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Timing Of Noninvasive Ventilation Failure

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Timing Of Noninvasive Ventilation Failure Question: Discuss about the Timing of Noninvasive Ventilation Failure.     Answer: Introduction: Mucociliary clearance system is a very important lung defence mechanism it is made up of mucus, periciliary layers and ciliary epithelium and cough clearance mechanism. In a healthy person, the cilia beat at perfect frequency hence propelling mucus up the airway (McIlwaine et al., 2017).    Disease such as chronic obstructive pulmonary disease cause the impairment of the mucociliary system, this is due to one or more condition such as dehydration of the periciliary, lack of lubricant activity and defective cilia (Bashir et al., 2016). Leading to ineffective airway clearance. Diffusion is the process that enables the exchange of gas between the alveoli and the pulmonary capillaries, the concentration difference between the oxygen and carbon dioxide gases should always be maintained by ventilation and perfusion. Conditions such as pneumonia and acute respiratory distress can cause the collapse of alveoli and as a result stopping alveoli ventilation leading to gas exchange impairment as suggested by Ozyilmaz, Ugurlu, and Nava (2014).   Risk Of Impaired Ventilation Probable causes to impaired ventilation could be associated with weak cough reflex and excessive secretion as experienced by the patient as suggested by (Nicolini et al., 2014). However, the risk factors for the early impairment can be due to hypoxemic respiratory failure at the same time poor arterial blood gas is considered as a major cause (Ozyilmaz, Ugurlu, and Nava, 2014). It is caused by intake of an insufficient nutrient that can’t meet the body’s metabolic demands. In such cases, the caring nurse should be able to understand the nutritional requirement of the patient and develop a dietary regime in consultation with a nutritionist. A diet rich in protein and carbohydrate is always preferred according to (Reeves, Tran, and Collins, 2016). This problem can be caused by conditions that create a promising environment that enables the                   disease to develop and thrive such conditions include compromised primary body defence system due to damage caused on the mucociliary system and lack of proper blood circulation due to tissue damage on the alveoli capillaries. Nursing problem: Imbalanced nutrition: less than body requirements (Anker and Larsson, 2016).                                                        Underlying cause or reason: Poor dietary management, Lack of proper feeding (Sehgal, Dhooria, and Agarwal, 2017). Goal of care   Nursing interventions Rationale   Indicators your plan is working ·       Improved diet intake to meet caloric need ·       Boosting immune ·       Give frequent oral care and Remove expectorated secretions ·       Avoid giving patient very hot or very cold foods. ·       Unpleasant smell can be deterrent to appetite. ·       Can cause nausea and vomiting ·       Extremes temperature can aggravate coughing spasms ·       Improved appetite ·       Increased body weight ·       Absence of coughs when eating Nursing problem: Risk of infection Underlying cause or reason: Not washing hands and not handling sterile equipment aseptically Goal of care   Nursing interventions Rationale  Indicators your plan is working ·       Prevent hospital- acquired infections ·       Prevent reinfection ·       Keep the patient clean to prevent more infections ·       Maintain asepsis for dressing changes and wound care. ·       peripheral IV management, and catheter care and handling. ·       Teach patient hand washing techniques.         ·       Reduced chances of transmitting or spreading pathogens. ·       Interrupting the transmission of infection along the chain of infection is an effective way to prevent infection. ·       Reduced cases of opportunistic infection. ·       Reduced cases of hospital acquired infections.   Nursing problem:  Ineffective airway clearance Underlying cause or reason: Infection, allergy Goal of care Nursing interventions Rationale Indicators your plan is working ·        Increased Patient air exchange. ·        Patient will classify methods to enhance secretion removal. ·        Keep patient safe from complications   ·       Patient to be taught how to cough ·       Use well lubricated soft catheters ·       Coughing help patient remove most secretions ·       reduces irritation and prevents trauma to mucous membranes. ·       Smooth cough and more secretion removed ·       Ruduced irritation Nursing problem: Risk of impaired ventilation Underlying cause or reason: freezing temperatures Goal of care Nursing interventions Rationale Indicators your plan is working ·       Keep patient warm ·       To improve patient breathing ·       Advice patient to put on warm clothing during winter. ·       Advice the patient to warm the room during winter   ·       blood vessels and breathing airways contract in chilly air. ·       Helps in keeping the environment around the patient warm ·       No Shivering ·       No breathing problems Nursing problem: Dehydration Underlying cause or reason: lack of water in the body for proper physiology (Ghosh et al., 2015) Goal of care Nursing interventions Rationale Indicators your plan is working Hydration of the patient   ·       Administering I.V fluids to the patient ·       Teach the patient about  the importance of taking