Introduction
Septic shock is a life-threatening health condition that occurs in septic patients when they develop metabolic complications and extreme hypotension. Elodie is a 14-year-old septic patient who has been diagnosed with acute lymphoblastic leukemia (ALL) and has undergone chemotherapy sessions and transplantation treatment recently. Her current medical problems include low SpO2 levels (91%) and tachypnea (21 breaths/min). Impaired gas exchange, which is Elodie’s priority health problem, is to be addressed using evidence-based nursing interventions, such as supplemental oxygen and proper positioning. The problem statement is as follows: impaired gas exchange related to sepsis (related factors) as evidenced by hypoxemia and abnormal breathing (defining characteristics). The paper’s objective is to delve into evidence-based care in the management of impaired gas exchange. The ability to do so can significantly increase the chances of success when solving complex cases.
Health Issues
Elodie faces multiple health issues apart from ALL, and her physical condition has deteriorated recently. In the majority of cases, adverse health events occur after a period of abnormal changes in vital signs (Mok, Wang, Cooper, Ang, & Liaw, 2015). Monitoring vital signs is the task of paramount importance when it comes to high-risk patients, but it is sometimes neglected. In Elodie’s medical case, the first symptom of clinical deterioration associated with her current problem (sepsis) is presented by increases in respiratory rate (21 breaths per minute) and the signs of abnormally increased efforts when breathing.
In patients diagnosed with severe sepsis and septic shock, lasting tachypnea or respiratory rate exceeding 20 breaths per minute is a common predictor of mortality rates (Seo et al., 2016). In sepsis, the occurrence of tachypnea is regarded as a compensatory mechanism linked with metabolic acidosis (Seo et al., 2016). Increased work of breathing in the cases of septic shock is often caused by tissue edema leading to impaired oxygenation (Russell, Rush, & Boyd, 2018). Checking the airway for foreign materials and keeping the patient’s airway open is critically important in the case. Since the discussed sign of deterioration is closely associated with mortality in sepsis, it should be closely monitored.
The second symptom of deterioration is the level of oxygen saturation. The human body’s normal functioning is strictly dependent on the balance of oxygen in the blood, and any abnormalities lead to a number of pathological conditions. According to the case details, Elodie’s SpO2 is 91% on 2L via NP. Importantly, normal levels of oxygen saturation vary between 95% and 100% (Ciklacandir, Mulayim, & Sahin, 2017). Elodie’s blood oxygen level is not extremely low to indicate the presence of severe hypoxemia. However, keeping its level within the normal range is a high-priority task for the healthcare team. In patients with sepsis, measures to normalize blood pressure and blood oxygenation levels are hypothesized to reduce the risks of developing multiple organ dysfunction syndromes (Ostergaard et al., 2015). Sepsis is the condition characterized by rapid decreases in blood pressure, causing reductions in tissue perfusion pressure (Perner et al., 2016). In its turn, abnormal tissue perfusion contributes to hypoxia, the condition that is also caused by hypoxemia. The low level of oxygen in the blood is indicative of clinical deterioration and needs to be addressed to prevent its detrimental outcomes.
Impaired Gas Exchange
The priority problem associated with Elodie’s health situation is impaired gas exchange. This dangerous condition is defined as “an excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane” (Pascoal et al., 2015, p. 492). The nursing diagnosis in question belongs to the number of respiratory health problems that affect different age cohorts. Elodie’s symptoms indicative of this problem include general weakness, confusion, diaphoresis or excessive sweating, and difficulty breathing (Pascoal et al., 2015; Pascoal et al., 2018). Other symptoms linked to the patient’s medical details are hypoxemia and breathing abnormalities, such as increased respiratory rates (Pascoal et al., 2015). The priority problem in question occurs in multiple cases, including respiratory infections and pulmonary diseases in extremely obese patients.
Impaired gas exchange can be defined as the clinical priority since this condition causes tissue hypoxia. Based on the case, the patient is extremely close to developing severe hypoxemia – it is diagnosed when SpO2 levels fall below 90% (Ottestad, Kasin, & Hoiseth, 2018). Just like hypoxemia that can become more pronounced in Elodie’s case, impaired gas exchange often results in severe hypoxia (Bar-Or et al., 2015; Ottestad et al., 2018). The latter is the condition in which there is an inadequate oxygen supply at the tissue organizational level. Since it causes tissue hypoxia, impaired gas exchange often contributes to impairments in different systems of organs (Ziesmann & Marshall, 2018). Multiple organ failure that occurs in septic patients due to hypoxia is specifically dangerous when it comes to individuals with cancer such as Elodie.
