Before
An Acute Exacerbation of a Chronic Condition (AECC) refers to a sudden worsening or flare-up of symptoms in a person who has an ongoing, long-term illness. This deterioration is typically more severe than the person’s usual day-to-day variations and may require medical intervention or hospitalization.
Pathophysiology and Clinical Manifestations of Acute Exacerbation of Chronic Conditions
Pathophysiology
The pathophysiology varies depending on the specific chronic condition but generally involves:
Triggering factors (e.g., infections, non-adherence to medications, environmental exposure, stress) that disrupt the person's usual balance or disease control.
Inflammatory responses or physiological decompensation due to the body’s inability to maintain homeostasis.
Progression of organ dysfunction or worsening of symptoms.
Examples:
Chronic Obstructive Pulmonary Disease (COPD): Exacerbation often triggered by respiratory infections; leads to increased airway inflammation, mucus production, and airflow obstruction.
Heart Failure: Fluid overload or ischemia leads to worsening symptoms such as pulmonary edema and reduced cardiac output.
Diabetes Mellitus: Poor glycaemic control or infection may lead to hyperglycaemia or diabetic ketoacidosis.
Clinical Manifestations
These vary by condition but often include:
Respiratory distress (e.g., shortness of breath in COPD or heart failure)
Fatigue and weakness
Increased pain or discomfort
Changes in vital signs (e.g., tachycardia, hypotension)
Altered mental status (e.g., confusion, lethargy)
Lab/imaging abnormalities (e.g., elevated inflammatory markers, abnormal ECG, X-rays)
Role of the Nurse in Coordinating and Supporting Person-Centred Care During an Acute Exacerbation
1. Clinical Assessment and Monitoring
Perform timely assessments (vital signs, symptom monitoring)
Recognize early signs of deterioration
Monitor response to treatment (e.g., oxygen therapy, diuretics)
2. Coordination of Care
Collaborate with interdisciplinary teams (doctors, physios, pharmacists)
Ensure appropriate referrals and continuity of care
Facilitate hospital admission or escalation of care when needed
3. Person-Centred Communication
Involve the person and their family in care decisions
Provide clear explanations about the condition and treatments
Respect cultural and individual preferences
4. Education and Self-Management Support
Educate on symptom recognition and when to seek help
Support adherence to medications and lifestyle modifications
Help create or revise an action plan (e.g., asthma or CHF action plan)
5. Emotional and Psychosocial Support
Address anxiety, fear, or distress related to the acute episode
Connect patients with counselling or support services if needed
✅ Pathophysiology and Clinical Manifestations of an Acute Exacerbation of COPD
🔬 Pathophysiology of COPD
COPD is a progressive, irreversible lung disease that includes conditions like chronic bronchitis and emphysema. Its main characteristics are:
Chronic airway inflammation
Narrowing of the airways
Destruction of alveoli (air sacs), reducing gas exchange
Mucus hypersecretion
💥 What Happens During an Acute Exacerbation?
An acute exacerbation of COPD (AECOPD) is a sudden worsening of respiratory symptoms beyond usual day-to-day variation. The most common triggers are:
Respiratory tract infections (viral or bacterial)
Air pollution or allergens
Poor medication adherence
Cold weather or stress
Pathophysiological changes during AECOPD:
Increased inflammation → leading to further airway narrowing
Excess mucus production → blocks airflow
Air trapping → due to impaired gas exchange
V/Q mismatch (ventilation-perfusion) → causing hypoxaemia and possibly hypercapnia
All of this puts a strain on respiratory muscles, increases the work of breathing, and reduces oxygenation to tissues.
🩺 Clinical Manifestations of AECOPD
Increased dyspnoea (shortness of breath) – especially at rest or with minimal exertion
Increased cough and sputum production
Change in sputum colour – may indicate infection
Wheezing or chest tightness
Tachypnoea (rapid breathing) and tachycardia
Fatigue and confusion – due to hypoxia
Cyanosis in severe cases
Severe exacerbations may require hospitalization or ventilatory support.