more water ·       Advice patient to take fruits that are watery such as watermelon ·       I.V fluids helps the body to improve electrolyte balance ·       Improved blood circulation ·       No dryness of mouth   ·       No dizziness   Treatment Of COPD Oral Prednisone prescribed to the patient is a type of corticosteroid which helps in reducing the symptoms of COPD by reducing inflammation along the walls of the lung (Kruis et al., 2014). This drug is also prescribed to the patient to prevent acute exacerbation (McCarthy et al., 2015). The use of oral prednisone combined with other therapies is highly beneficial to patients with an acute exacerbation of COPD, there was clinically significant improvement among the hospitalized COPD patient who were treated using oral prednisone combined with other therapies according especially patients with hypercapnia and those without (Keen et al., 2017). However, oral prednisone should be avoided as it is considered to carry risks such as muscles wasting hence should be avoided as part of primary care as recommended by Keen and Medarov (2017). Due to the side effects caused by administering oral prednisone to the COPD patient is the responsibility of the nurse to adequately inform the patient about the potential side effect as well as the benefits the side effects should be monitored and nurse intervention needed where necessary to minimize them (Kruis et al., 2014). An acute respiratory deterioration of among the patients suffering from COPD can be as a result of other conditions such caused by bacterial infections among them pneumonia and venous thromboembolism among others. According to a randomized control study conducted by Janson et al. (2013), the risk of infection from pneumococcal was high among the COPD patients the findings are supported by (Sethi et al., 2016).  Neville the patient is also at elevated risk of contracting pneumonia. Therefore, amoxicillin is recommended as part of the treatment regime (Jaiswal et al., 216). It is the responsibility of the nurse to take note of Mr. Neville history regarding the use of antibiotic. This information will enable the nurse to advise on the use of amoxicillin as prescribed. Ipratropium bromide is a type of anticholinergic that act by blocking muscarinic receptors, as a result it causes bronchodilation (Jarenbäck et al., 2016). The dominant reversible airway obstruction activities have been associated with the parasympathetic cholinergic activity (Keen and Medarov, 2017). The drug protects the airways by preventing bronchospasm and it also prevents the increased production of mucus. According to (Afonso et al., 2011), there was an improved function in peripheral airway through increased airflow, reduced air trapping and reduction in the degree of alveoli hypoventilation after administering an anticholinergic drug such as Ipratropium bromide. Neville expressed symptoms such as shortness of breath on exertion and increased production of purulent sputum. Therefore, the doctors needed to prescribe bronchodilator such as Ipratropium bromide to help the patient have smooth breathing and reduced mucus production. It is the responsibility of the nurse to monitor and intervene whenever any side effect occurs to the patient. Such side effect to be watched by nurse include dry mouth, cough, and urinary retention.   Signs Of Deterioration Of COPD Early identification of indicators suggesting deteriorating patient condition contribute immensely towards reducing mortality, avoidable morbidity, the length of stay and associated healthcare costs to the patient (Ninane et al., 2017). Therefore, there is a need for the nurse to inform the patient about the benefits of reporting such signs immediately after they appear. Psychological changes witnessed in COPD patient should be considered as one of the indicators of worsening of COPD patient. According to (Doyle et al., 2014), deterioration in mood, increase level of fear are some of the indicators that the patient need further review by a doctor. The researcher recommended the use of hospital anxiety and depression scale to be used to assess the patient’s condition.  According to (Bratas et al., 2010), pulmonary rehabilitation has shown to improve the depression among COPD patients. It is therefore, important for the patient to be well informed about such signs so that he will be able to report them immediately to the nurse. Severe pain in the chest of a patient can be another indicator for a deterioration of COPD, this can be attributed to damage done on the lungs caused by the persistent bacterial infection like pneumonia which is nonresponsive to the antibiotics. Identifying this early sign in the case of patient Neville will help the doctor in reviewing the treatment regime to enhance the healing process. Presence of constant wheezing during sleep this is an indicator that there is continues airway obstruction caused by the mucus within the airways. This can cause air trapping and lack of proper breathing. Fatigue can be also related to nutrient imbalance. When such is reported, a dietary regime can then be developed depending on his current situation to help manage nutrient imbalance. He could be suffering from respiratory acidosis. I would perform chest physiotherapy to promote adequate ventilation and maintain an airway to the patient, Suction can be carried out to clear the airway. I would also administer theophylline combined with salbutamol to further maintain and prevent narrowing of the airway, I.V fluids may also be administered to correct patient’s dehydration.   