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 Prioritisation of complex patient health issues

  1. Choose one of the case studies from the lab sessions in Integrated Nursing Practice State the case study that you have chosen including whether the assignment addresses part one (morning shift) or part two (evening shift) of the case

Identify a total of five patient health issues from the case study that nurses can address within their scope of practice. You may include ‘risk for’ or ‘potential for’ health issues.

Select the three highest priority patient health issues from the five health issues that have been identified.

  1. Rank the three patient health issuesthat were selected in part 1 in order of priority. Provide a rationale for the order of the rankings. The rationale must be supported with current 
  1. Outline the nurse’s role in addressing the top three priority patient health issuesusing assessment, coordination of care and provision of care. Relate the discussion to regulatory frameworks of nursing and health department policies e.g. RN Standards for Practice, NSW health policy, National Safety and Quality Health Service (NSQHS) standards 
Case study analysis

In my assignment, I have decided to write about a case study about the patient transferred from the Emergency Department to the Respiratory Medical Unit. The scenario took place on 30th July 2018 at 10AM and that means it was a morning shift. The identity of the man was Jim Cooper and he was 68 years old. The patient presented on an early morning and had a medical history of productive cough for a week as well as SOB which seemed more than the usual level. His medication included GP for Oral AB. The patient further claimed that he had been sitting in his chair during the night and that it is becoming very difficult for him to care for himself while at home. The patient further claimed that he stays alone and that regular drinking assists him to calm down. The patient also noted that he feels lonely and that it has been getting him down of late. The past medical history include COPD that was diagnosed 5 years ago, reflux and finally Hypercholesterolemia. On assessment, the following signs were vital that necessitated admission at the Emergency department. The Heart rate was at 118 beats/min, the RR was at 36 breaths/min,SpO2 was 88% RA-93% 2L O2 NP while the Blood pressure was at 146/92 mmHg. The oral temperature was 380 C. Finally the Auscultation was characterized by scattered whizzes throughput both the two lung fields. The recommendations included treatment with oxygen, IV fluids, IVAB, Prednisolone and finally the physiotherapy.

From the case study presented above, there arises several health issues which Nurses can address within their scope of practice. The health issues identified include:

  • Impaired social interaction
  • Possible alcohol withdrawal
  • Potential for hypoxia.
  • Compromised airway clearance

Compromised airway clearance is the first priority because COPD is an umbrella of different conditions that affect the airways and lungs like asthma. The condition according to studies, makes breathing very difficult (Sessa et al., 2017 p.126). The condition is characterized by inflammation in the air passages and this leads to narrowing of the same airways and this makes it difficult for oxygen to reach the lungs. It is the inflammation that compromise the airway clearance and that is why the initial step to manage the condition is improving or rather correcting on the compromised airways.

According to different studies, bronchodilators and corticosteroids are the ones used to reduce inflammation. There are different classes of bronchodilators and they include the beta-2 agonists, the anticholinergics and finally the methylxanthines (O'Donnell, 2008p.25). The mentioned drugs are usually introduced step by step beginning with the Beta-2 Agonists. The role of this drugs is to ensure that the airway muscles are smooth enough. The beta 2 agonists are also divided into short and long acting. An example of the short acting beta-2 Agonists are albuterol and the formoterol are the long acting beta-2 Agonists.

Identifying priority health issues

Anticholinergics are introduced after the beta-2 Agonists. The role of this drugs is to reduce inflammation by facilitating bronchodilation through blocking of the acetylcholine that is found on the postganglionic cholinergic nerves. An example of such a drug is the Tiotropium which is also called Spiriva and it is a long acting anticholinergic that has duration of over 24 hours (Giembycz, 2015). This is the only drug needed once on a daily basis. The final drug to reduce inflammation is the Methyxanthines. Studies have shown that this drugs prevent phosphodiesterase thus elevated levels of the cyclic adenosine monophosphate and this leads to bronchodilation (Chung, Lin, & Kao, 2015, p. 54). Studies though show that the corticosteroids have no value in handling COPD but they only reduce inflammation for subsequent management steps.

Potential for hypoxia is the second priority health issue and it is usually reserved to patients with hypoxia. According to studies, the oxygen therapy does not improve lung function but only boosts survival in patients with hypoxia. The objective of this process according to studies is to achieve an oxygen saturation level of around 90%.It is the arterial blood gas value and desaturation as well nocturnal desaturation that determine the oxygen prescribed.

Impaired social interaction is ranked third among the health issues. Patients suffering from COPD are known to have impaired social status and they should be assisted as well. According to studies, medical management cannot reduce symptoms of the COPD in any way and they can’t reverse the pathological changes as well. In this case, the health care providers often prescribe what is called pulmonary rehabilitation whose objective is to ensure that the patients improve on both their physical and the social functioning. The patients are usually scheduled to exercise about 3-5 times a week and the sessions last for about 30-90 minutes.

Nurses have different roles in assisting patients with COPD. The initial role is to ensure diagnosis of the condition and this is usually carried out by the help of an instrument called a spirometer. Nurses that are found in the secondary care will however be involved in very few diagnostic processes. Since patients with COPD will have compromised airway clearance and impaired oxygenation, it is the role of the nurse to ensure the above conditions are well managed or taken care of (Lainscak et al., 2013 p.453). Nurses can achieve this through regular exercise. Whenever a patient is active especially those suffering from COPD, there general fitness and wellbeing improves. Breathlessness leads to stress among patients with COPD. Regular exercise will allow the muscles in the airways to effectively move mucus away from the airways so that there is no obstruction in the airways during breathing .The nurse should therefore organize or rather schedule a timetable that will allow the patient carry out light exercises. The exercise should however not that be vigorous as they can lead to breathlessness at the same time.

