Contexts of Practice: Health Alteration 

Q.1 In the case of Mr Krum, he is diagnosed with the chronic obstructive pulmonary disease and he presented with shortness of breath, dyspnea, wheezing and he also had productive sputum which was yellow. For identifying the priority problems ABCDE framework was used (Smith et al. 2017). The airway of the patient was clear and patent as there was no obstruction but he was not able to breathe properly which is the priority. The oxygen saturation of arterial blood was reduced and that affects the circulation of the blood which makes it the second priority.

Q.2 The chronic obstructive pulmonary disease is a chronic disease of infection and related infection which causes the inability to breathe (Kim 2017). The most common causation of the disease is chronic irritations like the presence of smoke or dust and if the patient is a chronic smoker. In the present case, it is seen that Mr Krum is a current smoker which has attributed to the disease and the condition is a progressive one and is irreversible. Due to the presence of inflammation the patients have an exaggerated response to the presence of even minimal irritants or noxious substance (Hikichi et al. 2018).

The changes are seen in structural as well as functional aspects of the respiratory system including lungs, bronchi, bronchioles and even alveoli (Schellack et al. 2015). The presence of irritation there is an increase in the level of mucus secretion which is also altered in consistency which further does not allow the easy passage of the air (Kim 2017). Due to exaggerated inflammatory reaction, there is the presence of an increase in the number of macrophages, neutrophils and lymphocytes which further increases the resistance to the flow of air (Tőkés-Füzesi et al. 2018).

Due to inflammation the submucosal gland in the bronchi is enlarged and metaplasia of goblet cells is seen (Wang et al. 2018). This is combined with metaplasia of mucosa, impaired ciliary clearance and hypertrophy of smooth muscles in the respiratory system which can cause alveolar collapse and hyperinflation of the lungs. This increases the respiratory rate and in order to meet the oxygen demand of the body, there is the use of accessory respiratory muscles (Sarlabous et al. 2017). This is seen in the case of Mr Krum where it was seen that his respiratory rate was 30 breathes per minute and there is evidence of the use of intercostal and substernal muscles which are accessory muscles for respiration.

Heart rate and blood pressure are increased to manage the reduced oxygen level of the blood as a compensatory mechanism and in the present case, it was seen that oxygen saturation was 87% which caused an increase in heart rate to 105 and blood pressure to 140/90 mmHg (Divo et al. 2020). Due to the decrease in the oxygen saturation of the arterial blood the respiratory centre in the brain is stimulated which increases the respiratory rate and causes activation of accessory respiratory muscles to aid in increased respiration (Spinelli et al. 2020). The circulatory system which is also present in the same region is also activated to increase the flow of blood to the lungs to increase the exchange of gases.

Q.3 For the first priority problem the intervention that is required is such that the breathing of the patient becomes normal and the passage of the air is easier. Pharmacological intervention is required so that the condition of the patient improves. One of the drugs that need to be administered to the patient is bronchodilators though Mr Krum is already administered Ventolin with help of spacer. As a nurse, it is important that the doctor in charge is updated about the change in the condition of the patient with proper documentation and verbal and written communication (Nordness & Beukelman 2017). Appropriate orders are obtained from the doctors which are documented before the administration of the medication. It is required that the patients are informed about the addition or changes in the medication.

The drug which is advised and regularly administered is salbutamol and depending on the severity of breathlessness or acute exacerbation of it can be given by the use of spacer or nebulizer, in this case, it is given as nebulization (Levy et al. 2016). It is a short-acting drug which acts on the selective beta-2 receptors and causes their activation which is given to patients with asthma and COPD to improve their breathing (House et al. 2015). Beta-2 adrenergic receptors are present in the smooth muscles of the lungs, bronchi and bronchioles, activation of these receptors cause an increase in the production of cyclic AMP (Kume et al. 2018).

