NURBN2022: Nursing-Centered Practice – Assessment Answer

Introduction

The patient in the case study is a 36-year-old woman called Sarah Smith who is hospitalized in the respiratory ward. Shortness of breath, a fever, and a severe cough led to the patient's admission to the ED. Influenza PCR is forthcoming and the COVID-19 test is negative. The patient's medical history indicates that she had minor asthma as a child, wasn't a smoker, and had received the COVID-19 vaccine. The patient's social history indicates that she lives with her spouse Michael and their two kids, who are 6 and 8 years old. The patient also works part-time at an elementary school as a teacher. The patient's temperature is 39.2, and their heart rate is 100 breaths per minute. The respiration rate is 28 breaths per minute, the GCS score is 14, and the blood pressure is 110/60 mm Hg. The patient is taking modest sips of drink since, according to the subjective data, eating makes him or her too breathless. The patient requires two pillows, and as the patient experienced 2/10 pleuritic thoracic pain, the number of analgesics prescribed for it should be decreased. Sunken eyes and dry mucous membranes have both affected the patient.

Collecting Cues

According to the patient's current condition, she has been complaining of fever, a strong cough, and shortness of breath. The patient has been identified as having community-acquired pneumonia (CAP), according to the analysis of the objective and subjective data. The primary and most significant cause of death or morbidity worldwide is CAP. The clinical manifestation of CAP can range from moderate pneumonia, which is also accompanied by significant respiratory distress and sepsis, to severe pneumonia. The causes of CAP are broken down into numerous categories below. Flu A, Streptococcus pneumonia, Chlamydophila pneumonia, and Mycoplasma pneumonia are a few of the culprits. Shortness of breath, fever, and a strong cough are some of the symptoms the patient in the case study has encountered. Smoking and chronic lung conditions such as cystic fibrosis, COPD, and bronchiectasis are two risk factors for CAP. stroke, dementia, cerebral palsy, brain damage, and other neurological conditions. In addition to this, there are other ailments, such as diabetes, heart disease, and liver cirrhosis, that put patients at high risk if they are detected. There are lots of patients that have immune system issues brought on by things like cancer therapy, organ transplants, HIV/AIDS, and other illnesses.

Process

The following list of the patient's aberrant data that were discovered while gathering objective data is provided. Although the measured pulse rate is 100 beats per minute, the usual pulse rate is 60 to 100 beats per minute. The patient's RR is reported as 28 breaths per minute, while the usual range is 12 to 14 breaths per minute. The patient's blood pressure was also measured as 110/60 mm Hg, which is outside the normal range of 120/80 mm Hg. The Sp02 level is also lower than anticipated when measured; instead of 95%, it should be 92% (Brekke et al., 2019). The amount of pee that the patient has observed is orange in color and 350 ml in 12 hours for the patient, although the typical range is 800-2,000 ml/day, thus the value is not maintained. Similar to how patients with CAP experience respiratory issues, this was seen in the case study. In addition to respiratory issues, dry mucus is seen. Care must be taken with all of these gathered cues. There are several causes of CAP, and those who are at a higher risk of developing diabetes, heart disease, and liver cirrhosis are more likely to experience its effects. The likelihood of developing CAP increases if a person's immune system is compromised (Shneyderman et al., 2022).

Two Problems/ issues

The patient's breathing problems are the first concern; as a result, the patient is unable to breathe, which has an impact on the operation of other organs. It may also result in weariness and dry mouth in some circumstances, as well as panic episodes. In other instances, it can lead to respiratory troubles and is a risk factor for cardiovascular disease. Other areas of the body are also tense as a result of the erratic breathing pattern. The content of carbon dioxide rises and the body is unable to absorb oxygen if the breathing rate is not maintained. The lungs' movement-controlling muscles have to be in good working order (Sharma et al., 2023).

Another problem that is seen is pyrexia, which causes a rise in body temperature and fever. The core temperature is elevated in this situation and is set over a particular threshold. The hypothalamus is supposed to control the current set point. The pyrexia patient frequently has a fever, a cough, and purulent sputum. Dyspnea and pleuritic chest discomfort are also present. This disorder must be recognized and treated to be under control (Whited & Graham, 2023).

