ineffective breathing pattern and acute confusion, and the five nursing steps involved in these two nursing diagnoses and the multidisciplinary teams involved in addressing these two conditions

 ineffective breathing pattern and acute confusion, and the five nursing steps involved in these two nursing diagnoses and the multidisciplinary teams involved in addressing these two conditions

Introduction

Mr. Clarke MRN number 74937694 is a 72-year-old male patient who has a weight of 60, a height of 182 cm, and a BMI of 18.1, was brought in on grounds on COPD exercabation. He presented with shortness of breath, a productive cough, pyresis, and lethargy. Mr. Clarke currently resides in 5 Bentley Ave, Greenhaven SA 5119, with his wife Sandra of 65 years old. His medical history comprises of smoking, hypercholesterolemia, and myocardial infarction and when he was admitted to the respiratory ward, with the X-rays revealing bilateral lower lobe pneumonia. This paper explains two nursing diagnoses: ineffective breathing pattern and acute confusion, and the five nursing steps involved in these two nursing diagnoses and the multidisciplinary teams involved in addressing these two conditions. Finally, the legal and ethical considerations in each nursing diagnosis are well elaborated.

Assessment

Assessment is the procedural collection, organization, and documentation of a patient’s case. It can be both objective and subjective. In a medical setting, three steps are vital: history taking, physical exams, and tests. The history points out a worsening of the normal dyspnea in COPD. Clarke also presents with pyresis, a productive cough, and lethargy, which points out a respiratory infection. The Physical exams conducted to assess the temperature of levels, respiratory rate examination of sputum, pulse oximetry, blood pressure, and color of sputum produced. These are indicating an upper respiratory tract infection that manifests with tachycardia, green sputum, and tachypnea. The X-rays tests also showed bilateral lower lobe pneumonia, with the aspiration of foreign materials being ruled out. Consolidation patches appear as white patches on the plain radiographs.

Diagnosis

Ineffective breathing pattern

On Day 0, at 1000HRS, Albert Clarke recorded a respiratory rate of 25 breaths per minute, oxygen saturation of 80%, and a Blood Pressure of 135/90. The factors involved in Clarke’s ineffective breathing pattern include anxiety, decreased lung expansion, and the inflammatory response.

COPD constitutes a group of diseases that are characterized by the reduced inflow of air into the lungs. Asthma and bronchitis constitute the list. The symptoms are wheezing, sob, wheezing, and chronic cough. Pneumonia is inflammation of lung parenchyma, which leads to exudate deposition in the alveoli. This reduces the air exchanging capacity in the lungs, and hence the oxygen saturation drops in the body. Decreased lung expansion also occurs due to consolidation. As a compensatory technique, the central chemoreceptors in the body respond to higher levels of c02 in blood, and the respiratory rate is raised in the medulla. Anxiety increases the blood pressure and causes altered breathing patterns too.

Planning

Assessment of the respiratory rates after every 2 hours assists in the evaluation of hypercapnia and the Hypoxemia. This is a reflection of the degree of lung exchanging capacity in the lungs. The desired levels are between 14-20. Assessment of the blood arterial gas analysis tests also evaluates the level of Hypoxemia in blood. Levels are to avoid acidotic states with C02

above 45mmhg. The rationale being trying to achieve monitoring the breathing patterns those Clarke’ s-complications of pneumonia includes bacteremia. Sepsis spread to the brain manifests with meningitis that is a crucial finding in Cheyne- stokes breathing. Further assessment of signs of respiratory distress in Clarke, such as the use of accessory muscles, which move paradoxically, nasal flaring, use of abdominal muscles for breathing, and the tracheal tug enable the nurse to gauge the levels of respiratory discomfort. Checking central cyanosis on the tongue and peripheral cyanosis on the extremities assesses the extent of Hypoxemia in respiratory illness.

Auscultation of respiratory sounds that Clarke’s could have- pneumonia is characterized by added lung sounds such as crackles and Ronchi. Persistency, increase, or decrease could indicate the magnitude of the disease. COPD also manifests with wheezing sounds.

