a medical diagnosis of bronchits

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Task 1
Ms Laura Purple, a 59-year-old female from Darwin has been admited to CDU’s medical ward
with a one-day history of dyspnoea related to a medical diagnosis of bronchits. Bronchits is a
disorder and/or disease of the lower respiratory system, classed as either acute or chronic,
characterised by inflammaton of lung bronchioles, frequently associated with excessive
mucus producton (LeMone et al., 2017). Acute bronchits is fairly prevalent within general
populatons, however, is generally self-limitng, resolving within a few days to weeks (Hart,
2014). Individuals who suffer repeated and prolonged episodes, may be diagnosed with
chronic bronchits, a serious conditon leading to progressive destructon of lung parenchyma
(LeMone et al., 2017).
Laura’s episode of acute bronchits would likely be secondary to a viral or opportunistc
bacterial infecton of her upper airway, proceeding down to her lower respiratory system
(LeMone et al., 2017). Other triggers include irritants and allergens; however, these are less
common (LeMone et al., 2017). Substances inhaled would initate an inflammatory response
and Laura’s bronchial epithelium, infltrated by inflammatory cells and mediators would suffer
vasodilaton and oedema within her mucosa (LeMone et al., 2017), proceeded then by
desquamaton of epithelial cells and basement membrane injury (Hart, 2014). Excessive
exudate/mucus formaton would cause congeston, initatng a cough reflex when combined
with mucosal irritaton (LeMone et al., 2017). Hypersensitsaton within Laura’s bronchioles
would cause bronchospasm and development of paroxysmal coughing, while sloughing of
inflammatory cells and epithelium may cause purulent sputum expectoraton (Hart, 2014;
LeMone et al., 2017). Inflammaton within Laura’s bronchioles would damage her cilia,
impairing their ability to clear secretons or work as defence mechanisms against inhaled
pathogens (LeMone et al., 2017). Laura may have initally presented with symptoms such as
fever, malaise, dyspnoea, sore throat, and/or runny nose (Hart, 2014; Kinkade & Long, 2016).
Wheeze and/or rhonchi may be noted on auscultaton of Laura’s chest, furthermore, she
might complain of pleuritc chest pain (Hart, 2014; Kinkade & Long, 2016).
Many risk factors towards the development of acute bronchits can be identfed in Laura’s
past medical history including asthma and diabetes, while modifable risk factors include
weight, smoking status and alcohol consumpton. Characteristcs of asthma, such as narrowed
airways, inflammaton and bronchospasm would impair Laura’s ability to clear secretons,
increasing likelihood of trapped pathogens, damaging epithelium, subsequently elevatng risk
of acquiring infecton (LeMone et al., 2017). Diabetes impairs defence mechanisms as
antbody’s ability to protect against certain protein antgens are weakened, increasing
susceptbility to respiratory infecton and therefore bronchits (Klekotka, 2015). Furthermore,
smoking is a signifcant causaton due to persistent irritaton and damage of bronchial
epithelium (LeMone et al., 2017). Additonally, respiratory muscle strength, resistance,
functonal residual capacity and expiratory reserve volume are reduced within obesity;
requiring more respiratory effort and increased oxygen/energy demand, causing impairment
of Laura’s total lung functon (Mafort et al., 2016). Lastly, excessive alcohol consumpton has
been identfed as a trigger in airway disease exacerbatons; mucociliary clearance is damaged
by alcohol metabolites, there is interference with macrophage actvity and oesophageal tone
may decline causing aspiraton, increasing risk of respiratory infecton (Bailey et al., 2011;
Simou et al., 2018) and subsequently bronchits (LeMone et al., 2017).
Task 2
Nursing Care Plan:
Nursing problem: Risk of infecton
Related to: Inadequate defence mechanisms associated with ineffectve airway clearance of secretons/pathogens as evidenced by low Sp02%, tachypnoea,
tachycardiac and fever
Goal of care
Nursing interventons
Ratonale
Evaluaton
Laura demonstrates
effectve sputum
expectoraton/improved
airway patency/free of
signs of infecton by end
of shif
Administer antbiotcs as prescribed
Encourage fluid intake
Place in high flowers positon/encourage
frequent ambulaton and/or movement in
bed
If gram-negatve bacteria were
cultured, azithromycin combats
proliferaton/destroys these
organisms/Has lower incidence of
adverse effects/treatment failure than
other antbiotcs (Laopaiboon et al.,
2015).
Increasing fluid consumpton (2Lites-
3Litres/day) liquifes viscous secretons
leading to easier expectoraton
(LeMone et al., 2017).
