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Introduction
People are often diagnosed with diverse illnesses, and some diseases can cause prompt changes in a persons condition. Healthcare professionals face various challenges in terms of recognising and assisting acutely ill patients in a timely manner (Bliss and Aitken, 2018). Typically, deteriorating patients have modifications in their physiological parameters, which can be indicated by the usage of early warning tools (Bliss and Aitken, 2018). However, providing medical assistance to individuals whose soundness is rapidly declining is demanding due to the involvement of various factors and processes. Care management of an acutely ill patient encompasses assessment, planning, monitoring, and treatment procedures that should be tailored to each specific patient.
Case Study
MA, a 67-year-old male, had been complaining of persistent chest pain and was delivered to the intensive care unit (ICU). Initially, the patient was brought to the hospital due to community-acquired pneumonia, and his condition worsened on the fifth day of the clinic stay. On arrival at the ICU, MA exhibited difficulty breathing, drowsiness, and inability to complete sentences. Some results of the physical exam for MA were as follows:
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Blood pressure: 126/71 mmHg
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Heart rate: 120 beats per minute
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Respiratory rate: 29 breaths per minute
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Oxygen saturation: 76% on room air
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Temperature: 37,7 °C
Furthermore, the patient indicated hypoxia, worsening confusion, and memory loss. MA tested negatively for COVID-19, had no sick contacts, did not travel recently, and was retired. The patient reported smoking cigarettes on a daily basis for the past several years alongside increased alcohol consumption but denied using recreational drugs. MA exhibited signs of acute respiratory failure and was kept in the ICU until full recovery through oxygen therapy.
Acute Respiratory Failure
Prior to discussing the care management of the patient, one must comprehend the nature of acute respiratory failure (ARF) identified in MA. ARF is a life-threatening condition associated with a variety of clinical signs, gas exchange alterations, and radiographic findings (Azoulay et al., 2018; Parcha et al., 2020). Such an illness can be seen in all acute care settings and can be hypoxaemic or hypercapnic (Robinson and Scullion, 2021; Rolfe and Paul, 2018). ARF is often caused by acute respiratory distress syndrome (ARDS), which can be characterised by impairment in gas exchange due to fluids leaking into the alveolar spaces (Parcha et al., 2020; Robinson and Scullion, 2021). Similar to several other respiratory problems, ARDS and ARF can be induced by pneumonia, as the disease leads to breathlessness and can result in rapid deterioration in a short time frame (Peate and Dutton, 2021). Notably, the rates of ARDS and subsequent ARF have raised because of the spread of COVID-19 (Carter, Aedy, and Notter, 2020). Accordingly, the case study suggests that MA experienced ARF due to pneumonia.
Assessment
People admitted to hospitals are at risk of becoming acutely ill, and patients representing the older population require special attention. An acute care setting can be considered an unfamiliar environment for older adults who face considerable challenges as their condition changes (Guidet et al., 2018; Potter et al., 2021). Individuals whose health is deteriorating experience major physiological transformations since the body attempts to maintain homeostasis and activates compensatory mechanisms associated with additional physiological demands on the person (Peate and Dutton, 2021). Therefore, patients who are likely to become critically ill, especially those of older age, like MA, need comprehensive care management, which begins with assessment procedures.
ACVPU
Healthcare professionals can start the examination of patients whose health may be deteriorating by utilising the ACVPU (Alert, Confusion, Voice, Pain, and Unresponsive) scale. The approach is an extension of the previous version that did not consider the Confusion parameter (Grant, 2018). The ACVPU assesses an individuals consciousness level based on how they react to different triggers (Grant, 2018). The Alert indicator determines if the patient is fully awake, whereas Confusion displays any new change to mentation (Grant, 2018). Voice detects a response to a verbal stimulus, and Pain shows whether the person is reactive to a pain impulse (Grant, 2018). Finally, the Unresponsive scale signifies that the individual does not respond to either of the influences (Grant, 2018). Consequently, the ACVPU demonstrates if a patient functions in a normal way or requires medical assistance.
Furthermore, although the case study does not mention if the ACVPU was applied to MA, it appears that he was not completely responsive. In particular, on his arrival at the ICU, MA was drowsy, meaning that he was not quite awake, and could not complete sentences, signifying that he probably could not adequately react to verbal stimuli. In addition, while it is not clear if MA was affected by a pain trigger, his worsening confusion and memory loss can be considered relevant for the Confusion scale (Grant, 2018). Therefore, the ACVPUs parameters suggest that MA was not quite conscious.