This cyclic-AMP further activates the production of protein kinase A which acts as an inhibitor to myosin in smooth muscles which further reduces the levels of intracellular calcium in the smooth muscles and ultimately leads to relaxation of smooth muscles (Kume et al. 2018). Administration of salbutamol results in relaxation of muscles in the respiratory system and help in the reduction of restriction to the flow of air to the lungs. Salbutamol also reduces the inflammation that is seen in the respiratory system as it inhibits the production of mast cells and other inflammatory mediators in the mucosa (Jadhav et al. 2015).

A nurse should document the time and dosage of the drug in the charts of the patient so that there is an appropriate flow of information. The nursing care that is given for salbutamol is that the respiratory rate of the patient is continuously monitored to know the effectiveness of the intervention that is given. The positioning of the patient is the nursing care restriction to the airflow can happen due to the positioning of the patient (Negi et al. 2019). The patient is positioned such that his head is in the midline with flexion so that patency of airway is maintained and the patient is encouraged to cough so that excess mucus that is formed can be cleared from the respiratory system.

For the second priority problem, it is necessary that the oxygen saturation of the arterial blood gas level is maintained within the range of 92 to 95%. For the monitoring of the arterial blood gas oxygen and oxygen saturation, pulse oximetry is done. For the administration of oxygen, the blood oxygen saturation is the level below 88% and the oxygen saturation of Mr Krum is 87% and it requires that the administration of oxygen. It can be done under pressure as well as passively as in the present case there is an obstruction to the flow of air to the respiratory system it is advised that the oxygen is administered to the patient with pressure (Branson 2018). For better care of the patient, it is required that the patient information is updated to the patient chart and the doctor is informed about the progress or deterioration of the patient's condition.

The orders from the doctor are obtained for the administration of oxygen and it is recorded and documented before it is administered to the patient. The rationale behind the administration of oxygen is that oxygen is required for the proper functioning of the cells, organs and organ systems (Spoletini et al. 2019). Due to the obstruction to the flow of air, the peripheral oxygen availability is reduced which if prolonged can cause organ dysfunction and even failure. Prolonged reduction in oxygen saturation can cause respiratory acidosis (Kargin et al. 2016).

Some organs like the brain and kidneys are extremely sensitive to the presence of oxygen in the blood and prolonged level of reduction in the oxygen saturation can lead to hypoxia of brain and can lead to cognitive dysfunction (Bickler et al. 2016). The nursing care that is required in case of oxygen administration is continuous monitoring of oxygen level as an increase in oxygen in the blood can lead to the destruction of cells. Pulse oximetry is recommended continuously for every two hours initially and then every four hours to check for the levels of oxygen (Lam et al. 2017). The effectiveness of the intervention can be seen when the respiratory rate, heart rate and blood pressure returns back to normal. The nurses should monitor the vital signs which may change depending on the change in the condition of the patient. Peripheral cyanosis can be seen if the oxygen level reduces and the nurse should monitor it continuously to know the effectiveness of the intervention given (Allibone et al. 2018).

Q.4 discharge planning is essential in the healthcare of the patient as it can improve the health outcome of the patient and can have a better quality of life after the patient is discharged from the hospital care setting. Aim of discharge planning is to make sure that the transition from hospital to home is smooth while doing so social justice framework is included so that the care plan that is made is just for the patient (Nordmark et al. 2016). In the discharge planning the most important component is patient education where the patient is educated about his condition and how can he manage his condition (Saunier 2017). He is educated the ill-effects of smoking and how it causes the aggravation of his condition like being in the presence of dust or overexertion by physical activity (Stoilkova-Hartmann et al. 2018).

The patient should be educated about the effects of medication so that the compliance towards taking the medication is increased and quality of life is improved. It is seen that the patient is malnourished and he is asked to consume a more nutritious and balanced diet (Henoch et al. 2018). Social justice is often merged with the fact that of healthcare equity (Dukhanin et al. 2018). For the same, the patient is further referred to nutritionist r dietician from the same community and near to the home of the patient. also, the patient is a current smoker and it is required that the patient is given tobacco cessation counselling to reduce and quit the habit for that also he referred to the setting close to his home. Following the social justice, he is referred to a local general practitioner for further follow-ups (Dukhanin et al. 2018).

