also gives a good indicator of temperature and perfusion (Peate and Dutton H 2012).
The assessment also requires a calm and reassuring manner as Dominic is quite anxious (Creed and Spiers 2010). The priority in Dominic’s situation is to raise his oxygen saturation level of 85% which is monitored by the application of a pulse oximeter which is seen as the 5th vital sign according to the British Thoracic Society (2008a) as severe hypoxaemia will lead to respiratory failure (Sheppard M and Wright M 2006). The oximeter measures the percentage of haemoglobin saturated with 02 (Creed and Spiers C 2010).
According to GOLD (2014) the target level for 02 saturation level should be between 88-92% and then 30-60 minutes later an arterial blood gas (ABG) measurement should be taken to ensure adequate xygenation without the retention of C02 or acidosis because excess oxygenation may lead to hypercapnia. Although Barnett (2007 cited in McKinney A 201 2) suggests that if saturation levels are below 93% an ABG should be taken first before the consideration of 02 therapy and NICE (2010) suggest that if the saturation level is below 92% 02 should always be considered. In Dominic’s case therapy was given before an ABG was taken.
According to O’Driscoll et al (2011) the administration of oxygen is needed to alleviate 3 key indications which are: to correct hypoxaemia (the deficiency of xygen in the tissues); the prevention of hypoxaemia; and to ease breathlessness. The 02 was commenced cautiously at the level of 28% as some COPD patient’s respiratory function depends on their level of hypoxia rather than the dependence of hypercapnia and therefore in such patients uncontrolled oxygenation can result in the suppression Of their respiratory drive and they may develop respiratory arrest.
The use of a Venturi mask at 4 litres per minute is recommended by NICE (2010) and GOLD (2014) as this enables a more accurate and controlled delivery but Dominic became increasingly nxious with a mask on his face so to make him less uncomfortable it was switched to a nasal cannula. This type of therapy is used as it is non-invasive in the first instance with the advantages of using nasal cannula being that they are generally more comfortable than a face mask; Dominic is able to eat and drink normally and no C02 will be rebreathed.
With the use of the nasal cannula he is also able to communicate freely. The disadvantages are that the delivery of 02 is less accurate than the mask and if Dominic were to breathe through his mouth then inspiration of 02 would be decreased; and it an make the nasal passages dry (Field D 2006); the 02 flow rate will also vary with the patient’s own respiratory rate (Gronkiewicz C and Borkgren-Okonek M 2004) however, the cannula was used to decrease his anxiousness.
Dominic is told that he should remain in an upright position as possible as this gives his lungs the maximum capacity to facilitate his ventilation (British Thoracic Society 2008a). Also ventilation is not only affected by COPD but also by gravitational forces therefore positioning may aid perfusion in healthy lung areas (Peate and Dutton H 2012). To aid this, Dominic was seated hilst being supported by pillows also tilting the foot of the bed upwards slightly to prevent him slipping down. The 02 should be progressively increased until his saturations reach an acceptable level for the patient.
To assess whether the therapy is effective full observations of Dominic’s vital signs are taken every 15 minutes and these must include observation of his saturation levels and counting his respiratory rate for a full minute whilst observing his work of breathing (McKinney A 2012). GOLD suggests that 02 therapy improves the outcomes of exacerbation of COPD by increasing the H balance and decreasing the partial pressure of C02 (which is critical in regulating breathing levels and maintaining body pH); decreases the respiratory rate and work of breathing and also ultimately decreases the length of hospital stay.
Once Dominic’s saturation level has become stable a number of other tests could also be administered. GOLD (2014) recommend that a chest x-ray is to be given and an ECG is to be administered. A sputum sample was sent to the laboratory so that effective antibiotics could be prescribed. As Dominic was too breathless on arrival, he had a spirometry test before discharge (British Thoracic Society 2008a). It is important to realise that not being able to breathe normally is a frightening experience and the patient will need to feel safe and supported by the healthcare professionals.
Dominic required to be reassured and this needed to be provided in calm and sympathetic manner with compassion (Department Of Health CNO Directorate 2008 cited in Creed F and Spiers C 2010). Dominic was told that he was being closely monitored and that his daughter (his next of kin) had been informed and she was on her way in to be with him. It is vital that Dominic could see that there was ffective team work and efficient delivery of care and that the care was person centred and individual to him (Creed F and Spiers C 2010).
Therefore, it is key to have open communication with Dominic throughout the assessment and treatment process as it is important that Dominic gives his consent and understands what is happening to him to make him less anxious. Anxiety itself can potentially interfere with the management of his therapy as this could make him dyspnoeic (Gronkiewicz C and Borkgren-Okonek M 2004). He is made to understand the importance of keeping the 02 on and to reathe through his nose and that this will ease his discomfort.
After 3 days in hospital Dominic’s condition improved enough to be able to be discharged home. Before being discharged Dominic was given advice on how to prevent further exacerbations. The advice given should include smoking cessation; as this is one of the most important elements in the management of exacerbations. This included the encouragement to attend specialised groups or getting his GP to offer nicotine replacement therapy (McKinney A 2012, GOLD 2014).
Advice was also given to Dominic that he should be vaccinated gainst influenza to assist prevention of an exacerbation in the winter months (GOLD 2014). Britton (2002) suggests that focus on what can be done rather than what cannot and to take regular exercise such as walking or condition specific exercise programmes should also be encouraged as inactiveness may lead to deconditioning of the respiratory system (Prigmore S et al 2012). NICE (2010) also recommend physical exercise to enhance the effects of nutrition.
Guidelines published by GOLD (2014) also suggest a follow-up appointment is made for 4-6 weeks after the hospitalisation which should include the ssessment for the need for long term 02 therapy; how Dominic is coping with his activities of daily living; reassess his inhaler technique and a further spirometry test; address any other co-morbidities; his need for psychological support and perhaps conversations about end of life or advanced life planning.
The rapid assessment of the acutely ill patient is vital particularly because respiratory compromise may occur quickly which will result in severe hypoxaemia and eventually respiratory failure. The ABCDE approach, although may be subjective, allows the healthcare professionals to perform a olistic, systematic assessment with close monitoring which alerts for any further deterioration and in a timely manner which helps prevent suboptimal care. This approach works by enabling the practitioner to provide lifesaving treatment in manageable sized chunks whilst buying time for a final diagnosis and a treatment plan to be made.
Hypoxia is life threatening and therefore the cautious intervention of 02 as the cornerstone of management of COPD exacerbations with close monitoring of ABGs is recommended to raise the saturation level and decreases the respiratory rate which helps regain omeostasis and ultimately reduces length of hospital admission. Calm and reassuring communication with the patient is of paramount importance as this helps the patient become more confident and relaxed in an otherwise extremely frightening and disruptive episode as anxiety may exacerbate breathlessness further.
The patient with respiratory compromise needs thoughtful, intelligent nursing which must be underpinned by knowledge, skill and understanding.