I am Nurse Kimberly Registered Nurse for Mr. Neville. Neville is a 62-year-old man with established chronic obstructive pulmonary disease and has a long history of smoking. He has not completely refrained from smoking but he has reduced to 10 cigarettes per day. He was admitted three days ago with worsening dyspnoea, cough and increased purulent sputum. In the last one day, he has developed further deteriorating signs of COPD including depression, fatigue, tachycardia and slightly elevated blood pressure. He has been treated for nasal prong oxygen @ 2l/min to maintain oxygen saturation 88-92%, he has been on high protein and carbohydrate diet. The patient has been treated with ipratropium bromide and salbutamol nebulizers, oral prednisone, oral amoxicillin, prn paracetamol and coloxyl. In the last one day, he developed more complication after being nebulized with a prn salbutamol, he was restless, anxious, plucking randomly at his bed linen, dyspnoeic, flashed skin and diaphoretic. He further presented with more complication his oxygen saturation was 98%, elevated heart rate of 110 beats /minute, with his respiratory rate dropping to 8-10 breathes/minute. I have suspected respiratory acidosis. Therefore, in response I have put the patient on oxygen controlled concentration using venturi mask, administered oral theophylline at the same time, chest percussion and chest vibration have been performed on the patient. It was also necessary to perform suctioning to the patient to clear the airway. The patient was also put on 2L/day of I.V fluid. The use of amoxicillin was continued. I would recommend the following: Continuously asses his respiratory status; monitor the vital signs frequently; monitor his neurologic status; maintain accurate fluid intake; carry out acid blood gas analysis; request for laboratory analysis of serum electrolytes.   Reference Afonso, A. S., Verhamme, K., Stricker, B. H., Sturkenboom, M. C., & Brusselle, G. G. (2011). Inhaled anticholinergic drugs and risk of acute urinary retention. BJU international, 107(8), 1265-1272. Akner, G., & Larsson, K. (2016). Undernutrition state in patients with chronic obstructive pulmonary disease. A critical appraisal on diagnostics and treatment. Respiratory Medicine, 117, 81-91. Bashir, S., Muzamil, J., Guru, F. R., Mohsin, N., Nabi, F., & Kanwar, M. S. (2016). Patterns of infections in chronic obstructive pulmonary disease exacerbations and its outcome in high dependency area, intensive care setting in a tertiary care hospital. Community Acquired Infection, 3(3), 77. Bhattacharya, A., Bhargava, S., Singh, V., Talwar, D., Whig, J., Rebello, J., … & Gogtay, J. (2016). Efficacy and safety of ipratropium bromide/salbutamol sulphate administered in a hydrofluoroalkane metered-dose inhaler for the treatment of COPD. International Journal of Chronic Obstructive Pulmonary Disease, 11, 1469. Ghosh, A., Boucher, R. C., & Tarran, R. (2015). Airway Hydration and COPD. Cellular and Molecular Life Sciences: CMLS, 72(19), 3637–3652. Jaiswal, A., Chichra, A., Nguyen, V. Q., Gadiraju, T. V., & Le Jemtel, T. H. (2016). Challenges in the Management of Patients with Chronic Obstructive Pulmonary Disease and Heart Failure with Reduced Ejection Fraction. Current heart failure reports, 13(1), 30-36. Jarenbäck, L., Eriksson, G., Peterson, S., Ankerst, J., Bjermer, L., & Tufvesson, E. (2016). Bronchodilator response of advanced lung function parameters depending on COPD severity. International Journal of Chronic Obstructive Pulmonary Disease, 11, 2939. Keen, C., & Medarov, B. I. (2017). Current strategies in chronic obstructive pulmonary disease management. Journal of Public Health and Emergency, 1(2). Kruis, A. L., Boland, M. R., Assendelft, W. J., Gussekloo, J., Tsiachristas, A., Stijnen, T., … & Chavannes, N. H. (2014). Effectiveness of integrated disease management for primary care COPD patients: results of a cluster randomised trial. The Effectiveness of Integrated Disease Management in COPD Patients, 349, 189. McCarthy, B., Casey, D., Devane, D., Murphy, K., Murphy, E., & Lacasse, Y. (2015). Pulmonary rehabilitation for chronic obstructive pulmonary disease. The Cochrane Library. McIlwaine, M., Bradley, J., Elborn, J. S., & Moran, F. (2017). Personalising airway clearance in chronic lung disease. European Respiratory Review, 26(143), 160086. Nicolini, A., Ferrera, L., Santo, M., Ferrari-Bravo, M., Del Forno, M., & Sclifò, F. (2014). Noninvasive ventilation for hypercapnic exacerbation of chronic obstructive pulmonary disease: factors related to noninvasive ventilation failure. Pol Arch Med Wewn, 124(10), 525-31. Ozyilmaz, E., Ugurlu, A. O., & Nava, S. (2014). Timing of noninvasive ventilation failure: causes, risk factors, and potential remedies. BMC pulmonary medicine, 14(1), 19. Reeves, A., Tran, K., & Collins, P. (2016). Nutrition During Noninvasive Ventilation: Clinical Determinants and Key Practical Recommendations. In Noninvasive Mechanical Ventilation (pp. 203-207). Springer International Publishing. Sehgal, I. S., Dhooria, S., & Agarwal, R. (2017). Chronic obstructive pulmonary disease and malnutrition in developing countries. Current opinion in pulmonary medicine, 23(2), 139-148. Sethi, S., Anzueto, A., Miravitlles, M., Arvis, P., Alder, J., Haverstock, D., … & Wilson, R. (2016). Determinants of bacteriological outcomes in exacerbations of chronic obstructive pulmonary disease. Infection, 44(1), 65-76.

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