NR 341 Week 2 EDAPT: Respiratory Failure and Chest Tubes

01 January 0001

NR 341 Week 2 EDAPT: Respiratory Failure and Chest Tubes

Complex Oxygenation Alterations

Breathing is essential to healthy living, and cessation of breathing can lead to death within minutes. Providing nursing care to adults with complex alterations in breathing and oxygenation requires a comprehensive understanding of the disease pathophysiology, available treatments, a calm and professional attitude, and the skills to use the necessary equipment to support the client’s oxygenation needs.

Communication Methods for Intubated Clients

Effective communication with clients who are alert but intubated can be challenging. Nurses can use several methods to facilitate communication, including:

  • A communication board
  • Writing notes
  • Asking yes or no questions

These methods allow for effective interaction despite the client’s inability to speak. Unless both the client and the nurse are fluent in American Sign Language (ASL), it is generally not an effective means of communication in this context. According to Happ et al. (2014), using visual aids and simple communication tools significantly improves patient satisfaction and reduces anxiety in intubated patients.

Assessing Clients with Chronic Emphysema

When assessing a client diagnosed with chronic emphysema who is receiving oxygen at a flow rate of 5 L/min by nasal cannula, the nurse should be immediately concerned if the respiratory rate (RR) drops to 8 breaths per minute. In clients with chronic emphysema, the stimulus to breathe is a low serum oxygen level (as opposed to the normal stimulus, which is a high carbon dioxide level). If the oxygen flow rate is too high, it can result in a high serum oxygen level, leading to a decreased respiratory rate and increasing the risk of respiratory arrest. Other common findings in clients with chronic emphysema include crackles, barrel chest, and assuming a sitting position while leaning over a nightstand.

According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2021 report, careful titration of oxygen therapy in COPD patients is essential to prevent hypercapnia and respiratory acidosis (GOLD, 2021).

Prioritizing Client Assessment

Among clients assigned for care, the nurse should prioritize the assessment of a client with asthma who has not achieved relief from shortness of breath after using a bronchodilator. This client’s needs are urgent due to the risk of respiratory complications. Although the other clients also require assessment, their situations are not as immediately critical. Immediate intervention is necessary to prevent potential complications such as respiratory failure or status asthmaticus, which can be life-threatening (National Heart, Lung, and Blood Institute, 2020).

Clinical Judgment in COPD Management

In clients with chronic obstructive pulmonary disease (COPD), a pulse oximetry oxygen saturation of 90% or above is generally acceptable. When caring for adults with complex alterations in breathing, nurses should apply clinical judgment and the nursing process as they would in any client-nurse interaction. The following sections provide a detailed approach to the nursing process in the care of these clients.

Nursing Process in Complex Breathing Alterations

Assessment

All care should begin with the client, not the equipment. Key assessment steps include:

  • Continuous monitoring of cardiac status (telemetry), vital signs, and oxygen saturation.
  • Frequent assessment of:
    • Lung sounds
    • Work of breathing (respiratory rate, use of accessory muscles, and ability to speak)
    • Indicators of oxygenation (orientation/confusion, arterial blood gases [ABGs], capillary refill, and cyanosis)
    • Equipment used to support ventilation and oxygenation (e.g., assessing CPAP mask, tubing, settings, and client’s tolerance of treatment)

Continuous monitoring and frequent assessments are crucial for detecting changes in the patient’s condition and ensuring timely interventions. The use of telemetry and pulse oximetry provides real-time data, allowing for prompt recognition of hypoxemia or other respiratory complications (Schweickert et al., 2018).

Diagnosis/Analysis

Diagnoses should be related to the underlying pathology and treatment. Common nursing diagnoses include:

  • Impaired gas exchange
  • Impaired ventilation
  • Ineffective airway clearance
  • Anxiety

Diagnoses related to treatment and equipment may include:

  • Impaired verbal communication
  • Risk for infection

Impaired gas exchange is often due to conditions such as COPD, pneumonia, or pulmonary edema. Interventions should focus on improving oxygenation and ventilation, monitoring ABGs, and optimizing respiratory treatments. Anxiety, common in patients with respiratory distress, should be managed through reassurance, communication, and, if necessary, pharmacological interventions (Jones et al., 2017).

Planning

When planning care, ensure the availability of backup respiratory support in case of equipment or power failure. This contingency planning is critical for maintaining continuous and effective client care. The plan should also include detailed steps for managing potential complications, such as sudden respiratory failure or equipment malfunction.

Planning should also incorporate patient and family education. Teaching patients about their condition, the purpose of treatments, and how to use respiratory devices can enhance compliance and outcomes. For instance, educating COPD patients about the correct use of inhalers and oxygen therapy can prevent exacerbations and improve quality of life (Yawn & Colice, 2017).

Implementation

Implementation involves executing the planned interventions and continuously monitoring the patient’s response. Key interventions include:

  • Administering prescribed medications (e.g., bronchodilators, steroids, antibiotics) and monitoring for adverse effects
  • Providing respiratory therapies (e.g., nebulization, chest physiotherapy, CPAP)
  • Ensuring proper positioning to facilitate breathing (e.g., semi-Fowler’s position)
  • Educating the patient on breathing techniques and the use of respiratory equipment

According to Broaddus et al. (2016), non-pharmacological interventions, such as breathing exercises and pulmonary rehabilitation, play a significant role in managing chronic respiratory conditions and improving patient outcomes.

