year-old male -- pt known to me -- recently admitted to the ward with Non-STEMI & LVF.
Discharged five days ago.
Was found collapsed in his house by his niece. Duration not known.
Could not get up from the floor, no chest pain/SOB. No dysuria/constipation -- ? Incontinence
Pt was discharged with a package of care last week.
Detailed history not available as the pt is confused and not answering any questions.
Rationale To Justify Choice Of The Aspect Of Care
Shortness of breath is an almost universal symptom in cor pulmonale. Incidents of leg edema, atypical chest pain, dyspnea on exertion, exercise-produced peripheral cyanosis, prior respiratory failure, and extreme daytime somnolence are all chronological clues suggestive of the presence of cor pulmonale. Chest pain could be connected to right ventricular ischemia. Cough and complaints of uncomplicated fatigability are common (Ghosh, et al. 1998). A number of patients with nocturnal hypoventilation and sleep apnea may present with personality changes, mild systemic hypertension, and headache. Abdominal pain may be present if bowel edema results from venous hypertension (Engleman & Joffe, 1999).
A number of patients will only need oxygen therapy while in their sleep, at the same time as others may require it 24 hours a day. The quantity and duration of oxygen therapy that you use will depend upon the suggestion of your healthcare giver.
What are the Benefits of Oxygen Therapy?
Not counting helping prevent heart failure in people with strict lung diseases, including COPD, supplemental oxygen has a number of benefits. For instance, some studies have discovered an improvement in survival rates in patients who use oxygen more than 15 hours a day. Furthermore, according to the American Lung Association, supplemental oxygen augments sleep, mood, mental attentiveness and stamina and gives individuals to perform normal, day by day functions.
How Do I Use Oxygen Safely?
Even though oxygen is a safe gas and is nonflammable, it makes combustion, meaning materials glow more quickly in its presence. It is very imperative to follow wide-ranging oxygen safety guidelines if you are planning to use, or be around, supplemental oxygen.
II. Explanation of Underlying Pathophysiology
Manual dexterity was found to be impaired in moderate to severe OSAS patients (Brillinger, 1986), but not in mild to moderate patients (Kim et al., 2000). Block et al. (1986) also found lowered psychomotor speed in mildly sleep-disordered breathing. Interestingly, a relationship between hypoxaemia and reduced complex perceptual motor and simple motor performance has been repeatedly demonstrated in chronic obstructive pulmonary disease patients (Jones et al. 1999). Moreover, these lung patients exhibit a lower finger-tapping speed than OSAS patients (Abramson et al. 2002).
Before concluding this overview of neurocognitive function, we now return to the available executive function data. In general, it has been claimed that OSAS patients exhibit executive control deficits (Jones et al. 1999). It should be noted, however, that research on higher attentional (executive) dysfunction should be guided by sound theoretical neuropsychological models of attention. This is especially important in sleep disorders characterized by excessive daytime sleepiness, since it is well-known that sleepiness, as a result of sleep deprivation and/or sleep fragmentation, has significant effects on cognitive function (Besag, et al. 1991), not the least of which is general cognitive slowing. As cognitive slowing underlies the higher executive functions, the effect of this basal slowing in information processing should be controlled for. This can be illustrated using the already mentioned Trail Making Test (Ghosh, et al. 1998). Part A of this test is a measure of visual search, psychomotor speed, and visuomotor tracking. Part B, in addition to the same visuomotor activity and visual search processes as in part A, also requires task switching. Because of this additional demand, part B is considered to be a measure of cognitive flexibility. This test is scored in terms of the time in seconds required for part A and part B, respectively. However, it should be kept in mind that performance on part B can never be evaluated without taking into account the performance on task A. In other words, an underlying impaired basic process, such as in part A, can be responsible for a deficit in part B (MacEachren et al. 2008). Overall, this is true for all complex attention tests. Data from other tasks or other task conditions within the same test should always be considered to interpret neuropsychological data appropriately (Engleman & Joffe, 1999). Other typical examples of such tests are the Digit Span Forwards and Backwards (Lehto, 1996) and the Stroop Color-Word Task (Henik, 1996). As the pervasive effects of sleepiness on cognitive function are not fully taken into account in the sleep apnoea literature, the findings of executive deficits should be regarded as tentative.