ABCDE
Another way to assess an acutely ill patient is by employing the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach. The ABCDE structure is well recognised in rapidly examining patients at risk of deterioration (Peate and Dutton, 2021). The method is meant to identify and stabilise the most life-threatening signs and give healthcare practitioners time to determine a diagnosis and relevant treatment (Peate and Brent, 2021). First, the airway has to be reviewed for any obstruction indicated by abnormal speech, paradoxical breathing, or central cyanosis (Peate and Brent, 2021; Peate and Dutton, 2021). Second, the patients breathing must be examined based on respiratory rate, oxygen saturation, and quality of breathing (Peate and Brent, 2021; Peate and Dutton, 2021). Third, circulation can be assessed by measuring pulse, blood pressure, and urine output (Peate and Dutton, 2021). Fourth, disability is analysed by using the ACVPU scale, as the AVPU method may not be accurate enough (Peate and Brent, 2021). Fifth, exposure should be examined based on body temperature, laboratory investigations, and clinical history (Peate and Brent, 2021). The ABCDE encompasses many parameters, but the listed ones can display the start of deterioration.
Consequently, MAs condition can be investigated by utilising the ABCDE approach. First, the patients airway was impaired due to difficulty breathing and inability to complete sentences. Second, MAs respiratory rate of 29 breaths per minute surpassed the most commonly accepted pace of not exceeding 20 breaths per minute (Grant, 2018; Peate and Brent, 2021; Robinson and Scullion, 2021). Moreover, MAs oxygen saturation of 76% on room air was significantly lower than the normal level of 94% and above (Grant, 2018; Robinson and Scullion, 2021). Third, the patients blood pressure was 126/71 mmHg, and the average parameters should be approximately 100-140 mmHg systolic and around 60-80 mmHg diastolic (Grant, 2018; Peate and Dutton, 2021). Fourth, as discussed earlier, the ACVPU scale suggests that MA was not quite conscious. Fifth, the patients laboratory investigations are unavailable, but his body temperature was 37,7 °C, normally between 35,6-38,7 °C (Grant, 2018; Peate and Dutton, 2021). In addition, MA had a history of smoking and consuming alcohol, which may increase the chance of pneumonia and ARDS, followed by ARF (Peate and Dutton, 2021). The ABCDE approach demonstrates that MAs condition was at considerable risk.
Notably, although the ABCDE method provides a comprehensive assessment, in MAs situation, one specific factor would indicate trouble. In particular, the patients health could be considered endangered even based on his oxygen saturation, as a percentage below 90 exhibits life-threatening hypoxia, which was identified in MA (Robinson and Scullion, 2021). Therefore, upon reviewing MAs oxygen saturation level, the medical team would need to respond immediately.
Planning
Upon examining and responding to a person whose condition is deteriorating, healthcare providers should proceed with planning the care of the patient. A care plan (CP) is formulated based on the information gathered during the assessment and provides goals that direct care (Carter, Aedy, and Notter, 2020). The case study suggests that MA exhibited signs of ARF and, alongside the above appraisal, indicates hypoxia in the patient. Consequently, MAs CP may center around ways to help the older man overcome the symptoms and make his condition stable. As noted earlier, ARF can be hypoxaemic or hypercapnic, and it appears that MA had the former type (Robinson and Scullion, 2021; Rolfe and Paul, 2018). Hypoxaemic ARF represents an insufficient level of oxygen in the blood (hypoxaemia) that can lead to cellular oxygen shortage (hypoxia), with oxygen saturation being below 90% (Robinson and Scullion, 2021; Rolfe and Paul, 2018). Accordingly, to handle ARF in MA, healthcare providers would need to address his hypoxia.
Furthermore, ARF and lack of oxygen in MA are associated with more concerns. For instance, the patients worsening confusion may have developed because of hypoxia (Grant, 2018; Robinson and Scullion, 2021). Consequently, to improve MAs overall condition and relieve the life-threatening situation, hypoxia should be handled first. Therefore, a primary objective of CP for MA would be overcoming hypoxia, which could be done through oxygen therapy (Robinson and Scullion, 2021; Rolfe and Paul, 2018). The care plan for MA would need to focus on ARF with the main goal of managing hypoxia by increasing the patients oxygen saturation to a normal level.
Monitoring
The condition of a person whose health is deteriorating should be monitored throughout their stay under the care of medical professionals. For example, patients can be observed utilising a continuous electrocardiogram (ECG) or based on their blood pressure and central venous pressure (Carter, Aedy, and Notter, 2020). However, individuals having acute respiratory problems, like MA, should be specifically monitored by using a pulse oximeter (PO). The device is a probe that is attached to the finger or ear lobe and employed to survey the haemoglobin percentage saturated with oxygen (Peate and Dutton, 2021). POs are simple but practical instruments that are necessary for those in respiratory distress.
