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Discussion

In healthcare system, the role of nursing practitioners is impregnable since they are committed to provide direct care to the patients (Ortiz et al., 2018). There are situations when nursing professionals have to prioritize the clinical problems faced by the patients and take actions according to their decision- making skills. There are clinical tools which facilitate the process of clinical decision making among the nurses, one of the tools which enables the nursing professionals in incorporating systematic approach during their clinical practice include Clinical reasoning cycle invented by Levett Jones (Gummesson, Sundén & Fex, 2018). According to Joan Blackmore's case study, an 84 years old lady was taken to the emergency room with the major complaints of fever, tachypnoea, hypotension and hypoxia. She had an ineffective pattern of breathing and an excessively elevated respiratory rate, thus she was sent from the Residential Aged Care Facilities to emergency room within a few minutes.

Clinical reasoning framework is based on consecutive steps which enable a nurse in finding clinical cues related to patient’s situation, processing that information, identifying the clinical issues, establishing goals of care and taking appropriate actions so that heath outcomes of the patient can be improved (Vierula et al., 2020). The clinical reasoning cycle also provides the opportunity to contemplate and learn from own clinical practice. In this paper, CRC will be applied in terms of planning care for Joan Blackmore.

Background information about the patient

Her medical history includes an open reduction and internal fixation (ORIF) which was done just before few days due to a fall. The medical history also included dementia, lipid disorders, atrial fibrillation, high blood pressure and osteoporosis. Atorvastatin, Aspirin and Metoprolol were among the medications she was taking at the time, although she had no known pharmaceutical allergies.

The patient's A to G evaluation data revealed that her respiration rate was almost 36 breaths per minute, her SpO2 level was 88 percent, her GCS score was 13 out of 15, and she displayed heavy diaphoresis. Her right hip surgical site showed oozing of fluid as well. Although the oral mucosal membrane appeared dry, no information on fluid intake or outflow was available at the time of the examination. The blood glucose concentration (4.2 mmol/L) can be cosidered close to the lower reference range which is 4.0 mmol/L.  

As per the assessment information of Mrs. Joan Blackmore, this old patient's respiration rate was clearly higher, since the typical respiratory rate is considered between 12 and 20 breaths in a minute (Rittayamai et al., 2019). The patient showed breathing at a rate of 36 breaths per minute, which is considered an excessively high respiratory rate that might damage the body's equilibrium if it is not regulated on a priority basis. Interstitial diseases modify the mechanical stimulation to the respiratory centre, resulting in rapid breathing (Grieco et al., 2020). Acute hypoxia might be caused by ineffective breathing, which could result in irreversible cell death. As a result, it is critical for healthcare practitioners to take proactive measures to address the clinical condition and adopt evidence-based therapies in order to avoid the patient's worsening.

Background information about the patient

A nurse must administer oxygen treatment to the patient in the context of resolving this patient's poor respiratory pattern and bring the respiratory rate back into normal range. This direct activity of oxygen supply would assist the patient in receiving the necessary oxygen, therefore addressing the task of breathing. Non-invasive ventilation (NIV) might not be tolerated as high-flow nasal cannula (HFNC) of oxygen therapy, according to a study done by Sun et al., (2019). HFNC has been investigated as a potential treatment option in comparison to NIV in the treatment of acute hypoxemic respiratory failure and post-extubating issues in these years (Drake, 2018; Tan et al., 2020).

HFNC appears to enhance patients' breathing rates, and hence can be deemed useful in keeping critical patients from worsening (Macé et al., 2019). If the oxygen saturation percentage of blood falls below the usual level of 92 percent in older people, professional recommendations typically prescribe that oxygen be administered to avoid cardio-respiratory problems (Rch.org.au, 2022). The patient's SpO2 level in the above case scenario was 88 percent, indicating a substantial decline in blood oxygen levels (that is a major pathophysiological reasons of rapid respiratory rate), and oxygen treatment should be started as a first line medical intervention for the patient (Spinelli et al., 2020).

Facilitation of the aforementioned strategy may be linked to favourable health outcomes such as a healthy breathing pattern, a normal breathing rate, and calm breathing. As per the study conducted by Pan et al. (2020), in the standardised oxygen therapy nursing method for COVID-19 patients, nursing monitoring of the patient's oxygenation is highlighted. It is supervised by nursing professionals and initiates oxygen therapy earlier. It not only improves vital patient outcomes, but it also reduces the danger of infection amongst the healthcare professionals by focusing on quality control for the nurses. Wang et al. (2020) found that administering oxygen to elderly people resulted in positive clinical results. Carbon dioxide retention can be more frequent in the elderly, who often have respiratory issues. As a consequence of this, the patient's blood gas must be monitored periodically, and oxygen therapy should be adjusted as needed. The degree of hypoxia, tolerance, and doctor's recommendations should all be considered when selecting respiratory support options for very ill older adults with respiratory problems.

