Nursing Practice 3

Nursing Problem 1

Jasmin Dowton is experiencing impaired gaseous exchange related to increased preload and alveolar-capillary membrane changes as evidenced by fatigue, dyspnoea, tachypnoea, pink frothy sputum, SpO2 89% on room air and patient’s statement, ‘I get so short of breath’

Nursing Goal (SMART)

 By the end of the two days, I will try to improve the respiratory rate of the patient about 70 % to increase the comfort of the patient by improving the gaseous exchange.

Nursing intervention 1

The first nursing interventions that can help to improve the gaseous exchange of the patient include semi-Fowler’s position of the patient that help to improve respiration. It is the semi-sitting position and the head of the patient is elevated up to 45-60 degree. This position helps in the lung expansion that helps to improve the gaseous exchange. The upright position helps to increase the thoracic capacity that leads to diaphragmatic descent which helps to increase the inhalation with decreased work on breathing. The patient chest expansion occurs due to the upright position without any effort which increases the patency of the airways. It is of three types according to the position of the patient which include semi, low and high (Albarrati et al. 2018). The nurses can help the patient to maintain the semi-Fowler’s position which will help the patient to improve the breathing rate which leads to a better health outcome. Fowler’s position helps to promote the oxygenation by improving the chest expansion which occurs due to reduce abdominal tension and reduce the effect of gravity on the chest wall. The nurses are expected to clearly explain the procedure to the patient accurately and frequently change the position of the position to reduce the detrimental effect of one position (Kubota et al., 2015). According to the case study Dowton is having difficulty in gaseous exchange that lead to dyspnoea, tachypnoea and difficulty in breathing.

Nursing intervention 2

Second nursing interventions that can help to improve the breathing rate of the individual include performing breathing exercise in daily routine.

Breathing exercises are also considered to be one of the good methods that can help to improve the gaseous exchange. The Breathing exercise directly improves the gaseous exchange by improving the lung capacity and reducing shortness of breath. The breathing exercise includes a different set of exercise that helps the patient to reduce shortness of breath by improving the respiration of the individual. The different set of exercise that can be performed to improve the breathing rate includes pursed-lip breathing, coordinated breathing, diaphragmatic breathing and deep breathing exercise. One of the major reasons that can lead to difficulty in breathing is the weak respiratory muscle that leads to shortness of breath. The breathing exercise help to improve the strength associated with the respiratory muscle that eventually leads to better respiratory rate (Seo et al. 2017). The nurse can assist the patient to perform accurate breathing exercise that will help her to reduce shortness of breath by improving the respiration capacity. The inspiratory breathing exercise help to improve the muscle strength involved in respiration that directly helps to improve the respiration rate. The continuous breathing exercise also involved improving the breathing pattern of the individual that directly reduce the breathing discomfort. The inspiratory breathing technique also reduces the chances of dyspnea that can occur due to the dysfunction of the respiratory muscle which can increase the complication of the patient (Xu et al., 2018).

As per the case study Dowton is having difficulty in breathing that lead to impaired gaseous exchange so there is need for the breathing exercise to improve the lungs functionality and improve the breathing pattern.

Collaborative intervention:

Prepare and administer prescribed medication

Order: glyceryl trinitrate (GTN) continuous infusion 10 microg/min

The dose required: 10 microg/min

Preparation availability: 50 mg/10mL

 Preparation instructions: Dilute 50mg glyceryl trinitrate to 50mL with sterile 0.9% sodium chloride.

 

The dose required per hour: 600 microg/hour

Final preparation concentration:

Rate per hour infusion to be set at 0.6 mg per hour

Precautions/monitoring required: Continuous monitoring is required to understand the effect of medicine and reduce the chances of side effect. The patient position should also be continuously changed to improve the comfort of the patient. The dose should be accurately prescribed as per the patient current condition to reduce the chances of side effect. The proper dilution should be done as improper dilution can lead to hypotension which leads to increase patient complication. 

 

The impaired gaseous exchange that is observed in the Jasmine as directly increased his complication. The impaired gaseous exchange is a condition when there is excessive or deficiency of the respiratory gases. The gaseous exchange in the respiratory tract occurs via diffusion and it is required to maintain the proper balance between the concentrations of the gaseous. The impaired gaseous exchange leads to dead space generation that is the breath volume which does not involve din gaseous exchange. The impaired gaseous exchange leads to alveoli collapse that leads to dysfunction of the lungs. There are many risk factor that can lead to the impaired gaseous exchange which includes increased age, smoking, respiratory infection and the disturbing surrounding environment that can increase complication. The impaired gaseous exchange directly decreases the functioning of the lung which lead to shortness of breath and dyspnoea (Qureshi & Mustafa, 2018).

 

The pharmacodynamics that is associated with glyceryl trinitrate start by directly improving the endothelial function which has impaired due to misbalance in the gaseous exchange. The disturbance in the endothelial functioning directly leads to a decrease in the production of endothelium-derived relaxing factor (EDRF). The EDRF is involved to activates soluble guanylate cyclase which directly increase intracellular cyclic guanosine monophosphate. The glyceryl trinitrate directly increases EDRF activity that leads to increased vasorelaxation, platelet disaggregation and reduces platelet adhesion. The glyceryl trinitrate converts the GTP to cyclic GMP that leads to platelet disaggregation and inhibit the adhesion. The dephosphorylation of the myosin light chain leads to the reduction of the cytosolic Ca+ which causes the relaxation of the smooth muscle and improve breathing pattern (Sidhu et al., 2015).

