Introduction:
Scientific and social changes of the 21st century have brought as radical change in the Health care delivery system. Nursing is an important component of the health care delivery system and the role of a nurse in patient welfare has no boundaries for praise. The Nursing profession has evolved through time to establish a firm role in the medical domain based on strong ethical, moral and professional principles. The nursing practice has undergone a positive shift from that of a vocation to a professional status today. That is to say, nursing has a more active role to play in the health care delivery system than the past and nursing as a profession is ‘Accountable’ today. Florence Nightingale was the founder of modern nursing who established the nursing philosophy based on health maintenance and restoration. The civil war (1860-65) enhanced the growth of nursing in United States and the two World Wars saw the nobility of the nursing practice.
The patient in this case was admitted for an acute exacerbation of COPD with the following three complications; 1. Atelectasis 2. Anxiety and 3. Cor pulmonale. Chronic obstructive pulmonary disease (COPD), also known as chronic obstructive lung disease (COLD), is a term used to describe progressive lung diseases, which include emphysema, chronic bronchitis and chronic asthma. The common symptoms of COPD are progressive limitations of the airflow into and out of the lungs and shortness of breath. Emphysema and chronic bronchitis are closely related and patients with COPD may have both, which affects lung function, preventing the lungs from bringing oxygen
to the body and getting rid of carbon dioxide. Some cases with COPD may also have an “asthma-like” or reactive component. Emphysema involves destruction of the alveoli in the lungs. Chronic bronchitis is characterized by a chronic cough and mucus production.
Although, smoking is the main cause of COPD, other environmental and industrial pollutants also contribute to COPD even in non-smokers. Passive cigarette smoke also contributes to acute respiratory symptoms and COPD. The other major causes of COPD include occupational dusts and chemicals vapors, irritants and toxic fumes. Respiratory infections in early childhood also contribute towards reduced lung function and increased respiratory problems in adulthood, leading to COPD.A rare, inherited form of emphysema, known as alpha-1-antitrypsin deficiency, also causes COPD. Emphysema is the progressive destruction of the alveoli that perform the lung’s basic function of exchanging oxygen in the air for carbon dioxide in the cardiovascular system. Thus, the alveoli are unable to completely deflate after inflation and unable to fill with fresh air. Although Emphysema is irreversible, the disease can be managed through medications, exercise and good nutrition. In emphysema due to smoking, the bronchioles that join the alveoli are damaged and the walls lose elasticity leading to formation of pockets of dead air in the damaged lung areas reducing the ability to exhale, reducing normal lung function. Though Inhalation is not impaired in the early stages, oxygen and carbon dioxide levels are abnormal and breathing becomes difficult in the late stages of the disease. Emphysema patients are deprived between 50% and 70% of their lung function by the time symptoms begin to appear. Emphysema is mostly due to an imbalance in chemicals that protect the lungs from infection and damage. Any imbalance in these substances triggers emphysema. For example, Cigarette smoke contains irritants that
inflame the air passages, triggering biochemical events that damage cells in the lung, thus increasing the risk both for emphysema and lung cancer. Smoking is overwhelmingly the cause of emphysema and chronic bronchitis. In the inherited form of emphysema known as alpha-1-antitrypsin deficiency, both the walls of the bronchioles and alveoli ,usually in the lower lungs, are affected. Chronic bronchitis is the inflammation of the main air passages, bronchi to the lungs resulting in the production of excess mucous, a reduction in the ventilation and shortness of breath. Chronic bronchitis is characterized by excessive bronchial mucus with a productive cough for three months or more over two consecutive years without any other disease that will account for these symptoms.