Promoting bed rest and calmness helps prevent anxiety in Clarke. This reduces epinephrine release, which is associated with increased B.P and increased respiratory states. This brings along the ineffective breathing pattern.

Implementation

Implementation by nurses ensures that Clarke takes his medication to reduce the level of infection and disease progression. Drug charts for the various drugs should be properly recorded when administration. These are azithromycin for bacteria and salbutamol for airway relief. Encouraging Clark to breathe diaphragmatically and through abdominal muscles forces air into and out the respiratory tract, and thus reduces the respiratory distress. Through Propping up Clarke’s bed at 45 degrees, or placing a pillow reduces instances of orthopnea, since inspiratory capacity is reduced when lying as compared to when sitting. Monitoring Clarke during episodes of respiratory distress helps determine the interventions needed. An example would be switching from a non-breather mask at 4L/min to CPAP masks that aid in air entry in the body. Educating both Clarke and his wife on his conditions reduces instances of exercabation such as limited movement and the importance of rest during his hospital stay. Finally, ensuring that Clarke takes his medication reduces bacterial load, thus reducing s/s.

Evaluation

Monitoring vitals such as respiratory rate after every one hour, checks for improvement of deterioration of ineffective breathing patterns. Monitoring oxygen saturation via a pulse oximeter.

Checking impact of bed propping on respiratory distress

Check for any drug side effects. Salbutamol could cause an undesirable increase effect on blood pressure, especially in coronary artery disease patients.

Part 2

Assessment

Acute confusion is the change that occurs in attention, and disturbances in cognition, psychomotor activities, and level of consciousness. Acute confusion occurs as a sequel to delirium that indicates a disruption in cerebral metabolism.

History: At 1300 hours, it is indicated that Clarke is oriented in time, place, and person and can follow commands. He also refuses to eat, and speaks doesn’t speak in full sentences. He also appears anxious and distressed about his diagnosis. Anxiety is linked to his current pneumonia state.

The standard gold test for delirium is the short confusion assessment method (S-CAM). It assesses the thinking, mental organization, consciousness, and onset of symptoms. A mini-mental state exam that evaluates the overall appearance, behavior, mood and affect, insight and judgment, cognition, and attention could also be conducted for further evaluation.

The abnormal physiological factors that could induce delirium in the patient, such as infection, hypotension, and electrolyte imbalance, should be closely monitored. An infection has been manifested through the chest X-ray that points pout bilateral pneumonia. Pyresis and dyspnea further corroborate on a respiratory tract infection.

Diagnosis– Acute confusion secondary to delirium

Delirium is a mental state of agitation, confusion, and altered sleep-wake cycles that is secondary to a physiological imbalance in the body. It can either be hypoactive or hyperactive. Hyperactive is reflected in alcoholism, while hypo is reflected in Clarke’s case. Delirium is known to cause acute confusion in two ways, direct brain insults and chronic stress responses. A direct brain insult occurs from hypoxia/hypercapnia, metabolic abnormalities, stroke, hypovolemia, and hypoglycemia. Infection induces hypotensive states, and these could lead to inadequate cerebral perfusion and, thus, cognitive disruptions. Furthermore, hypercapnia/hypoxemia that occurs during Clarke’s dyspnea could lead to a deficiency of oxygen delivery to brain cells, eventually leads to cell regression; this also adds to the cognitive deterioration. Aberrant stress responses are known to induce inflammatory responses, which cause fatigue, reduced appetite, and anhedonia.

Planning

Alleviate underlying condition-antibiotics/monitor the drugs. Treatment of underlying pneumonia reduces its aggravating impact on delirium. Restore fluid and electrolyte balance, and oxygen levels and vitals reduce the brain insults and hence reverse the delirium. Provide safety needs for Clarke, such as side rails, close supervision, and call bells, to ensure the patient doesn’t self-harm or accrue injury due to the delirium. Call bells to ensure fast response in case of any distress. Educate other staff and the MDT on Clarke’s condition helps other professionals address Clarke appropriately. He should be addressed in a calm way, without initiating any form of psychosocial stress to him. Ensure bed rest and appropriate sleep-wake cycles to reduce inflammatory stress mediators. Sleep disruptions in paroxysmal nocturnal dyspnea induce inflammatory and stress mediators, which can cause delirium.