References for Health Alteration

Allibone, E, Soares, T, & Wilson, A 2018, ‘Safe and effective use of supplemental oxygen therapy’ Nursing Standard (Royal College of Nursing (Great Britain) : 1987), vol. 33, no. 5, pp. 43–50, doi: 10.7748/ns.2018.e11227.

Bickler, E, Feiner, R, Lipnick, S, Batchelder, B, Macleod, W, & Severinghaus, W 2016, ‘Effects of Acute, Profound Hypoxia on Healthy Humans: Implications for Safety of Tests Evaluating Pulse Oximetry or Tissue Oximetry Performance’ Anesthesia & Analgesia, vol. 124, no. 1, pp. 146–153, doi: 10.1213/ANE.0000000000001421.

Branson, RD 2018, ‘Oxygen Therapy in COPD’ Respiratory Care, vol. 63, no. 6, pp. 734–748, doi: 10.4187/respcare.06312.

Divo, MJ, Depietro, MR, Horton, JR, Maguire, CA, & Celli, BR 2020, ‘Metabolic and cardiorespiratory effects of decreasing lung hyperinflation with budesonide/formoterol in COPD: A randomized, double-crossover, placebo-controlled, multicenter trial’ Respiratory Research, vol. 21, no. 1, p. 26, doi: 10.1186/s12931-020-1288-3.

Dukhanin, V, Searle, A, Zwerling, A, Dowdy, DW, Taylor, HA, & Merritt, MW 2018, ‘Integrating social justice concerns into economic evaluation for healthcare and public health: A systematic review’ Social Science & Medicine, vol. 198, pp. 27–35, doi: 10.1016/j.socscimed.2017.12.012.

Henoch, I, Löfdahl, C-G, & Ekberg-Jansson, A 2018, ‘Influences of patient education on exacerbations and hospital admissions in patients with COPD - a longitudinal national register study’ European Clinical Respiratory Journal, vol. 5, no. 1, p. 1500073, doi: 10.1080/20018525.2018.1500073.

Hikichi, M, Hashimoto, S, & Gon, Y 2018, ‘Asthma and COPD overlap pathophysiology of ACO’ Allergology International, vol. 67, no. 2, pp. 179–186, doi: 10.1016/j.alit.2018.01.001.

House, S, Matsuda, K, O’Brien, G, Makhay, M, Iwaki, Y, Ferguson, I, Lovato, L, & Lewis, L 2015, ‘Efficacy of a new intravenous beta(2)-adrenergic agonist (bedoradrine, MN-221) for

patients with an acute exacerbation of asthma’ Respiratory Medicine, vol. 109, no. 10, pp. 1268–1273, doi: 10.1016/j.rmed.2015.08.003.

Jadhav, A, Padwal, S, Jadhav, R, Jadhav, S, Pise, H, & Choure, M 2015, ‘Anti-inflammatory property of salbutamol on acute and chronic models of inflammation’ National Journal of Physiology, Pharmacy and Pharmacology, vol. 5, no. 2, pp. 101–104, doi: 10.5455/njppp.2015.5.180920141.

Kargin, F, Irmak, I, Ciyiltepe, F, Gungor, S, Acarturk, E, Takir, H, Guney, P, Mocin, O, Adiguzel, N, & Karakurt, Z 2016, ‘Chronic obstructive pulmonary disease admitted to an intensive care unit because of acute respiratory failure: How do severity of acidosis effect short and long term mortality?’ European Respiratory Journal, vol. 48, no. s60, doi: 10.1183/13993003.congress-2016.PA3060.