Continuing on the priority problem, the lack of efforts to address impaired gas exchange in the discussed situation may weaken Elodie’s immune system even more. Due to the risks of total organ failure, hypoxia, as has been shown in a variety of studies, is associated with more frequent fatal outcomes in intensive care units (Kiers et al., 2016). As a consequence of impaired gas exchange and hypoxemia, tissue hypoxia affects the immune system, whereas oxygenation is supposed to have favorable immunologic effects (Kiers et al., 2016). As is clear from the patient’s medical records, she has been diagnosed with ALL and undergone chemotherapy treatment. Apart from cancer-related fatigue, chemotherapy typically provides an immunosuppressive effect (Brandolini, D’Angelo, Antonosante, Allegretti, & Cimini, 2019). Due to Elodie’s cancer and treatment history, her immune system is likely to be stressed. For instance, several studies have found that hypoxia contributes to cancer cells’ capacity for survival and resistance to anti-cancer drugs in ALL (Petit et al., 2016). Thus, failure to prevent the adverse outcomes of impaired gas exchange can become the cause of further immune stress, which is particularly dangerous given the patient’s previous diagnosis.
Role of Nursing
The first nursing intervention that can be implemented into practice is oxygen therapy. Nurses deliver it in collaboration with other members of the healthcare team. In the majority of life-threatening conditions, hyperoxia caused by oxygen therapy tends to worsen damage to tissues and organs, but there are mixed findings showing the intervention’s negative results in sepsis (Vincent, Taccone, & He, 2017). To prevent rapid increases in blood oxygen levels, the team can adhere to a conservative protocol for the use of supplemental oxygen (Girardis et al., 2016). Thus, the target level of oxygen saturation will vary between 94% and 98% (Girardis et al., 2016).
Concerning nurses’ role, these specialists are not supposed to initiate the use of oxygen therapy without doctors’ request when it comes to emergency cases. The team will evaluate Elodie’s ability to breathe without help to choose between simple facial masks, nasal cannulas, and positive pressure devices for oxygen delivery (Rabbat, Blanc, Lefebvre, & Lorut, 2016). If delivered correctly, oxygen therapy allows normalizing blood oxygen saturation and reducing the risks of tissue hypoxia and further complications, which makes it the best option in the case (Tipping & Nicoll, 2018). In general, the intervention’s effectiveness will be measured with the help of regular blood gas tests. However, vital signs monitoring and visual assessment will also provide helpful information concerning the patient’s condition.
The use of therapeutic positions is the second intervention that can be helpful in Elodie’s case. The intervention involves nurse-initiated use of Fowler’s position for different purposes related to patient management. In critically ill patients, low- or semi-Fowler’s position (15-45 degrees) is associated with improvements in oxygen saturation and blood pressure (Anchala, 2016). Such outcomes result from increases in thoracic capacity and diaphragmatic descent (Anchala, 2016). High Fowler’s position (60-90 degrees) is beneficial to patients who receive oxygen treatment or experience breathing difficulties (Dirkes & Kozlowski, 2019). The position in question can also be helpful during feeding. In patients with respiratory issues, Fowler’s position is much more appropriate compared to the supine position (Kubota, Endo, Kubota, Ishizuka, & Furudate, 2015). There is a large body of evidence demonstrating strong associations between Fowler’s position and improvements in the quality of life in patients with serious health issues (Kubota et al., 2015). Judging from modern researchers’ claims, the selected intervention is likely to improve the positive outcomes of oxygen delivery and be helpful during the subsequent health management in Elodie’s situation.
To implement the mentioned intervention, the nurse will select the type of Fowler’s position depending on Elodie’s current needs and treatment methods being utilised. The ways to measure this intervention’s effectiveness are not widely discussed in modern academic literature since it is aimed at achieving a wide range of results. However, the physiological advantages of Fowler’s position discussed in modern studies can be taken into account (Anchala, 2016; Kubota et al., 2015). Thus, when working with Elodie, it will be possible to rely on beneficial changes in SpO2 levels and blood pressure to evaluate the results and take corrective action if needed.