In the early stages of chronic bronchitis, cough occurs in the morning and on progress, coughing persists throughout the day. Over a period of time the patient experiences abnormal ventilation-perfusion: insufficient oxygenation of blood (hypoxemia), hypoventilation and right-sided heart failure. Chronic bronchitis can be difficult to treat because of recurring bacterial infections aided by excessive mucous production, which serves as a good environment for infection causing inflammation and swelling of the bronchial tubes. In the later stages of chronic bronchitis, the thick, tenacious mucus cannot be cleared causing damage to the cilia that help sweep away fluids and particles in the lungs. This severely affects the lung’s defense against air-borne irritants. Chronic bronchitis also can have an asthmatic component. In severe stages, patients often have emphysema and are called “blue bloaters”. Because lack of oxygen causes the skin to have a blue cast (cyanosis) and the body is swollen from fluid accumulation caused by congestive heart failure. COPD symptoms when ignored usually leads to hospitalization in intensive care (ICU) units. Although patients with COPD do not have asthma, many do
have an asthmatic component to either emphysema or chronic bronchitis. Unlike emphysema and chronic bronchitis, asthma can be reversed and responds well to various medications. Hence, there is always a controversy surrounding the argument if asthma should be included into the concept of COPD. People with COPD have a variety of illnesses such as, asbestosis – A respiratory disease caused by inhaling asbestos fibers; aspergilloma – A fungal mass grows in pre-existing lung cavities, or can cause new lung cavities; aspergillosis – An acute infection caused by a fungus that produces illness almost exclusively in immuno suppressed people; aspergillosis (allergic) – An infection, colonization in the lung, or allergic response due to the Aspergillus sp.fungus.
atelectasis – The collapse of part or all of a lung by blockage of the bronchus or bronchioles or by very shallow breathing;bronchiectasis – An acquired disorder of the large bronchi that become dilated after destructive infections of the lungs; congestive heart failure (CHF) – A disorder in which the heart loses its ability to pump blood efficiently, thereby failing to meet the demands of the body; cor pulmonale – Enlargement of the right ventricle that occurs because of pulmonary hypertension from lung disorders (most commonly chronic bronchitis, emphysema). This does not include right ventricle enlargement that results from congestive heart failure or heart valve disease; cystic fibrosis – Affects the mucus and sweat glands of the body and is caused by a defective gene. Thick mucus is formed in the bronchial tree, which predisposes the person to chronic lung infections; eosinophilic pneumonia (Loeffler’s syndrome) – Acute pulmonary eosinophilia is a self-limiting inflammation of the lungs associated with infiltration of eosinophils in the lungs and blood; interstitial lung disease – The scarring and thickening of the deep lung tissues of unknown cause; lung cancer – A malignant
tumor that arises from lung tissue; metastatic lung cancer – The process by which cancer cells are spread from another organ to the lungs; necrotizing pneumonia – Aspiration pneumonia is an inflammation of the lungs and bronchial tubes caused by inhaling foreign material, usually food, drink, vomit, or secretions from the mouth into the lungs. This may progress to form a collection of pus in the lungs; plural effusion – An accumulation of fluid between the layers of the membrane lining the lung and the chest cavity; pneumoconiosis (black lung disease; pneumoconiosis) – A respiratory disease caused by inhaling coal dust for prolonged periods; pneumocystosis – An infection of the lungs caused by the microorganism Pneumocystis carinii. ; pneumonia – An inflammation of the lungs caused by an infection; pneumonia (in immunodeficient patient) – An inflammation of the lungs caused by infection, which occurs in a person whose mechanisms to fight infection are severely affected; pneumothorax – A collection of air or gas in the chest causing the lung to collapse; .pulmonary alveolar proteinosis – A disease in which a phospholipid, a compound widely distributed in living cells, accumulates within alveolar spaces in the lung where oxygen and carbon dioxide are exchanged; pulmonary anthrax – A disease that affects mostly farm animals; humans acquire it through inhaling spores when in direct contact with infected animals; Pulmonary arteriovenous malformation – An abnormal passageway between an artery and vein that occurs in the blood vessels of the lungs; pulmonary edema – A condition characterized by fluid accumulation in the lungs caused by back pressure in the lung veins; pulmonary embolus – A blockage of an artery in the lungs by fat, air, tumor tissue, or blood clot; pulmonary histiocytosis X (eosinophilic granuloma) – Pulmonary histiocytosis is characterized by inflammation of the small airways (bronchioles) and the
small blood vessels in the lungs. This inflammation leads to stiffening (fibrosis) and destruction of the walls of the alveoli; pulmonary hypertension (idiopathic pulmonary hypertension) – A disorder in which the blood pressure in the pulmonary (lung) arteries is abnormally high in the absence of other diseases of the heart or lungs; pulmonary tuberculosis – A contagious bacterial infection caused by Mycobacterium tuberculosis (TB). The lungs are primarily involved, but the infection can spread to other organs;
pulmonary veno-occlusive disease – A progressive obstruction of the pulmonary veins.
rheumatoid lung disease – A disease that is associated with rheumatoid arthritis and includes pleural effusions, diffuse interstitial pulmonary fibrosis, and other rarer conditions and silicosis – A granulomatous disease in which inflammation occurs in lymph nodes, lungs, liver, eyes, skin and other tissues.