Prioritizing patient health issues based on severity

Proper nutrition is another role of the nurses in patients with COPD. According to several studies, majority of the patients with COPD are either underweight or obese. Studies found out that obesity is likely to increase the workload of breathing and therefore, it is the role of the nurses to ensure that the patients with COP are within the normal weight through proper nutrition so that they don’t struggle breathing (Vandivier & Voelkel, 2005 p.167). It is recommended that carrying out regular Body Mass Index monitoring so that the patients can be effectively assessed. In case the patient is found to have a low BMI, then that means that the recuperating is quite poor. It is however not clear as to why many patients with COPD lose weight. Some scientists however argue is due to high energy demand as compared to energy intake. To be able to counter this fact, it is therefore the role of the nurses to supplement the patients with proper diets (Peters et al., 2016 p.213) .In most cases, the patients are advised to eat little but often and this is thought to improve sensitivity to breathlessness.

Preventing and managing of exacerbations of the disease is another key role by the nurses in the priority health issues. COPD exacerbations are very common especially during the winter and the nurses should therefore ensure regular influenza vaccination on an annual basis (Bewley et al., 2016 p.68). Despite the fact that there exists little evidence on the effectiveness of pneumococcal immunization, patients with COPD are still immunized with it.

Nurses also have a role in educating the patients on how they can easily recognize the exacerbations and seek remedy early enough. The nurses also have a role in ensuring clearance of airways through treatment that aims to maximize bronchodilation, treating any other underlying infections and finally reducing inflammation of the airways and the lungs (Waatevik et al., 2017 p.45).Nurses should also administer antibiotics especially the oral steroids with the aim of reducing recovery and boosting the functioning of the lungs during the exacerbations.

Nurses should ensure that patients admitted at the hospital receive oxygen therapy and this should be for a minimum of 15 hours on a single day. The nurse should ensure that this exercise is carried out on two different conditions when the patient is in a stable condition (Miller, 2015 p.97). This is usually between 4-6 weeks after the admission. The nurse should ensure that the patient receiving oxygen therapy does not smoke as this reduces the efficacy of the medication.

References

Bewley, M. A., Belchamber, K. B., Chana, K. K., Budd, R. C., Donaldson, G., & Wedzicha, J. A. (2016). Differential Effects of p38, MAPK, PI3K or Rho Kinase Inhibitors on Bacterial Phagocytosis and Efferocytosis by Macrophages in COPD. PLOS ONE, 11(9), e0163139. doi:10.1371/journal.pone.0163139

Chung, W., Lin, C., & Kao, C. (2015). Comparison of Acute Respiratory Events Between Asthma–COPD Overlap Syndrome and COPD Patients. Medicine, 94(17), e755. doi:10.1097/md.0000000000000755

Giembycz, M. (2015). Faculty of 1000 evaluation for Long-acting inhaled therapy (beta-agonists, anticholinergics and steroids) for COPD: a network meta-analysis. F1000 - Post-publication peer review of the biomedical literature. doi:10.3410/f.718326329.793503055

Lainscak, M., Farkas, J., Frantal, S., Singer, P., Hiesmayr, M., & Schindler, K. (2013).lb023-mon self-rated health, nutritional status and nutritional intake predict in-hospital mortality in adult hospitalized patients: results of a european-wide nutritionday survey . Clinical Nutrition, 32, S241. doi:10.1016/s0261-5614(13)60625-1

Miller, M. R. (2015). Breathing New Perspectives into Chronic Obstructive Pulmonary Disease. COPD: Journal of Chronic Obstructive Pulmonary Disease, 12(2), 113-114. doi:10.3109/15412555.2015.1018510

O'Donnell, R. (2008). Early discharge care with ongoing follow-up support may reduce hospital readmissions in COPD. International Journal of Chronic Obstructive Pulmonary Disease, 55. doi:10.2147/copd.s4069

Peters, J. B., Boer, L. M., Molema, J., Heijdra, Y. F., Prins, J. B., & Vercoulen, J. H. (2016). Integral Health Status-Based Cluster Analysis in Moderate–Severe COPD Patients Identifies Three Clinical Phenotypes: Relevant for Treatment As Usual and Pulmonary Rehabilitation. International Journal of Behavioral Medicine, 24(4), 571-583. doi:10.1007/s12529-016-9622-3

Sessa, M., Mascolo, A., Mortensen, R. N., Andersen, M. P., Rosano, G. M., Capuano, A., … Torp-Pedersen, C. (2017). Relationship between heart failure, concurrent chronic obstructive pulmonary disease and beta-blocker use: a Danish nationwide cohort study. European Journal of Heart Failure, 20(3), 548-556. doi:10.1002/ejhf.1045

Vandivier, R. W., & Voelkel, N. F. (2005). The Challenges of Chronic Obstructive Pulmonary Diseases (COPD)—A Perspective. COPD: Journal of Chronic Obstructive Pulmonary Disease, 2(1), 177-184. doi:10.1081/copd-200050676

Waatevik, M. J., Eagan, T. M., Hardie, J. A., Bakke, P., Real, F., Frisk, B., & Johannessen, A. (2017). Repeated desaturation in 6 minute walk test increases risk for mortality in COPD patients. Epidemiology. doi:10.1183/1393003.congress-2017.oa1788

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