Given Elodie’s current physical condition, the healthcare team is to concentrate on making timely and justified decisions to improve her ability to breathe and other health indicators. However, her and her family’s psychosocial issues should also be considered to implement humanitarian values into practice (Kocher & Ayanian, 2016). In particular, the patient-centred approach has to inform the healthcare team’s ethical decision-making (Kocher & Ayanian, 2016). Judging from the case, one of the main problems is the emotional condition of the patient’s mother. Given her daughter’s present health state and primary diagnosis, the woman’s anxiety is absolutely understandable. However, since Elodie’s physical and mental well-being are the main priorities at the moment, the girl’s emotional suffering is strongly discouraged. With that in mind, it is instrumental to talk to the patient’s mother and explain that everything is being done to improve Elodie’s condition. Her mother is also to be encouraged to conceal her negative feelings and stay as calm as possible when visiting Elodie. Therefore, the patient will be protected from stress and negative emotions impacting her mental well-being.
Conclusion
Finally, having analysed the signs of clinical deterioration, such as tachypnea and SpO2 levels indicating hypoxia, the healthcare team is to implement measures helping to address impaired gas exchange. The recommended interventions, including oxygen therapy and proper patient positioning, are expected to reduce the risks of tissue hypoxia and improve the girl’s general well-being. The use of the patient-centred approach to care provision should also involve educating Elodie’s relatives on how to protect her from anxiety.
References
Anchala, A. (2016). A study to assess the effect of therapeutic positions on hemodynamic parameters among critically ill patients in the intensive care unit at Sri Ramachandra Medical Centre. Journal of Nursing Care, 5(348), 2167-1168.
Bar-Or, D., Carrick, M. M., Mains, C. W., Rael, L. T., Slone, D., & Brody, E. N. (2015). Sepsis, oxidative stress, and hypoxia: Are there clues to better treatment? Redox Report, 20(5), 193-197.
Brandolini, L., D’Angelo, M., Antonosante, A., Allegretti, M., & Cimini, A. (2019). Chemokine signaling in chemotherapy-induced neuropathic pain. International Journal of Molecular Sciences, 20(12), 1-13.
Ciklacandir, S., Mulayim, N., & Sahin, S. (2017). Low cost real-time measurement of the ecg, spo2 and temperature signals in the Labview environment for biomedical technologies education. The Eurasia Proceedings of Educational & Social Sciences, 7, 162-168.
Dirkes, S. M., & Kozlowski, C. (2019). Early mobility in the intensive care unit: Evidence, barriers, and future directions. Critical Care Nurse, 39(3), 33-42.
**Girardis, M., Busani, S., Damiani, E., Donati, A., Rinaldi, L., Marudi, A.,… Singer, M. (2016). Effect of conservative vs conventional oxygen therapy on mortality among patients in an intensive care unit: The oxygen-ICU randomized clinical trial. JAMA, 316(15), 1583-1589.
The study compares the outcomes of two approaches to oxygen treatment. It proves that conservative therapy is associated with decreased mortality rates in ICU. Conservative therapy involves the SpO2 target levels of 94-98%.
Kiers, H. D., Scheffer, G. J., van der Hoeven, J. G., Eltzschig, H. K., Pickkers, P., & Kox, M. (2016). Immunologic consequences of hypoxia during critical illness. Anesthesiology: The Journal of the American Society of Anesthesiologists, 125(1), 237-249.
Kocher, K. E., & Ayanian, J. Z. (2016). Flipping the script – A patient-centered approach to fixing acute care. New England Journal of Medicine, 375(10), 915-917.
**Kubota, S., Endo, Y., Kubota, M., Ishizuka, Y., & Furudate, T. (2015). Effects of trunk posture in Fowler’s position on hemodynamics. Autonomic Neuroscience, 189, 56-59.
The article is significant since it contributes to knowledge on the benefits of Fowler’s position. The study proves the quality-of-life improvements resulting from the method. Its use is associated with differences in blood pressure and heart rate.
Mok, W., Wang, W., Cooper, S., Ang, E. N. K., & Liaw, S. Y. (2015). Attitudes towards vital signs monitoring in the detection of clinical deterioration: Scale development and survey of ward nurses. International Journal for Quality in Health Care, 27(3), 207-213.