Establish Goal

Another problem that is seen is pyrexia, which causes a rise in body temperature and fever. The core temperature is elevated in this situation and is set over a particular threshold. The hypothalamus is supposed to control the current set point.

The pyrexia patient frequently has a fever, a cough, and purulent sputum. Dyspnea and pleuritic chest discomfort are also present. This disorder must be recognized and treated to be under control (Balli et al., 2022).

Take Action

The following list of nursing interventions includes ones that can be used to regulate the respiratory rate. By instructing the patient in proper breathing, the nurse should be of assistance. Breathing can be controlled through a variety of exercises, such as respiratory muscle training, which will assist in restoring regular breathing. To control the patient's breathing rate, the nurses might also evaluate the patient's medical history. In some circumstances, nurses also aid with mechanical ventilation, which helps the patient breathe. To fully understand the gas exchange process and how it functions, nurses need also to measure the ABG level. After observing the patient's breathing pattern, the underlying disease malfunction or process should be investigated. The following list includes some of the rates or depths of breathing patterns: In addition to the temporary halt of breathing caused by apnea, ataxic patterns are occasionally seen (Bolzani et al., 2017).

Certain actions can be taken to manage pyrexia. The administration of medications is the first crucial factor. Ibuprofen or paracetamol are examples of necessary medications that are utilized; these drugs should be taken as directed on the label. It is caused by several risk factors, all of which must be taken into account (Steindal et al., 2019).

Evaluate

The patient's condition is improved by all nursing care techniques used by the nurse. The patient's breathing pattern will become better with practice. The usage of mechanical ventilation is made to aid in breathing restoration. The temperature needs to be managed to prevent pyrexia. The temperature needs to be managed in some pyrexia cases to keep the patient comfortable. Pyrexia causes the body temperature to rise, and the main cause of this is an increase in inflammation, which must be addressed. Effective measures must be adopted to control all risk variables that are present.

Reflect

There are several lessons to be learned from this case study, but the most crucial one is to focus on the patient's well-being. After administering the medication, the nurse will have a better understanding of the medication and how to deliver it.

Conclusion

Many of the patient's statistics in the case study, when the patient is being observed, do not fall within the usual range, therefore this needs to be balanced. The patient has mostly been diagnosed with two issues: the first is breathing problems, which prevent the patient from being able to breathe. Another problem that is seen is pyrexia, which causes a rise in body temperature and fever. For proper functioning, it is important to manage both of these circumstances. Controlling the respiratory rate and body temperature can be accomplished through a variety of nursing treatments.

References

Balli, S., Shumway, K. R., & Sharan, S. (2022). Physiology, fever. StatPearls. StatPearls Publishing.

Bolzani, A., Rolser, S. M., Kalies, H., Maddocks, M., Rehfuess, E., Swan, F., Gysels, M., Higginson, I. J., Booth, S., & Bausewein, C. (2017). Respiratory interventions for breathlessness in adults with advanced diseases. The Cochrane Database of Systematic Reviews, 2017(6), CD012683. https://doi.org/10.1002/14651858.CD012683

Brekke, I. J., Puntervoll, L. H., Pedersen, P. B., Kellett, J., & Brabrand, M. (2019). The value of vital sign trends in predicting and monitoring clinical deterioration: A systematic review. PloS One, 14(1), e0210875. https://doi.org/10.1371/journal.pone.0210875

Sharma, S., Hashmi, M.F., & Badireddy, M. (2023). Dyspnea on exertion. StatPearls [Internet]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499847/

Shneyderman, M., Yin, E., Levin, A., Aliu, O., Sun, D., & Cohen, A. J. (2022). Vital sign measurement and response to abnormal measures in surgical specialty clinics. JAMA Network Open, 5(4), e229491. https://doi.org/10.1001/jamanetworkopen.2022.9491

Steindal, S. A., Torheim, H., Oksholm, T., Christensen, V. L., Lee, K., Lerdal, A., Markussen, H. Ø., Gran, G., Leine, M., & Borge, C. R. (2019). Effectiveness of nursing interventions for breathlessness in people with chronic obstructive pulmonary disease: A systematic review and meta-analysis. Journal of Advanced Nursing, 75(5), 927–945. https://doi.org/10.1111/jan.13902

Whited, L., & Graham, D.D. (2023). Abnormal respirations. StatPearls. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470309/

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