CNA772 Interpreting Patient Deterioration Case Study

The aim of the essay is to evaluate the case scenario of Mr. Fred who presented with respiratory distress due to exacerbation of chronic obstructive pulmonary disease (COPD). The paper will evaluate alterations in vitals signs and health status due to respiratory shock and evaluate the pathophysiology linked to the altered physical state of patient. The paper will give insight into two management strategies that were used to manage acute respiratory distress among patient. The nursing management strategy that will be explored in the essay is the implementation of deep breathing exercise for the patient and the medical strategy that will be explored is the use of oxygen therapy.

Mr. Fred is a 65 year old factory worker who was admitted to the ward following increased breathlessness and mobility concerns. The patient complained about increased difficulty in breathing. He reported producing sputum, feeling tired and was found with symptoms of dyspnea. He was experiencing these symptoms since one week but last night his symptoms worsened as it became difficult to manage and he could not go to sleep. The patient had a history of COPD and diabetes. He had smoking habits and he used to take 20 cigarettes per day. He was a smoker since the past 40 years. During my first assessment of Mr. Fred in my shift, he appeared to be tired. On chest auscultation, bilateral basal crackles were. The patients RR value was 30 bpm, SpO2 values was 88%, BP was 178/92 and HR was 108 bpm. The assessment of the sputum sample was done and it was noted to be purulent and green. It is indicative of high bacterial load. The drop in oxygen saturation value was identified as a concern as it was indicative of acute respiratory distress. According to (), shortness of breath is the first symptom of acute respiratory distress (ARD). Other signs indicative of the same are rapid breathing and wheezing sound in the lungs when breathing. As all the above signs were present in Mr. Fred, it is indicative of deterioration of his condition and risk of ARD.

During the assessment, the patient seemed tired and he could not speak in full sentences because of inability to breath. A call for medical emergency was initiated as HR increased to 123 bpm and SpO2 value dropped to 86%. The acute worsening of respiratory symptoms indicated that the patient was suffering from COPD exacerbation. Thus, immediate treatment and clinical intervention is required for such patient to minimize negative impact and prevent likelihood of subsequent events such as relapse of symptoms, decrease in early readmissions to hospital. The pathophysiology behind dyspnea and breathing difficulty will be further explored in this section. According to Leap et al. (2021), the increase in upper and lower airway inflammation are important pathophysiological mechanisms in COPD exacerbations. In stable COPD, the inflammatory process alters the bronchi and bronchioles on exposure to pollutants, toxic gases and smoking. It contributes to progressive airflow restriction and increase in emphysema. There is a rise in CD 8+ lymphocytes in the bronchial mucosa. The number of neutrophils increases with the severity of the disease. It is known to cause all components of COPD such as emphysema and mucous hypersecretion. Compared to healthy individuals, people with COPD has been found to have high number of tumor necrosis factot, interleukin-1, interleukin 9 and leukotriene B-4 (Rodrigues et al., 2021). In case of exacerbation, the inflammation in the airways amplifies. The neutrophil counts in the bronchial walls increases in patients with exacerbation. Other inflammatory markers also increase during exacerbation such as inflammatory cytokines, IL-6, endothelin 1 and the neutrophil chemoattractant (Leap et al., 2021).

 There are can be many causes behind COPD exacerbations such as bacterial or viral load, air pollution and changes in the weather. The symptom of dyspnea or shortness of breath is a common symptom in patients with COPD exacerbation. Hyperventilation is the primary cause behind COPD exacerbation and worsening airway inflammation increases the risk of such inflammatory reactions. Such intense inflammatory response is seen due to respiratory viruses and bacteria that infect the lower airway and increases the airway inflammation process. Hyperinflation takes place due to increase in physiological changes and increase in airway systematic inflammation. Studies exploring biopsies of patient with severe COPD revealed pronounced airway neutrophilia and upregulated expression of neutrophil chemokine. Evidence has been found for increase in interleukin-8 and increased oxidative stress in patients with oxidative reactions. Airway inflammation is the cause behind bronchoconstriction, mucus production, expiratory flow limitation and dynamic hyperinflation (Santus et al., 2019). These changes in the airway were the cause behind shortness of breath in Mr. Fred.

 In addition, his condition deteriorated further because of the history of smoking in patient. Evidence shows that smoking is a major trigger for COPD exacerbations. A study by Badaran et al. (2012) explored smoking habits among patients for COPD exacerbation. The retrospective study found that around 26.5% of patients continued to smoke. Pneumonia was found in 26% of smokers. There were 37 readmissions every year and out of them, nine of them continued smoking. Song et al. (2021) gave the argument that cigarette smoke contains a large number of toxic substances that can change the trachea and lung tissues. The primary pathophysiological mechanism behind onset of COPD were airway inflammation, oxidative stress and lung emphysema. The study shows that pulmonary vascular apoptosis initiates in patients with COPD. The symptom of dyspnea or shortness of breath in Mr. Fred was seen due to various involved mechanisms such as airflow limitation, gas trapping and gas exchange abnormalities and respiratory muscle dysfunction. In COPD patients, respiratory muscle dysfunction could be caused by hyperinflation or the lungs or diaphragm flattening. The dysfunction in respiratory muscle is the cause behind hypercapnic respiratory failure, limited exercise and acute exacerbation (Kim et al., 2019. Thus, nursing interventions and medical intervention needs to be prioritized to manage respiratory distress in Mr. Fred. 