Ostergaard, L., Granfeldt, A., Secher, N., Tietze, A., Iversen, N. K., Jensen, M. S.,… Jespersen, S. N. (2015). Microcirculatory dysfunction and tissue oxygenation in critical illness. Acta Anaesthesiologica Scandinavica, 59(10), 1246-1259.
Ottestad, W., Kasin, J. I., & Hoiseth, L. O. (2018). Arterial oxygen saturation, pulse oximetry, and cerebral and tissue oximetry in hypobaric hypoxia. Aerospace Medicine and Human Performance, 89(12), 1045-1049.
**Pascoal, L. M., de Oliveira Lopes, M. V., Chaves, D. B. R., BeltrĂŁo, B. A., Nunes, M. M., da Silva, V. M., & de Sousa Freire, V. E. C. (2018). Impaired gas exchange: prognostic clinical indicators of short-term survival in children with acute respiratory infection. International Journal of Nursing Knowledge, 30(2), 87-92.
The source establishes clear links between hypoxemia and impaired gas exchange (IGE). The consequences of hypoxemia are discussed in a detailed manner. IGE’s significant impact on mortality rates is thoroughly discussed.
**Pascoal, L. M., Lopes, M. V. D. O., Chaves, D. B. R., BeltrĂŁo, B. A., Silva, V. M. D., & Monteiro, F. P. M. (2015). Impaired gas exchange: Accuracy of defining characteristics in children with acute respiratory infection. Revista Latino-Americana de Enfermagem, 23(3), 491-499.
The study delves into the manifestations of impaired gas exchange in children. Hypoxemia’s critical role in making the diagnosis is established. In addition, diagnostic criteria are discussed in a detailed manner.
Perner, A., Gordon, A. C., De Backer, D., Dimopoulos, G., Russell, J. A., Lipman, J.,… Walsh, T. (2016). Sepsis: Frontiers in diagnosis, resuscitation and antibiotic therapy. Intensive Care Medicine, 42(12), 1958-1969.
**Petit, C., Gouel, F., Dubus, I., Heuclin, C., Roget, K., & Vannier, J. P. (2016). Hypoxia promotes chemoresistance in acute lymphoblastic leukemia cell lines by modulating death signaling pathways. BMC Cancer, 16(1), 1-17.
The study explains the links between hypoxia and cancer cells’ resistance to anti-leukaemia drugs. Hypoxia is demonstrated to contribute to such cells’ ability to survive. The findings have implications to measures to improve cancer treatment.
Rabbat, A., Blanc, K., Lefebvre, A., & Lorut, C. (2016). Nasal high flow oxygen therapy after extubation: The road is open but don’t drive too fast! Journal of Thoracic Disease, 8(12), e1620.
**Russell, J. A., Rush, B., & Boyd, J. (2018). Pathophysiology of septic shock. Critical Care Clinics, 34(1), 43-61.
The study explains the features of septic shock, including hypotension and heart issues. The condition’s pathophysiology and appropriate management options (heart rate normalisation) are discussed. Pathophysiologicial considerations are used to conceptualise new treatment goals and approaches.
**Seo, M. H., Choa, M., You, J. S., Lee, H. S., Hong, J. H., Park, Y. S.,… Park, I. (2016). Hypoalbuminemia, low base excess values, and tachypnea predict 28-day mortality in severe sepsis and septic shock patients in the emergency department. Yonsei Medical Journal, 57(6), 1361-1369.
The source sheds light on the health outcomes of sepsis. In particular, it proves tachypnea to be among the basic predictors of mortality in severe sepsis. The results indicate the need for urgent measures in septic patients with abnormal breathing.
Tipping, R., & Nicoll, A. (2018). Mechanisms of hypoxaemia and the interpretation of arterial blood gases. Surgery, 36(12), 675-681.
**Vincent, J. L., Taccone, F. S., & He, X. (2017). Harmful effects of hyperoxia in postcardiac arrest, sepsis, traumatic brain injury, or stroke: The importance of individualized oxygen therapy in critically ill patients. Canadian Respiratory Journal, 2017, 1-7.
The study is devoted to the unwanted effects of oxygen therapy. In patients with severe conditions, hyperoxia can lead to further complications. To avoid them, target blood oxygen levels are to be selected after complex case evaluations.
Ziesmann, M. T., & Marshall, J. C. (2018). Multiple organ dysfunction: The defining syndrome of sepsis. Surgical Infections, 19(2), 184-190.