Assessing respiratory rate between a standard reference range of 12 to 20 breaths per minute can be used to assess the effectiveness of the therapies. The patient has an effective breathing pattern, as evidenced by normal breathing at a reasonable rate and depth and the absence of dyspnea (Rolfe, 2019). The patient might be in no pain and have a good breathing rhythm. If the respiratory rate is within the normal limit, oxygen therapy might be discontinued; if it is not within the normal range, oxygen therapy would be continued along with other interventions such as arterial blood gas (ABG) level testing (Castro, Patil & Keenaghan, 2021).

A heart rate of more than 100 beats per minute might be referred to as tachycardia. This clinical condition may be accompanied with arrythmia or irregular heartbeats. The heart may be unable to pump adequate blood in the body if it beats too rapidly. As a result, organs and tissues might lack enough oxygen. Tachycardia is often noted as a critical indicator in the initial diagnosis of hemorrhagic shock, and it is assumed to be associated to hypotension. As a result, it should be treated as one of the medical team's top priorities.

Assessment Findings

The tachycardia management strategy should be centred on vigorous measures to reduce tachycardia in order to improve heart failure symptoms and reverse left ventricular malfunction. Following the use of antiarrhythmic medicines, an ECG report should be obtained to determine the heart's rate, conduction pattern, and rhythm. In terms of tracking aberrant changes for patients, assessing vital signs in conjunction with the ECG might be beneficial. Because the patient has a history of high blood disorders and atrial fibrillation, tachycardia may be dangerous if it isn't treated very away.

The patient being oriented in a semi- fowler's body postures may also benefit the patient acquire enough oxygen and so replace the cardiopulmonary oxygen need. As a consequence, the heart would not have to work as hard to collect more oxygen from the environment, and the heart rate would finally return to normal, or fewer than 100 beats per minute.

The outcomes must represent typical heartbeats of 70 to 80 beats per minute, as well as normal cardiac rhythm (Xie et al., 2018). Based on the patient's clinical situation and the type of tachycardia, rate control and/or rhythm control procedures are routinely utilised. If any underlying illness concerns exist, they should be addressed as soon as possible (Hafeez et al., 2021). There should be no signs of chest pain, and the patient's blood pressure should be normal.

Monitoring heart rate and blood pressure in the normal range should be done as part of the evaluation (Hwang et al., 2019). If the report reveals abnormal findings, the patient may be prescribed a greater dose of antiarrhythmic medication, and oxygen treatment may be facilitated (Sandroni, Skrifvars & Soar, 2019).

Conclusion

Hence it can be concluded that the actual problem that has been identified in the patient is ineffective respiratory patter and the potential problem might include shock which can be related to tachycardia. A nursing professional must administer oxygen to the patient in order to rectify the patient's inefficient breathing pattern and restore a normal respiratory rate. This action of oxygen supply might help the patient get the oxygen they need while also allowing them to control their breathing effort. After utilising antiarrhythmic drugs, the ECG report must be evaluated to estimate the rate, the status of conduction and the cardiac rhythm. Assessing vital signs in combination with the ECG may be helpful in tracking abnormal changes in patients. Since the patient has a medical history of high blood pressure and atrial fibrillation, tachycardia may be life- threatening if not treated immediately.

References

Castro, D., Patil, S. M., & Keenaghan, M. (2021). Arterial blood gas. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK536919/

Chourpiliadis, C., & Bhardwaj, A. (2019). Physiology, respiratory rate. https://www.ncbi.nlm.nih.gov/books/NBK537306/#:~:text=Clinical%20Significance&text=Metabolic%20acidosis%20states%20increase%20the,to%20a%20rapid%20breathing%20rate.

Drake, M. G. (2018). High-flow nasal cannula oxygen in adults: an evidence-based assessment. Annals of the American Thoracic Society, 15(2), 145-155. https://www.atsjournals.org/doi/abs/10.1513/AnnalsATS.201707-548FR

Grieco, D. L., Menga, L. S., Raggi, V., Bongiovanni, F., Anzellotti, G. M., Tanzarella, E. S., ... & Antonelli, M. (2020). Physiological comparison of high-flow nasal cannula and helmet noninvasive ventilation in acute hypoxemic respiratory failure. American journal of respiratory and critical care medicine, 201(3), 303-312. https://www.atsjournals.org/doi/abs/10.1164/rccm.201904-0841OC

Ineffective Respiratory Pattern

Gummesson, C., Sundén, A., & Fex, A. (2018). Clinical reasoning as a conceptual framework for interprofessional learning: a literature review and a case study. Physical Therapy Reviews, 23(1), 29-34. https://www.tandfonline.com/doi/abs/10.1080/10833196.2018.1450327

