CNA508: Respiratory Acidosis And Alkalosis - Capillary Blood Gas - Clinical Nursing Assessment Answer

Subject Code: CNA508 Internal Code: 1AHIGA

Clinical Nursing Assessment Answer

TASK: Nurses are responsible for a considerable amount of the findings and decisions made in healthcare and are involved in numerous clinical reasoning events each day (Levett-Jones & Hoffman, 2013). The potential to react to challenging clinical scenarios calls for extensive knowledge, psychomotor skills and complex thinking abilities, with the commitment of these clinical reasoning skills having a beneficial effect on patient outcomes (Levett-Jones & Hoffman, 2013). This essay will follow the case study of Josie and utilise the first five steps in the Clinical Reasoning Cycle developed by Tracy Levett-Jones to discuss Josie’s clinical situation (Levett-Jones & Hoffman, 2013). CNA508 Josie was born at 26 weeks gestation, is currently 49 days old and 33 weeks corrected. Josie was ventilated for the first 5 days of life, is currently on seven litres of high flow nasal cannula in 25 percent oxygen as her current respiratory support and is on full feeds of fortified expressed breast milk. The nurse caring for Josie aspirated her nasogastric tube prior to a feed and obtained an eight millilitre dark bile aspirate. When Josie was moved she also had a fleeting apnoea, bradycardia and desaturation episode with facial grimacing. CNA508 The nurse caring for Josie wishes to get a better picture of her respiratory condition and reviews her last capillary blood gas (CBG). Blood gases are advantageous in establishing the sufficiency of respiratory function including ventilation and oxygenation as well as the acid-base balance (Department of Health & Human Services, 2018a). Elements of blood gases include measured values of PaO2, PaCO2 and pH and calculated values that include oxygen saturation, bicarbonate concentration and base excess (Barry et al, 2016). As nurses have the expertise to interpret blood gas data, the nurse caring for Josie is able to establish that Josie’s CBG shows compensated respiratory acidosis (Soltau & Carlo, 2014). If PaCO2 increases to above normal and the pH falls the patient will suffer from respiratory acidosis (Soltau & Carlo, 2014). However, if the respiratory acidosis is chronic, the body reacts by attempting to expel acid and maintain bicarbonate in the urine, resulting in a compensatory rise in serum bicarbonate and leading to compensated respiratory acidosis with a raised base excess (Department of Health & Human Services, 2018a).  Josie’s ongoing lung damage is contributing to her compensated respiratory acidosis as a result of chronic lung disease characterised by impaired gas exchange and respiratory distress (Gardner, Enzman Hines & Nyp, 2016). CNA508 Respiratory rate, work of breathing and oxygenation are the key parts of a respiratory assessment (Aylott, 2006). A precise measurement of respiratory rate is vital in identifying respiratory distress, this can be done by counting the number of respirations by observing chest and abdominal wall movement, however the most accurate way is to auscultate using a stethoscope to ensure breaths of all volumes are counted (Aylott, 2006). A respiratory rate between 30 and 60 breaths per minute is considered normal in neonates and a decreasing respiratory rate may signify deterioration rather than improvement (Aylott, 2006; Gardner, Enzman Hines & Nyp, 2016). Normal respiration is effortless as it is a passive process that counts on the elastic recoil of the chest wall and lungs, therefore any action that increases airway resistance and stiffens the lungs results in increased work of breathing and recession being seen as intercostal, sterna, suprasternal or surpaclavicular (Aylott, 2006). Assessment of oxygenation is best done using pulse oximetery as it facilitates the early detection of hypoxemia and ensures ample oxygenation (Aylott, 2006). CNA508 From Josie’s respiratory assessment the nurse could expect to find possible mild to moderate work of breathing with intercostal recession. A chest x-ray could be done to further evaluate her respiratory status to exclude a pneumothorax or possible infection such as pneumonia. CNA508 Premature infants have increased and fluctuating fluid needs based on clinical condition, gestation age, weight and the nursing environment, therefore continuous assessment and monitoring are indicated to support normal hydration status (DeMarini & Rath, 2014). The investigations relevant to assessing Josie’s renal function and fluid and electrolyte status includes urine output, urinalysis, capillary refill, abdominal inspection, palpation and auscultation, oedema and fluid balance. Urine output and urinalysis are vital in determining renal perfusion and compromise, while inaccuracies and imbalances in fluid balance can cause severe deterioration or impair the neonate’s recovery (Beresford & Connolly, 2010). Reduced capillary refill time can indicate compromised cardiac output and peripheral vasoconstriction suggesting possible volume depletion, while abdominal inspection, palpation and auscultation are useful for the fact that abnormal kidney sizes are able to be felt (Beresford & Connolly, 2010). To further