• normalizing respiration rate;
• ensuring adequate oxygenation of the blood and tissues;
• preventing hypoxia;
• correcting the cause of/reducing the impact of respiratory disorders;
• ensuring compliance with treatment;
• continuous monitoring;
• preventing secondary risks such as skin breakdown in older/frail people, or exposure in cases of TB;
• smoking cessation using NRT.
Table 6.6 provides an illustration of factors that you might consider when writing a care plan for someone suffering from a respiratory problem using Roper and colleagues’ (1996) model.
Table 6.6 Factors you might consider when writing a care plan for someone suffering from a respiratory problem
Activity of daily living Example of care planning activity 1 Maintaining a safe
environment
This might relate to homeostasis as the internal body environment. Our aim is to restore as normal respiration rate as possible, given any respiratory tract damage. We also want to prevent/reduce the risk of hypoxia. We can achieve this by:
• monitoring baseline observations
• monitoring physical interventions such as medications
• evaluating the effectiveness of treatment
• prescribing oxygen therapy
• offering appropriate immunizations as a primary prevention of respiratory infections
• revisiting care plan if condition deteriorates
Adapting the physical home environment is an important consideration for limiting the amount of physical exertion required when moving around. Installing a stair lift, using mobility aids (e.g. handrails and other supports), adapting showers, etc., could help minimize levels of physical exertion
2 Breathing Monitoring respirations is a core observation. With respiratory problems breathlessness is a clinical feature. Breathlessness can be anxiety-provoking due to the associated discomfort and its role as a reinforcing agent of illness.
Breathing should also be monitored when the MHSU is asleep. Observations and interventions include:
• respiration rate
• presence of cyanosis
• pulse oximetry
• oxygen therapy
• posture when sitting or lying
• ABGs
• review of antipsychotic medications
• physiotherapy advice on exercise or removing excess sputum
• collecting sputum samples for pathology and assessing any cough 3 Communicating Care planning and treatment for respiratory problems can be very complex.
Any instructions or explanations should:
• be jargon-free
• be easy to understand
• seek regular feedback to ensure comprehension
• seek clarification that things have been understood
You should also reassure the MHSU to alleviate any anxiety. Encourage them to express feelings and develop psychological coping strategies, or acceptance of a physical illness. This will decrease anxiety as they find they can still have a social life as long as they are not overexerting. You should also try to establish if there are any peer support groups that they or their carers/family can attend in the community
Table 6.6 Factors you might consider when writing a care plan for someone suffering from a respiratory problem (Continued)
Activity of daily living Example of care planning activity
4 Mobilizing While encouraging fitness is important, this should not be too strenuous. Set small and safe targets, for example:
• involve physiotherapy to develop an exercise plan
• walking short distances gradually increasing this
• encourage rest also and explore the best postures for optimal ventilation
• consider relaxation therapy to help the resting process and cope with stress
• encourage the use of walking aids (this might feel disempowering for the MHSU but our aim is to promote independence; emphasize that if they use aids appropriately, they will become more independent)
(Also refer to maintaining a safe environment above)
5 Eating and drinking Diet may need to change, as in respiratory conditions weight gain or weight loss may occur. The dietitian can advise on appropriate diets in whichever circumstances but as a general rule diets should be well balanced:
• encourage fruit and fibre
• control calories to prevent/increase weight
• explore healthy cooking options/meal choices depending on level of independence
• use of food supplements such as Complan
• promote a low-salt diet
• reduce/stop alcohol intake
Occupational therapy can help with cooking skills
6 Eliminating Levels of physical activity may reduce, so it is important to prevent elimination problems such as constipation (this is also a side-effect of antipsychotic medication)
• encourage adequate hydration
• introduce dietary changes to promote bowel function
• take bloods to monitor electrolytes 7 Personal cleansing
and dressing
In some cases, assistance may be required but the goal should be to promote independence. This will illustrate to the MHSU that they can still function normally
• ensure safety when bathing/showering as this can be tiring
• use shower seat aids to minimize exertion
• observe skin integrity – reduced oxygenation of blood may compromise skin integrity
• show respect for privacy and dignity 8 Maintaining body
temperature
Temperature should be monitored regularly if the respiratory condition is caused by an infection. If medication is given (e.g. paracetamol), temperature should be monitored to evaluate the effectiveness of this
• treat any infection
• ensure adequate hydration
• use a fan or cool flannel to reduce temperature
(continued)
Summary of key points
A high prevalence of smoking in mental health means a greater risk of more respiratory (and cardiovascular) disorders in MHSUs. Respiratory assessment is an important part of our work and we should be able to conduct a safe and thorough examination. A medical approach will be one aspect of the assessment but nurses should follow this up with a psycho-social assessment.
The British Thoracic Society (2006) state that 44 per cent of all deaths from respiratory dis- ease are associated with social class inequalities. This presents a clear public health challenge to us, as MHSUs tend to come from the lower social classes. Therefore, assessment should also explore smoking behaviour and attitudes to stopping, living conditions, and supportive environments.
As health promoters we must also remember that one in eight of all lung cancer cases are people who have never smoked a cigarette (UK Lung Cancer Coalition 2005). In the debate about the rights of smokers to smoke, we should remember that non-smokers are put at risk of developing respiratory disorders due to passive smoking.
We need to increase our knowledge of pharmacology as a necessary by-product of the preva- lence of physical illness in MHSUs. Greater awareness of ADRs associated with treating respi- ratory conditions is needed. Practitioners should have appropriate training and the necessary Table 6.6 Factors you might consider when writing a care plan for someone suffering from
a respiratory problem (Continued)
Activity of daily living Example of care planning activity 9 Working and
playing
Refer to mobilizing above
• time off work may be required for those who are employed
• ensuring appropriate benefits are in situ, e.g. if homes have to be renovated to help mobility
• recreational activities may have to be less strenuous initially
• explore local self-help or support groups that might have social activities 10 Sleeping Sleep may be affected by breathing problems. We should observe for sleep
difficulties and consider commencing a sleep chart
• use of extra pillows to assist breathing
• discourage sleeping during the day
• consider medication if required 11 Expressing
sexuality
Depending on the severity of the problem:
• sexual activity may decrease initially due to respiratory condition
• explain this to the MHSU and partner to promote understanding
• reassure that sexual activity will return but this will take some time 12 Dying MHSUs may be preoccupied with death or dying
• allow MHSUs to express fears
• reassure that with treatment and lifestyle changes life can still be enjoyed
• discuss fears of the future openly and discourage catastrophic thinking
• encourage joining a support group to get peer support
• palliative care may need to be considered depending on the severity and associated outcomes. At this stage MHSUs should be empowered to plan their death so that they retain control of their life. Advanced directives may be required, so you may have to seek legal advice and advocate for the MHSU’s rights with this
clinical instruments to conduct a respiratory assessment. It is through screening and identify- ing signs and symptoms of respiratory disorders that we can promote the physical health of MHSUs. Thus a more appropriate exchange should be:
Q: Do your MHSUs cough?
A: Yes, they cough all the time because they may have a smoking-related respiratory disorder.
Quick quiz
1 What is external respiration?
2 What is internal respiration?
3 Define diffusion.
4 Describe the effects of smoking on the respiratory system.
5 What is the role of the mental health nurse in respiratory health?