Prolonged immobility increases
respiratory infecton risk/High flowers
positon expands lung volume,
encourages postural drainage/Frequent
movement facilitates secreton
dislodgement/clearance (LeMone et al.,
2017).
Aids secreton clearance facilitatng
Temperature reduces between 36-
37.5degress
Observe enhanced expectoraton/Laura
verbalizes same
Laura verbalizes deceased
dyspnoea/decreased WOB/Sp02 95%-
100%RA/RR12-20/wheeze dissipates/HR60-
100BPM
Refer to physiotherapist for chest
percussion/vibraton
Teach focused coughing
techniques/diaphragmatc
breathing/incentve spirometry use
beter ventlaton/respiraton (Andrews
et al., 2013).
Promotes clearance of respiratory
secretons, improving pulmonary
functon (LeMone et al., 2017).
Observe enhanced expectoraton, Laura
verbalizes same/deceased WOB/decreased
dyspnoea/improved vital signs
Observe correct technique utlizaton/Laura
verbalizes increased expectoraton/deceased
WOB/decreased dyspnoea/improved vital
signs
Nursing problem: Impaired tssue perfusion
Related to: Reduced gas exchange associated with ineffectve breathing patens due to inflammaton/oedema/mucus obstructon, as evidenced by low Sp02%,
tachypnoea, tachycardiac and expiratory wheeze
Goal of care
Nursing interventons
Ratonale
Evaluaton
Reduced subjectve
dyspnoea/objectve
WOB/achieve
normotensive vital signs
by end of shif
Perform respiratory assessment/regularly
atend vital signs/auscultate chest
Administered
salbutamol/ipratropium/prednisolone as
prescribed/asses response
Administered oxygen as prescribed
Frequent observaton leads to early
detecton of deterioraton/appropriate
interventon implementaton (LeMone
et al., 2017).
Individuals suffering acute bronchits
with asthmatc history beneft from
inhaled beta-2 agonists/acetylcholine
antagonists/cortcosteroids, aiding in
smooth muscle
relaxaton/bronchodilaton/ease of
wheeze/reduced inflammaton
(Billington et al., 2017; Hart, 2014;
Kirkland et al., 2017).
Actvity tolerance (facilitatng secreton
dislodgment) is enhanced through
Improved vital signs
Sp02 rises 95%-100%RA, RR12-20, wheeze
dissipates, HR60-100BPM
Verbalises deceased dyspnoea/appropriately
actvity engagement/improved vital signs
Plan/provide periods of rest between
scheduled actvites/treatments
Encourage nutritonal intake
Actvely listen to concerns/provide regular
emotonal support, especially during
periods of distress
supplemental oxygen/simultaneously
improving gas exchange (LeMone et al.,
2017).
Conserves metabolic
expenditure/minimises fatgue/reduces
WOB/Supportng improved breathing
paterns/improving actvity
tolerance/Minimises splintng
promotng enhanced ventlaton
(LeMone et al., 2017).
Eatng is challenging with dyspnoea,
providing small/frequent meals
maintains nutritonal status/energy
requirements for healing/immune
functon (LeMone et al., 2017).
Aids expression of worries/fears;
Promotes trust/reassurance/comfort;
Hypoxia induced anxiety exacerbates
symptoms of
tachypnoea/tachycardia/poor
ventlaton/dyspnoea (LeMone et al.,
2017).
Laura verbalizes decreased
dyspnoea/fatgue/observe reduced
WOB/appropriate actvity engagement
Observe adequate intake/Laura verbalises
increased energy
Laura remains calm/content throughout shif
Nursing problem: Knowledge defcit
Related to: Absence/defciency of cognitve informaton, as evidenced by ineffectve self-care/contnuaton of smoking
Goal of care
Nursing interventons
Ratonale
Evaluaton
Laura verbalizes
Asses Laura’s understanding of
Aids identfcaton of potental
Laura’s able to correctly teach back
increased knowledge
about smoking/able to
identfy appropriate
community cessaton
resources by end of shif
asthma/acute bronchits. Provide
additonally required teaching/informaton
Asses understanding of smoking
risks/provide informaton as
required/reinforce learning
Discuss percepton of illness/smoking’s
impact on lifestyle. Atempt to understand
why she smokes/address those reasons.
Then address why Laura would choose
to/how she would quit
Actvely listen to
concerns/values/beliefs/be respectul of
choices
Supply with cessaton support
packages/pamphlets, refer to
quitlines/websites/support
groups/counsellors
difcultes/misconceptons about
management. Good understanding of
disease/disorder assists in
autonomy/self-care regarding
preventon/treatment/maintenance
(LeMone et al., 2017).