assess Josie’s cardiac function and output, the nurse should have continuous cardiorespiratory monitoring in place as the electrical activity of her heart can be displayed and recorded through non-invasive chest leads (Bradshaw & Tanaka, 2016). Josie’s radial, brachial and femoral pulses should be examined for intensity and timing (Wright Lott, 2014). While the adequacy of her perfusion can be assessed by checking capillary refill, by depressing the skin on an extremity or over the abdomen until the area blanches and timing the number of seconds it takes for the colour to return, this should be less than three seconds (Wright Lott, 2014). Echocardiography can be used to provide vital information regarding the pulmonary and systemic circulation (eds Sinha, Miall & Jardine, 2012). CNA508 Necrotising enterocolitis (NEC) is defined as an inflammatory condition of the bowel identified by ischaemia, haemorrhage and necrosis of the mucosal and submucosal layers of the intestinal tract (Montrowl, 2014; Bucher et al, 2016). The aetiology of NEC is currently poorly understood but is thought to be due to a mixture of factors including enteral feeding, mucosal injury, invasion of bowel organisms and an associated inflammatory response (Bradshaw, 2015). The early signs of NEC are generally non-specific and can include apnoea, temperature instability, lethargy and bile stained aspirates, with these signs progressing to blood and/or mucous stools, abdominal distension, pitting oedema, respiratory distress and ultimately septic shock (eds Sinha, Miall & Jardine, 2012; Bucher et al, 2016). NEC most commonly effects preterm infants weighing less than 1500 grams, with patent ductus arteriosus, formula feeding and infection also being associated and can occur within the first week of life to several weeks following birth (Bradshaw, 2015; Bucher et al, 2016). Large and bile stained gastric aspirates is indicative of feed intolerance with the presence of these requiring a full assessment and further investigations such as laboratory tests and radiological exams to assess for intestinal obstruction or NEC, with feeds being withheld while these are carried out and the cause determined (Montrowl, 2014; Brown et al, 2016). CNA508 Nutritional management of the sick or preterm infant is crucial for optimal outcome and survival (Spence, 2010a). Nutritional needs differ for each neonate according to their gestation at birth, their current age, degree of growth restriction and any accompanying diseases (Spence, 2010a). Energy requirements are based on measurements of basal metabolic rates and estimation of calories required to achieve physiological functioning, taking into account thermoregulation, cardiac function, respiration, and cellular activity, with these requirements increasing for sepsis, fevers and hypoxia (Spence, 2010a). Preterm neonates require a higher growth and metabolic rate, have an increase in insensible water losses which leads to an increase in nutritional and energy requirements to maintain these rates (Spence, 2010a). The best way of ensuring nutritional goals are being met is through the monitoring of short term growth, measured by weight, length and head circumference, with the pattern of growth influencing the management of the neonate (Spence, 2010a). CNA508 Josie is at risk of developing NEC due to her prematurity and weight being less than 1500 grams, she also has several of the early signs and symptoms, including temperature instability, lethargy and bile stained aspirates. Josie is also at risk of hypoglycemia as a result of her prematurity, low birth weight, current feed intolerance and possible suspected infection (eds Sinha, Miall & Jardine, 2012; Department of Health and Human Services 2018b). CNA508 A neurological examination is beneficial for assessing for the presence of and defining the degree of neurological dysfunction (Ditzenberger & Tucker Blackburn, 2014). Factors examined during a neurological assessment include activity, tone, level of consciousness, posture and reflexes, with influences such as health status, gestational age and medications being considered in the interpretation of any findings (Ditzenberger & Tucker Blackburn, 2014). As Josie is described as lethargic and floppy, it needs to be considered against what her activity level is generally like when she is well and taking into account her full clinical picture at this stage. CNA508 A skin, musculoskeletal and neurovascular assessment is relevant for all neonates and is able to offer numerous insights. Skin colour is used as a possible indicator of haemodynamic changes with pale skin being a significant sign of decreased haematocrit levels (Halbardier, 2015). A skin assessment is significant in preterm neonates as their immature skin has an increased risk for infection, fluid and electrolyte losses, absorption of toxic substances and thermoregulation instability, therefore they are at an increased risk for skin injury from oedema, multiple line and tube placements, numerous monitors and skin probes and limited movement (Lund and Durand, 2016; Ness, Davis & Carey, 2013). Muscle tone is important during this assessment as neonate’s who are floppy and have decreased muscle mass have an increased risk