Patient with Complex Care Needs

Answer

Patient with Complex Care Needs

Introduction

The purpose of this essay is to provide an assessment, evaluation, nursing diagnosis, and care plan for a patient with complex care needs. The case study involves a patient known as John West, 35 years-old who was availed to the Accident and Emergency department after reporting loss of his ability to smell, which has lasted for three days. He fears having infected with SARS-CoV-2 and is being investigated for the same. He was diagnosed with community-acquired pneumonia, and has since received doxycycline for treatment of the infection. The scope of the essay includes provision of a critical appraisal of the assessment frameworks used in the case study and development of a care plan for two nursing diagnoses, which include ineffective breathing pattern and excess fluid volume. A summary of the care plan is provided in the appendix section (Appendix 1 and 2).

Critical Appraisal of the Assessment Frameworks

Assessment frameworks that were used to assess John in this case include Glasgow Coma Scale (GCS) and the National Early Warning Score (NEWS) system.  GCS is utilized to empirically define the degree of compromised consciousness in both trauma and acutely ill patients. GCS assess patients according to their responsiveness to motor, eye-opening, and verbal responses (Jain & Iverson, 2020). Scoring of John using the GCS indicated that his score was GCS 15/15. This implies that he can spontaneously open his eyes with blinking at the baseline (4 points), his verbal responses are oriented (5 points), and he obeys commands for movement (6 points). This score may rule out possibility of brain injury. Thus, observed symptoms such as cyanosis, breathless, and peripheral cyanosis are likely to be caused by brain injury (Jain & Iverson, 2020). Refer to Appendix 1.

NEWS is used as an early warning system for deteriorating adult patient in hospital. Six physiologic measures scored by NEWS scoring system include oxygen saturation, respiratory rate, pulse rate, systolic blood pressure, new-onset confusion, level of consciousness and temperature (National Institute for Health and Care Excellence (NICE), 2020). A score of 3, 2, 1, or 0 for each parameter, the higher the score the farther is the physiologic parameter from the normal (NICE, 2020). John’s respiratory rate was 24-breaths per minute, oxygen-saturation level was 92%, systolic pressure was 130 mmHg, pulse rate was 90 beats per minute, conscious, and his temperature was 37.6°C. He was assigned a NEWS aggregate score of 4. According to NICE (2020) guidelines this is implies a low risk aggregate score that prompts assessment of the patient by the ward-nurse to choose on the need to change monitoring frequency of the patient or to escalate clinical care. Thus, the client just requires a ward response (NICE, 2020).

Comprehensive Assessment

The ABCDE (Airway, Breathing, Circulation, Disability, and Exposure) assessment tool (Refer to Appendix 2) is hereby used for assessment of the patient in addition to above assessment frameworks.

Airway: John’s airways not obstructed by blood, edema, vomit, or foreign body. Speaking in full sentences but wheezing. No reports of stridor or snoring. Productive cough, shortness of breath and loss of sense of smell reported (Resuscitation Council UK, 2020). Loss of smell may be indication of COVID-19 (Marshall, 2020). Treatment includes suctioning and oxygen therapy (Vera, 2020).   Refer to Appendix 2.

Breathing: Elevated breathing rate (24 bpm), low SpO₂ (92%), and there are signs of peripheral cyanosis.  Normal respiratory rate for an adult at rest ranges from 12 to 16 breaths per minute (Johns Hopkins Medicine, 2020). On the other hand, normal SpO₂ is at least 95% (Minnesota Department of Health, 2020). There is evidence of use of accessory muscles of respiration due since he experiences pain in his intercostal muscles as he coughs. Chest X-ray shows moderate pneumonia and areas of consolidation. Management includes proper positioning of the patient and oxygen therapy. Arterial blood gas analysis should be considered (Resuscitation Council UK, 2020). Refer to Appendix 2.

