Acute on Chronic Respiratory Failure with Hypoxia
The patient who I will refer to as M.J is a 55-year old single male Caucasian American living in Cleveland OH. He relocated to Cleveland 10 years ago from South Carolina where he has family. He has never been married. He has 4 siblings, a sister 20 years his junior who he claims he has never met and 3 brothers ages 22, 25 and 35 years respectively. His family according to M. J still reside in South Carolina. He has no family here in Cleveland. The assessment was done on June 10, 2019, at Metro Health Cleveland.
History of Present Illness
M.J has been relatively healthy until a month ago when he had noticed difficulty breathing while doing yard work around his property. He has been doing this for the past 5 years without any issues but was now experiencing shortness of breath after working on a small family garden. The symptoms according to M.J did not decrease with time but has gotten worse over the past few days. M.J mentioned he has shortness of breath for simple things like taking a shower, walking his dog two blocks from his home and lying down for a nap. He said he had always slept with his windows closed and one pillow, but now must sleep with his windows open, a working fun and two to three pillows with the bed adjusted to a 30 to 45-degree angle. M.J also said he has recently suddenly gain lost about 5 to 15-pound weight without trying.
Relevant Past Medical and Surgical History
He has no known drug-related allergies and is a full code patient. He has no past surgical history. Additional findings of M.J past medical history includes Cirrhosis of the Liver diagnosed within the past 3 years, hepatitis C, severe back and shoulder pain from a work-related injury, pressure headaches, depression, COPD, anxiety, abdominal distension, GERD and GOUT. M.J said he quit drinking and smoking 2 years ago. He reported smoking approximately 108 pack of cigarettes a year an average of 2 packs a day for the past 40 years. He also reported drinking 9 ounces of alcohol a day for 40 years. The patient was admitted to Metro Health Cleveland on June 7, 2019, for exacerbation of respiratory symptoms. The rest of M.J medical history is unremarkable. The patient upon arriving at the hospital did not use supplementary oxygen at home and at the time of his hospital assessment. He reported bowel incontinent which he stated started about 4 months ago and consistently occur once or twice a week. He gets about 4 loose liquid like stool per day.
He was rescued with a bipap for shortness of breath (dyspnea). The patient was diagnosed with the following including but not limited to, acute on chronic respiratory failure with hypoxia, COPD exacerbation, Paroxysmal A-fib and pneumonia of the left upper lobe due to an infectious organism, Atrial Fibrillation (also called AFib or AF) with RVR (HCC) after an EKG was ordered. The patient initial RVR responded to diltiazem however he developed RVR again after a few hours that failed to respond to bolus. His heart rate was now at 98 with diltiazem drip and jumping up.
Laboratory and Diagnostic Tests
A chest X-ray revealed bilateral pleural effusions. Chest x-ray showed changes consistent with COPD. An electrocardiogram showed Paroxysmal atrial (A-fib). A transthoracic echocardiogram revealed a dilated left atrium, an increase in right-sided filling pressure, and mild to moderate mitral regurgitation. The left ventricular ejection fraction (LVEF) was within normal limits. The patient’s Vital signs were as follows: temperature, 99.4 F(37.4°C); heart rate, 62 beats per minute; respiratory rate, 23 breaths per minute; blood pressure, 92/56 mmHg. The patient was well-nourished and in an acute on chronic hypoxic and hypercapnic respiratory distress (oxygen saturation of 96% on room air). His current weight was 71.5kg with a height of 5’8 inches. The patient’s physical exam was normal with clear respiratory sounds and no lower extremity edema. However, the patient failed NIV due to increased work of breathing and was intubated and sedated on mechanical ventilation. The ventilation settings were as follows FiO2 (30), Tidal Volume (400), Respiratory Rate (23), PEEP (5). Lab ordered included WBC count 17.4, RBC count 4.25, Hemoglobin 12.9,Hematocrit 38.4,Platelet count 211,APTT 20,Sodium 135 mEq/L, Potassium 4.5 mEq/L ,Chloride 118 mEq/L ,Magnesium 1.3 mEq/L,CO2 21 mEq/L, BUN 8 mg/dL ,Creatinine 0.5 mg/dL, AST 28 U/L, ALT 17 U/L, Total protein 6.8 g/dL, Albumin 4.6 g/dL, Total bilirubin 0.9 mg/dL, Direct bilirubin 0.2 mg/dL and BNP of 827.
