Case Study 8 – JSs Online Case Study Nursing Assessment

Case study 8 –JSs

Mr. Smith is a 45-year-old who came to the hospital to perform gastroscopy under general anesthetic. Mr. Smith is a mental delay patient and has a history of hypertension. He tolerated the procedure very well, and his vital signs were stable in theatre. When Mrs. Smith came to recovery, he was not arousable, and his vital signs were within normal range initial. He only received Propofol in theatre and was supplied 6 liters oxygen with Hudson mask in recovery. I conducted airway way and breathing assessment when Mr. Smith arrived in the post-anesthesia care unit (PACU). I observed that Mr. Smith was placed in the recovery position and he was not obesity. No facial, mandible and laryngeal fractures and no respiratory and significant cardiovascular disease.  One of the common side effects of Propofol is to stopping breathing. His airway was patent and no artificial airway. Mr. Smith airway was not obstructive and no foreign bodies, vomit or tongues. He did not use respiratory accessory muscle to breathe in and out. I was not able to observe that his chests up and down and air moving freely in and out of his chest when he breathed. His respiratory rate was 10 initial, and the oxygen saturation was 98% according to a monitor. The Hudson mask was not fogging. Mr. Smiths’ fingertips and lip were in peak, and the capillary refill was under 3 seconds. There was no cyanosis symptom on Mr. Smith. Mr. Smith’ pupil was dilated. His temperature was 36.5 digress, and his pulse rate was regular and remained between 60 and70, and his systolic blood pressure remained between 110 and 120mmHg.          

After the anesthetist left recovery, Mr. Smith started to desaturate gradually from 98% to 85% in 10 seconds. I turned the oxygen up to 10 liters and tried to wake Mr. Smith up with the shaking of the shoulders and to call his name. Mrs. Smith was still not responding to these normal interactions. Mr. Smith’ chest still does not move up and down, and his Hudson mask was still not forging, and his respiratory rate was down to eight. I was quick to insert the Guedel and did jaw thrust to Mr. Smith. After 5 seconds, Mr. Smiths oxygen saturation was up to 90% then continually went up to 95% with 10liter oxygen with Hudson mask. The anesthetist was called in to review the patient immediately, and high flow oxygen with 30 liters oxygen with 100% was applied to Mr. Smith, and his oxygen saturation remained 100%, and respiratory rate was within normal ranges, Mrs. Smith was still not arousable, and Geduel was still institute and jaw support was still performed. I observed Mrs. Smith used his abdominal muscle to breathe in and out slightly and his chest was moving up and down slightly when he breathed. The shape of his chest was normal, and the expansion of chest was observed.  Mr. Smith was doing shallow breathing; I counted his respiratory rate was 8 compared to 18 in the monitor. After 10 minutes, Mr. Smith waked up smoothly. Guedel was removed, and jaw support stopped. He was able to ask my question about his procedure, and his airway was patent. I applied Hudson mask with 6-liter oxygen as per order, and I observed the mask was fogging, and the air moved freely in and out of the chest. His oxygen saturation remained at 100%, and pleth waveform was normal. I used the stereoscope to listen to Mrs. Smith chest, no rattling, wheezes, stridor, crackles, and obstruction was heard. All vital signs were within normal range; Mr. Smith went home at the same day. Mr. Smith experienced airway obstruction and even no noisy airway present in Mr. Smith case

Discussion

Airway obstruction is one of common airway issue in PACU, and it refers to a blockage in any part of the airway. Airway way assessment and management skills are crucial and essential for PACU nurses as the most common serious PACU complication was airway obstruction and airway depression (Higgion& Jones 2009; Brent 2010). When patients come to recovery, PACU nurses must conduct the assessment. The first three assessment components assessment includes airway, breathing, and circulation (ABC). Airway assessment includes patient has a patient airway, air can move freely in and out of the chest, and patients have appropriate oxygen supply form. Breathing assessment includes a look for signs of obstruction, respiration rate and depth, SaO2 level, and breathing pattern. It is important to visually monitor the patient continually, treat the patient rather than the monitor (Higginson & Jones 2009).