for possible heat loss through their reduced ability to flex their body and conserve heat and the decreased capacity to generate heat (Pappas & Robey, 2015). Neurovascular assessments enable the nurse to assess perfusion by assessing capillary refill, feeling pulses and observing colour (Judge, 2007). CNA508 Pain can be characterised as an unpleasant emotional and sensory experience associated with potential and actual tissue damage (Walden, 2014; Walden, 2015). In neonates, behavioural, physiological and hormonal indicators give quantifiable and objective information regarding the duration, intensity and location of the pain (Walden, 2015). At birth, all the components of the neonate’s nociceptive pathways are present, even though they have an incomplete and developing myelinated nervous system, therefore the neonate’s nervous system is completely capable of transmitting, perceiving and responding to and remembering painful stimulus (Spence 2010b, Gardner, Enzman Hines & Agarwal, 2016). Pain assessment tools are used throughout neonatal nursing as it is challenging to assess neonatal pain due to the fact they are unable to verbalise. These pain assessments should include measurements of both behavioural and physical indicators of pain and should include gestational age and the type of pain experienced such as post operative or procedural (Walden, 2014; Gardner, Enzman Hines & Agarwal, 2016). Behavioural indicators of pain involve localised or widespread motor activity, crying, change in activity, agitation and facial grimacing, with physical indicators showing an increased heart rate, respiratory rate and blood pressure and a decrease in oxygen saturations (Gardner, Enzman Hines & Agarwal, 2016, Walden, 2015). The approach to pain management should be multidisciplinary and involve identifying pain and stress triggers (Spence, 2010b). Pain relief in neonatal intensive care units consists of non-pharmacological interventions such as swaddling, skin-to-skin, sucrose, breastfeeding and containment and pharmacological interventions such as fentanyl or morphine for neonates undergoing invasive procedures or following surgery (Spence, 2010b). If a pain assessment was done on Josie it would show that she is exhibiting some of the physical and behavioural indicators of pain including increased heart rate, facial grimacing and fleeting bradycardia, apnoea and oxygen desaturation with movement. At this stage it would be best to withhold Josie’s feeds until further investigations are done to determine if she has NEC. If feeds were to continue there would be an increased risk for NEC and further gastrointestinal tract trauma such as perforation. While taking into account that feeds would be withheld Josie would need to be supplemented with parental nutrition or intravenous therapy to ensure that she is getting her nutritional requirements and won’t be at greater risk of becoming hypoglycaemic. Overwhelming sepsis results in inadequate oxygenation, perfusion and delivery of nutrients to fulfil tissue requirements and ultimately leads to cellular dysfunction and damage, therefore prompt identification and treatment is vital in preventing imminent death from sepsis (Wilson & Ingals Turner, 2015). The clinical presentation of septic shock include increased work of breath, tachypnoea and or apnoea, progressing to respiratory failure, tachycardia or bradycardia, persistent pulmonary hypertension, hypotension, decreasing oxygenation, poor perfusion with delayed capillary refill, decreased urinary output, electrolyte disorders, oedema, with all leading  to cardiac dysfunction and arrest (Wilson & Ingals Turner, 2015). Josie’s does show some of the clinical signs on septic shock such as tachycardia and bradycardia with apnoea and oxygen desaturation when moved, however further investigation such as a septic workup is needed to further determine Josie’s state of sepsis. CNA508 From the information available throughout this case study Josie’s main problems can be narrowed down to chronic compensated respiratory acidosis due to her chronic lung disease and respiratory distress, possible NEC due to large bile aspirate and feed intolerance and the potential for her to become septic if further investigations are not carried out to determine her current septic level. Josie is also exhibiting sig ns of pain, therefore the important short term goals for Josie would be for her nurse to assess her pain and offer pain relief and have her reviewed by a Doctor as soon as possible with the hopes of having further investigation started to determine the possibility she may have NEC and be in septic shock. Central or peripheral access should be gained and a septic workup done by a Doctor, with Josie being promptly commenced on parenteral nutrition, antibiotics and pharmacological pain relief if needed. CNA508 To conclude, the case study and research conducted has shown that nurses who conduct thorough assessments of their patients are able to put their clinical reasoning skills into practice to gain an improved understanding of their patient’s current clinical status and escalate care, therefore ultimately having beneficial outcomes for their patients. CNA508

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