III. Evidence Based Analysis Of The Nursing Interventions
Relief of hypoxia is of prime importance in reducing pulmonary hypertension. All hypoxemic patients should be treated with oxygen to restore arterial O2 tension to greater than 60 mmHg.
In COPD, oxygenation may be improved by bronchodilators for bronchospasm and antibiotics for acute exacerbations of bronchitis. Nocturnal aspiration of gastric fluid is now known to be a common cause of exacerbation of chronic lung disease and proton pump inhibitors are useful in patients with nocturnal aspiration.
Tranquilizers, sedatives, and narcotics should be avoided in unstable patients and patients with hypoventilation. Short-term ventilator stimulants may be useful in some cases of decreased ventilator drives, although nasal CPAP has become the first choice in most cases of sleep apnea (Kahn & Raftery, 1996).
Oxygen therapy is usually well tolerated in patients with stable lung disease but not in patients with acute acidosis or respiratory muscle fatigue. When low-flow nasal O2 causes significant increases in PCO2, mechanical ventilation may be required to relieve hypoxia. Studies have shown conclusively that home oxygen therapy, nocturnal or continuous, is effective in treating cor pulmonale or in postponing its onset. Continuous 24-h/day oxygen therapy is the desired goal in most patients, because desaturation occurs during both sleep and physical activity (Bates, 1989).
Treatment of Heart Failure
General principles of management of heart failure apply. Diuretics are the mainstay therapy for treatment of RVF. Pulmonary vasodilators are efficacious in some patients with primary pulmonary hypertension but are of unproven value in cor pulmonale from COPD. Vasodilator use has not become widespread because of small observed reductions in pulmonary hypertension and occasional worsening of gas exchange. Diuretics are effective in the treatment of RVF, and indications for their use are the same as in other forms of heart disease (Besag, et al. 1991). The effects of diuretics should be monitored carefully by measurement of electrolytes as well as arterial PO2, PCO2, and pH, because acid-base abnormalities are often present in cor pulmonale. Contraction alkalosis can be a problem in hypercarbic patients with a large buffer base that has had vigorous diuresis. When the hematocrit is above 55 to 60%, phlebotomy may reduce PAP and PVR and possibly improve right ventricular function. The phlebotomy should be in small volumes (200 to 300 mL) and done cautiously (Jones et al. 1999).
Salvage in the terminal phase of several diseases complicated by cor pulmonale. The diseases most commonly treated by lung transplantation are primary pulmonary hypertension, emphysema, idiopathic pulmonary fibrosis, and cystic fibrosis. Two-year survival for single and double-lung transplant has risen to 66%, still lower than the approximately 80% for heart transplant alone (MacEachren et al. 2008). One interesting finding is that the right ventricle can recover function after lung transplant even after the chronic stress of severe pulmonary hypertension. Volume-reduction surgery for selected patients with emphysema improves ventilatory function and gas exchange, and the long-term benefit of this approach is under study (Ghosh, et al. 1998).
Oxygen Therapy. Oxygen therapy prolongs survival and improves physical and psychologic functioning in hypoxemic patients with COPD. Indications for continuous oxygen therapy include the following:
Pao2 55 mm Hg or O2 saturation 88% while in usual state of health or Pao2 60 mm Hg or O2 saturation 89% with evidence of chronic hypoxemia, such as erythrocytosis, ankle edema, venous engorgement, or psychologic impairment
Oxygen should be prescribed at the lowest level necessary to maintain an arterial oxygen saturation at or above 90%, usually 1 to 4 L/min via nasal cannula for a minimum duration of 18 hr/day. Portable liquid oxygen systems allow mobility out of the home and should be used whenever possible. Stress the danger of smoking in the presence of oxygen (Bates, 1989).
Educate the patient regarding the disease process, prevention of disease progression, treatment of complications, drug treatment to maximize lung function, and rehabilitation to optimize activity levels. The patient should be given realistic expectations about the long-term progressive course of the disease, tempered by the understanding that temporary worsenings are treatable. Achievement of maximum social and physical functioning may be assisted by simple measures such as special parking areas for the disabled, use of wheelchairs and motorized carts in shopping malls, and portable oxygen and oxygen supplementation during air travel. Patients and…