Initially, I observed Mr. Smith had no airway obstruction because no noisy airway and vital signs were within the normal range. Although I was aware Mr. Smith was no arousable and no air and out of chest for Mr. Smith, I did not prepare that airway obstruction occurred on him. Brent (2010) commented that patient recovery from anesthetist was not always straightforward and it needed assessment continuously.

Mr. Smith had shallow breathing and used his abdominal muscles to breathe when sleeping. Shallow breathing could be apart of Mr. Smith ageing process (Moore 2007). Use abdominal muscle to could relate to increasing effort to breathe or could be normal for a man when sleeping (Moore 2007)

Mr. Smith may have floppy tongue and relaxed jaw. Jaw supported, and insertion Geduel could open patients’ airway. Mr. Smith was unconscious, and his airway muscle tone could be lost and lead to airway obstruction. Due to the propofol effect, Mr. Smith’ mandibular muscles lose tone, and the tongue falls back to obstruct the pharynx. The epiglottis may obstruct the airway at the pharynx; jaw support could reposition the head and jaw could reinstate the airway.

Airway obstruction could lead to hypoxia. Hypoxia is an immediate lift threaten situation, and 100% oxygen should be supplied. 10-liter oxygen with Hubson mask was not appropriate to form when Mr. Smith was desaturation. The open airway is a fundamental step for administering oxygen for obstructive airway patients. Insertion duel, jaw support and administer 100% oxygen should be a priority rather than try to wake Mr. Smith up. Maintaining the airway and facilitating breathe is the first priority in an emergency situation (Higginson & Jones 2013).

Reflection

Reflection is a part of the nursing professional development, and it refers to looking back and rethinking about clinical episodes (Asselin et al. 2012). Nurses could understand insight and have the intention to change their nursing practice through reflection (Asselin et al. 2012). The clinical reason is another component to ensure nurse to provide safe and effective care (Carvalho et al. 2016). Nurses’ action and decision are associated with nursing experience, skills, and abilities involving in clinical reasoning (Carvalho et al. 2016). After I reflected on Mr. Smith case, I could be realized how important monitor patient closely and regularly in PACU. Patients’ condition could change in a minute. Performing airway and breathing assessment could not only reply on the monitor data rather than the patient. Observing noisy airway could indicate airway obstruction. However, not all obstructed airway breathing is noisy. Although Mr. Smith had no noisy airway, he experienced airway obstruction. Look, feel and listen to breathing should be performed all the time when assessing patient airway. I could set up a high flow nasal cannula device in PACU. Assessed appropriate sizes Guedel and nasopharyngeal for each patient and get the equipment ready in case I need it. I did observe no air moved in and out of Mr. Smith chest initially, plus he was unconscious which could indicate early sign his airway issue. Due to the vital signs were within the normal range, I focused on monitor data and ignored this clue. In the future, I would observe, feel and listen to breathing when performing the respiratory assessment. In addition, I would combine vital signs with respiratory assessment information together to identify patients’ early signs of respiratory deterioration.

 Reference

Asseslin, MR, Schwartz-Barcott, D &Osterman, PA 2012, ‘Exploring reflection as a process embedded inexperienced nurses’ practice: a qualitative study,’ Journal of advanced nursing, vol. 69, no. 4, 905-914.

 Brent, R 2010, ‘Patient assessment in recovery’, Journal of Perioperative Practice, vol. 20, no. 3, 103-107.

Carvalho EC, Oliveira-Kumakura ARS, Morais SCRV, 2017, 'Clinical reasoning in nursing: teaching strategies and assessment tools,' Rev Bras Enferm, 70, 3, 662-668

Higginson, R & Jones, B 2009, ‘Respiratory assessment in critically ill patients: airway and breathing,’ British Journal of Nursing, vol. 18, no.8, 456-461.

 Higginson, R & Jones, B 2013, ‘Assessment and management of airway and breathing,’ nursing and residential care, vol. 15, no. 5, 140-145.

 Moore, T 2007, ‘Respiratory assessment in adults,’ nursing standard, vol. 21, no. 49, 48-56.