Consider the patient situation

Consider the patient situation: 

Mr James Hodges is 83 years of age, admitted today from an aged care facility. You are working on the medical ward, and he is a patient who is delegated to you to care for. Mr Hodges has recently been discharged following an acute exacerbation of COPD and the residential care staff are concerned that he has been unable to eat because of dyspnoea and that he may not be responding to his medications. Mr Hodges is on continuous oxygen at 2 litres/minute via nasal prongs for at least 15 hours per day. 

Subjective data:

Feeling anxious; tremor evident; dyspnoeic and fatigued. 

Objective data:

Vital signs: Temperature: 38.6°C, pulse 104 beats per minute (BPM), blood pressure (BP) 140/90 mmHg, respirations 28 breaths per minute, SpO2 (oxygen saturation measured by pulse oximetry) 89% on 2 litres oxygen via the nasal prongs.

Administer oxygen to maintain SpO2 at 88 to 92%.

Collect cues/information

Q1. Outline the pathophysiology of COPD (approx. 200 words)

COPD development is influenced by a number of pathophysiological variables. One of the major factors that might obstruct the mucociliary clearance machinery is the destruction of the epithelial barrier. Inflammatory mucous exudates build inside the narrow lumens of the airway as a consequence, and the airway becomes clogged over time. The infiltration of the airway walls by inflammatory cells, as well as the deposition of connective tissue along the airway walls, might be a contributing reason to restricted airflow via the tiny conducting airways. This method involves remodelling and repair at the same time, which results in thickening of the airway walls, which decreases lumen calibre and prevents the normal rise in calibre that happens with lung expansion. The infiltration of similar sorts of inflammatory cells present in the airways is connected to respiratory organ emphysema. Despite the fact that the process begins in the pulmonary bronchioles, cigarette smoking is the most strongly linked to the centrilobular mechanism of emphysematous destruction. Individual lesions may combine to cause significant lung tissue damage. The panacinar pattern of emphysema can be distinguished by a more homogenous acinus involvement, which is linked to alpha1 antitrypsin insufficiency. 

Q2. Give a written explanation of the pathophysiological basis for the subjective and objective data (approx. 150 words)

Why is Mr Hodges feeling anxious?

• Breathing issues are common among COPD patients. As a result, the brain sends out distress signals, which can contribute to anxiety, as demonstrated by Mr Hodges.

What is causing dyspnoea?

• Dyspnoea is a complex pathophysiology that entails activation of various pathways which might lead to increased labour of breathing, stimulation of upper or lower airways, lung parenchyma, and chest wall receptors. Peripheral and central chemoreceptors stimulate the respiratory centres excessively.

Why is his temperature raised?

• The temperature may have risen as a result of inflammatory responses brought on by respiratory infections. Fever might be an early warning sign of an upcoming flare-up.

Why is his heart rate raised?

• A decrease in arterial oxygen saturation might have contributed to the patient’s increased cardiac output. Furthermore, pulmonary dysfunction has been associated to a decrease in left ventricular size and stroke volume, particularly in COPD patients. When stroke volume is reduced, maintaining cardiac output requires an increase in heart rate.

Why is his BP raised?

• COPD causes pulmonary gaseous exchange to be disrupted, as well as decreased oxygen intake and CO2 production. As a result, the body’s blood oxygen levels are reduced (O’Donnell et al., 2020). Low oxygen levels can cause the vessels or  the pulmonary arteries to contract, raising blood pressure.

Subjective data

Why are his respirations increased?

• The respiratory system fails to give appropriate oxygen to various body parts due to inadequate air flow in the lungs. As a result, the body tries to receive extra oxygen through inspiration, which raises the respiratory rate.

Why is his oxygen saturation low?

• COPD causes alveolar hypoxia, which reduces blood oxygen saturation by encouraging certain chain processes. 