Furthermore, the net effect of delirium is worse, especially in old age. Encouraging visits by his wife, friends, and family help Clarke feel compassionate. Offering reassurance to the Clarke on his safety provides a calming effect. It reduces his anxiety by feeling that he is in safe hands and that he will get well soon. In case of deterioration, medication such as bupropion could be issued to reduce anxiety without affecting his sleep cycles.

Implementation

Ensure drug compliance with azithromycin and salbutamol, aspirin and… as the mainstay drugs. Hydrating Clarke with Ringer’s lactate through an I.V line to restore his electrolyte balance helps reverse delirium. Furthermore, this should be followed by ensuring 1-hour roll calls on Clarke, and evaluation of his vitals.

Bed rails should also be put on bed rail to ensure safety while on his bed. This should be followed by responding immediately to any distress calls on his call bell. Finally, educating the staff in nursing rooms concerning Clarke’s acute confusion status should be done to prevent further pressure on him. Clarke should also be allowed to call his wife and friends via phone and organize visits during visiting hours for comfort. Finally, offering empathy and assurance to the patient enhances his confidence in the medical team.

Evaluation

Behavioral observations are the first step in evaluating Clarke. Reduced anxiety levels and peace of mind should be reflected in the way he speaks. The S-CAM test can be used to gauge the extent of delirium on a daily basis. The mini-mental score test should also be repeated once daily for evaluation of progress or worsening of symptoms such as cognition mood and affect, since they aren’t in the record in a S-CAM test. His sleeping hours and rest could also be gauged via active questioning after the interventions.

Multidisciplinary-Team

The multidisciplinary team is a combination of professionals who act together through their respective specialties to address specific concerns.

Respiratory specialists address ineffective breathing patterns. They should recommend suction machines for sputum removal. Respiratory physiotherapists could also aid with movement, which helps remove the respiratory secretions. These respiratory secretions increase airway blockage, which could be partially responsible for ineffective breathing patterns.

An occupational therapist could also design a walking aid to enhance mobility in Clarke’s case. Mobility aids, such as walkers, could be significant. Nutritionists should come in place to create a diet that offers high-calorie intake, but still, avoid high cholesterol levels to prevent exercabation of the coronary artery disease Clarke already faces. This is because infections require higher calorie intake due to elevated metabolism levels, as seen in temperature rise. A hospital-based social worker could also assist Clarke with his daily activities since his fatigue could limit him. Such activities include personal hygiene assistance.

Ethical and Legal Issues

Ethical and legal issues are the laws that govern medical practice. They constitute autonomy, equity and justice, beneficence, and non- maleficence. Autonomy depicts that Clarke should be able to choose his medication without external interference. All antibiotics and airway relievers should be given with his consent. Legal issues, especially in the elderly, evaluate the importance of treatment or not. He retains the right to accept or reject treatment despite his acute confusion. Justice depicts that Clarke should receive an equitable portion of the hospital’s resources when compared with the rest. Beneficence and non-maleficence represent that the nurse should act towards the best interests of the patient and cause minimum harm.

Code of ethics NMBA

Effective communication with the patient. This has been well represented when educating Clarke about his ineffective breathing patterns.

It offers a person-centered practice that is safe and evidence-based for the wellbeing of Clarke and his family.

Legal issues, especially in the elderly, evaluate the importance of treatment or not.

The nursing code of ethics is the official document that guides nurses. It is seconded by the professional code of ethics and the national competency standard levels for nurse practitioners. They all have one objective that outlines the role of a nurse in promoting health, prevention of illness, and restoration of health.

Conclusion

In summary, the case study of Clarke enables the nurse to understand the five nursing steps of assessment, diagnosis, planning, implementation, and evaluation. The importance of the assessment of the patient, come up with a proper diagnosis. Finally, implementation of the plan through adherence to the ethical and legislative laws in Australia ensures quality and safe patient care. Evaluation through tests and exams also measures the efficacy of care. The emphasis of the nurse in involving multidisciplinary teams and their roles is clear in Clarke’s case.