1.Atelectasis:
Atelectasis is a condition where there is a collapse of part or all of a lung by blockage of the bronchus or bronchioles or by very shallow breathing. Atelectasis can be both acute and chronic. Acute atelectasis is the recent collapse of the lung and is primarily notable only for airlessness. In chronic atelectasis, the affected area is often characterized by a complex mixture of airlessness, infection, bronchiectasis, and fibrosis. The most common cause of atelectasis is an obstruction of a large bronchus. Smaller airways also become blocked. The obstruction is caused by a plug of mucus, a tumor, or an inhaled foreign object inside the bronchus. Alternatively, the bronchus is also blocked by a tumor, enlarged lymph nodes, or a significant amount of pleural effusion or pneumothorax in the pleural space. When an airway becomes blocked, the air in the
alveoli beyond the blockage is absorbed into the bloodstream, causing the alveoli to shrink and retract. The collapsed lung tissue commonly fills with blood cells, serum, and mucus and becomes infected. Acute atelectasis is a postoperative complication, especially after chest or abdominal surgery. Acute atelectasis also occurs with an injury, usually to the chest. Atelectasis following surgery or injury, involves most alveoli in one or more regions of the lungs. Chronic atelectasis may occur in one of two forms namely, middle lobe syndrome or rounded atelectasis. In middle lobe syndrome, the middle lobe of the right lung contracts, usually because of pressure on the bronchus from enlarged lymph glands .The blocked, contracted lung sometimes develops pneumonia that fails to resolve completely and leads to chronic inflammation, scarring, and bronchiectasis. In rounded atelectasis, an outer portion of the lung slowly collapses as a result of scarring and shrinkage of the pleura. The Symptoms includes shortness of breath due to the loss of functioning lung tissue; persistent blood flow through the collapsed area leading to a decrease in the blood oxygen level; increase in the heart rate and cyanosis. The symptom severity depends on rapidity of the bronchus block ; the volume of the lung is affected; the precipitating factors; and lung infection. When blockage is rapid and a large part of lung tissue is affected, the patient turns blue or ashen in color, has sharp pain on the affected side, and experiences shortness of breath. The patient also experiences shock with a sudden drop in blood pressure; an increased pulse rate; and fever in case of infections.
2.Anxiety:
Generalized anxiety disorder and panic disorder are commonly prevalent anxiety
disorders in COPD cases. It is well known that Anxiety has a negative impact on the quality of life of adults with COPD. Anxiety causes disability , impaired functional status, affects general health, social activity, Psychological function, and vitality. Anxiety has been recognized as a significant predictor of the frequency of hospital admission for acute exacerbations of COPD. Studies have documented the use of psychotropic medications in COPD patients.
3. Cor pulmonale:
Cor pulmonale is the failure of the right side of the heart caused by prolonged high blood pressure in the pulmonary artery and right ventricle of the heart.The left side of the heart exerts a higher level of blood pressure to pump blood to the body.Whereas, the right side pumps blood through the lungs with a lower pressure. Thus, any condition that leads to prolonged high blood pressure in the arteries or veins of the lungs causes a condition called pulmonary hypertension.This pulmonary hypertension is not tolerated by the right ventricle of the heart and thus fails to properly pump against these abnormally high pressures leading to cor pulmonale.Chronic lung diseases like COPD or other conditions like Obstructive sleep apnea,Central sleep apnea,Cystic fibrosis causing prolonged low blood oxygen can lead to cor pulmonale.The symptoms include shortness of breath,wheezing, coughing,swelling of the feet or ankles,exercise intolerance,chest discomfort, cyanosis,distension of the neck veins indicating high right-heart pressures,abnormal fluid collection in the abdomen, enlargement of the liver,swelling of the ankles and abnormal heart sounds.