The patient’s medications included, Albuterol (proventil), Propofol infuse and Fentanyl just to mention a few. (a). Albuterol (Proventil) 0.083 % nebulizer solution 2.5mg/3ml. This medication belongs to a class of drugs known as bronchodilators. Therapeutic use of the medication is to relax patient muscles in the airways and increases air flow to the lungs helping him breathe easily without laboring. Major adverse effects include dysphonia, increased sweating, and dry mouth just to mention but a few. Nursing interventions- assess Bp, lung sounds, pulse before a domain and during peak, observe for wheezing, and note amount, color, and character of sputum produced. (b). Propofol infuse 30 mcg/kg/min. Diprivan. Generic Name: propofol; Brand Name: Diprivan. This medication belongs to a class of drugs known as anesthetic, sedative-hypnotic. This medication used as part of balanced anesthesia and on conscious sedation in the mechanically ventilated patient. Major adverse effects include respiratory depress, hypotension, bacterial infection, seizures, and increased triglycerides (prepared in lipid emulsion). Nursing interventions- use strict aseptic technique when preparing and dedicated IV line due to lipid base and a chance of infection, discard after 12 hrs., respiratory support nearby, constant monitoring pump. (c). Fentanyl- the trade name for Fentanyl is Sublimize. Is a synthetic opioid analgesic that suppresses pain by agonizing opioid receptors in the central nervous system. Adverse reactions include Euphoria, Drowsiness, Pupillary constriction, Respiratory arrest, Decreases gastric motility, Nausea, and vomiting, Bradycardia, Chest wall rigidity. Nursing intervention -Initiate safety measures -Assess pain and pain relief with appropriate pain scale -Assess BP, pulse, and respiratory rate/status -Assess the level of sedation -Assess bowel function and prevent constipation -Perform good oral hygiene and intervention to decrease dry mouth.
Nursing Diagnoses and Nursing Interventions and Rationales
Nursing Diagnoses include possible ineffective airway clearance and breathing pattern; high risk for aspiration, infection, and/or altered respiratory function; Assessments include determining baseline respiratory status (assess patient’s ability to cough and deep breathe effectively, auscultate the chest, and note the breathing pattern); monitor chest x-rays, blood gas levels, CBC, sputum cultures, and pulmonary function tests. Nursing Interventions include frequent suctioning, intubation and ventilator support, as well as supplementary oxygen and consultation with pulmonologist, if necessary, and the respiratory regimen of chest percussion, and deep breathing due to the patients ventilator; assist with cough as needed; provide tracheostomy care every 4 hours, chest physical therapy and deep breathing exercises every 2 – 4 hours, IPPB every 4 hours, and use of incentive spirometer every 4 hours. This will reveal the level of decompensation as well as if interventions are effective Complete a full respiratory assessment to detect changes or further decompensation as early as possible and notify MD as indicate. Nursing Diagnoses include decreased cardiac output, altered tissue perfusion, the risk for peripheral neurovascular dysfunction, dysrhythmias, DVT, and hypovolemia. Assessments include monitoring vital signs, cardiac monitoring for arrhythmias, monitoring response to head elevation, observation for signs of thrombophlebitis, DVT, and PE, and EKG, electrolyte and coagulation tests. Nursing Interventions include treating life-threatening arrhythmias, heparin to prevent DVT, use of sequential compression boots, vasopressors and consultation with a cardiologist as needed. Provide supplemental oxygen as appropriate- Supplemental oxygen will ideally increase patient oxygen levels. (Use caution with COPD patients, as they cannot breathe out the CO2 adequately, so over-oxygenation is a concern, and they also may have a lower baseline SpO2 level). Ensure patient is in an optimal position to decrease work of breathing- Sitting up in bed to enable appropriate lung expansion allows for adequate inspiration and expiration, which facilitates better gas exchange (if clinically appropriate to be sitting up) Prepare for rapid sequence intubation, if necessary-Helpful to be prepared, as this can progress quickly. Know where the necessary meds and equipment are and how to get ahold of assistive personnel. Remove any negative/distracting stimuli: turn the TV off, encourage family members to be calm When patients are anxious or cannot focus it can increase their work of breathing and exacerbate the issue. Promote a calming environment so all the patient must worry about is breathing. Provide oral care- If a patient is intubated or receiving oxygen via nasal cannula/face mask or tent, or other methods of delivery, oral care is essential to protect the mucous membrane and prevent infection. Cluster care- Decreases oxygen demands if the patient’s rest can be maximized
BiPAP therapy targets these dysfunctional breathing patterns. The nurses, especially the respiratory nurses, bedside nurses, and primary care physician play a big role in the management of the condition. It is responsible for the medical team to work together in managing the patient condition and to advocate for things when the condition worsens. On the other hand, the home physician plays a role in ensuring all the medications, exercises and deities are followed well to avoid further complications (Toshikuni et al., 2014).
