Assessment 3: NUR2102 Written Assignment

Part A

Collect cues 

           In the present case study, Mr Smith has been admitted to the hospital with the complaint of audible wheezing and dyspnea increasing from 24 hours. He has lung auscultation and decreased air entry. Audible bilateral wheeze is found while respiration (Harrison, et al., 2019). Such symptoms in the case of Mr Smith are under the hyperinflation of Asthma (Harrison, et al., 2019). Clinical signs of acute asthma exacerbation differ among individuals and by frequency. Shortness of breath, cough, wheezing, diaphoresis, tachypnea, and tachycardia are typical signs and symptoms (Schaper-Magalhães, et al., 2017). 

          Mr Smith has a past medical history of asthma, Obstructive Sleep Apnoea, hypertension and Gastroesophageal Reflux Disease. This results in the constraint of ventilation and the degradation and deterioration of alveoli, marginal bronchioles and adjacent capillary arteries and membranes, which contributes to the difficulty of airflow and contributes to a reduction in the potential to transport oxygen (Marone et al., 2019,). The degree of airflow restriction is defined by the magnitude of the irritation, fibrosis formation inside the airway and the production of fluids or exudates. Decreased exhalation ventilation contributes to air saturation, leading to reduced inspiratory efficiency, which can trigger exhaustion shortness of breath (also known as dyspnoea) and diminished exercise potential as evident in Mr Smith’s case (Sinyor & Perez, 2019). During inspiration, the gases in the lungs cause unhealthy pleural pressure, low stroke size, and increases ventilator concentrations (Gon & Hashimoto, 2018). Increasing breathing rhythms can accelerate the signs and symptoms of asthma from hyperinflation.

Recall knowledge

          The evaluation of objective data shows that Mr Smith has 95 kgs of weight and his BMI is 30.7. According to Kim and Shin (2020), individual males having BMI 30 and above are considered to be obese. Further, Mr Smith’s blood pressure is 155/95. Wu et al. (2016) state that standard blood pressure for a healthy individual is 120/80, hence it can be evaluated that Mr Smith’s blood pressure is elevated to abnormal levels. His heart rate is also increased above the normal ranges (60-100 breaths per minute) reported as 110 (Zeki et al., 2018). Although the major risk factor for Mr Smith is smoking as the major significant factor that causes and worsens asthma is smoking (Accordini et al., 2018). 

          His SpO2 is observed at 92% on room air. According to Zubieta-Calleja and Zubieta-DeUrioste, N. (2020), to SpO2 around 92% is considered as hypoxia. Also, he has a high respiration rate as compared to the standard range (12 to 20 breaths per minute) (Badawy et al., 2017). Mr Smith appears alert but speaking in short sentences. His subjective data shows that he is having chest tightness. He made a concern of shortness of breath has a diagnosis of asthma but his asthma medication is not well regulated. He does not have a management plan and hence the deterioration of vital signs shows that needs immediate medical attention.

Part 2

Identify problems 

From the case analysis, it was found that Mr Smith suffers from different issues. The nurses must recognise the person's immediate deterioration and offer specialised life support to the patient to protect the body, airways and respiratory tract function. The first clinical issue, in this case, is dyspnoea. It is important to treat individuals with asthma must maintain and manage their condition with proper medications but Smith does not take his medications which have worsened his condition. The major consequences are due to the smoking habit of the patient. Considering the quick recovery of the patient the nursing identified problems are severe asthma (dyspnoea) (Kendall et al., 2018). Further, it is of prime importance to provide the patient with nurse-led education to cope up with his medicine regime as the patient refuses to take his medicines (Kendall et al., 2018).  So that he can follow his medicine properly and can ensure rapid recovery. 

Establish goals

                    In order to deliver clinical treatment to promote better patient safety outcomes, healthcare providers and nurses need to develop SMART goals that address the defined problems and aims to address chronic diseases (Schubert et al., 2019). The SMART goal, in this case, is reducing the impact of acute exacerbation of asthma and help to achieve positive health outcomes of the patient.  This is important as patients asthmatic condition is worsening and the vital signs and lung capacity needs immediate interventions. 

Take action 

            Oxygen therapy- To achieve 90 percent and above oxygen saturation, the adequate supply of oxygen as quick as practicable is essential. In an severe exacerbation, a person inevitably suffers from hypoxia. More oxygen lowers the intensity of V / Q. Inconsistency, promotes bronchodilation and reduces vascular constriction of the lungs (Martínez, et al., 2019). Also, in Smith’s case, dyspnoea is a major symptom so it is the first nursing management priority to provide the patient with oxygen supply (Martínez, et al., 2019). In addition, the benefit of supplying large quantities of oxygen (relieving hypoxemia in acute asthma aggravation) can outweigh the complexity (Ballestero, et al., 2018). 

           Active oxygen regulation is required to mitigate the risks (Ballestero, et al., 2018). The use of the nasal cannula must be used to support the oxygen supply (Nishimura, 2016). The nurse should react to the patient's acute decline and provide appropriate treatment for primitive life support in compliance with the NMBA guidelines for nurses (NMBA, 2017). Smith’s oxygen saturation showed that she has SpO2 93% so oxygen therapy will help attain the normal levels of oxygen saturation that is 96-98% (Gimenez, et al., 2017). 