Nursing interventions:
Dorothea Orem (1971) defined nursing with emphasis on client’s self-care needs. Self-care, according to the theory, is a learned, goal-oriented activity directed towards the self in the interest of maintaining life, health, development and well-being. The ultimate emphasis of Orem’s theory is on client’s self care. Accordingly, nursing care is needed when the client is unable to fulfill biological, psychological, developmental or social needs and the nurse determines by duty why a client is unable to meet the needs or what must be done to enable the client to meet them. Thus, Orem defines the goal of nursing as to increase the client’s ability to independently meet their needs i.e., the self care of the client.
Intensive Care Unit (ICU) nursing is commonly referred to as critical care nursing. Critical care nursing deals specifically with the human response to life threatening conditions. Critical care nursing is challenging due to the nature of life-threatening health situations in the ICU. Critical care nurses are often in high-stress situations which demands complex assessments, high-intensity therapies and interventions and continuous vigilance. Nursing interventions should be based on evidence-based practice. Evidence based practice is the conscientious, explicit and judicious use of current best evidence in making decisions about the case of individual patients (Sackett, 1996). The practice of evidence-based medicine is the integration of individual clinical expertise with the best available external clinical evidence from systemic research. Individual clinical expertise is the proficiency and judgment that nurses acquire through clinical experience and practice. External clinical evidence is the relevant patient centered clinical research from
the science of medicine. This includes the accuracy and precision of diagnostic tests, prognostic markers, and therapeutic, rehabilitative and preventive regimens. External evidence sometimes replaces previously accepted treatments by virtue of accuracy and safety. Evidence based medicine takes patient’s perspective also into account. Hence, evidence based medicine involves a big process of question building and this process of question building takes into account Clinical findings, Aeotiology, Diagnosis, Prognosis, Therapy and Prevention of diseases. This question building process gives the idea on the most important question, the question which is encountered very often in practice and the question’s relevance very often in practice and the question’s relevance to the patient situation. Evidence based nursing practice is probably best understood as a decision – making framework that facilitates complex decisions across different and sometimes conflicting groups. It involves considering research and other forms of evidence on a routine basis when making health care decisions. Such decisions include choice of treatment, tests or risk management for individual patients, as well as policy decisions for large groups and populations (Baum, 2003). At a broader level, evidence based nursing practice works by providing a safe framework in which different groups can make tough decisions by safe guarding their concerns by a fair and scientifically sound process.
Medical interventions of nurse care: People with chest deformities or neurologic conditions that cause shallow breathing benefit from mechanical devices that assist breathing, such as continuous positive airway pressure, which delivers oxygen through a nose or face mask that prevent airways collapse, even at the end of a breath. Additional respiratory support can be provided with a mechanical ventilator. The primary treatment
for acute massive atelectasis is removal of the underlying cause. If the blockage cannot be removed by coughing or by suctioning the airways then it should be removed by bronchoscopy. Antibiotics are to be given for any detected infection as in chronic atelectasis, when infection is almost inevitable. Treatment of atelectasis due to deficient or ineffective surfactant, is done by treating the low blood oxygen either with mechanical ventilation or positive end expiratory pressure. For Cor pulmonale, Supplemental oxygen can be administered to increase the level of oxygen in the blood. A low salt diet is recommended. Diuretics can be given to remove excess fluid from the body. Calcium channel blockers, intravenous prostacyclin, or the oral medication bosentan are frequently used to treat pulmonary hypertension. Blood thinning anticoagulants are also useful.Oxygen administration relieves symptoms and prolongs survival.Careful intervention is essential because progressive pulmonary hypertension and cor pulmonale often leads to severe fluid retention, life-threatening shortness of breath, shock, and death. Benzodiazepines are not recommended to relieve anxiety in patients with COPD because they decrease respiratory drive and compromise lung function. An anxiolytic, buspirone, have been found to be safe in reducing anxiety in COPD patients.
