The purpose of this essay will be to analyse and evaluate the nursing care given to an individual during their stay at a respiratory ward whilst using the nursing process as its foundation (Kozier at al., 2008).
Permission was sought from the individual in question to have access to their medical and nursing notes with the intent of writing this essay. In accordance with the Data Protection Act (1998) and the NMC’s Code (2008), sensitive personal data has been anonymised and the individual gave full valid consent.
The name Cecil has been given in order to not continually refer to the subject of this essay as ‘the individual’.
At the time of writing, Cecil was 76 years old. He lived on his own in a council bungalow with no help from relatives. He had a sister, however they fell out many years previously and she lived in Chester 150 miles away. He never had children, even though he confided that he had wanted them but an unfortunate accident caused by playing football with his brother as a child made it out of the question. He had been married but had been widowed two years previously. He sincerely loved his wife and he would always talk about her, (they were both sergeants in the British Army) she was 12 years older than he and he would tell anyone that would listen how much he missed her. It was after his wife passed away that he began to suffer frequent panic attacks.
At home Cecil had carers visit twice a day to assist with cooking meals and dressing if his shortness of breath was too great. It was just before his admission to hospital that he had fallen.
Primarily Cecil was admitted to the accident and emergency department presenting shortness of breath and low oxygen saturations in his blood. His immediate concern was the panic he felt over the shortness of breath and the effort it took to breathe. His longer-term concern was how long he would be admitted for.
His physiological measurements on admission were:
1. Temperature 36.6 degrees Celsius
2. Heart rate 106bpm
3. BP 145/68mmHg
4. Respirations 24 per minute
5. O2 saturations 75% on 28% oxygen.
Cecil’s O2 saturations increased to 92% once 40% oxygen was administered, once stable Cecil was admitted to the respiratory ward. The overall assessment of his immediate actual needs by paramedics and staff at the A&E department was his shortness of breath and low O2 saturations. This was obtained from Cecil’s notes. His long-term needs included chronic obstructive pulmonary disease (COPD), type II respiratory failure, hypotension, sleep apnoea and a recent fall at home. His potential needs could have been that he would fall again, anxieties related to his fall, depression due to lack of independence, fatigue from the sleep apnoea and related social issues and mobility issues as his COPD became more severe.
When admitted to the respiratory ward assessments were made by use of the universal NHS Waterlow Risk Assessment (pressure ulcer prevention) and MUST (Malnutrition Universal Screening Tool) put him in high-risk categories for each. Cecil had an air mattress for his bed and the MUST was repeated and documented weekly.
This essay will focus on two key areas; they are Cecil’s sleep apnoea and his increasing intolerance to mobility because of worsening COPD. These areas have been chosen because Cecil believed that they had the highest impact in his daily routine. They also prevent him from carrying out most of the twelve activities of the Roper-Tierney-Logan Activities of Daily Living Model (ADLs) (Roper et al., 1983, cited in Kozier et al., 2008). Of the twelve ADLs Cecil has difficulties communicating due to shortness of breath. Evidently he has problems breathing which relates to finding it difficult to wash and dress which also leads on to problems with mobilising. Cecil does not do much in the way of working and playing, he is retired and his COPD prevents him from doing most activities outside of his home such as visiting shops. Finally he has problems with sleeping due to sleep apnoea which has been artificially corrected with treatment.
Firstly, focus will begin with sleep apnoea and its assessment. Sleep apnoea literally means not breathing whilst sleeping (McFerran et al., 2008). In this case, Cecil suffers from obstructive sleep apnoea, which is the blocking of the upper airway. This is caused by the muscles supporting the airway and tongue being too ‘slack’, these can then totally occlude the airway causing total lack of breathing and lead to a drop in oxygen saturations (Vara, 2007).
In order to assess whether Cecil had sleep apnoea, he underwent a test called partial polysomnography. The test measures heart rate, oxygen saturations, chest wall movement, airflow and body positions. These parameters are measured by a monitor and electrodes placed on the body and head (Vara, 2007). Another assessment used was the Apnoea-Hypopnoea Index which is a simple equation. It is the number of episodes of apnoea and hypopnoea divided by the hours of sleep (Phillips & Naughton, 2004).
Once established that Cecil suffered from sleep apnoea (SA) it was planned for him to have non-invasive positive pressure ventilation (NIPPV or nippy for short) overnight. NIPPV involved Cecil wearing a mask that covered his nose and mouth. The machine was calibrated to deliver a set pressure as Cecil inhaled to help inflate his lungs. The pressure then dropped off so he could exhale. If the machine monitored that he had not taken a breath in a set period, the machine could initiate a breath for him, thus overcoming the sleep apnoea (Vara, 2007). NIPPV was planned over other more invasive measurements because it would have the least impact on Cecil and his ADLs. The goal of this treatment was to increase his quality of life by ensuring better sleep. NIPPV was implemented nightly as planned during his stay at the respiratory ward.
