Principles And Practice Of Adult Nursing

Introduction:

Scientific and social changes of the 21st century have brought as radical change in the Health care delivery system. Nursing is an important component of the health care delivery system and the role of a nurse in patient welfare has no boundaries for praise. The Nursing profession has evolved through time to establish a firm role in the medical domain based on strong ethical, moral and professional principles. The nursing practice has undergone a positive shift from that of a vocation to a professional status today. That is to say, nursing has a more active role to play in the health care delivery system than the past and nursing, as a profession is ‘Accountable’ today. Florence Nightingale was the founder of modern nursing who established the nursing philosophy based on health maintenance and restoration. The civil war (1860-65) enhanced the growth of nursing in United States and the two World Wars saw the nobility of the nursing practice.

An Overview of the Patient Personal History:

The patient in this case was admitted for an acute exacerbation of COPD with a complication of Atelectasis and Cor pulmonale. Chronic obstructive pulmonary disease (COPD), also known as chronic obstructive lung disease (COLD), is a term used to describe progressive lung diseases, which include emphysema, chronic bronchitis and chronic asthma. The common symptoms of COPD are progressive limitations of the airflow into and out of the lungs and shortness of breath. Emphysema and chronic bronchitis are closely related and patients with COPD may have both, which affects lung function, preventing the lungs from bringing oxygen to the body and getting rid of carbon dioxide.

Some cases with COPD may also have an "asthma-like" or reactive component. Emphysema involves destruction of the alveoli in the lungs. Chronic bronchitis is characterized by a chronic cough and mucus production. Although, smoking is the main cause of COPD, other environmental and industrial pollutants also contribute to COPD even in non-smokers. Passive cigarette smoke also contributes to acute respiratory symptoms and COPD. The other major causes of COPD include occupational dusts and chemicals vapors, irritants and toxic fumes. Respiratory infections in early childhood also contribute towards reduced lung function and increased respiratory problems in adulthood, leading to COPD.A rare, inherited form of emphysema, known as alpha-1-antitrypsin deficiency, also causes COPD. Atelectasis is a condition where there is a collapse of part or all of a lung by blockage of the bronchus or bronchioles or by very shallow breathing. Atelectasis can be both acute and chronic. Acute atelectasis is the recent collapse of the lung and is primarily notable only for airlessness. In chronic atelectasis, the affected area is often characterized by a complex mixture of airlessness, infection, bronchiectasis, and fibrosis. The most common cause of atelectasis is an obstruction of a large bronchus. Smaller airways also become blocked. The obstruction is caused by a plug of mucus, a tumor, or an inhaled foreign object inside the bronchus. Alternatively, the bronchus is also blocked by a tumor, enlarged lymph nodes, or a significant amount of pleural effusion or pneumothorax in the pleural space. When an airway becomes blocked, the air in the alveoli beyond the blockage is absorbed into the bloodstream, causing the alveoli to shrink and retract. The collapsed lung tissue commonly fills with blood cells, serum, and mucus and becomes infected. Acute atelectasis is a postoperative complication, especially after chest or abdominal surgery. Acute atelectasis also occurs with an injury, usually to the chest. Atelectasis following surgery or injury, involves most alveoli in one or more regions of the lungs. Chronic atelectasis may occur in one of two forms namely, middle lobe syndrome or rounded atelectasis. In middle lobe syndrome, the middle lobe of the right lung contracts, usually because of pressure on the bronchus from enlarged lymph glands .The blocked, contracted lung sometimes develops pneumonia that fails to resolve completely and leads to chronic inflammation, scarring, and bronchiectasis. In rounded atelectasis, an outer portion of the lung slowly collapses as a result of scarring and shrinkage of the pleura. The Symptoms includes shortness of breath due to the loss of functioning lung tissue; persistent blood flow through the collapsed area leading to a decrease in the blood oxygen level; increase in the heart rate and cyanosis. The symptom severity depends on rapidity of the bronchus block; the volume of the lung is affected; the precipitating factors; and lung infection. When blockage is rapid and a large part of lung tissue is affected, the patient turns blue or ashen in color, has sharp pain on the affected side, and experiences shortness of breath. The patient also experiences shock with a sudden drop in blood pressure; an increased pulse rate; and fever in case of infections. Cor pulmonale is the failure of the right side of the heart caused by prolonged high blood pressure in the pulmonary artery and right ventricle of the heart.The left side of the heart exerts a higher level of blood pressure to pump blood to the body.Whereas, the right side pumps blood through the lungs with a lower pressure. Thus, any condition that leads to prolonged high blood pressure in the arteries or veins of the lungs causes a condition called pulmonary hypertension.This pulmonary hypertension is not tolerated by the right ventricle of the heart and thus fails to properly pump against these abnormally high pressures leading to cor pulmonale.Chronic lung diseases like COPD or other conditions like Obstructive sleep apnea,Central sleep apnea,Cystic fibrosis causing prolonged low blood oxygen can lead to cor pulmonale.The symptoms include shortness of breath,wheezing, coughing, swelling of the feet or ankles,exercise intolerance,chest discomfort, cyanosis,distension of the neck veins indicating high right-heart pressures,abnormal fluid collection in the abdomen , enlargement of the liver,swelling of the ankles and abnormal heart sounds.