Circulation: Circulation assessment indicates elevated blood pressure (130/50 mmHg) but normal pulse rate (90 bpm). Normal blood pressure range is systolic pressure of <120 mmHg and diastolic pressure of <80 mmHg and pulse rate is 60 to 100 bpm (Johns Hopkins Medicine, 2020). No signs of bleeding or skin paleness. Electrocardiogram and capillary refill time need to be measured. Management no need of fluid therapy. But fluid and sodium restriction is indicated. Urinary catheter may be taken into consideration (Resuscitation Council UK, 2020). Refer to Appendix 2.

Disability: Disability assessment indicates that John is alert, voice is responsive, pain is responsive, there are intact limb movements, and there are normal pupillary light reflexes. No sign of neck stiffness. The patient is normal on Glasgow Coma Scale (15/15). Blood glucose needs to be measured for this patient. Continuous monitoring and assessment are indicated (Resuscitation Council UK, 2020). Refer to Appendix 2.

Exposure: Exposure assessment indicates no fractures, trauma, lesions, or bleeding. But potential exposure to SARS-CoV-2 and confirmed exposure to community-acquired pneumonia. Additionally, there is potential exposure to secondary cigarette smoke. The patient is using doxycycline to manage community-acquired pneumonia. COVID-19 investigation is underway (Resuscitation Council UK, 2020). Refer to Appendix 2.

Nursing Diagnoses

Ineffective Breathing Pattern

The first nursing diagnosis for John is ineffective breathing pattern related to compensatory tachypnea as evidenced by increased breathing rate (24 breaths per minute (bpm)), reduced oxygen saturation (SpO₂) when breathing on room air, peripheral cyanosis, pain (4/10) in the intercostal muscles when breathing, and coughing thick yellow sputum. Ineffective breathing pattern common related factors include anxiety, alteration of patient’s oxygen and carbon (IV) ratio, hypoxia, decreased lung expansion, pain, and inflammatory process (Vera, 2020). Ineffective breathing pattern is a distressing sensation that is associated with breathing difficulty. It is related with various long-term and acute conditions. Breathless has been identified as a key symptom of COVID-19, which has caused a global pandemic. Common clinical features of COVID-19 include sore throat, fatigue, cough, headache, myalgia, loss of smell and/or taste, and a rash; but not in all cases. It remains asymptomatic in some individuals (Marshall, 2020).

Effective breathing pattern is associated with the inability to meet metabolic demands of the body. It is a common problem that is experienced by patients with pneumonia (Vera, 2020). Similarly, John has been diagnosed with community-acquired pneumonia. He has been prescribed doxycycline (200 mg OD as starting dose and reduced to 100mg OD for subsequent doses) for management of community-acquired pneumonia. Alterations in breathing pattern arise since the affected alveoli fails to effectively exchange carbon (IV) oxide and oxygen, due to increased body temperature and chest pain (Vera, 2020). However, John’s temperature (37.6°C) remains within the normal range; oral 36.4 to 37.6°C (Sampson & Nall, 2020).

Ineffective breathing pattern is related to numerous factors such as existence of group of diseases, obesity, fatigue, and presence bronchial secretions (Prado, Bettencourt, & Lopes, 2019). John weighs 80 kg and his height should be determined so that body mass index is calculated to help establish whether he is obese or not. He reports products a productive cough, which may contribute to ineffective breathing pattern. He has community-acquired pneumonia and yet to be confirmed for COVID-19; in which both can contribute to this clinical diagnosis. Changes that are observed in case of presentation of ineffective breathing pattern include auscultation with adventitious sounds, changes in respiratory depth, decreased vesicular murmurs, dyspnea, cough, tachypnea, utilization of the accessory muscles breathing, and cough (Prado et al., 2019).

Goals

1. The patient’s respiratory rate remaining within the established normal rate (Vera, 2020).
2. The patient retains an effective breathing pattern as demonstrated by a normal depth, absence of dyspnea, and relaxed-breathing at normal rate (Vera, 2020).

