Nursing Intervention Case Study
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1. Impaired gas exchange relation to the patient’s assessment data
According to Carpenito-Moyet (2005), the term “Impaired Gas Exchange” is used to describe “the state in which an individual experiences an actual or potential decreased passage of gases (oxygen and carbon dioxide) between the alveoli of the lungs and the vascular system” (p.378). The first prime characteristic to define this diagnosis is dyspnea on exertion. In other words, it is hard for a patient to breathe in and breathe out. Being 69 years of age, the patient Graham Peters has Chronic Obstructive Pulmonary Disease (COPD) difficulties with breathing are obvious.
As Miller (2008) warns, impaired respiratory function is rather typical for elderly people with chronic illnesses (p. 447).Meanwhile, the symptoms are admitted by the patient who has labored getting his breath. Decreased air entry in both lower lobes is revealed by coarse creps (Torres & Moayedi, 2007, p. 310). Another wide-spread sign is prolonged expiratory phase noticed during the examination, as well.
Green colored sputum and abnormally pale skin are the next widely spread, clinical manifestations of impaired gas exchange (Kumar & Klark, 2009, p. 221) discovered during the examination of Peters. Coughing, in turn, is a consequence of problematic breathing. Elevated HCO3 (35 mEq/L), while the normal rate is up to 28 mEq/L, indicates chronic respiratory acidosis. All these symptoms obviously stand for Impaired Gas Exchange.
2. First intervention ‘Educate the patient effective cough and breathing technique, position
Definitive treatment is not prescribed for Impaired Gas Exchange. Although this dysfunction is not treated by nurses, there are certain actions nurses should take to improve the patient’s functional health patterns affected by decreased oxygenation (Longmore et al., 2004, p. 630). Breathing and coughing are among these patterns. Thus, nurse interventions are required to prevent potential complication.
One of the techniques to improve gas exchange is pursed-lip breathing. The expiration phase of breathing is consciously prolonged by the patient. If this procedure is performed correctly, extra carbon dioxide can be eliminated from the lungs. First, the patient is taught to inhale slowly through the nose and count to three. Secondly, the lips should be purse as if the patient is going to whistle. Thirdly, the abdominal muscles are contracted. Finally, the patient exhales through pursed lips (Carpenito-Moyet, 2007, p. 338). It is pertinent to note that the expiration should be at least twice or even three times longer than inspiration. It is not easy as it may seem, since much practice is needed under careful supervision of a nurse. With time, the length of expiration will increase if the procedure is done properly.
Another problem is that the patient tends to use his shoulders and upper chest while breathing. It is necessary for the patient to learn to use his diaphragm for more effective breathing, as well as coughing. “Controlled coughing uses the diaphragmatic muscles, which makes the cough more forceful and effective” (Ackley & Ladwig, 2008, p. 389). Upper chest muscles are not able to provide the same gas exchange as lower muscles. That is the reason why diaphragmatic breathing is used “to increase the volume of air exchanged during inspiration and expiration” (Timby, 2008, p. 464). When the procedure is performed properly, rapid, ineffective breathing is relieved, and the respiratory effect is reduced. To define whether the patient is breathing with diaphragm, he should lie down on a smooth surface with his knees slightly bent. One of the hands is put on the chest, while another one is put on the abdomen. Slow and deep inhaling is to be performed to make the abdomen rise more than the chest. The expected outcome is the improvement of breathing patterns.
As Timby (2008) notes, “pursed-lip breathing and diaphragmatic breathing are especially helpful for clients who have chronic lung diseases” (p. 464).
3. Second intervention ‘Encourage/retrain the patient to use bronchodilator (nebuliser, ventolin)’
In order to ease the sufferings of a patient, bronchodilators are prescribed. These are substances used to increase the airflow to the lungs by reducing the resistance in the respiratory airway. “Bronchodilators work by relaxing and expanding the smooth muscle of the airways making it easier to breathe” (Leader, 2011, p. 601). These medications are indispensable for patients with chronic obstructive pulmonary disease, like in case under consideration. More stress is put on bronchodilators with long-term effect.
The situation involving Graham Peters is not as critical as it may be to turn to “rescue relief” medications. As the symptoms need to be controlled and prevented better, long-acting bronchodilators are recommended. Long-acting are β2-agonists and theophylline. The first (for instance, Salmeterol or Formoterol) need about 12 hours to relieve airway constriction. Normally, they should be given to the patient twice a day in aggregate with anti-inflammatory medications (Holleman & Simel, 2008, p.319). They are especially needed at night.
However, COPD is more often treated by means of anticholinergic bronchodilators like tiottopium and ipratropium bromide (only as an inhalant). The drawback of the latter is a number of side effects, including dry throat. While the patient has enough problems with his mouth without these medications, these side effects should be considered to take a right decision. Theophylline is an alternative way out. Not only the dosage level should be controlled, but also the other substances taken by the patient, as some of them (like erythromycin) may interfere with the effectiveness of theophylline.
There can be individual reactions to the medication, so the supervision is necessary at the first stage. Still, “side effects of beta agonists are often dose related and more frequent in oral than inhaled methods of delivery” (Leader, 2011, p. 601). It is one more task for the nurse to teach the patient to use an inhaler correctly. Only after his safety is ensured, the patient is free of nurse’s control.
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