Medical interventions of nurse care:

People with chest deformities or neurologic conditions that cause shallow breathing benefit from mechanical devices that assist breathing, such as continuous positive airway pressure, which delivers oxygen through a nose or facemask that prevent airways collapse, even at the end of a breath. Additional respiratory support can be provided with a mechanical ventilator. The primary treatment for acute massive atelectasis is removal of the underlying cause. If the blockage cannot be removed by coughing or by suctioning the airways then it should be removed by bronchoscopy. Antibiotics are to be given for any detected infection as in chronic atelectasis, when infection is almost inevitable. Treatment of atelectasis due to deficient or ineffective surfactant, is done by treating the low blood oxygen either with mechanical ventilation or positive end expiratory pressure. For Cor pulmonale, Supplemental oxygen can be administered to increase the level of oxygen in the blood. A low salt diet is recommended. Diuretics can be given to remove excess fluid from the body. Calcium channel blockers, intravenous prostacyclin, or the oral medication bosentan are frequently used to treat pulmonary hypertension. Blood thinning anticoagulants are also useful.Oxygen administration relieves symptoms and prolongs survival.Careful intervention is essential because progressive pulmonary hypertension and cor pulmonale often leads to severe fluid retention, life-threatening shortness of breath, shock, and death. Benzodiazepines are not recommended to relieve anxiety in patients with COPD because they decrease respiratory drive and compromise lung function. An anxiolytic, buspirone, have been found to be safe in reducing anxiety in COPD patients. Dyspnea is common in individuals with chronic obstructive pulmonary disease (COPD). Respiratory assessment of the patient should include present level of dyspnea measured using a quantitative scale such as a visual analogue or numeric rating scale.Usual dyspnea is measured using a quantitative scale such as the Medical Research Council (MRC) Dyspnea Scale.The other assessments include Vital signs, Pulse oximetry , chest auscultation ,chest wall movement and shape/abnormalities, presence of peripheral edema, accessory muscle use , presence of cough and/or sputum, ability to complete a full sentence and the level of consciousness.By doing so, nurses should be able to detect stable and unstable dyspnea and acute respiratory failure (American Thoracic Society, 1998). Nurses should also be able to offer nursing interventions for all levels of dyspnea including acute episodes of respiratory distress which includes acceptance of patients' self-report of present level of dyspnea ,Medications ,Controlled oxygen therapy , Secretion clearance strategies,Non-invasive and invasive ventilation modalities,Energy conserving strategies ,Relaxation techniques,Nutritional strategies and Breathing retraining strategies. It is important for the nurses to remain with patients during episodes of acute respiratory distress. Medications include Bronchodilators ,Beta 2 Agonists ,Anticholinergics and Methylxanthines,Corticosteroids ,Antibiotics ,Psychotropics and Opioids Nurrses have to assess patients for hypoxemia/hypoxia and administer appropriate oxygen therapy for individuals for all levels of dyspnea. Continuous Positive Airway Pressure Oxygen therapy is part of any ICU and requires absolute attention. Patient safety checks includes circuit leaks; maintenance of positive pressure; adequate inspiratory airflow and not leaving the patient alone. Managing the therapy involves maintenance of the desired FIO2; level of positive airway pressure and time period for CPAP therapy, attaching CPAP machine medical air and oxygen gas lines to wall sources, preparation of humidification source, selection of prescribed FIO2 onoxygen blender, turning flow on to level above 25 litres / min., positioning of rubber securing band behind the patient's head, centred on occiput, positioning of face mask over the patient', adjusting the level of positive expiratory pressure to prescribed level, adjusting inspiratory gas flow so that minimal fluctuations are present on pressure gauge, Observing and documenting respiratory rate; work of breathing and SpO2, increasing inspiratory flow if respiratory work is excessive or the patient complains of continuing dyspnoea, Maintaining continuous SpO2 monitoring with alarm function in place, maintaining humidification temperature at 36 degree C or at temperature tolerated by the patient. Patient observations include, visual check every half an hour, documentation of respiratory rate, SpO2, nausea and vomiting, monitoring pulse rate and rhythm; blood pressure; peripheral circulation and proper functioning of humidification system every hour, checking the condition of skin around and under mask and rubber securing band, documentation of condition and interventions, condition of conjunctivae every two hours, auscultation of lungs for equal air entry and palpitation of abdomen for distension every four hours. Ventilator-Associated Pneumonia is a common nosocomial infection in the ICU accounting for 13% to 18% of all nosocomial infections. Critically ill patients supported by mechanical ventilation are especially vulnerable to ventilator-associated pneumonia, leading to increased mortality and morbidity and prolonged hospital stay. Because of intubations, bacteria have direct access to the lower airways and the endotracheal tube bypasses normal filtration mechanisms and the epiglottis .The endotracheal tube serves as a route for inoculation of the bacteria such as P. aeruginosa. Infection may be even due to improper hand washing, not changing the gloves from patient to patient, and contamination of respiratory devices like nebulizers, spirometers, oxygen sensors, bag-valve mask devices, and suction catheters (Shelby Hixson, 1998).

Conclusion:

Thus, a nurse needs insight, sensitivity, effective communication skills and strategies to give what the patient needs and uphold the values of nursing care. As the saying goes, “Everyone needs a nurse”.

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Robert Smith has spent more than 15 years working as a professor at New York University. Now he spends most of his time with his family and shares his Univesity experience with the customers of Custom Writing Service. He is a right person you can ask about custom essay.

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