Needs full comprehension regarding
consequences of smoking
contnuaton/benefts of quitng
(LeMone et al., 2017).
Identfes conflicts between lifestyle
and smoking. Open discussion offers
safe/meaningful interventon optons
which consider her preferences
(Roberts et al., 2013; Sweeney, 2019).
Promotes patent-centred
care/trust/partnership/self-worth and
autonomy in care planning (Halladay et
al., 2015).
Supports individuals wantng to quiet to
formulate plan/set a date/improves
emotonal wellbeing/abstnence
(Langley et al., 2014)
pathophysiology of disease/disorder
including exacerbatng
factors/preventon/treatment/maintenance
of same
Engages in discussion/able to teach back
consequences of smoking/benefts of
quitng
Engages in discussion/contemplates effects
of smoking on health/lifestyle/provides own
suggestons on appropriate
interventons/therapies/support systems to
quit
Openly engages in discussion without
distress
Laura discusses which optons would best
support/meet her needs
Task 3
Laura’s multple comorbidites increase her risk of adverse events post discharge and
likelihood of readmission (Donzé et al., 2013). Therefore, effectvely transitoning Laura from
hospital to home is essental, requiring holistc educaton, discharge instructon and follow
up/community care (Horwitz et al., 2013). Two crucial healthcare requirements identfed for
Laura include need for medicaton adherence and important lifestyle modifcatons.
Medicaton adherence is a signifcant determinant of health outcomes (Oliveira-Filho et al.,
2014), reducing future illness, disease exacerbaton and/or progression, improving functonal
capacity and quality of life (Jimmy & Jose, 2011). An essental requirement is to educate Laura
on her new antbiotc regime, stressing the need for course completon to cure current
infecton and prevent development of microbial resistance (LeMone et al., 2017).
Furthermore, an asthma acton plan should be designed in collaboraton with her treatng
physician, assistng Laura to use her asthmatc medicatons appropriately, preventng future
exacerbatons, reducing likelihood of reinfecton and acute health service utlizaton (LeMone
et al., 2017). Furthermore, Laura must be provided with important informaton regarding her
medicaton regime during admission, including name, relaton to disease/ratonal, importance
of taking them, administraton frequency, technique, how long they will be prescribed for and
any adverse effects, identfying symptoms to report (Brown, & Bussell, 2011). Using the teach
back method will confrm understanding, allowing for reiteraton of vital informaton (Marcus,
2014). In additon to appropriate educaton, Laura should be supplied with visual aids and
writen instructons to allow for future reference and reinforcement of teachings (Marcus,
2014).
Harmful alcohol consumpton, tobacco use, and obesity increase the burden of disease
(Palmer et al., 2018), therefore lifestyle modifcatons are the foundaton of preventve
management (LeMone et al., 2017). However, smoking cessaton itself will surpass any other
interventon towards reducing Laura’s risk of both respiratory and cardiac conditons
(Godtredsen & Prescot, 2011).
The persistent stmulus of smoking creates an overall chronic inflammatory response within
Laura’s lung parenchyma, dysregulating normal healing processes (Balbi et al., 2010).
This
causes excessive mucus secreton, cilia injury, endothelial cell loss via apoptosis, muscle
hypertrophy, luminal occlusion, cell metaplasia, inflammatory cell/mediator infltraton and
fbrosis of airway walls, which overtme will reduce Laura’s overall lung functon (Balbi et al.,
2010; Baraldo et al., 2012). Additonally, smoking increases risk of respiratory infecton and
asthmatcs such as Laura become prone to exacerbatons (Godtredsen & Prescot, 2011).
These factors may lead Laura towards the potental development of disorders such as chronic
bronchits, emphysema and chronic obstructve pulmonary disease (Balbi et al., 2010).
Furthermore, smoking more than doubles Laura’s risk of atherothrombotc/cardiovascular
complicatons, this is of concern when considering her diabetes, dyslipidaemia and obesity
(Bermudez et al., 2019; Godtredsen & Prescot). Chemicals within tobacco smoke cause
endothelial dysfuncton, atherosclerotc changes to vessel walls, narrowing of vascular lumens,
tssue remodelling and hypercoagulable/prothrombotc states (Messner & Bernhard, 2014).
This may cause Laura to develop hypertension, coronary heart disease (CHD) and peripheral
vascular disease (LeMone et al., 2017).
Pharmacotherapy such as nicotne replacement therapy and psychosocial counselling are
proven to be effectve smoking cessaton initatves, especially when combined (Lancaster &
Stead, 2017). Individual counselling and group therapies are available for Laura in the
community, while quitlines are a convenient route of access for home support (Lancaster &
Stead, 2017). Smoking interventon should be part of routne nursing practce, beginning
during Laura’s hospital admission and contnuing for at least one-month post discharge for
maximum success, promotng patent-centred care (Lancaster & Stead, 2017).
