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Part B: Scholarly Paper

Ariel-Dominique Owootoah


March 14, 2016

NURS 252 - Complex Issues and Patient Safety

Vasanthy Harnanan

Humber College


The wonders of the human body are endless. The mechanics that sustain the human body
are the physiological processes such as breathing and the circulation of blood and oxygen to
maintain optimum health and body functions. Identifying the changes in the body, with the help
of the feedback from the patient, allows health care providers to further investigate problems and
assist the patient in achieving universal wellness.
The clinical scenario I received described a 51-year-old male with type one diabetes
mellitus. He had been admitted to a surgical spine unit 24 hours prior, following a laminectomy.
He presented as being pale, with a dusky grey face, and anxious, while using his accessory
muscles to breathe. Although he denied radiation of pain, he complained of chest pain on
inspiration and was unable to rate his pain. His temperature was 36.8 degrees Celsius and his
respirations were 28 breaths per minute. He maintained an oxygen saturation of 86% on room
air. His heart rate was 128 beats per minute and his blood pressure was 140/80. An intravenous
line was instituted with normal saline with 20 mEq of potassium chloride infusing at 25
milliliters per hour and he also had a Foley catheter in place with a urinary output of 250
milliliters over the last three hours.
Upon reading this scenario, the first thing that alarmed me was how the patient presented
post operatively. All information regarding the patients status presented in the scenario were
concerning excluding the temperature of 36.8 degrees Celsius. After surgery, the primary focus
is on protecting the patient, who has been put in physiological risk during surgery, and
preventing complications while the body heals. (Lewis, 2014, p457) Protecting the patient
requires constant monitoring of the airway, the patients breathing and circulation, as well as vital
signs and full assessment of the patients body and personal feelings. Hypoxemia is an
abnormal deficiency in the concentration of oxygen in arterial blood.(Mosby, 2013, p888) It is


significant such that insufficient levels of oxygen in the blood can result in inadequate amounts
of oxygen available to the tissues. Should this condition persist, cellular hypoxia may ensue
resulting in grave neurological or cardiac repercussions, or even death. (Marley, 2006) Based on
this scenario and evidence provided, the breathing and oxygenation of the patient required the
most immediate attention.
The patient presented with ineffective breathing patterns which is evident by him
appearing pale, with a dusky grey face and by him using his accessory muscles to breathe. His
28 breaths per minute only caused an oxygen saturation of 86% on room air while he complained
of chest pain on inspiration. With that observation, I would immediately raise the head of the bed
and initiate oxygen therapy if an order was present. Because of the nature of the surgery, raising
the head of the bed may not be conducive to the patients healing, therefore initiating oxygen
therapy would be my priority to increase the oxygen saturation level to a standing 95% if
possible. This would be followed by vital signs and a focused respiratory assessment to
determine effectiveness and cause.
Patient education is another intervention in stabilizing the breathing patterns of the
patient. Educating the patient on how the incentive spirometer device relies on sustained
maximal breathing and is thought to prevent the development of atelectasis (Hassanzadeh, et al.,
2012) will encourage the patients cooperation. That, along with pursed lip breathing, deep
breathing, and coughing exercises assists in encouraging the patient to breathe to their normal
inspiratory capacities (Potter, 2014, p920) and mobilizes alveolar secretions while promoting
lung expansion after surgery. The removal of alveolar secretions and the increase of lung
expansion allows a greater amount of air to be inhaled, which results in a higher oxygen
saturation and a decrease in respirations and effort.


The intervention of including the patient in their care regime is an important aspect of the
therapeutic nurse client relationship. Negotiating with the client in achieving goals identified in
the care plan is a part of the CNO 2006 Practice Standard for the Therapeutic Nurse-Client
Relationship. (CNO, 2006) If the patient is in a position that they are not comfortable in,
collaborating with them to determine what position of comfort is suitable will ensure compliance
and relaxation. Knowing that relaxation decreases anxiety, respirations should decrease causing
less workload on the accessory muscles and may also decrease the chest pain. By reducing the
work of the accessory muscles and possibly decreasing the chest pain, the oxygen saturation has
a chance to increase while the patient is relaxed and less anxious.
Another intervention in controlling the breathing patterns of the patient is to obtain an
order for blood work to rule out any overcompensating factors related to the patients diabetes
and blood sugar levels. The bodys response to surgery is understood as compensating from a
major trauma that triggers a stress-induced metabolic response. This response is a safety
mechanism that provides the person with metabolic energy, which helps the body to overcome
the effects of anaesthesia and manage pain.(Holt, 2012) Because of the metabolic deficiencies
with those with diabetes, the body reacts differently to the trauma of surgery. People with
diabetes are unable to respond effectively to high blood glucose levels and as a result
hyperglycemia occurs.(Holt, 2012) A symptom of hyperglycemia is shortness of breath and
restlessness. By collaborating with the physician and dietician, a strict diet and medication
administration schedule can be incorporated into the patients recovery care plan to control the
blood sugars and reduce the stress on the respiratory system. This may start off with a liquid diet
and slowly progress as tolerated by the patient.


With the clinical manifestations concerning the ineffective breathing patterns of the
patient in the identified scenario, a focused respiratory assessment should be done regularly to
identify any changes in the patients breathing. Assessing the patients skin colour and ensuring
there is no cyanosis present is necessary to notice if there is any respiratory distress. The patients
chest shape and configuration should be observed as well as well as the position the patient takes
to breathe. The chest should also be palpated to determine equal and full lung expansion.
Percussing the lung fields and mindfully listening to the lung sounds will assist in determining
the abnormalities, if any are present. Lastly, auscultation of the lung fields allows evaluation of
the quality of breaths and the status of the airway. By focusing on the ineffective breathing
patterns as a post-operative complication, the basic principles of life take priority and facilitate to
support the other systems that may also be compromised by the lack of oxygen.


CNO. (2006). Therapeutic Nurse-Client Relationship. Retrieved from College of Nurses:
Hassanzadeh, H., Jain, A., Tan, E. W., Stein, B. E., Van Hoy, M. L., Stewart, N. N., & Lemma,
M. A. (2012, June). Postoperative Incentive Spirometry Use. Retrieved from ProQuest:
Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M. (2014). Medicalsurgical nursing in Canada: Assessment and management of clinical problems (3rd. ed.).
Toronto: Mosby Elsevier Canada.
Holt, P. (2012, August). Pre and post-operative needs of patients with diabetes. Retrieved from
Marley, R. A. (1998, December). Postoperative oxygen therapy. In Journal of PeriAnesthia
Nursing (6 ed., Vol. 13, pp. 394-412). Retrieved from ScienceDirect: ,
Marley, R. A. (2006, January 25). Postoperative Oxygen Therapy. Retrieved March 1, 2016,
from ScienceDirect:
Mosby. Mosby's Dictionary of Medicine, Nursing & Health Professions, 9th Edition.
Mosby, 2013. VitalBook file.
Potter, Patricia, Anne Perry, Jannet Ross-Kerr, Marilynn Wood, Barbara Astle, Wendy Duggleby,


Canadian Fundamentals of Nursing, 5th Edition, Mosby Canada, (2014). VitalBook file.