Integrated Nursing Practice 92445 Report

This report focuses on the prioritization of complex health issues in nursing practice, specifically addressing a case study involving a patient with Chronic Obstructive Pulmonary Disease (COPD). It identifies key health issues such as poor oxygen saturation, increased respiratory rate, and elevated b...Read More

Running head: NURSING
Nursing
Name of the Student
Name of the University
Author Note

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Identification of Patients’ Health Issue
The three priority issues are poor oxygen saturation (SpO2: 88%; normal: 95 to
97% at room temperature), increased respiratory rate (36 beats per minute; normal: 12
to 22 beats per minute) and elevated blood pressure 146/92 mmHg (normal: BP: 120/80
mm Hg) (Urden, Stacy & Lough, 2019). She is also exacerbating scattered wheezes from
both the lungs. According to Ramos, Krahnke and Kim (2014), Chronic Obstructive
Pulmonary Disease (COPD) is associated with shortness of breath (SOB) along with
wheezing or generation of gasping sound coming from lungs during breathing. Airway mucus
is the part lung’s native immune that helps in trapping of the micro-organisms and
particulates and thus helping in lung clearance through ciliary transport and cough. Mucus
hyper-secretion and generation of choric productive cough are main features of COPD.
Hyper-secretion and over-production by goblet cells reduces the elimination of mucus and is
regarded as the principal mechanism of responsible for excessive mucus production and
formation of chronic bronchitis. This is reasons why Jim is experiencing wheezing of breath.
Wheezing of breath or block in the pulmonary airways is causing SOB followed by decrease
in the oxygen saturation of the body or hypoxia (Urden, Stacy & Lough, 2019). Thus poor
oxygen saturation is a major concern. Under hypoxic condition, the lungs are unable to
exchange adequate oxygen from the external environment leading to decrease in the
dissolved oxygen content in the blood. Thus the oxygen reaching to the corners of the body
reduces along with the reduction of the oxygen supply in the brain that ultimately might lead
to cyanosis and in extreme cases, development of coma. Hypoxia stimulates ventilation along
with dyspnea (SOB) and this is reason why Jim was forced to seat all the night for managing
his discomfort. Chronic alveolar hypoxia leads to the development of corpulmonate – right
ventricular hypertrophy either in the presence or absence of right ventricular failure (Vold et

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al. 2015). However, pulmonary hypertension (increased respiratory rate) in COPD patients
increase the pulmonary atrial pressure leading to increased heart beat and blood pressure.
Under increased blood pressure, there occurs increase in the peripheral resistance leading to
atrial fibrillation and subsequent development of heart failure. Jims’ increased blood
pressure and respiratory rate thus must be taken into consideration. Slightly elevated
body temperature (by 1 degree C) is not a significant concern for Jim as it might be due to
formation of mucus and can get reduced upon airway management. The elevated heart beat
can be managed by reduction of the high blood pressure and thus can be omitted from the
priority level (Urden, Stacy & Lough, 2019).
Prioritization of patients condition
Management of oxygen saturation
The first priority of care includes administration of the external oxygen supply in
order to increase the level of oxygen saturation within the body. The recommended treatment
issued administration of oxygen. The administration of oxygen must be undertaken in high
Fowler’s position (60 to 90 degree angle). The high Fowler’s position facilitates the relaxing
of the tension of the abdominal muscles and thereby helping to increase the surface area of
the diaphragm and promoting the process of ease breathing. The administration of the oxygen
must of done through vapotherm small bore cannula with high intensity oxygen
administration. This type of nasal cannula will reduce the unwanted loss of oxygen from the
surrounding while increasing the velocity to flushing out CO2 and increasing the inflow of
oxygen. It also ensures optimal patients’ comfort along with minimal occlusion for promoting
gas egress (Fujita et al,. 2019). A nursing professional must also monitor the level of oxygen
saturation in the body through pulse oxymetry in order to regulate the external oxygen supply
(Peyton et al., 2019).