Respiratory system improvement post smoking cessaton will be noted in areas of
inflammaton, functonal capacity parameters, reduced rescue medicaton requirements and
acute exacerbaton decline, enhancing quality of life (Godtredsen & Prescot, 2011).
Cardiovascular status improves within just months of quitng, reducing overall risk of CHD,
lowering dyslipidaemia and viscosity of blood (LeMone et al., 2017).
Task 4
Prednisolone a cortcosteroid, is a synthetc variant of adrenal cortex steroid hormones (Liu et
al., 2013). It has mainly glucocortcoid effects with low mineralocortcoid actvity (Liu et al.,
2013). Glucocortcoids have immunosuppressive, antproliferatve, ant-inflammatory and
vasoconstrictve propertes (Liu et al., 2013). They act on cytosolic glucocortcoid’s receptors,
altering gene transcripton (Liu et al., 2013). Specifcally, upregulatng ant-inflammatory
transcripton and downregulatng inflammatory transcripton which represses a number of
proinflammatory mediators required for initaton and maintenance of an inflammatory
response (Liu et al., 2013). Because of efcacy at multple levels of the inflammatory cascade,
cortcosteroids are used routnely in the treatment of asthma (Ramsahai & Wark, 2018).
Inflammatory cells undergo apoptosis, mucus secreton declines due its effects on submucosal
glands and over tme hypersensitzaton of airways improves, while thickening of basement
membranes reduces (Ramsahai & Wark, 2018). However, long-term administraton of these
analogues may be associated with signifcant adverse effects (Liu et al., 2013). Of specifc
concern to Laura, would be increased risk of hyperglycaemia, proliferatng the effects of her
diabetes leading to possible ketoacidosis (Cazzalo et al., 2013; Liu et al., 2013). Additonally,
there is an increased susceptbility towards development of cardiovascular disease and
worsening of dyslipidaemia, this would be compounded by Laura’s current risk factors possibly
leading to atherothrombotc/cardiovascular complicatons including stroke or myocardial
infarcton (Kaur, 2014; Liu et al., 2013). Additonally, there may be potental
immunosuppression related to cortcosteroid use, worsening Laura’s health outcome if she
were to suffer respiratory reinfecton due to her asthma, bronchits and/or smoking history
(LeMone et al., 2017; Liu et al., 2013).
Salbutamol is a short-actng selectve beta2-adrenergic receptor agonist, developed through
epinephrine molecule alteratons, giving it more specifcity for pulmonary receptors (Bryant et
al., 2019). The beta-2 receptor actvates the enzyme adenylyl cyclase which produces cyclic
adenosine monophosphate (cAMP). cAMP then causes smooth muscle relaxaton due to
phosphorylaton of regulatory proteins within muscle and alteratons within cellular calcium
concentratons (Barisione et al., 2010). Short-actng beta2 agonists are used as frst-line
treatment for acute asthmatc exacerbatons or as preventatves against known stmulus such
as exercise (Ullmann et al, 2015). The relaxing effect on smooth muscle promotes
bronchodilaton, increasing ventlaton, providing rapid relief of symptoms such as dyspnoea,
chest tghtness, wheeze and cough (Ullmann et al, 2015). Associated adverse effects include
palpitatons and tachycardia because despite salbutamol’s selectvity, some beta-2 receptors
are located within cardiac ventricles and atria; furthermore, potental hypokalaemia
associated with salbutamol use may precipitate arrhythmias (Cazzalo et al., 2013), this is
concerning when considering Laura’s cardiovascular risk factors. Stmulaton of beta-2
receptors within Laura’s liver will promote glycogenolysis, raising blood sugar levels risking
potental ketoacidosis due to her diabetes (Cazzalo et al., 2013). Lastly, prolonged/repeated
administraton may cause desensitzaton to treatment, leading to decreased asthma control
(Cazzalo et al., 2013); subsequently, if Laura required increasing salbutamol administraton, it
would indicate need for controller/preventatve implementaton (Ullmann et al, 2015).
Word Count: 2300 including headings, in text references and template
KEY
– RR, respiratory rate
– RA, room air
– WOB, work of breathing (accessory muscle use)
– HR, heart rate
– BPM, breaths per a minute (respiratory) or beats per a minute (cardiovascular)
– Sp02%, saturated oxygen percentage of haemoglobin using pulse oximeter
Cook_309948_NUR250_S1_2020_Assesment_One

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