The critically ill individual requires close examination of the essential elements that affect the functioning of the individual. Administration of synthetic food and readily dissolving minerals is essential to rescue the individual (Bernardi et al., 2014). The more critical a critically ill individual requires the engagement of the exercises that are performed through the help of the mechanic machines. The engagement with exercises is limited as the person may lack enough energy. The individual needs to take precautions such as a healthy diet and lifestyle that plays an essential role in avoiding further damage to their health.
Nursing Role Reflection
My interaction compares to what I have learned is very similar. M.J was very cooperative in answering my question and the assessment went smoothly without any difficulty in communication. The assessment took place on Thursday, June 7, 2019, at 10: 30 am. It took place questions herself to clarify things if he did not understand me. There was no communication at the critical care unit at Metro Health Cleveland. The questions were honestly answered, but asked questions herself to clarify things if he did not understand me. There were no communication barriers since we both spoke English. With M.J very cooperative and all the information needed for the assessment gained no unanticipated challenges. As a nursing student, this assessment gave me a glimpse into life as a critical nurse, what will be expected of me when attending to critically ill patients. It is important for me to always show confidence and make my patient feel comfortable and safe during the assessment and process. The experience was a good one I will never forget since M.J was very kind enough to trust me with his care and to allow me to ask the necessary questions. However, there is nothing I will alter to my approach next time since the assessment was successful, but I can always ask for more details with the client’s response. With that said, I am always open to learning and be taught. Collaborative Resources-Health and Quality of Life Outcomes. Anxiety, depression, and Personality: The Concept of a Directing Object and Its Applications.
Acute on chronic respiratory failure with hypoxia is caused by many factors that affect the normal functioning of the patient especially the lungs. The common causes include certain lung diseases which can cause chronic respiratory failure. Conditions that affect the way in which the brain, muscles, bones, or surrounding tissues support breathing can also cause chronic respiratory failure. Diseases and conditions that commonly lead to chronic respiratory failure include chronic obstructive pulmonary disease (COPD) complicated pneumonia. An injury to the chest or ribs alcohol overdose, which can harm the brain and affect breathing Lung damage from breathing in smoke which my patient drunk and smoked most part of his life. Excessive consumption of alcohol and smoking over a decade contributes significantly to the development of the disease at a median age of 55 years. Both male and female are at risk of getting the condition in cases where an unhealthy lifestyle is involved. Treatment varies depending on the underlying cause. Antiviral drugs are used in the case where infection or pneumonia is involved, and excessive consumption of alcohol and smoking requires therapy against alcohol consumption and smoking. Some medications are involved in the balancing of oxygen and carbon dioxide in the blood. Regulation of the body temperature and proper diet are employed in the treatment of the critical condition. Home health care following physicians, nurses and all medical team involved are essential in helping individuals in critical conditions.
- Bernardi, M., Ricci, C. S., & Zaccherini, G. (2014). Role of human albumin in the management of complications of liver cirrhosis. Journal of clinical and experimental hepatology, 4(4), 302-311.
- Dasarathy, S., & Merli, M. (2016). Sarcopenia from mechanism to diagnosis and treatment in liver disease. Journal of hepatology, 65(6), 1232-1244.
- Leung, C., Yeoh, S. W., Patrick, D., Ket, S., Marion, K., Gow, P., & Angus, P. W. (2015). Characteristics of hepatocellular carcinoma in cirrhotic and non-cirrhotic non-alcoholic fatty liver disease. World Journal of Gastroenterology: WJG, 21(4), 1189.
- Mokdad, A. A., Lopez, A. D., Shahraz, S., Lozano, R., Mokdad, A. H., Stanaway, J., … & Naghavi, M. (2014). Liver cirrhosis mortality in 187 countries between 1980 and 2010: a systematic analysis. BMC medicine, 12(1), 145.
- Toshikuni, N., Arisawa, T., & Tsutsumi, M. (2014). Nutrition and exercise in the management of liver cirrhosis. World journal of gastroenterology: WJG, 20(23), 7286.
- Tsochatzis, E. A., Bosch, J., & Burroughs, A. K. (2014). Liver cirrhosis. The Lancet, 383(9930), 1749-17
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