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Introduction

The main aim of this assignment is to identify the problems that are associated with tracheostomy weaning in patients. The assignment deal with the understanding of the importance and usage of evidence in the High Dependency Unit and how the research and evidence can be incorporated into the nursing practice has been taken up. The case study deals with the problems that are faced by the patient with tracheostomy weaning. Two major problems that have been identified in the patient include anxiety and acute kidney injury. Diagnosis by the nurse can help in the clinical judgment which has enabled them to perform a care plan for the patient. The analysis and the reflection on the nursing interventions that have provided relief to the patient have been discussed. It has been considered that the anxiety of the patient is due to the injury that has occurred due to tracheostomy insertion as well as feeding the patient via a nasogastric tube. The second problem is AKI which is caused by the changes in the hemodynamics that had happened due to Ventilator-induced kidney injury.

Presentation of the Patient

The case study that has been chosen deals with the patient Mr. B who is 70 years old. He was admitted to the ICU due to a spinal cord injury after sustaining a fall. The main reason for performing a tracheostomy was that the patient had undergone fusion and anterior cervical discectomy. The patient was then weaned off of invasive ventilation and was switched to NIV. The discharge of the patient to the unit that deals with spinal problems was done for Mr. B. but soon’ after the transfer, the patient was readmitted to the ICU after a week. The holistic care could include encouraging the patient to cough out the secretions and suctioning the mucus if the patient is unable to do so own their own. The tracheostomy was done with 6 size tube. The toleration towards cuff deflation was negative for the patient. The transfer of the patient was done to HDU. This was done after the patient was weaned off from NIV from mechanical ventilation. As the tracheostomy had resulted in the incorrect amount of water consumption but the outflow of the water was higher in the patient, the problem of acute kidney injury can be seen in the patient. The level of creatinine that is seen in Mr.B is low around 48 when the normal range of creatinine for male adults is 61.9 umol/L. the problems of anxiety and acute kidney injury was seen as the persistent problem in the patient. The selection of these two problems has been taken up for the critical analysis that is based on evidence. The problems that are faced by the patient include anxiety and acute kidney injury is problems that are prioritized in the critical analysis of evidence based practice. Other problems can include high blood pressure, risk of urinary tract infection and mental pressure on the patient.

Evidence Based Analysis

Anxiety due to tracheostomy weaning

Removal of tracheostomy will cause anxiety for the patients. Thus, proper weaning and decannulation will require careful planning and this will however require support from various multiprotection team.the tracheostomy is just a surgical opening in the anterior wall of the trachea and this help in the process of breathing ((Bandelow et al., 2017)). The tracheostomy tube mainly enables the airflow. The aim of the weaning is to help the airflow to the upper way and this help in restoring physiological functions. Due to the whole complicated process that the patients go through the tracheostomies have high level of psychological distress and this will create high level of anxiety in patients. A patient with respiratory distress will develop respiratory distress and this happen during the ward weaning process and this might lead to anxiety in the person. There ae severe chances of anxiety in the patients once after the removal of tracheostomy and this will lead to narrowing of larynx and in many cases, there are risk of severe aspiration pneumonia and thus the patients’ needs to be monitored regularly (Guia et al., 2021). Anxiety is very common in patient whenever the tracheostomy is being removed and this cause more problems to the person. The tracheostomy is very much essential as this will facilitate in the process of breathing. The holistic care includes continued care and integration. The nurses can make the patient practice deep breathing as this will allow the patient to relax his body and mind. Placing the patients in quiet area can also help in reducing anxiety.

The patient experiences anxiety when weaning their tracheostomy because they are unsure of the process, what to expect, and what they ought to expect, and they also worry that they won't be able to breathe normally without their tracheostomy tube. This teantio0jn about breathing without the tracheostomy tube after the weaning processes increases the level of anxiety, because this tube provides a secure airway for the breathing process. Patients worry because of the thought difficulty in. The difficulty in breathing may also cause the respiratory failure and the condition of the patient can deteriorate within few minutes. Because of the pain and discomfort that are related to the weaning process, the patient's degree of worry and anxiety also rises as a result. The tracheostomy place in the patient throat for extends period and that can be the reason of sore an irritation in throat. Sometimes the concerns about the setbacks as well as the potential complications also create the anxiety in the patient (Liney et al., 2019). The patient with a tracheostomy weaning experiences worry because of the potential for infection in their specific respiratory tract or other infections. Coughing, fever, and trouble speaking may be brought on by this.