Interventions

Pharmacological Interventions

            Oxygen therapy is indicated to improve SpO₂ levels from the current level of 92%. Oxygen should be supplied over a heated humidified system. Oxygen therapy effectiveness should be monitored using arterial blood gas analysis or pulse oximetry as appropriate. Caution should be observed so as to observe oxygen induced hypoperfusion in a timely manner (Lima et al., 2018).  The oxygen delivery devices should be monitored regularly so as to guarantee that the prescribed concentration of oxygen is being administered at any particular time. The flow liters of oxygen need to be monitored (Lima et al., 2018). In patients with greater severity of respiratory failure who are on oxygen therapy, mechanical-ventilator may completely substitute the work of the ventilator musculature which may cause the patient to present with lower number of defining-characteristics of ineffective breathing pattern (Seganfredo et al., 2017). Apart from oxygen therapy bronchodilators are commonly used to manage breathlessness (Marshall, 2020).

Non-Pharmacological Interventions

            The patient should be assessed for depth and respiratory rate for at least every four hours since the average respiratory rate in adults is 10 – 20 bpm. Immediate action needs to be taken if there is change in the breathing pattern to detect respiratory compromise early signs. Assessment of arterial blood gas levels in accordance with facility policy is also required so as to monitor ventilation and oxygenation status (Vera, 2020). In addition, the patient’s breathing patterns should be observed since unusual breathing patterns may indicate a dysfunction or underlying disease process. The Cheyne - Stokes respiration implies bilateral dysfunction related with deep diencephalon or cerebral related with metabolic disorders or brain injury. Ataxic and apneusis breathing are associated with respiratory centers failure in the medulla and the pons. On the other hand, auscultation of breathing sounds at least every four hours is necessary to enable detection of reduced adventitious breath sounds (Vera, 2020).

            It is also important to assess the patient for the use of accessory muscles of respiration because the work of breathing tends to increase greatly due to decreased lung compliance. Similarly, the patient should be monitored for diaphragmatic muscle weakness or fatigue (also known as paradoxical motion) since paradoxical movement of the abdomen implies respiratory muscle weakness and fatigue. In addition, the patient should be observed for flaring or retractions of the nostrils since these are signs of increased respiratory effort (Vera, 2020).

            The patient needs to be placed in a proper alignment of the body to promote maximum breathing pattern. A sitting position enables maximum chest expansion and excursion. The patient should also be encouraged to maintained sustained deep breaths by using incentive spirometer, demonstrating to the patient and requiring the patient to yawn. Sustained deep inspiration prevents atelectasis and increases oxygenation. Controlled breathing may reduce tachypnea while prolonged expiration prevents air trapping (Vera, 2020).

            Respiratory secretions may be suctioned so as to clear blockage of the airway. Staying with the patient during an acute episode may help anxiety as well as reduce oxygen demand during an episode of respiratory distress. Due to potential diagnosis of COVID-19 the patient should be taught on proper coughing, splinting and breathing methods. These will allow for sufficient mobilization of secretions. Other patient education needs include pursed lip breathing, performing relaxation techniques, abdominal breathing, taking of prescribed medications, and scheduling of activities so as to avoid fatigue and plan for rest periods. These interventions will help John to participate in improvement of ventilation and maintenance of his health status (Vera, 2020).

            Cognitive behavioral therapy (CBT) may be considered for management of symptoms of anxiety, which is associated with respiratory problems. John can be taught self-management strategies for his breathless episodes using CBT. He should make challenging and significant changes in his own behavior and approach (Marshall, 2020). Cognitive strategies that may be used to take better control of breathlessness include pacing and planning activities, breathing-control exercises, focusing their breathing on other activities rather than breathing, relaxation techniques, appropriate positioning to help reduce state of breathlessness, room temperature control, and cooling of the face (Marshall, 2020). Refer to the Appendix 1 for a summary of the care plan for ineffective breathing pattern.