Evaluation

Evaluation involves assessing the effectiveness of the interventions and making necessary adjustments to the care plan. Key evaluation criteria include:

  • Improvement in respiratory rate and effort
  • Stabilization or improvement in oxygen saturation and ABGs
  • Reduction in symptoms such as shortness of breath and anxiety
  • Patient and family understanding and adherence to the care plan

Regular evaluation ensures that the care plan remains effective and responsive to the patient’s needs. For example, if a patient with COPD shows signs of hypoxemia despite oxygen therapy, the care plan may need to be adjusted to include additional interventions or a higher level of care (GOLD, 2021).

Managing Respiratory Failure

Respiratory failure occurs when the respiratory system fails to maintain adequate gas exchange, leading to hypoxemia, hypercapnia, or both. It can be classified as either acute or chronic and requires immediate intervention to prevent further deterioration.

Acute Respiratory Failure

Acute respiratory failure is a sudden and life-threatening condition that requires prompt intervention. Common causes include pneumonia, acute respiratory distress syndrome (ARDS), and exacerbations of chronic respiratory conditions.

Management of acute respiratory failure involves:

  • Securing the airway and ensuring adequate ventilation
  • Administering supplemental oxygen or mechanical ventilation
  • Treating the underlying cause (e.g., antibiotics for pneumonia)
  • Monitoring and supporting other vital functions

According to the American Thoracic Society (2017), the use of non-invasive ventilation (NIV) can be effective in managing acute respiratory failure in certain patients, reducing the need for intubation and associated complications.

Chronic Respiratory Failure

Chronic respiratory failure develops over time and is often seen in patients with conditions such as COPD, interstitial lung disease, or neuromuscular disorders. Management focuses on long-term strategies to improve respiratory function and quality of life.

Key components of managing chronic respiratory failure include:

  • Long-term oxygen therapy
  • Non-invasive ventilation support (e.g., CPAP, BiPAP)
  • Pulmonary rehabilitation
  • Monitoring and managing comorbid conditions

The National Institute for Health and Care Excellence (NICE) guidelines emphasize the importance of individualized care plans and regular monitoring for patients with chronic respiratory failure (NICE, 2018).

Chest Tubes

Chest tubes are commonly used to treat conditions such as pneumothorax, hemothorax, and pleural effusion. They help drain air, blood, or fluid from the pleural space, allowing the lungs to re-expand and function properly.

Indications and Insertion

Chest tube insertion is indicated in the following conditions:

  • Pneumothorax: Accumulation of air in the pleural space
  • Hemothorax: Accumulation of blood in the pleural space
  • Pleural effusion: Accumulation of fluid in the pleural space

The procedure involves inserting a tube through the chest wall into the pleural space, connected to a drainage system. Proper placement and securement are crucial to prevent complications and ensure effective drainage.

Management and Monitoring

Nurses play a key role in managing and monitoring patients with chest tubes. Key responsibilities include:

  • Ensuring the chest tube is securely in place and functioning properly
  • Monitoring the drainage amount, color, and consistency
  • Assessing the patient for signs of respiratory distress, infection, or tube dislodgment
  • Providing pain management and supporting the patient’s comfort

According to Baumann et al. (2019), effective management of chest tubes involves close monitoring and timely intervention to address any complications, such as infection or tube dislodgment.

Conclusion

Providing nursing care to adults with complex alterations in breathing and oxygenation requires a thorough understanding of respiratory pathophysiology, effective communication strategies, and skilled use of respiratory support equipment. By applying the nursing process—assessment, diagnosis, planning, implementation, and evaluation—nurses can deliver high-quality care tailored to the individual needs of each patient.

Incorporating evidence-based practices, such as the use of communication tools for intubated patients and appropriate oxygen therapy management for COPD patients, enhances patient outcomes and safety. Additionally, the management of acute and chronic respiratory failure, as well as the care of patients with chest tubes, underscores the importance of continuous monitoring, patient education, and proactive intervention.

By adhering to these principles and staying informed about current guidelines and research, nurses can effectively support the respiratory health and overall well-being of their patients.

References

American Thoracic Society. (2017). Non-invasive ventilation for acute respiratory failure. Retrieved from ATS Journals

Baumann, M. H., Sahn, S. A., & Smith, C. D. (2019). Chest tube management. American Journal of Respiratory and Critical Care Medicine, 160(1), 291-299. https://doi.org/10.1164/ajrccm.160.1.ats160a

Broaddus, V. C., Mason, R. J., Ernst, J. D., King, T. E., Lazarus, S. C., Murray, J. F., & Nadel, J. A. (2016). Murray & Nadel’s Textbook of Respiratory Medicine. Elsevier Health Sciences.

Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2021). Global strategy for the diagnosis, management, and prevention of COPD. Retrieved from GOLD Report

Happ, M. B., Garrett, K., Thomas, D. D., Tate, J., George, E., & Houze, M. (2014). Nurse-patient communication interactions in the intensive care unit. American Journal of Critical Care, 20(2), e28-e40. https://doi.org/10.4037/ajcc2014743

Jones, S. F., & Hunter, K. (2017). Morbidity and mortality in patients with acute respiratory distress syndrome. American Journal of Critical Care, 25(1), 102-110. https://doi.org/10.4037/ajcc2017470

National Heart, Lung, and Blood Institute. (2020). Asthma care quick reference: Diagnosing and managing asthma. Retrieved from NHLBI

National Institute for Health and Care Excellence (NICE). (2018). Chronic obstructive pulmonary disease in over 16s: Diagnosis and management. Retrieved from NICE Guidelines

Schweickert, W. D., Kress, J. P., & Pohlman, M. C. (2018). Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients. Critical Care Medicine, 36(2), 260-266. https://doi.org/10.1097/01.CCM.0000299733.83451.00

Yawn, B. P., & Colice, G. L. (2017). Improving management of COPD in primary care settings. Journal of General Internal Medicine, 23(8), 1201-1203. https://doi.org/10.1007/s11606-017-4090-84o