While Cecil was in hospital, it was also planned for him to have his pulse oximetry measured overnight. This measure ensured that his sleep apnoea was being treated effectively and to make sure there was no deterioration in oxygen saturations (Dougherty & Lister, 2011). At first it was in the nursing care plan to have the oximetry probe on all night, however Cecil complained of the noise the machine made and of being woken to gain consent. It was discussed and agreed with Cecil that his pulse oximetry could be measured at intervals by the night staff without waking him. This discussion with Cecil meant that he was actively involved in his own care and that his wishes were respected (Matthews, 2010).
This now leads us to Cecil’s intolerance to mobility, which is determined by his COPD. COPD is essentially damaged airways, which affects the efficiency of oxygen being circulated throughout the body (British Lung Foundation, 2007). Usually COPD is combination of chronic bronchitis and emphysema. In chronic bronchitis the inflamed airways swell, narrowing the airway. The airways also produce excess mucus narrowing the airways further. In emphysema the alveoli lose their elasticity, which affects the transfer of oxygen and carbon dioxide (Midgley, 2008).
On admission it was assessed that Cecil had a high risk of falling by using the universal NHS patient falls risk assessment tool (FRAT) in place at the hospital. This was assessed by his unstable gait, needing assistance with toileting and his history of a previous fall at home.
He also suffered with hypotension and postural hypotension (also known as orthostatic hypotension). Hypotension is defined as a systolic pressure of below 100mmHg and postural hypotension is a sudden drop in blood pressure of 20mmHg systolic or 10mmHg diastolic within three minutes of rising from a lying or sitting position (Winkler & Bosman, 2003 and Marieb & Hoehn 2010, cited in Dougherty & Lister 2011). The main cause of Cecil’s hypotension was his inability to urinate using a bottle while sitting (most men find this uncomfortable) and so he would stand. Another complicating factor for risk of falls and postural hypotension was that Cecil was taking the drug furosemide intra-venously to relieve breathlessness caused by COPD. One side effect of furosemide is postural hypotension (BNF, 2011) and for that reason it was not administered to him if his systolic blood pressure was below 100 mmHg.
Due to Cecil’s high falls risk, it was planned and implemented that in order to avoid future falls and to help his unstable gait, nurses encouraged Cecil to use his call bell to make them aware of his needs. It was ensured that all personal items were within reach and he was also referred to the physiotherapist linked to ward, whom he jokingly referred to as ‘physio-terrorists’ because of memories of physiotherapists in his Army days. The physiotherapists assessed Cecil using the Elderly Mobility Scale (EMS) which gauges how well he could mobilise in different scenarios such as sitting to standing and timed walks. It is scored out of a maximum of twenty and Cecil scored eighteen. The tool’s interpretation of this score was that Cecil was able to manoeuvre safely and was independent. However it is easily argued that due to Cecil’s postural hypotension he would still need assistance and observation.
When it came to assisting him with his toileting needs, the level of assistance was determined by asking him how breathless he felt and by either helping him to stand with verbal encouragement and guidance so he could urinate or by delivering a commode to him.
As previously mentioned, Cecil had already experienced a fall at home. It was ensured that Cecil was placed in the bay closest to the corridor which ran down the ward so he could be seen at all times. Again, he was told to use the call bell, his personal items were within reach and he was referred to the physiotherapists to help gain independence with his mobility once more. The physiotherapists’ plan was that Cecil would be able to take short walks over to the bathroom while accompanied and that someone should wait outside in case he needed assistance.
On one occasion, after the physiotherapists’ assessment, Cecil was having assistance to urinate using a bottle because he did not have the time to walk over to the bathroom. As was his custom he was urinating whilst standing but he began to feel dizzy caused by postural hypotension (Marieb & Hoehn, 2010 cited in Dougherty & Lister, 2011). This made him panic because of the fall he had at home, he fainted and fell to the ground because the action of standing had caused cerebral hypoperfusion (Winkler & Bosman, 2003). Put simply, the act of standing had put additional strain on his heart, which had a harder job to pump blood and therefore oxygen to his brain. The lack of oxygen then caused his brain to cease functioning momentarily and he fainted. He would often remove his venturi mask with a 28% concentrator for his oxygen when he urinated which sometimes resulted in hypoxia or a lack of oxygen in his tissues and he complained of feeling ‘light-headed’ before his fainting spell (Foxall, 2009 cited in Dougherty & Lister 2011). Luckily he was not seriously hurt and bruised only the side of his left hand, which he hit against the bed as he fell.
Cecil was helped back into a sitting position once he regained consciousness and his oxygen was re-administered at four litres. His oxygen saturations at this time measured 80% and he was observed until his saturations reached 88-92% which The British Thoracic Society recommends (O’Driscoll et al., 2008 cited in Dougherty and Lister, 2011) and the incident was documented in his nursing notes.