Dyspnea is common in individuals with chronic obstructive pulmonary disease (COPD). Respiratory assessment of the patient should include present level of dyspnea measured using a quantitative scale such as a visual analogue or numeric rating scale.Usual dyspnea is measured using a quantitative scale such as the Medical Research Council (MRC) Dyspnea Scale.The other assessments include Vital signs, Pulse oximetry , chest auscultation ,chest wall movement and shape/abnormalities, presence of peripheral
edema, accessory muscle use , presence of cough and/or sputum, ability to complete a full sentence and the level of consciousness.By doing so, nurses should be able to detect stable and unstable dyspnea and acute respiratory failure(American Thoracic Society,1998). Nurses should also be able to offer nursing interventions for all levels of dyspnea including acute episodes of respiratory distress which includes acceptance of patients’ self-report of present level of dyspnea ,Medications ,Controlled oxygen therapy ,Secretion clearance strategies,Non-invasive and invasive ventilation modalities,Energy conserving strategies ,Relaxation techniques,Nutritional strategies and Breathing retraining strategies. It is important for the nurses to remain with patients during episodes of acute respiratory distress. Medications include Bronchodilators ,Beta 2 Agonists ,Anticholinergics and Methylxanthines,Corticosteroids ,Antibiotics ,Psychotropics and Opioids (www.guidelines.gov). Nurses have to assess patients for hypoxemia/hypoxia and administer appropriate oxygen therapy for individuals for all levels of dyspnea.
Continuous Positive Airway Pressure Oxygen therapy is part of any ICU and requires absolute attention. Patient safety checks includes circuit leaks; maintenance of positive pressure; adequate inspiratory air flow and not leaving the patient alone. Managing the therapy involves maintenance of the desired FIO2; level of positive airway pressure and time period for CPAP therapy, attaching CPAP machine medical air and oxygen gas lines to wall sources, preparation of humidification source ,selection of prescribed FIO2 on oxygen blender, turning flow on to level above 25 litres / min., positioning of rubber securing band behind the patient’s head, centred on occiput, positioning of face mask over the patient’, adjusting the level of positive expiratory pressure to prescribed level,
adjusting inspiratory gas flow so that minimal fluctuations are present on pressure gauge, Observing and documenting respiratory rate; work of breathing and SpO2, increasing inspiratory flow if respiratory work is excessive or the patient complains of continuing dyspnoea, Maintaining continuous SpO2 monitoring with alarm function in place, maintaining humidification temperature at 36 degree C or at temperature tolerated by the patient. Patient observations include, visual check every half an hour, documentation of respiratory rate, SpO2, nausea and vomiting, monitoring pulse rate and rhythm; blood pressure; peripheral circulation and proper functioning of humidification system every hour, checking the condition of skin around and under mask and rubber securing band, documentation of condition and interventions, condition of conjunctivae every two hours, auscultation of lungs for equal air entry and palpatation of abdomen for distension every four hours. Ventilator-Associated Pneumonia is a common nosocomial infection in the ICU accounting for 13% to 18% of all nosocomial infections. Critically ill patients supported by mechanical ventilation are especially vulnerable to ventilator-associated pneumonia, leading to increased mortality and morbidity and prolonged hospital stay. Because of intubations, bacteria have direct access to the lower airways and the endotracheal tube bypasses normal filtration mechanisms and the epiglottis .The endotracheal tube serves as a route for inoculation of the bacteria such as P. aeruginosa. Infection may be even due to Improper hand washing, not changing the gloves from patient to patient, and contamination of respiratory devices like nebulizers, spirometers, oxygen sensors, bag-valve mask devices, and suction catheters (Shelby Hixson,1998). Intubation affects and alters the natural host mechanisms by reducing the cough effort, interfering the mucociliary clearance, and damaging the epithelial layer exposing the
basement membrane allowing bacterial colonization. Intubation also results in increased mucus production to trap bacteria which results in accumulation of mucus in the respiratory tract. Proper hand washing, use of fresh gloves when suctioning patients orally or through the endotracheal tube helps in reducing infections. Oral hygiene is often neglected in intubated patients. Oral care includes brushing the patient’s teeth, use of solutions and mouthwash to cleanse the mouth, and periodical suctioning of oral secretions. Nasal care and proper cleansing of the nasopharynx reduces bacterial infection. For patients who have an nasogastric or nasoenteric tube, the endotracheal tube is placed nasally. Since the tubes remain for prolonged periods, secretions accumulate and crust in the nares. Thus, routine cleansing of the nose and suctioning nasopharyngeal secretions should be done and evaluated. Stagnated mucus in the lower airways serves as an excellent medium for bacterial growth, when the pathogens reach the lower airways. Periodic turning and positioning of the patient assists in disintegration of these secretions. Use of beds that provide vibration or rotation to prevent VAP is also recommended. Suction of patients is done only during auscultation of adventitious lung sounds or other assessments. This suction mandate reduces trauma to the airways. Stagnant mucus aided by a lack of a cough reflex aids infection and hence suctioning and interventions that facilitate effective coughing are to be done periodically.