The relaxation of the respiratory muscle directly helps the Jasmien to reduce breathing comfort and improve the breathing pattern. The increased discomfort of the Jasmine occurs due to shortness of the breath and fatigue which is the result of the impaired gaseous exchange. The pharmacological intervention helps the patient to improve the lung functioning that directly maintain the respiration rate.

 

According to Australian Commission on Safety and Quality in Health care (2020) standard 5 discusses the comprehensive care of the patient which aims to provide the accurate care to the patient that is tailored according to the individual need to improve the health status. the Comprehensive Care Standard improve the coordinated delivery method of the health care professional as per the patient need to reach up to a patient expressed goal by providing quality of care. The care provided to the Jasmine meet the standard as the two nurses in the CCU collaborate to work as per the handover provided to the emergency department to improve the discomfort of the patient. 

 

Nursing Problem 2

Increased weight is one the issue with jasmine as she is on the edge of the obesity that can increase the complication.

Nursing Goal (SMART)

I will try to reduce her body weight up to 10kg by the end of the 3 months by improving lifestyle

Nursing Intervention 1

The obesity can lead to multiple complications for the individual as it increases the risk of cardiac failure, diabetes and reduced metabolism. The physical activity intervention can help the patient to reduce the chances of obesity by improving body metabolism. The daily routine of the physical exercise will help to reduce the weight and improve the body functioning. The physical activity includes aerobic exercise, walking and yoga that help to improve the mental and physical wellbeing of the individual. The daily routine of the mild exercise not only improve the body weight but it also increases the cardiovascular fitness of the individual. The daily routine of the physical exercise should be according to the individual preference to increase the participation of the individual in the care (Baker et al., 2016).

Nursing Intervention 2

The nutritional intervention is another method that can be utilised to manage the weight and improve body metabolism. The nutritional intervention help to monitor the nutritional intake of the individual which help to reduce weight and decrease the burden created over the body functioning unit. The first step related to the intervention includes a nutritional assessment that is followed by the nutrition diagnosis according to individual need. The nest step to provide the dietary plan according to individual preference to improve the implementation of the intervention. The last step to the intervention includes nutritional monitoring and evaluation to understand the effect of the nutritional over the individual. The patient can be aware of the dietary guideline and importance of the intervention to increase the chances of proper implementation of the intervention (Park et al., 2018).

According to the Nursing and Midwifery Board (2016) standard 4 that comprehensively conducts assessment state that nurses are expected to conduct an accurate patient assessment by using a holistic approach and they should work in partnership to accurately assist patient in need. The nurses in the case study try to work collaborate to improve the Jasmine condition as she was facing difficulty in breathing and accurately analysed the issue associate with deteriorated health of the Jasmine that is impaired gaseous exchange. The nurses in the case study try to use their clinical skill during patient care to improve health by reducing the discomfort of the patient.

References for Nursing Practice

According to Australian Commission on Safety and Quality in Health Care. (2020). Comprehensive Care Standard. Retrieved from: https://www.safetyandquality.gov.au/standards/nsqhs-standards/comprehensive-care-standard

Albarrati, A., Zafar, H., Alghadir, A. H., & Anwer, S. (2018). Effect of upright and slouched sitting postures on the respiratory muscle strength in healthy young males. BioMed Research International, 2018, 1–5. doi:10.1155/2018/3058970

 Baker, A., Sirois-Leclerc, H. & Tulloch, H. (2016). The impact of long-term physical activity interventions for overweight/obese postmenopausal women on adiposity indicators, physical capacity, and mental health outcomes: a systematic review. Journal of Obesity, 2016(6169890), 1-21.

Kubota, S., Endo, Y., Kubota, M., Ishizuka, Y., & Furudate, T. (2015). Effects of trunk posture in Fowler’s position on hemodynamics. Autonomic Neuroscience, 189, 56–59. doi:10.1016/j.autneu.2015.01.002

Nursing and Midwifery Board. (2016). Registered nurse standards for practice. Retrieved from: https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/registered-nurse-standards-for-practice.aspx

Park, S., Woo, M. H., Lim, H. J., Chon, S., & Woo, J. T. (2018). A nutrition intervention focused on weight management through lifestyle improvements in prediabetic subjects. Clinical nutrition research, 7(1), 69–79. https://doi.org/10.7762/cnr.2018.7.1.69

Qureshi, S. M., & Mustafa, R. (2018). Measurement of respiratory function: gas exchange and its clinical applications. Anaesthesia & Intensive Care Medicine, 19(2), 65–71. doi:10.1016/j.mpaic.2017.11.006

Seo, K., Hwan, P. S., & Park, K. (2017). The effects of inspiratory diaphragm breathing exercise and expiratory pursed-lip breathing exercise on chronic stroke patients’ respiratory muscle activation. Journal of Physical Therapy Science, 29(3), 465–469. doi:10.1589/jpts.29.465

Sidhu, M., Boden, W. E., Padala, S. K., Cabral, K., & Buschmann, I. (2015). Role of short-acting nitroglycerin in the management of ischemic heart disease. Drug Design, Development and Therapy, 9, 4793–4805.

Xu, W., Li, R., Guan, L., Wang, K., Hu, Y., Xu, L. & Chen, X. (2018). Combination of inspiratory and expiratory muscle training in same respiratory cycle versus different cycles in COPD patients: a randomized trial. Respiratory Research, 19(1). doi:10.1186/s12931-018-0917-6

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