Pulse oximetry can be utilised to monitor MAs condition toward achieving his CPs goal of overcoming hypoxia caused by hypoxaemia and increasing oxygen saturation. While not covering a variety of indicators, PO provides valuable information about oxygen saturation and enables the detection of hypoxaemia (Carter, Aedy, and Notter, 2020; Peate and Dutton, 2021). The average normal oxygen saturation level on a PO is about 94-98% on room air, with an exactness of approximately 3-5% (Peate and Dutton, 2021; Robinson and Scullion, 2021). Nonetheless, modern POs are likely to demonstrate unreliable measurements at saturations below 70% (Robinson and Scullion, 2021). Notably, although the most common method is the finger probe, some researchers argue that ear probes offer greater accuracy at lower saturations (Potter et al., 2021; Robinson and Scullion, 2021). Therefore, considering that MAs oxygen saturation indicated 76% during the assessment, the patients condition can be monitored with a PO on his ear lobe or finger.
Another approach to observing an individuals health parameters is by using the EarlySense system. The technique represents a contactless sensor that is placed under a patients mattress (Breteler et al., 2019). The system measures the persons heart rate and respiratory rate, updating the vital signs every 60 seconds (Breteler et al., 2019). While the case study does not specify MAs heart rate, the ABCDE approach showed that the patients respiratory rate was higher than normal. Consequently, monitoring MAs respiratory rate would be crucial in addressing ARF and stabilising his condition.
Treatment
Care management of an acutely ill patient depends on the treatment, and ARF, hypoxaemia, and hypoxia can be relieved through oxygen therapy (OT). Although the method does not significantly help with breathlessness, OT should be administered without delay to hypoxaemic patients (Peate and Dutton, 2021). OT is based on distributing supplementary oxygen to achieve a higher concentration of oxygen than is received when breathing air (Peate and Dutton, 2021; Rolfe and Paul, 2018). Many patients experiencing acute respiratory deterioration are at risk due to insufficient oxygen (Robinson and Scullion, 2021). However, one must remember that for the older generation, the most appropriate treatment does not necessarily mean maximal (Guidet et al., 2018). Oxygen must always be considered a drug prescribed by a qualified practitioner (Robinson and Scullion, 2021; Rolfe and Paul, 2018). Accordingly, oxygen dosage depends on several factors, and treatment of older patients should be based on shared decision-making (Guidet et al., 2018; Robinson and Scullion, 2021). The case study states that MA was cared for by utilising OT, which appears to be a relevant approach, but it should be done carefully, considering the mans age and condition.
Healthcare providers administering OT should consider some important aspects. In particular, the amount of oxygen received depends on the system used, the persons breathing pattern, and the flow rate (Robinson and Scullion, 2021). For instance, patients experiencing ARF are often prescribed more than 6l/min of standard oxygen (Azoulay et al., 2018). Nonetheless, for those with saturation below 85%, the drug should be at 10-15l/min dispensed via a non-rebreather reservoir mask (Peate and Dutton, 2021). Such an instrument is a low-flow device that can quickly deliver the highest possible oxygen concentration of 60-80% but should be used only for short periods (Azoulay et al., 2018; Robinson and Scullion, 2021). Notably, OT is administered upright to facilitate ventilation, and unless the patient has a specific requirement, such as a spinal trauma, the supine position should be avoided (Peate and Dutton, 2021). Accordingly, to treat ARF with consideration of his low oxygen saturation, MA should receive OT through a non-rebreather mask at 10-15l/min while being seated.
Professional Practice
The professional practice of a nurse plays a crucial role in the management of acutely ill patients. Nurses participate in all processes of providing care for people whose health is deteriorating while connecting patients with other medical specialists (Peate and Dutton, 2021; Robinson and Scullion, 2021). For example, nurses must act as recognisers with assessment skills who can interpret signs of changing conditions (Peate and Dutton, 2021). Moreover, in various settings, nurses are the ones administering treatments that can save a persons life (Peate and Dutton, 2021; Robinson and Scullion, 2021). Therefore, a nurses professional practice can be evaluated as highly important in managing deteriorating patients.
Conclusion
To summarise, the discussion of assessment, planning, monitoring, and treatment procedures and the reflection on MAs case demonstrate that care management of an acutely ill patient must consider various factors specific to each person. For instance, an individual in respiratory distress can be assessed in many ways, yet the one suitable for MA is the ABCDE approach due to providing a comprehensive examination of vital parameters and mental state. Furthermore, while monitoring can be done using multiple instruments, a pulse oximeter is the one relevant to the primary goal of MAs care plan. Oxygen therapy is a treatment that can help MA overcome hypoxaemic ARF and subsequent hypoxia because the method can increase MAs oxygen saturation to a normal level, thus reducing the threat to the patients life. However, OT for MA is likely to differ from other patients in respiratory distress due to MAs distinct characteristics, like his age and low oxygen saturation. Therefore, care management of an acutely ill patient is a complex process that depends on diverse factors, indicating that medical professionals must be knowledgeable and critically approach each situation.
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