Acute and Enduring Health Care Needs

When Mrs X arrived she was assessed and admitted to the ward, the assessment revealed that she has more than one health care need and so care plans were commenced for diabetes, hypertension, and nutrition and for shortness of breath. Of these I completed the shortness of breath assessment, using the standard care plan and framework from the clinical area I was in, completed upon admission. I explained to the patient that I would be writing an essay, and if possible I would like to base it on her case. Mrs X agreed to me taking copies of her care plan and writing about her and so I gained her consent.

The primary nursing need that Mrs X required in relation to her shortness of breath on the day of admission was for her respiratory rate to be 18 per minute. Most adults on rest will have a respiratory rate of 12-18, Mrs X had tachypnea or rapid breathing. To lower her respiratory rate she needs to be breathing humidified oxygen at 24% with a view to changing to BIPAP over night, her oxygen saturations need to be monitored every hour. To assist her breathing immediately she would need to be positioned upright and be supported. Diuretics to be commenced as prescribed and a fluid balance chart to be recorded immediatly, as she was to be on daily waits during her stay she needed to be weighed.

Once Mrs X had been settled I began her on 24% humidified oxygen, the reason humidified oxygen was being used was to ensure that Mrs X did not become to dry. If oxygen is not humidified then drying of the mucosa of the respiratory tract can be caused. The rationale for oxygen therapy in this case was to prevent Mrs X from becoming hypoxic, a condition where there is insufficient oxygen available for the cells of the body; this can particularly affect cells of the brain and other vital organs. Mrs X was to remain on 24% and no higher, it is very important that the percentage of oxygen is not changed from the prescribed rate. This is because people with COPD have altered respiratory physiology. They have a respiratory drive that is only able to respond to a low arterial blood level of oxygen. If there arterial blood levels become too high then they are at risk of respiratory arrest. (Jamieson 2002) This is due to the fact that in patients with COPD their stimulus to breathe is a decrease in blood oxygen levels rather than an elevation in carbon dioxide, and so if oxygen is delivered in high concentrations then the patients drive to breathe is removed. So the patients drive to breathe is due to hypoxia the administration of oxygen removes this drive and the patient can develop carbon dioxide narcosis. Mrs X was to be changed from humidified oxygen to BIPAP overnight. BIPAP (Bi-level positive airway pressure) is a non-invasive means of ventilation, it allows the patient to control when they inspire and expire unless programmed not to and can be set to ensure the patient takes a defined number of respirations per minute. BIPAP is ideal for COPD patients has it assists patients with inspiration and expiration and so patients can not retain carbon dioxide which could lead to hypoxia and that oxygen levels can not become high enough to risk respiratory arrest. (Smeltzer 2004)

While Mrs X is on oxygen she is having her oxygen saturations monitored every hour to ensure they are at level high enough for her to function without a risk of hypoxia, a level above 90% would be acceptable. The saturations will be monitored using pulse oximetry, this is an electronic probe that fits on the finger and detects absorption of red and infrared light passing through living tissue. This gives readout of arterial blood oxygen levels, although this could be achieved more accurately by taking blood gases, this way is non-invasive and will not disturb the patient through the night (Coull 1992). It is important for the saturations to be monitored closely while she is receiving oxygen therapy, if they do not improve then the patient's needs to be assessed further to see if this is the correct treatment for them. (Armstrong 2000) Although using pulse oxiemty is useful in assessing oxygen saturation care has to be taken with patients who are smokers as carbon monoxide also saturates haemoglobin and so a false reading can be obtained. (Bare 2004) The patients saturations will be monitored hourly through the night the reason for this is that she will be receiving BIPAP overnight and the saturations will be needed in order to asses its success, if it is not keeping her saturations at a satisfactory level then the settings will need to be reviewed.

It was important that Mrs X was immediately positioned and supported in way that would aid her breathing. This could be achieved by supporting the patient with pillows, supports or with positioning of an electric bed. The rationale for this care is that if the patient is sitting upright it makes breathing less difficult and can help the patient to cough and so remove any sputum they may have, and to allow for efficient secretion drainage (Marinin2002). Having the patient in an upright position makes it easier to keep the airway open, as being in a supine position predisposes the airway to closure. Both gas exchange and arterial blood oxygenation are improved by sitting the patient upright. The rationale for this care is that if Mrs X is upright and so as a result she is able to breathe with more ease and to increase are oxygen levels then her respiration rate will decrease to a more acceptable level. (Rubenfield 2002) While positioning Mrs X we ensured that she had no sores on her pressure areas as she has been immobile for a long time at home before this admission and she has been advised that some mobilisation will be necessary to help her recovery and so a physiotherapy consultation will be arranged. (Jamieson 2002)

Mrs X has been on diuretics long term at home to treat hypertension. Now that she has been admitted to hospital her usual dose has been changed, the reason for this is because she has swollen ankles as a result of immobility. As Mrs X has been admitted to the ward in the evening she will not be receiving her diuretic to the next morning. The rationale for this is taking diuretics causes patients to urinate more frequently. If this was given in the evening then the increased elimination needs would interfere with their sleep. While a patient is on a diuretic then the nurse must check that the patient is not experiencing any negative effects. A fluid balance chart must be commenced, to identify if the patient is having a negative output, also the patient should be weighed at the same time each day to look for any weight gain. Monitor the edema to look for improvement. Observations should be taken with a view to checking for hypotension as a result of dehydration. Skin turgor for signs of dehydration and finally assessing for symptoms of fluid overload. (Bare 2004) Another side effect of diuretics and in particular Bendrofluazide is hyperglycaemia as Mrs X is a diabetic patient and had an elevated blood sugar level on admission her glucose levels must be reviewed as part of her diuretic care.

As Mrs X would be commenced on a diuretic she would need to have her urine output monitored. Mrs X is not to be catheterised and so she had to be made aware that she would need to use a commode so her urine could be collected and measured. The rationale for this is because the effect of the diuretic needs to be monitored to see if it is having the desired effect. It is used equally to look for any negative effects the treatment maybe having such as dehydration. The average urine output for an adult is 1500ml a day, for a person to stay adequately hydrated their total loses must much their total gains. It is important to remember that adult will loose approximately 400ml of water vapour via lungs each day; this amount is increased with elevated respiratory rates (Bare 2002). By recording all outputs and inputs you can see if the patient has a positive balance where the input is larger than the output, this could be a sign of retention. A negative balance when the output is greater than the input is a sign of a patient becoming dehydrated, as is the patient complaining of thirst, having dry mucous membranes of the mouth and loss of skin turgor. As well as documenting the volumes of urine produced the electrolyte balance needs to be investigated, as the use of diuretics can result in the loss of sodium and potassium. (Whittaker 2004)

The final aspect of care to be addressed by Mrs X's shortness of breath care plan was for to be weighed each day. Mrs X was weighed upon admission at approximately 17.30, when she weighed 102kg. When a patient is weighed daily it must be at the same time each day and on the same set of scales. The best time to do it is every morning before breakfast and after the patient has urinated. Keeping the extraneous variables the same e.g. time of day you can get an accurate picture of weight gain or loss. Coupled with the fluid balance chart the action of the diuretic therapy can be assessed. (Whyte 2002)