✅ The Nurse's Role in Person-Centred Care During an AECOPD
👩⚕ 1. Assessment and Monitoring
Frequent monitoring of respiratory rate, oxygen saturation, and work of breathing
Auscultation for wheezes, crackles, or diminished breath sounds
Monitor ABGs (Arterial Blood Gases) if available – to assess for respiratory acidosis or hypoxaemia
Observe for signs of fatigue or deterioration
🔄 2. Care Coordination
Liaise with doctors for treatment (e.g., bronchodilators, corticosteroids, antibiotics)
Coordinate respiratory therapy (e.g., nebulisers, chest physiotherapy)
Arrange for diagnostics (e.g., chest X-ray, sputum culture)
Plan for escalation of care (ICU referral if needed)
🗣 3. Person-Centred Communication
Involve the patient in all decisions (e.g., treatment goals, use of NIV)
Use non-technical language to explain interventions and progress
Be aware of anxiety, which often accompanies breathlessness – offer reassurance and information
🎓 4. Education and Self-Management
After stabilization, educate the person on:
Early signs of exacerbation and what to do (e.g., action plan)
Inhaler technique and adherence to meds
Avoiding triggers like smoke, dust, cold air
Pulmonary rehabilitation programs
Smoking cessation support if relevant
❤ 5. Psychosocial and Emotional Support
AECOPD can be frightening – provide emotional support
Involve family or carers in planning
Explore advanced care planning if appropriate (e.g., goals of care for recurrent/severe exacerbations)
Great question! Nursing actions during an Acute Exacerbation of COPD (AECOPD) are critical for stabilizing the patient, relieving symptoms, preventing complications, and supporting recovery. Below is a clear breakdown of key nursing actions—categorized into immediate care, monitoring, communication, coordination, and long-term support—all framed around person-centred care.
👩⚕ Nursing Actions During an Acute Exacerbation of COPD
🔴 1. Immediate Interventions (Stabilization)
Nursing Action | Rationale |
|---|---|
Administer prescribed oxygen therapy (e.g., via nasal cannula or Venturi mask) | To maintain SpO₂ typically between 88–92% in COPD patients (to avoid suppressing respiratory drive) |
Administer bronchodilators via nebuliser or inhaler (e.g., salbutamol, ipratropium) | To relieve bronchospasm and open airways |
Administer systemic corticosteroids as prescribed (e.g., prednisolone) | To reduce airway inflammation |
Administer antibiotics if infection is suspected | To treat underlying infection contributing to the exacerbation |
Position patient in high Fowler’s position | To maximise lung expansion and ease breathing |
Provide a calm, reassuring environment | To reduce anxiety, which can worsen dyspnoea |
📊 2. Monitoring and Ongoing Assessment
Nursing Action | Rationale |
|---|---|
Monitor vital signs and SpO₂ regularly | To detect signs of deterioration early (e.g., rising RR, falling SpO₂) |
Perform chest auscultation | To assess breath sounds for wheeze, crackles, or diminished air entry |
Monitor level of consciousness and fatigue | Confusion or lethargy may indicate hypoxaemia or hypercapnia |
Monitor ABG results (if available) | To assess respiratory function and guide oxygen therapy |
Track fluid intake/output if IV therapy or diuretics are given | Fluid balance is important in COPD management, especially if right-sided heart strain is present |
🤝 3. Person-Centred Communication
Nursing Action | Rationale |
|---|---|
Explain all procedures and treatments clearly and calmly | To build trust, reduce anxiety, and empower the person |
Actively listen to the person's concerns | To provide emotional support and ensure care aligns with their values |
Involve family or carers in care decisions (with consent) | Supports continuity of care and shared decision-making |
Use non-verbal reassurance (e.g., eye contact, touch, calm tone) | Especially helpful when the person is breathless and can’t speak easily |
🔄 4. Multidisciplinary Coordination
Nursing Action | Rationale |
|---|---|
Notify medical team promptly of any deterioration | Ensures timely escalation or treatment modification |
Coordinate with physiotherapists for chest physio or breathing techniques | To aid sputum clearance and improve lung function |
Arrange respiratory nurse consult or referral to pulmonary rehab | For longer-term disease management support |
Ensure timely administration of medications | To optimize response to treatment and symptom relief |
🌱 5. Discharge Planning and Long-Term Support
Nursing Action | Rationale |
|---|---|
Educate on inhaler technique and medication adherence | Incorrect use is a common cause of exacerbations |
Provide a COPD action plan | Helps patients recognize and respond to early symptoms of exacerbation |
Educate on trigger avoidance (smoking, pollutants, infection prevention) | Reduces risk of future exacerbations |
Refer to smoking cessation programs (if relevant) | Smoking is the main cause of COPD progression |
Discuss advanced care planning if exacerbations are frequent/severe | Encourages discussion about goals of care and preferences for future treatment |
Definition of Acute Heart Failure
Acute Heart Failure (AHF) is a clinical syndrome characterized by:
A rapid onset or worsening of signs and symptoms of heart failure
It leads to reduced cardiac output, tissue hypoperfusion, increased pulmonary pressure, and congestion
Requires urgent medical evaluation and treatment
It can present de novo (new onset) or as a decompensation of chronic heart failure.