Medical intervention in response to deterioration

The medical intervention that is necessary to manage decrease in oxygen saturation level and decreased work of breathing is the administration of oxygen therapy. The primary purpose of initiating controlled oxygen therapy is to control deterioration of lung function and health status of Mr. Fred. In case of patients with stable COPD, use of supplemental oxygen is not recommended as it leads to poor prognosis. However, it is a suitable therapy for patients experienced hypoxemia due to COPD exacerbations. According to Brill and Wedzicha (2014), oxygen therapy is defined as the administration of oxygen at concentrations greater than the surrounding environment. The primary purpose is to treat respiratory failure indicated by fall in oxygen saturation value. The normal oxygen saturation value for any young adult is 94-98%. In addition, hypoxemia is defined as a condition when the oxygen saturation value is less than 90%. However, the use of oxygen therapy in stable COPD patient is controversial. In contrast, oxygen therapy use is more prevalent for patients with acute exacerbations of COPD. Exacerbations with hypoxemia are a severe condition and it can be treated mainly in hospital settings (Pilcher et al., 2015).

The evidence based for the effectiveness of oxygen therapy in patients with acute exacerbation and the presence of respiratory failure was explored. In the study by Echevarria et al. (2021), various guidelines related to oxygen therapy was explored. The British Thoracic Society guideline recommended achieving a target saturation value of 88-92%. The update National Early Warning Score (NEWS) evaluates additional oxygen saturation for people with hypercapnic respiratory failure. This goal of this scale was to minimize the harms of excess oxygen by promoting target saturation level. Such guidelines or scales were important due to the evidence for injudicious use of oxygen in clinical settings. The study by Zheng et al. (2021) suggests that oxygen therapy is recommended only for patients who experience respiratory failure. In such patient, the same needs to confirm if acidosis and hypercapnia in patient. However, the study recommends the need to take precaution while implementing oxygen therapy. All conditions leading to respiratory failure should be confirmed. Mr. Fred’s vital sign value and declining oxygen saturation status value indicated the need to immediately implement oxygen therapy

Nursing strategy in response to deterioration

One nursing strategy that will be important in response to shortness of breath and decreased oxygen saturation level is prioritizing respiratory assessment and supporting patients with deep breathing exercise. Regular respiratory assessment can ensure early identification of deterioration and implementing appropriate intervention for patients. According to Steiner et al. (2015), comprehensive respiratory assessment can provide a mechanism for systematically evaluating vital signs and respiratory parameters of patient. The integration of respiratory assessment in nursing plan can support developing care plan for patient and developing tailored interventions. It can help to understand whether ventilator support or other intervention is required for patient. This can be followed by breathing exercise for Mr. Fred. The systematic review by Ubolnuar et al. (2019) investigated the effects of breathing exercises in patients with COPD. Breathing exercise is important part of rehabilitation program for COPD patients. Some of the different types of breathing exercise are pursed-lip breathing, relaxation breathing, diaphragmatic breatahing and ventilatory feedback. These types of breathing exercise have been mainly prioritized to decrease lung hyperventilation, promote respiratory muscle function, exercise tolerance and quality of life in COPD patients. The systematic review explored the effect of pursed-lip breathing exercise on improving respiratory rate in patients in the intervention group compared to control group. Thus, nurses can guide patient in the improving several ventilation related outcomes.

The role of nurse in implementing pursed-lip breathing exercise for Mr. Fred will be to demonstrate patient the appropriate way of engaging in pursed-lip breathing exercise. Pursed lip breathing is an intervention that supports breathing by opening of the airways during exhalation and increasing the excretion of volatile acids in the form of carbon dioxide. Through this exercise, people can get relief from symptom of shortness of breath, decreased work of breathing and gas exchange. They also support patients to gain a control over their breathing as well as promoting relaxation for patient. However, the issue of concern is that most of the patients are not able to perform the technique correctly (Nguyen & Duong, 2021). For the process to be effective, it is important that proper coordination is maintained to promote exhalation. The intervention is limited to 3-5 breaths as prolonged duration of the exercise may cause respiratory muscle fatigue. Hence, nurses have implications in educating and guiding patients regarding the correct method of pursed-lip breathing exercise. They can demonstrate the process themselves or use different modes such as videos to provide clarity regarding the technique. In addition, the nurse should educate Fred regarding the duration of the therapy and important things to consider to promote effectiveness of the therapy. The study by Cabral et al. (2015) revealed that when the process is done correct, people can relief from dyspnea and air trapping. According to Vatwani (2019), the accurate way of pursed lip breathing are standing in upright position, relaxing the shoulders and neck muscles, slowly inhaling through the nose at least 2 seconds with mouth closed and then following it up with slowly exhaling all the air with lips pursed for at least 4 seconds. Thus, Mr. Fred is likely to gain control over symptom of breathing difficulty using the above intervention.