             Monitoring of vitals- Mr. Smith is experiencing hypertension and it is important that his blood pressure is regulated in a timely way to prevent any increase in his blood pressure. Vital signs require timely identification which can be obtained by diligent recognition and evaluation of nursing care (Kowalski, et al., 2017). Proper documentation of vital signs is essential. The main objective of the nursing evaluation is to examine the patient's vitalities continuously. Any worsening in the vitals is important for the nurse. It was found that avoiding changes in vital signs could contribute to worsening in health and severe health consequences (Churpek, Adhikari & Edelson, 2016).   

          Fowler’s position- To assist with ventilation during asthma, the patient must stay in a semi-fowler position. The client must try to relax and breathe out of their diaphragm as much as possible. Hypoxia can easily occur. The nurse will assist Mr Smith to sit in a comfortable position high or seated Fowler, for promoting relaxation. The nurse will assist Mr. Smith to sit up or seated in Fowler relaxed position, to encourage relaxation. The purpose of the Fowler position facilitates the relaxation of abdominal muscle pressure, enabling better airflow (Morrow et al., 2016). Mr Smith will be made to sit in a semi-Fowler posture with the head of the bed rising between “30 and 45 degrees” once the individual was unable to sit upright for whatever purpose (Morrow et al., 2016). In this position, another two-minute sEMG recording is taken after enabling the patient to recover from any activity during the change of position. 

          Patient education- Educating patients and offering resources to support patients address adherence challenges which is an important approach to increase adherence to the medications. Adherence to medicine is a major deterrent to obtaining optimal clinical outcomes. Patient education is emerging to be an essential factor for increasing compliance with medicine (Dinh et al., 2016). This can be done using the teach-back method. This method has proven to make patients comply with medicines by 96% (Mishra et al., 2017). Through this method nurse first educates and then ask questions which helps in ensuring whether the patient was attentive and whether h understood the dosage and importance of that drug.  

          Also, smoking is the major factor contributing to the worsening condition of asthma and hence the patient must be educated about the benefits of smoking cessation. According to Lancaster & Stead (2017), worsening ailments will cause physical immobility and ultimately death. Cessation of tobacco is the most affordable and efficient way to avoid asthma development and decreases the likelihood of experiencing asthma and lung complications, hospital stays attributable to severe exacerbations and an annual reduction in forced expiratory capacity in 1 second (Bala et al., 2017).

Evaluate outcomes

           Nurses are expected to document, revisit and change their ways according to the needs and requirements of the patient, according to the NNBA (2016) standard 5 of registered professional nursing. Significant changes can be observed in Mr Smith 's case. His asthma will not likely to be intensified with oxygen treatment and he will understand the value of compliance with drug protocols with patient education to avoid further hospital admissions.

Part 3

Reflection 

          Reflection is a process which establishes new experience from a person's past experiences. Reflecting on experiences lets nurses understand and develop their strategies and approaches as per the NMBA (2017) Standard 1 of registered nurse practice standards. In the assessment case study, I realized that person-centred practices and nursing strategies with defined priorities aid in achieving the patient's best available strategies for treatment. The measures used during the clinical reasoning cycle also contributed to devising evidence-based approaches and their positive impacts on patient safety. I have found that a combined strategy to nursing-led approaches and education for self-management is important for successful health outcomes (Irani et al., 2019).

           In attempts to establish the evidence base for advanced self-management methods, the nursing community, including both researchers and practitioners, plays a vital role and is best placed to incorporate such developments in a reasonable way (Irani et al., 2019). A primary role for nurses is to provide care for and inform patients with chronic disorders about self-management of the condition. Asthma, hypertension and diabetes are examples of effective nurse-led self-management services for chronic disease. Self-management service (SMS) is used in two ways : ( 1) as a range of strategies and instruments that help patients select healthier habits, and (2) as a profound transition of the clinician-professional relationship into a mutual collaboration (Wichit et al., 2017). A critical aspect of effective chronic condition treatment and increased health outcomes is the support of patient self-management (Wichit et al., 2017). Help for self-management extends beyond conventional evidence-based patient education to provide strategies that build problem-solving capabilities for patients, enhance self-efficacy, and facilitate the acquisition of knowledge to patients in real-life circumstances. In the primary care setting, this strategy often covers system-focused improvements. 

          Nurses may promote patient self-management by designing patient-nurse relationships to identify patient-related concerns, making improvements to the atmosphere that eliminate challenges to self-management, and ensuring individual education and accessible tools for patient self-management (Yao et al., 2019). The focus of trained nurses is primarily on improving the health of patients and mitigating their ailments by strengthening a balanced diet and exercise. For patients dealing with chronic illnesses, the promotion of self-efficacy may increase the effects and quality of life (Been, 2018). Hence, nurses play a key role in promoting self-management and self-efficacy as they promote professional relationships, educate the patients and helps them in maintaining positive health outcomes.