Hafeez, Y., Rodriguez, B. S. Q., Ahmed, I., Grossman, S. A., & Haddad, L. M. (2021). Paroxysmal Supraventricular Tachycardia (Nursing). In StatPearls [Internet]. StatPearls Publishing. ncbi.nlm.nih.gov/books/NBK568784/

Hwang, J., Kim, J., Choi, K. J., Cho, M. S., Nam, G. B., & Kim, Y. H. (2019). Assessing accuracy of wrist-worn wearable devices in measurement of paroxysmal supraventricular tachycardia heart rate. Korean circulation journal, 49(5), 437-445. https://synapse.koreamed.org/articles/1122104

Macé, J., Marjanovic, N., Faranpour, F., Mimoz, O., Frerebeau, M., Violeau, M., ... & Frat, J. P. (2019). Early high-flow nasal cannula oxygen therapy in adults with acute hypoxemic respiratory failure in the ED: a before-after study. The American journal of emergency medicine, 37(11), 2091-2096. https://www.sciencedirect.com/science/article/pii/S0735675719301536

Ortiz, J., Hofler, R., Bushy, A., Lin, Y. L., Khanijahani, A., & Bitney, A. (2018, June). Impact of nurse practitioner practice regulations on rural population health outcomes. In Healthcare (Vol. 6, No. 2, p. 65). Multidisciplinary Digital Publishing Institute. https://www.mdpi.com/305296

Pan, W., Li, J., Ou, Y., Wu, Y., Cai, S., Zhang, Y., & Wang, C. (2020). Clinical outcome of standardized oxygen therapy nursing strategy in COVID-19. Ann Palliat Med, 9(4), 2171-2177. https://doi.org/10.21037/apm-20-1272

Rch.org.au. (2022). Clinical Guidelines (Nursing) : Oxygen delivery. Rch.org.au. Retrieved 7 April 2022, from https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Oxygen_delivery/.

Rittayamai, N., Phuangchoei, P., Tscheikuna, J., Praphruetkit, N., & Brochard, L. (2019). Effects of high-flow nasal cannula and non-invasive ventilation on inspiratory effort in hypercapnic patients with chronic obstructive pulmonary disease: a preliminary study. Annals of Intensive Care, 9(1), 1-8. https://link.springer.com/article/10.1186/s13613-019-0597-5

Rolfe, S. (2019). The importance of respiratory rate monitoring. British Journal of Nursing, 28(8), 504-508. https://www.magonlinelibrary.com/doi/abs/10.12968/bjon.2019.28.8.504

Sandroni, C., Skrifvars, M. B., & Soar, J. (2019). Vasopressors, antiarrhythmics, oxygen, and intubation in out-of-hospital cardiac arrest: possibly less is more. Intensive Care Medicine, 45(10), 1454-1458. https://helda.helsinki.fi/bitstream/handle/10138/322073/Sandroni2019_Article_VasopressorsAntiarrhythmicsOxy.pdf?sequence=1

Spinelli, E., Mauri, T., Beitler, J. R., Pesenti, A., & Brodie, D. (2020). Respiratory drive in the acute respiratory distress syndrome: pathophysiology, monitoring, and therapeutic interventions. Intensive care medicine, 46(4), 606-618. https://link.springer.com/article/10.1007/s00134-020-05942-6

Sun, J., Li, Y., Ling, B., Zhu, Q., Hu, Y., Tan, D., ... & Xu, J. (2019). High flow nasal cannula oxygen therapy versus non-invasive ventilation for chronic obstructive pulmonary disease with acute-moderate hypercapnic respiratory failure: an observational cohort study. International Journal of Chronic Obstructive Pulmonary Disease, 14, 1229. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6556470/

Tan, D., Walline, J. H., Ling, B., Xu, Y., Sun, J., Wang, B., ... & Xu, J. (2020). High-flow nasal cannula oxygen therapy versus non-invasive ventilation for chronic obstructive pulmonary disease patients after extubation: a multicenter, randomized controlled trial. Critical Care, 24(1), 1-10. https://link.springer.com/article/10.1186/s13054-020-03214-9

Vierula, J., Hupli, M., Talman, K., & Haavisto, E. (2020). Identifying reasoning skills for the selection of undergraduate nursing students: a focus group study. Contemporary Nurse, 56(2), 120-131. https://www.tandfonline.com/doi/abs/10.1080/10376178.2020.1743732

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Xie, X., Wang, Y., Yang, Y., Xu, J., Zhang, Y., Tang, W., ... & Ma, X. (2018). Long-term exposure to fine particulate matter and tachycardia and heart rate: Results from 10 million reproductive-age adults in China. Environmental Pollution, 242, 1371-1378. https://www.sciencedirect.com/science/article/pii/S0269749118316117

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