General Interventions: ICU patients especially with COPD are not in a position to speak due to respiratory intubation and cognitive difficulties. In such situations, communication forms the pulse of the nursing interventions. Is it so because nurses are the ultimate care providers after the doctors treat the patients. Various theories on practice of nursing touch upon this aspect of nursing. Non-verbal communications do
occur in nurse–patient communication. The non-verbal communication includes patient directed eye gaze, affirmative head nod, smiling, learning forward, touch and instrumental touch (Wilma, 1999). If has been observed that these non-verbal communication have as tremendous impact on the patient’s well being and comfort. The nurses and the patients seem to eye gaze, head nod and smile to establish a good relationship. A caring touch is an important form of non-verbal but often effective communication. If should be understood that the nurse should be able to perceive the expressions of the critically ill to provide maximum comfort. The needs of these patients can be effectively addressed only then. Cognitive impairments pose a serious barrier on the reliability of patient assessments. Effects of cognitive impairment on the reliability of such assessments has been studied recently (Phillips et. al, 1993) to explore the relationship between cognitive status and reliability of multidimensional assessment data. The studies have proved that the reliability of the patients communication and sensory ability are affected by cognitive status. Another critical issues of debate in nurse – patient relation ship with reference to critically ill patients is that the patient’s contribution is always neglected. Literature reviews point out that nurses are seen to be controlling and restricting the conversations with the patients. There has been suggestions too, to train nurses on Communication skills. ‘Assumptions’ have been seen as an important factor which formed the basis of nursing communication without taking the views of the patients at all. Nurse-patient communication is not a series of isolated conversations, but a vital component of the care ; comfort concept (Jarret, 1995). It is also important for the nurse to allow emotional expressions like tears, anger and frustration of the terminally ill. Allowing expressions of emotions relieves their psychological pressures.Research studies
on the on the effect of information on illness in anxiety relief have shown that information to patients has little effect on the anxiety relief (Teasdele, 1993). The studies emphasize that patient anxiety can be relieved more reliably by the use of reframing and empowering interventions than by the presentation of information.
Thus, use of non-verbal communication skills (NVC) to improve nursing care, especially with people who have disability has been assessed in a study (Chambers, 2003). The study outlines a nursing diagnosis of altered non-verbal communication and a new wellness diagnoses for enhanced non-verbal communication with detailed discussion on use of NVC with people with comprehension difficulties. The study stresses on the fact that nurses can be important in enhancing the non-verbal skills of the patient to help them communicate. Adding support to the view, the importance of improving communication by touch has been documented (Vortherms, 1991). The article views touch as an integral aspect of nursing care, with the language of touch including tactile symbols of duration, location, action, intensity, frequency and sensation. The article classifies touch
as affectional, functional and protective. The article stress that age is not a category to decide upon touch in terms of reduced needs of touch. An examination of touch between nurse and elderly patients (McCann et. al, 1993) has shown that most nurse– patients touch interactions in a care of the elderly are instrumental in nature and expressive touches are usually given to body extremities like the forehead, arms and the legs. The gender and parts of the body touched influence the level of comfort.
Conclusion:
Thus, a nurse needs insight ,sensitivity, effective communication skills and strategies to give what the patient needs and uphold the values of nursing care. A nurse should look
for ways to improve the relationship between the family and the supporting health care of critically ill patients .The entire concept of care is based on communication, adaptation and recognition of the patient’s needs. The ICU setting demands maximum nursing interventions and constant monitoring of the patients especially with conditions like COPD. Thus, there is also a need for specialist nurses who are experts in not only medical care but also patient care. ICU nursing is stressful and hence lots of research studies are in place to stress the importance of educating the nurses at the curriculum level on such interventions with renewed interests on communication and care aspects of nursing.
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