Acute kidney injury due to tracheostomy weaning

The acute kidney injury takes place due to tracheostomy weaning and this mainly due to the kidney which is unable to filter waste products. this causes more problem to the person to continue the daily lifestyle. The tracheostomy mainly helps in the process of airflow to the upper way and this help in the physiological function of the human body. This mainly increases the workload of breathing. After the whole treatment process there are cases where the patient experiences leaking urine or delayed bleeding (Urology Care Foundation, 2022). The tracheostomy mainly works in facilitating weaning and this happen by reducing the dead space and this will work by improving the secretion clearance and this creates an effect on reducing the need for sedation. This will automatically create a huge accumulation of waste and this will eventually create more renal problems and thus the kidney will not be able to function properly. The renal trauma mainly takes place when the kidney gets injured due to the outside force. Due to the weaning the person might face severe contradictions and this will include the stage where the patient might reduce the intake of water and this will create an effect on the kidney and thus the kidney will not be able to perform its function. This is one of the most common problems faced by the person when the kidney condition gets deteriorated and the kidney is unable to perform its function. The holistic care would include encouraging the patient to drink a lot of water and giving him probiotics that will reduce the chances of any infection.

Acute kidney injury can be considered a serious problem and can cause several complications in the functioning of the kidneys. When the process of weaning starts, the support to the respiratory tract of the patient is reduced considerably and a change in the balance of the fluid intake as well as the changes in the blood flow can be taken up. All this factors result in the formation of injuries to the kidney (Bellomo et al., 2017). When the patient was put on a mechanical ventilator, the redirection of the blood flow to the lungs can be noticed. But when the breathing is done by the patient on his own the redirection of the blood is directly done to kidneys. This redirection results in additional stress on the kidneys of the patient causing injury. Another cause of kidney injury is the imbalance in the fluid intake. Reducing the dependency on ventilation can cause drastic changes in the fluid intake and output in the body of the patient (Vemuri et al., 2022). This is because the adjustment to the patterns of oxygenation and breathing can result in dehydration, thus, leading to impaired kidney disease.

Intervention

The evidence-based research of Mr. B has shown that he has been suffering from two common problems anxiety and AKI due to tracheostomy weaning. It is observed that patients who undergo weaning of mechanical ventilation having tracheostomy can be due to several factors including suffocation, discomfort, and pain. The medical intervention that can treat the anxiety of Mr. B is mentioned below:

Providing emotional support: It is important to provide emotional support to Mr. B who has been undergoing weaning after the tracheostomy. This can result in the early recovery of Mr. B with support from family members, healthcare providers, and health professionals. Providing emotional support to Mr. B can help in alleviating his mental anxiety by addressing his fear and concern, information about the weaning process, and motivating Mr. B.

Good communication: Use of presence and good communication technique that will encourage the patient can be taken up by the nurses ( Pyeon et al., 2017). Therapeutic communication can be taken up so make the patient understand that they are not alone. The expression of the feelings of the client can also be taken up that will enable the nurse to assess the problems that the patient is facing. Interaction with the patients in a peaceful manner can also be taken up by the nurses.

Recommending relaxation technique: Relaxation techniques including guided imagery, deep breathing, and progressive muscles can help provide relief to Mr. B due to the weaning of the mechanical ventilation (Ncbi, 2023).

AKI is a common symptom that is observed in patients undergoing weaning after tracheostomy. It can also result in complex situations such as electrolyte imbalances, hypotension, and hemodynamic instability. The medical intervention for treating AKI is mentioned below:

Maintaining the fluid as well as electrolyte balance: The symptoms of AKI can be worsened due to electrolyte imbalances (Sciencedirectassets, 2023). Therefore, to prevent the symptoms of AKI from occurring, it is important to have close monitoring of MR. B. For instance, the level of sodium, serum, and potassium needs to be monitored closely.

Avoiding nephrotoxic medicine: It is possible that AKI can occur due to the use of certain medications such as contrast agents, antibiotics, and NSAIDs (Ingrasciotta et al., 2014). To prevent, the AKI conditions from occurring to Mr. B, it is important that healthcare professionals minimize the uses of nephrotoxic medicine. Further, the dose of medications can be adjusted according to the renal function of Mr. B.

Managing hemodynamic stability: AKI can also occur due to hemodynamic instability resulting in decreased renal perfusion leading to AKI development (Krishnasamy et al., 2023). It is important that the caretaker of Mr. B need to monitor his blood pressure level and can prescribe medication doses according for maintaining hemodynamic stability. This requires maintaining the fluid level, optimizing ventilation and oxygenation, and administering vasoactive medicines.

Evaluation

Monitoring and evaluating the level of electrolytes and fluids is crucial for the acute kidney illness of Mr.B because these large alterations are typical of the condition. Dehydration, acid-based imbalance, electoral imbalances, and edema are just a few of the issues caused by an imbalance in the electrolyte as well as fluid balance (Grams et al., 2016). Nephrotixc medicines should be avoided in the treatment of the acute kidney illness of Mr. B since they can worsen the patient's circumstances and cause further damage to the kidneys. The danger of renal illness is increased higher by these Nephrotoxic drugs, according to the researcher Norbert Lameire, who detailed this in the article (Lameire, 2018). Reduced renal perfusion and additional kidney injury can be caused by hemodynamic instability that may be brought on by situations including hypotension, hypovolemia, or compromised heart function (Kwiatkowska et al., 2021). Reduced renal perfusion due to hemodynamic instability results in ischemia injury and further kidney damage. Supporting the patient Mr. B emotionally is important because it makes sense to support the patient emotionally if they are experiencing anxiety because doing so will give them support and reduce their sense of loneliness. This helps the patient understand the value of taking care of them. A number of anxiety symptoms are also lessened by this emotional support. Also, it protects the patient from unexpected panic attacks (Long, 2018). Complications are less likely with this medication.