Q3. Give a detailed explanation of the pharmacokinetics and pharmacodynamics of each of the prescribed medications. Include explanations about drug class, drug action and common adverse effects to demonstrate that you understand how the drugs work and interact with the body.

salbutamol sulfate (Ventolin) inhaler 100 microgram/metered dose. 2 puffs prn 4 hourly	Drug class: bronchodilators PD: This medication has the effect of relaxing the smooth muscles of the airway. It’s a functional antagonist that promotes airway relaxation regardless of the presence of spasmogens. This is how breathing may be improved. PK: This drug’s apparent terminal plasma half-life is roughly 4.6 hours. Approximately 80% of metabolites are eliminated in the faeces and urine. Common adverse effects: Headache, tremor, nausea, cough, taste change, dizziness, and throat dryness are all possible adverse effects of this medication. When this medication is administered, a fast, slow, or irregular heartbeat may be linked to sleeping problems.
ipratropium bromide (Atrovent) metered dose aerosol 21 microgram inhalation 2-4 puffs 3-4 times daily	Class: bronchodilators PD: Ipratropium is a muscarinic cholinergic receptor blocker that acts as an acetylcholine antagonist. As a result, the production of cyclic guanosine monophosphate is reduced by the cholinergic receptor (cGMP). The medicine eventually causes the smooth muscle of the airways to contract less (Sethi & Zakharyan, 2020). PK: The digestive tract absorbs very little ipratropium bromide. The drug’s bioavailability by inhalation ranges from 0.03 to 6.9%, and around 90% of the inhaled dosage is normally ingested. The bioavailability of 2 mg of medication after total inhalation was determined to be around 6.9%. The intranasal dosage has a bioavailability of less than 20%. Common side effects: urination trouble, pain during micturition, heartburn, constipation, headache, dry mouth, cough, stomach upset, sinus discomfort, hoarseness, stuffy nose, dizziness, urination difficulty, discomfort during micturition, heartburn
prednisolone (Panafcortalone) 30-50 mg orally once daily for 5 days.	Class: corticosteroids PD: It aids in the reduction of inflammation by inhibiting the migration of polymorphonuclear leukocytes. Furthermore, it reverses the enhanced permeability of capillaries. This medicine also has the effect of suppressing the immune system by reducing the activity and volume of immunological components. PK: It exhibits quick absorption after oral ingestion and so becomes fully accessible (about 80%-100%). The time it takes for the medicine to reach its peak plasma concentrations varies between 1 and 2 hours after it is given orally. Because of its reliance on protein-binding properties, prednisolone is widely dispersed. Common side effects: Headaches, dizziness, acne, sleeping problems, and mood disturbances are some of the most common symptoms.

Q4. Mr Hodges is prescribed 2 litres of oxygen via nasal prongs continuously. What are the important nursing considerations when administering oxygen to patients with COPD? 

Nurses are in charge of ensuring that the patient’s oxygenation levels are optimal on both a pulmonary and cellular level. A thorough grasp of respiratory and cardiac physiology is required for this. The first intervention might include taking vital signs, particularly the oxygen saturation level, which could be used to adjust the pace. Second, full hygiene of the nasal prongs is critical to reducing the risk of infection. Before starting the oxygen administration, be sure to evaluate your respiratory effort and state of awareness. In this scenario, look out for signs of cyanosis. In order to offer appropriate care to the patients, the nurse must ensure that the airway is clear. 

Q5. Mr Hodges is preparing for discharge and is prescribed a Salmeterol (serevent) accuhaler 50 microgram/blister to take home. Apply your pharmacotherapeutic knowledge to the patient education you would provide to Mr Hodge’s prior to discharge  

It is critical for a nurse to educate the patient about the drugs in order to encourage medical compliance from the patient’s perspective. This aids in the development of a deeper knowledge of the drug, and the patient recognises the need of receiving the proper amount. Salmeterol is a 2 adrenergic receptor agonist with a lengthy half-life (also known as LABA) (Gundry, 2019). This reduces the risk of COPD exacerbation by helping to avoid asthma symptoms. The person would be informed of the potential negative effects of each prescription provided to him, and he would be urged to take his drugs exactly as prescribed by the doctors, including the amount and time. Any missed doses or bad events should be reported to the nursing staff or physicians as soon as possible so that the patient’s condition does not deteriorate further. 

Application of the ACSQHC Medication Safety Standards and Quality Use of Medicines principles to inform safe medication practice in this case? 