Excess Fluid Volume

            The second nursing diagnosis for the patient is excess fluid volume related to decreased perfusion of the renal organ, increased water retention, increase in hydrostatic pressure and/or decrease of plasma proteins as evidenced by oliguria (35mL-40mL urine an hour) despite weighing 80kg, a cough, shortness of breath, and dyspnea (Martin, 2019). The patient should also be assessed for heart failure due to high blood pressure (130/50 mmHg) and fluid overload (Miller, 2016). Fluid congestion and volume overload is recognized clinical features of chronic heart failure. The simplified concept of passive intra-vascular fluid accumulation is not sufficient for explaining excess fluid volume since the pathophysiological explanation of volume regulation is complex. Dynamic intravascular fluid compartment and interstitial fluid interactions as well as fluid distribution from splanchnic beds to the central pulmonary circulation ought to be taken into consideration when developing strategies for management of excess fluid volume (Miller, 2016). It is also to assess the patient for acute kidney injury since there is a significant association with fluid overload. The rationale for further assessment is to develop personalized fluid management approaches for the patient (Ostermann, Straaten, & Forni, 2015). Refer to Appendix 1.

Goals

1. The patient demonstrates having a stable fluid volume by one week of treatment as demonstrated by balanced fluid intake and output, normal signs within normal range, stable weight, and absence of edema.
2. Normal urine output (0.5 ml to 1.5 ml per kg per hour), which is 40 ml (0.5×80) to 120 ml per hours in John’s case by 48 hours under treatment (Centers for Disease Control and Prevention, 2020).

Interventions

Pharmacological Interventions

            Administration of diuretics such as furosemide is indicated in John’s case. Diuretics help to decrease peripheral edema and plasma volume (Martin, 2019). Chronic volume excess can be managed with standard vasodilator and diuretic therapies (Miller, 2016).

Non-Pharmacological Interventions

            Monitoring of urine output and making an observation of urine volume and color is one of the required nursing interventions. The rationale of that urine output may be scanty and concentrated as a result of decreased renal perfusion. Another intervention is the need to auscultate the lungs for presence of adventitious-breath sounds such wheezing and crackles (Martin, 2019). The presence of cough, orthopnea, or dyspnea should also be noted. The rationale for this is that the above respiratory sounds may demonstrate pulmonary edema as a result of deteriorating pulmonary congestion and in such as case treatment should be started immediately (Martin, 2019).

            John’s fluid intake and output should also be monitored since decreased cardiac output can result in reduced renal perfusion and impairment with excess fluid volume that causes water and sodium retention and oliguria (Martin, 2019). The patient should also be assessed for edema since edema tends to present in the ankles and feet and gradually contribute to increase in weight. Another intervention is to assess John for weight gain and fluid balance since sodium and fluid retention tend to occur as a result of the impaired regulatory mechanisms. Body weight is an indicator of response to diuretic therapy. Assessment of the neck veins for distention is also indicated since jugular vein distention is a positive indicator of excess fluid. Monitoring of the patient’s electrolyte levels (particularly potassium) is necessary since hypokalemia may occur since diuretics promote potassium secretion (Martin, 2019).

            Chest X-ray need is also required so as to evaluate the patient for worsening lung condition or progress. On the other hand, John should be placed in a semi-Fowler’s position since this position helps to improve renal filtration and reduced production of anti-diuretic hormone promoting diuresis. It is also important to change the patient’s position at least every two hours since repositioning helps to improve breathing, mobilize secretions and decrease the risk of pressure ulcer. Patient education aimed at reducing sodium intake in diet is also indicated so as to decrease electrolyte retention and fluid retention (Martin, 2019).  Refer to the appendix section for a summary of the care plan of the excess fluid volume.

Conclusion

            The two major nursing priorities for John include ineffective tissue pattern and excess fluid volume. Evidence of ineffective tissue pattern include elevated breathing rate (24 bpm), reduced SpO₂ 92% on room air, peripheral cyanosis, pain (4/10) in the intercostal muscles when breathing, and coughing thick yellow sputum. Evidence of excess fluid volume includes increased water retention, low urine output (35mL-40mL urine an hour), a cough, shortness of breath, and dyspnea. Nursing interventions for the two priority problems include pharmacological and non-pharmacological interventions that are summarized in the care plan provided in the appendix section.