Conclusion

It can be concluded that the patient Mr. B had been admitted to the hospital due to spinal cord injury and was given a tracheostomy. This case study helped in the understanding of the evidence that is present and the way it has assisted in taking care of the patient. Two major problems that have been identified in the patient include anxiety and acute kidney injury. Diagnosis by the nurse can help in the clinical judgment which has enabled them to perform a care plan for the patient. AKI can also occur due to hemodynamic instability. The care for patients who have undergone injuries like the spinal cord has been properly understood with the help of evidence-based practice. The interventions that are used in the case study to solve the problem of anxiety and acute kidney injury have been supported by evidence. It is possible that AKI can occur due to the use of certain medications such as contrast agents, antibiotics, and NSAIDs. It is important to provide emotional support to Mr. B who has been undergoing weaning after the tracheostomy. The problem-solving and the evaluation of the vase study have been possible with the help of evidence-based practice.

References

Bandelow, B., Michaelis, S. and Wedekind, D. (2017) “Treatment of anxiety disorders,” Dialogues in Clinical Neuroscience, 19(2), pp. 93–107. Available at: https://doi.org/10.31887/dcns.2017.19.2/bbandelow.

Bellomo, R. et al. (2017) “Acute kidney injury in the ICU: From injury to recovery: Reports from the 5th Paris International Conference,” Annals of Intensive Care, 7(1), pp. 52–87. Available at: https://doi.org/10.1186/s13613-017-0260-y.

Grams, M.E. et al. (2016) “Fluid balance, diuretic use, and mortality in acute kidney injury,” Clinical Journal of the American Society of Nephrology, 6(5), pp. 966–973. Available at: https://doi.org/10.2215/cjn.08781010.

Ingrasciotta, Y. et al. (2014) The burden of nephrotoxic drug prescriptions in patients with chronic kidney disease: A retrospective population-based study in southern Italy, PloS one. U.S. National Library of Medicine. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3928406/#:~:text=The%20use%20of%20nephrotoxic%20drugs,can%20negatively%20affect%20CKD%20patients. (Accessed: April 1, 2023).

Krishnasamy, S., Sinha, A. and Bagga, A. (2023) Management of acute kidney injury in critically ill children - indian journal of pediatrics, SpringerLink. Springer India. Available at: https://link.springer.com/article/10.1007/s12098-023-04483-2 (Accessed: April 1, 2023).

Kwiatkowska, E. et al. (2021) “The mechanism of drug nephrotoxicity and the methods for preventing kidney damage,” International Journal of Molecular Sciences, 22(11), p. 6109. Available at: https://doi.org/10.3390/ijms22116109.

Lameire, N. (2018) “Prevention of acute kidney injury,” Oxford Medicine Online, pp. 2–7. Available at: https://doi.org/10.1093/med/9780199592548.003.0224_update_001.

Liney, T. et al. (2019) “Anxiety levels amongst patients with Tracheostomies,” British Journal of Anaesthesia, 123(4), pp. 23–67. Available at: https://doi.org/10.1016/j.bja.2019.04.027.

Long, A. (2018) “Relaxation techniques/relaxation,” SpringerReference, pp. 22–78. Available at: https://doi.org/10.1007/springerreference_36576.

Ncbi (2023) Relaxation techniques - statpearls - NCBI bookshelf. Available at: https://www.ncbi.nlm.nih.gov/books/NBK513238/ (Accessed: April 1, 2023).

Pyeon, T. et al. (2017) The effect of triazolam premedication on anxiety, sedation, and amnesia in general anesthesia, Korean journal of anesthesiology. U.S. National Library of Medicine. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5453890/ (Accessed: April 1, 2023).

Sciencedirectassets (2023) Preparing your download, ScienceDirect.com. Available at: https://www.sciencedirect.com/science/article/pii/S0007091217477105/pdf?md5=578ee9cf289f7708af7a0ab73af11106&pid=1-s2.0-S0007091217477105-main.pdf (Accessed: April 1, 2023).

Tracheducation and Tracheostomy Education (2022) Role of the family after tracheostomy, Tracheostomy Education. Available at: https://tracheostomyeducation.com/role-of-the-family-after-tracheostomy/ (Accessed: April 1, 2023).

Urology Care Foundation (2022) Kidney (renal) trauma, Kidney (Renal) Trauma: Symptoms, Diagnosis & Treatment - Urology Care Foundation. Available at: https://www.urologyhealth.org/urology-a-z/k/kidney-(renal)-trauma (Accessed: April 1, 2023).

Vemuri, S.V. et al. (2022) “Association between acute kidney injury during invasive mechanical ventilation and ICU outcomes and Respiratory System Mechanics,” Critical Care Explorations, 4(7), pp. 52–99. Available at: https://doi.org/10.1097/cce.0000000000000720.

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