Managers of a health-care organisation define, execute, and monitor processes to reduce medication mistakes and enhance the safety and quality of medicine use. The staff is familiar with these systems. The Drug Safety Standard identifies areas of medicine delivery where a known risk of error exists, which is typically caused by hazardous methods and variances in clinical practises (Millichamp & Johnston, 2020).

Objective data

Medication management includes all elements of prescribing, dispensing, administering, and monitoring. Medication administration is a complex process that necessitates the involvement of a number of experts. It is generally referred to as the medication management route because it contains several activities and three system processes for managing the safe and effective use of drugs for patients at each episode of care.

In this scenario, the patient must be informed about how to take the prescription that the physician has recommended (Kosari et al., 2018). He must be informed of the proper storage procedures in order to ensure the quality of the pharmaceuticals. The exact dose must be explained to the patient. In order to maximise medication management and assure drug quality, a nurse must apply the 5Rs principle. 

Application of nursing professional codes and standards to decision-making and safe medication practice in this case? 

The Nursing and Midwifery Board of Australia (NMBA) rules support safe professional practise by providing a framework for evaluation and decision-making (Cusack, 2019). One of the most successful criteria in this area is collaborating with customers. A nurse can help a patient become more involved in his or her personal care by using this standard. The caregiver should educate patient in such a way that medical compliance is created for safe drug practise. In order to alleviate the client’s psychological issues, treating them as people and in a polite manner would be beneficial. Important criteria in the delivery of care include professional and collaborative practise, provision of care, and reflective and analytical practise.

According to Mr. Hodges’ case study, he requires advanced medical support in age care facilities to maintain his entire well-being. Safeguarding older individuals is one of the main requirements for providing care to this population, according to the professional nursing practise guidelines for older adults. In this environment, the nursing practitioner should prioritise meeting the patient’s physical, psychological, and emotional needs (Liu, Hernandez Chilatra & Phelan, 2021). To guarantee safe medicine, a nurse must focus on the 5R principle of drug administration, and the implications of this must be beneficial in terms of maximising pharmaceutical efficacy (Barlow et al., 2020). It is critical to establish a connection with the patient in order to ensure collaborative decision-making. In the context of incorporating the patient in his own treatment, this method might be advantageous. Clinical decision-making would become more convenient as a result of this therapeutic interaction when delivering treatment to patients.

References

Barlow, A., Barlow, B., Tang, N., Shah, B. M., & King, A. E. (2020). Intravenous Fluid Management in Critically Ill Adults: A Review. Critical Care Nurse, 40(6), e17-e27. https://aacnjournals.org/ccnonline/article-abstract/40/6/e17/31232

Cusack, L. (2019). New decision-making framework for nurses and midwives. Australian Midwifery News, 19(4), 9. https://search.informit.org/doi/pdf/10.3316/informit.835228640999740

Gundry, S. (2019). COPD 2: management and nursing care. Respiratory Journal, 5, 48-51. https://www.nursingtimes.net/clinical-archive/respiratory-clinical-archive/chronic-opd-2-management-and-nursing-care-06-04-2020/

Kosari, S., McDerby, N., Thomas, J., & Naunton, M. (2018). Quality use of medicines in aged care facilities: A need for new models of care. Journal of Clinical Pharmacy and Therapeutics, 43(4), 591-593. https://onlinelibrary.wiley.com/doi/pdf/10.1111/jcpt.12714

Liu, P. J., Hernandez Chilatra, J. A., & Phelan, A. (2021). Examining nurses’ role in Adult Protective Services related to safeguarding older people. Journal of advanced nursing, 77(5), 2481-2497. https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/jan.14792

Millichamp, T., & Johnston, A. N. (2020). Interventions to support safe medication administration by emergency department nurses: an integrative review. International Emergency Nursing, 49, 100811. https://www.sciencedirect.com/science/article/pii/S1755599X19300990

Sethi, R., & Zakharyan, H. K. (2020). Salbutamol and Ipratropium Bromide are to be Prescribed with Caution by Nursing Staff Which are Risk Factors for Arrhythmias in Patients with CVS Diseases. International Journal of Cardiovascular Nursing, 6(1), 6-11. https://nursing.journalspub.info/index.php?journal=IJCN&page=article&op=view&path%5B%5D=1406