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Management of in-effective airway clearance and management productive cough
The in-effective airway clearance is associated with wheezing sound of breathing
along with SOB. The nursing intervention will include educating the patient about proper
ways of coughing and breathing like taking a deep breath and then holding the breath for 2
seconds following by coughing two or three times in a consecutive manner. The deep
breathing exercise must be conducted in the form of pursed lip breathing (inhaling through
nose and exhaling through mouth). This is a simple technique that helps to slowing down a
breathing rate of a person and also helps to inhale more air into the lungs. The regular
practice of pursed lip breathing helps to increase the strength of the pulmonary muscles and
helping them to work effectively (Cabral et al. 2015). The practice of cough in a high
Fowler’s position will help to excretion of accumulated mucus in the lungs (Satia et al. 2018).
Community based interventions for healthy lifestyle
Jim is feeling lonely and he stays alone at home. The constant feeling of loneliness
increases the chance of chronic depression. Thus it is the duty of the nursing professional to
improve the mental state of the patient by motivating him to take part in the community based
social activities like group based gardening or group based mild to moderate physical
exercise session. This will help to improve his level of physical fitness and will also help him
to fight against depression and loneliness. Community-based intervention also helps in
improving the disease self-management skills (Satia et al. 2018). Under disease self-
management skills, Jim will be educated about proper intake of fluid as he might be suffering
from dehydration as the case study reveals that drinking helps him to calm down. The fluid
intake will be managed based his body mass ratio (Urden, Stacy & Lough, 2019). Jim will be
educated to have small sips of water within frequent interval.

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Department policies and Nursing Board Rule
The care plan for Jim includes complementary or alternative therapy like breathing
exercise. As per the NSW policy the application of the complementary and alternative
policies must be done through informed consent and the progress of the patient must be
accurately documented (New South Wales Nurses and Midwives Association 2018).. NSW
policy also signifies that nurse must work in active collaboration with other allied health-care
professionals in order to improve the outcomes of patients’ care. For Jim, the allied
healthcare professionals that will be included are dietician for effective diet and fluid intake
and social care or residential care nurse who will assist the Jim is completing the activities of
daily living and giving Jim social company (New South Wales Nurses and Midwives
Association 2016). This again coincides with the NSW policy and guideline also support in
favour of the giving assistance in accomplishing personal care. The degree of assistance in
self-care must be judged based on the health status of the patient and thus reflecting the
importance of the person-centred care plan (New South Wales Nurses and Midwives
Association 2018).

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References
Cabral, L.F., D'Elia, T.C., Marins, D.S., Zin, W.A. & Guimaraes, F.S., 2015, ‘Pursed lip
breathing improves exercise tolerance in COPD: a randomized crossover study’,
European Journal Physical Rehabilitation Medicine, vol. 51, no. 1, pp.79-88.
Fujita, N., Grabitz, S.D., Shin, C.H., Hess, P.E., Mueller, N., Bateman, B.T., Ecker, J.L.,
Takahashi, O., Houle, T.T., Nagasaka, Y. & Eikermann, M., 2019. Nocturnal
desaturation early after delivery: impact of delivery type and the beneficial effects of
Fowler's position. British journal of anaesthesia, vol. 122, no. 4, pp.e64-e66.
New South Wales Nurses and Midwives Association. 2016. Policy on Nursing and Nursing
Care. Access date: 27th August 2019. Retrieved from:
http://www.nswnma.asn.au/wp-content/uploads/2013/07/NSWNMA-Policy-on-
Nursing-and-Nursing-Care.pdf
New South Wales Nurses and Midwives Association. 2016. Policy On The Provision Of
Personal Care. Policy on Nursing and Nursing Care. Access date: 27th August 2019.
Retrieved from:
http://www.nswnma.asn.au/wp-content/uploads/2018/10/NSWNMA-Policy-on-the-
Provision-of-Personal-Care.pdf
New South Wales Nurses and Midwives Association. 2018. Policy On Complementary And
Alternative Therapies In Nursing And Midwifery Practice. Access date: 27th August
2019. Retrieved from:
http://www.nswnma.asn.au/wp-content/uploads/2018/10/NSWNMA-Policy-on-
Complementary-and-Alternative-Therapies-in-Nursing-and-Midwifery-Practice.pdf

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Peyton, C., Bedard, D., Williams, M. & Wallrich, M., 2019, ‘Critical Care Nursing of the
Adult with Congenital Heart Disease,’ In Intensive Care of the Adult with Congenital
Heart Disease (pp. 457-468). Springer, Cham.
Ramos, F.L., Krahnke, J.S. & Kim, V., 2014, ‘Clinical issues of mucus accumulation in
COPD’, International journal of chronic obstructive pulmonary disease, vol. 9, p.139.
Satia, I., Badri, H., Lahousse, L., Usmani, O.S. & Spanevello, A., 2018, ‘Airways diseases:
asthma, COPD and chronic cough highlights from the European Respiratory Society
Annual Congress 2018’, Journal of thoracic disease, vol. 10(Suppl 25), p.S2992.
Urden, L. D., Stacy, K. M., & Lough, M. E. (2019). Priorities in Critical Care Nursing-E-
Book. Elsevier Health Sciences.
Vold, M.L., Aasebø, U., Wilsgaard, T. & Melbye, H., 2015, ‘Low oxygen saturation and
mortality in an adult cohort: the Tromsø study’, BMC pulmonary medicine, vol. 15,
no. 1, p.9.