It was because of this incident that Cecil’s care plan and treatment was re-evaluated in regards to his mobility. The FRAT was used again which indicated a higher risk of falling than before. It was discussed with Cecil that he tried to urinate sitting down but he explained that he simply could not to all options offered. In line with the NMC standards of conduct (2008) his right to decline this option was respected. It was then agreed with Cecil that a urinary catheter be fitted to help keep his independence with mobility. At first he was reluctant but he was more reluctant to have another fall and so the catheter was fitted. Physiotherapists used the Elderly Mobility Scale tool again to assess him and on this occasion Cecil scored fourteen, worse than before. The main areas of concern were that he now needed support on standing because he lost confidence in mobilising and so he was shown how to mobilise with a frame to give him support physically and psychologically.
To evaluate the care given starting with his SA, Cecil did report better moods during the day. Mood disturbances are characteristic in people with SA but a definite causal link has yet to be found (Phillips & Naughton, 2004). He also reported feeling less lethargic during the day which in turn improves quality of life. An Epworth Sleepiness Scale was filled out whilst he was on the ward which confirmed he had a low-risk score of sleeping during daily activities.
Complications of NIPPV can include conjunctivitis if air leaks through the mask around the bridge of the nose and pressure sores if the mask is ill fitting (Phillips & Naughton, 2004).
Cecil was also able to make suggestions for his care and become involved in it by suggesting that he not have the pulse oximeter on all night. When patients can have input in their care it is beneficial because it can motivate and give a much-needed sense of control, it also promotes patient concordance with their care plan (Matthews, 2010).
In hindsight it was not obvious if anyone spoke to Cecil about how his sleep apnoea affected him psychologically or socially. He mentioned a couple of times that he would like to ‘pull the plug and end it all’. An Italian study with a sample of 157 people who suffered with sleep apnoea reported that 33% of the sample were prone to light to severe depression and 9.1% suffered with suicidal thoughts (Pierobon et al., 2008), presumably this is due to the incurability of the disease. Socially he would not have had much interaction at home because he had no family and when asked he mentioned that no neighbours helped him.
In regard to Cecil’s increasing intolerance to mobility the care plan failed. The main aim as noted in the initial FRAT and EMS tool was to prevent falls because Cecil was in the high-risk category. Without question the fall was not prevented even though all procedures were followed as outlined in the care plan. So, the question does have to be asked, what else could have been done? On reflection it seems that one reason why Cecil had problems with postural hypotension was that he would constantly take off his oxygen mask and his lungs and heart could not cope with the extra effort of standing and supplying oxygen to his brain.
The COPD made his lungs lose their elasticity so to overcome the drop in oxygen he could inflate them more than normal but the COPD also meant that when Cecil expired they did not recoil back to their normal position and left stale air in his lungs. The mucus production and narrowing of the airways made it harder for the stale air to escape and so Cecil would be forced to breathe in harder which caused hyperventilation (Midgley, 2008).
The brain requires 20% of the blood supply in the body, if it cannot get this it can be damaged within minutes (Midgley & Smart, 2008). Cecil’s oxygen levels were decreasing and his carbon dioxide levels increasing every time he exerted himself, including standing to urinate, and so he would become confused because of the lack of blood and oxygen reaching his brain culminating in his fainting (Midgley & Smart, 2008).
It should have been made absolutely clear to Cecil the importance and benefits of wearing his oxygen mask. Unfortunately, due to Cecil’s family situation (there was no family), nurses and other professionals were not able to explain to relatives or carers of Cecil who may possibly have put it terms that Cecil could better understand. On the other hand the MDT should have taken note of this and made communication with Cecil as understandable as possible.
Cecil’s care was chosen to be the basis of this nursing care study because it is the writer’s personal view that it very much demonstrates 21st century care. Maslow (1954) devised a pyramid of needs. A person would need to fulfil each level of the pyramid before they could move to the next with the most basic needs coming first. If Cecil’s care is placed in juxtaposition with Maslow’s hierarchy of needs (1954) does he reach the pinnacle of self-actualisation? No, but that is what healthcare today wants. In fact Cecil’s care fell short at the second stage, safety and security after his fall. Care today is supposed to be holistic and person centred, taking in all of Cecil’s needs. There are instances were this does happen but it falls short in other areas. For example, treatment for his SA symptoms could be deemed successful, which had knock on effects on improving his mood. However no one seemed to take real interest in his suicidal statements, they were dismissed most likely because staff felt there was only time to concentrate on the physical symptoms. This is a real shame because whether the lack of time was real or perceived the nursing model still stipulates caring for the whole person which, in Cecil’s case did not happen.
Hence the writer feels this is a good example of the kind of care that was observed. If it were possible to help Cecil all over again, emphasis would wholly have been put on caring for Cecil not just Cecil’s SA or COPD or hypotension which were treated as inanimate extensions of him.