To conclude, Mr. Smith developed respiratory distress due to hyperventilation occurring in response to COPD exacerbation. He was found to be experienced shortness of breath and decrease in oxygen saturation value was a sign of deterioration. The altered physiology leading to the condition were airway inflammation, bronchoconstriction, narrowing of the airways and hyperinflation. The exposure to the triggers such as chemicals or cigarette smoke was followed by impaired gas exchanged manifestation of dyspnea and breathing difficulty. In response to the above concern, oxygen therapy was recommended to provide relief during breathing. In addition, nursing intervention or support through pursed-lip exercise was recommended. The review of research literature revealed being very cautious while initiating oxygen therapy due to its poor prognosis in stable COPD.

References

Badaran, E., Ortega, E., Bujalance, C., Del Puerto, L., Torres, M., & Riesco, J. A. (2012). Smoking and COPD exacerbations.

Brill, S. E., & Wedzicha, J. A. (2014). Oxygen therapy in acute exacerbations of chronic obstructive pulmonary disease. International journal of chronic obstructive pulmonary disease, 1241-1252.

Cabral, L. F., D'Elia, T. C., Marins, D. S., Zin, W. A., & Guimarães, F. S. (2015). Pursed lip breathing improves exercise tolerance in COPD: a randomized crossover study. Eur J Phys Rehabil Med, 51(1), 79-88.

Echevarria, C., Steer, J., Wason, J., & Bourke, S. (2021). Oxygen therapy and inpatient mortality in COPD exacerbation. Emergency Medicine Journal, 38(3), 170-177.

Kim, N. S., Seo, J. H., Ko, M. H., Park, S. H., Kang, S. W., & Won, Y. H. (2017). Respiratory muscle strength in patients with chronic obstructive pulmonary disease. Annals of rehabilitation medicine, 41(4), 659-666.

Leap, J., Arshad, O., Cheema, T., & Balaan, M. (2021). Pathophysiology of COPD. Critical Care Nursing Quarterly, 44(1), 2-8.

Nguyen, J. D., & Duong, H. (2021). Pursed-lip breathing. In StatPearls [Internet]. StatPearls Publishing.

Pilcher, J., Weatherall, M., Perrin, K., & Beasley, R. (2015). Oxygen therapy in acute exacerbations of chronic obstructive pulmonary disease. Expert review of respiratory medicine, 9(3), 287-293.

Rodrigues, S. D. O., Cunha, C. M. C. D., Soares, G. M. V., Silva, P. L., Silva, A. R., & Gonçalves-de-Albuquerque, C. F. (2021). Mechanisms, pathophysiology and currently proposed treatments of chronic obstructive pulmonary disease. Pharmaceuticals, 14(10), 979.

Santus, P., Pecchiari, M., Tursi, F., Valenti, V., Saad, M., & Radovanovic, D. (2019). The airways’ mechanical stress in lung disease: implications for COPD pathophysiology and treatment evaluation. Canadian Respiratory Journal, 2019.

Song, Q., Chen, P., & Liu, X. M. (2021). The role of cigarette smoke-induced pulmonary vascular endothelial cell apoptosis in COPD. Respiratory Research, 22, 1-15.

Steiner, M. C., Evans, R. A., Greening, N. J., Free, R. C., Woltmann, G., Toms, N., & Morgan, M. D. (2015). Comprehensive respiratory assessment in advanced COPD: a ‘campus to clinic’translational framework. Thorax, 70(8), 805-808.

Ubolnuar, N., Tantisuwat, A., Thaveeratitham, P., Lertmaharit, S., Kruapanich, C., & Mathiyakom, W. (2019). Effects of breathing exercises in patients with chronic obstructive pulmonary disease: systematic review and meta-analysis. Annals of rehabilitation medicine, 43(4), 509-523.

Vatwani, A. (2019). Pursed lip breathing exercise to reduce shortness of breath. Archives of physical medicine and rehabilitation, 100(1), 189-190.

Zheng, Z. G., Sun, W. Z., Hu, J. Y., Jie, Z. J., Xu, J. F., Cao, J., ... & Zhong, N. S. (2021). Hydrogen/oxygen therapy for the treatment of an acute exacerbation of chronic obstructive pulmonary disease: results of a multicenter, randomized, double-blind, parallel-group controlled trial. Respiratory research, 22(1), 1-12.doi: 10.2147/COPD.S41476

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