Kim, EK 2017, ‘Pathophysiology of COPD’ in COPD: Heterogeneity and Personalized Treatment, pp. 57–63, Springer Berlin Heidelberg, doi: 10.1007/978-3-662-47178-4_5.

Kume, H, Nishiyama, O, Isoya, T, Higashimoto, Y, Tohda, Y, & Noda, Y 2018, ‘Involvement of Allosteric Effect and KCa Channels in Crosstalk between β2-Adrenergic and Muscarinic M2 Receptors in Airway Smooth Muscle’ International Journal of Molecular Sciences, vol. 19, no. 7, doi: 10.3390/ijms19071999.

Lam, T, Nagappa, M, Wong, J, Singh, M, Wong, D, & Chung, F 2017, ‘Continuous Pulse Oximetry and Capnography Monitoring for Postoperative Respiratory Depression and Adverse Events: A Systematic Review and Meta-analysis’ Anesthesia & Analgesia, vol. 125, no. 6, pp. 2019–2029, doi: 10.1213/ANE.0000000000002557.

Levy, S, Alladina, J, Hibbert, K, Harris, R, Bajwa, E, & Hess, D 2016, ‘High-flow oxygen therapy and other inhaled therapies in intensive care units’ The Lancet, vol. 387, no. 10030, pp. 1867–1878, doi: 10.1016/S0140-6736(16)30245-8.

Negi, S, Chugh, D, & Velmurugan, D 2019, ‘A study to compare the five different body positions on peak expiratory flow rate and respiratory rate in patients with chronic obstructive pulmonary disease (COPD) at National Heart Institute, New Delhi, India’ Manipal Journal of

Nursing and Health Sciences (MJNHS), vol. 5, no. 2, pp. 16–22, Retrieved from http://search.proquest.com/docview/2337564686/.

Nordmark, S, Zingmark, K, & Lindberg, I 2016, ‘Process evaluation of discharge planning implementation in healthcare using normalization process theory’ BMC Medical Informatics and Decision Making, vol. 16, no. 48, p. 48, doi: 10.1186/s12911-016-0285-4.

Nordness, S & Beukelman, R 2017, ‘Supporting Patient Provider Communication Across Medical Settings’ Topics in Language Disorders, vol. 37, no. 4, pp. 334–347, doi: 10.1097/TLD.0000000000000133.

Sarlabous, L, Torres, A, Fiz, JA, Martínez-Llorens, JM, Gea, J, Jané, R, & Larcombe, A 2017, ‘Inspiratory muscle activation increases with COPD severity as confirmed by non-invasive mechanomyographic analysis’ PLoS ONE, vol. 12, no. 5, p. e0177730, doi: 10.1371/journal.pone.0177730.

Saunier, D 2017, ‘Creating an Interprofessional Team and Discharge Planning Guide to Decrease Hospital Readmissions for COPD’ Medsurg Nursing, vol. 26, no. 4, pp. 258–262, Retrieved from http://search.proquest.com/docview/1929674016/.

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Spoletini, G, Cortegiani, A, & Gregoretti, C 2019, ‘Physiopathological rationale of using high-flow nasal therapy in the acute and chronic setting: A narrative review’ Trends in Anaesthesia and Critical Care, vol. 26-27, pp. 22–29, doi: 10.1016/j.tacc.2019.02.001.

Stoilkova-Hartmann, A, Franssen, FM., Augustin, IM., Wouters, EF., & Barnard, KD 2018, ‘COPD patient education and support – Achieving patient-centredness’ Patient Education and Counseling, vol. 101, no. 11, pp. 2031–2036, doi: 10.1016/j.pec.2018.05.024.

Tőkés-Füzesi, M, Ruzsics, I, Rideg, O, Kustán, P, Kovács, GL, & Molnár, T 2018, ‘Role of microparticles derived from monocytes, endothelial cells and platelets in the exacerbation of COPD’ International Journal of Chronic Obstructive Pulmonary Disease, vol. 13, pp. 3749–3757, doi: 10.2147/COPD.S17560.

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