Question

Pre-Simulation Worksheet Simulated patient's Name in EHR: John Oscard Brief History: 65 y.o, male transferred to your unit from respiratory ICU. Admitted two weeks ago with exacerbation of COPD, requiring ventilator support. Tracheostomy performed day 5 of this admission for laryngeal protection. Patient weaned off ventilator 2 days ago. Remains on oxygen therapy 31% humidified via trach collar. Simulation Learning Objectives: Exhibit professional behavior at all times during the interaction with patient and family. Maintain patient and environmental safety at all times. Perform a focused respiratory assessment. Perform appropriate nursing interventions based on assessment findings. Evaluate the effectiveness of your interventions based on re-assessment. Document a nurse's note in the EHR regarding your interaction with this patient.

Answer 1

Question 3: The possible nursing diagnoses for the patient are:

• Ineffective airway clearance related to bronchoconstriction, increased mucus production, and ineffective cough
• Ineffective breathing pattern related to shortness of breath, mucus, and airway irritants
• Activity intolerance and self-care deficits related to hypoxemia, fatigue, and ventilator dependency
• Anxiety related to change in health status and inability to breath adequately without support
• Potential for respiratory infections including pneumonia related to chronic disease process

Question 4: The possible nursing interventions for this patient would be:

• Appropriately administer bronchodilators and corticosteroids to achieve the airway clearance
• Assess and monitor respiration and breath sounds. Assess for abnormal breath sounds including tachypnea, stridor, crackles, and wheezes
• Instruct the patient in direct and uncontrolled coughing, which is more effective and reduce the fatigue associated with undirected forceful coughing
• Provide inspiratory muscle training, diaphragmatic breathing, and pursed lip breathing to help improve the breathing pattern
• Assist the patient to assume a position of comfort - elevate the head end of the bed
• Suction the secretions as needed
• Demonstrate chest physiotherapy such as bronchial tapping when in cough and proper postural drainage
• Manage patient's daily activities. The daily activities must be paced throughout the day and support devices can be used to decrease the energy expenditure
• Assist the patient to turn every 2 hours
• Monitor for cognitive changes such as personality and behavior changes
• Monitor pulse oximetry values and administer supplemental oxygen as prescribed

Question 5: Maintaining the airway patency and facilitating the gas exchange and breathing would be priority while caring for this patient. Airway management is important to avoid potential complication including pneumothorax, airway injury, alveolar damage, ventilator-associated pneumonia and tracheobronchitis. Regular suctioning care should be performed and the frequency should be determined by the patient's needs.  

Question 6: The methods to evaluate the effectiveness of airway management interventions are as follows:

• Confirm the tube placement, tube security, and cuff status. The placement of the tube can be confirmed by auscultation of the breath sounds, end-tidal carbon dioxide monitoring, and CXR. The tube security support the correct placement of the tube and minimize the injury to the airway caused by excessive movement. Cotton tape, specifically designed tube holders, and non-stretch adhesive tapes can be used to support the tubing.    
• Assess the lung secretions and adequacy of humidification. Lung secretions should be assessed for color, consistency, and volume. Endotracheal suctioning provide the oppurtunity to assess the secretion but also support the patient by removing secretions.
• Check the respiratory rate, ABG analysis, pulse oximetry, and capnography