⚠ Risk Factors for Acute Heart Failure
Strong Risk Factors
Older Age
Prevalence is ≥10% in people ≥70 years of age.
Prior History of Heart Failure
Present in ~75% of patients hospitalized for AHF.
Coronary Artery Disease (CAD)
Leading cause (~50% of AHF cases); myocardial ischemia impairs LV function.
Hypertension
Present in 60–72% of cases; increases afterload and promotes LV hypertrophy.
Valvular Heart Disease
Especially aortic stenosis and mitral regurgitation.
Cardiac Arrhythmias (e.g., Atrial Fibrillation)
Present in 31–35% of patients.
Myocarditis and Pericardial Disease
Diabetes Mellitus
Contributes via ischemic and renal complications.
Nonadherence to Medications
Weaker Risk Factors
Excessive salt intake
Thyroid dysfunction
Alcohol misuse
Obesity (risk and prognostic factor)
Excessive catecholamine states (e.g., from drug abuse or stress responses).
🧬 Pathophysiology of Acute Heart Failure
In AHF, the heart fails to maintain adequate output to meet systemic demands. This leads to a cascade of compensatory and pathological events:
Hemodynamic Changes
Increased ventricular filling pressures (right and left)
Depressed cardiac output and cardiac index
May have normal/increased CO in early stages with infection
Neurohormonal Activation
Sympathetic Nervous System activation → tachycardia, vasoconstriction, ↑ myocardial oxygen demand
Renin-Angiotensin-Aldosterone System (RAAS) → salt and water retention, worsening congestion
Increased wall stress → myocardial damage, further ↓ in perfusion
If untreated, these compensatory mechanisms:
Worsen fluid overload and pulmonary congestion
Impair renal perfusion
Lead to organ dysfunction
Reversibility
With prompt and appropriate treatment (e.g., BP control, relieving ischemia), myocardial function can sometimes recover, especially in reversible cases (e.g., ischemia-induced dysfunction).
Acute on Chronic Kidney Disease (AoCKD)
✅ 1. Impact of Chronic Kidney Disease (CKD)
CKD is a long-term condition where the kidneys gradually lose their ability to filter waste, balance fluids, and regulate electrolytes and hormones.
🧠 Physical Impact:
Uraemia: Buildup of waste products → nausea, confusion, pruritus
Electrolyte imbalances: Hyperkalaemia, hyponatraemia, acidosis
Fluid overload: Oedema, hypertension, pulmonary congestion
Anaemia: Due to decreased erythropoietin
Bone disease: From altered calcium and phosphate metabolism
Fatigue and reduced quality of life
Cardiovascular disease is the leading cause of death in CKD.
Hypertension both causes and worsens CKD.
Increased risk of infections and bleeding disorders.
✅ 2. What is Acute on Chronic Kidney Disease (AoCKD)?
Acute on Chronic Kidney Disease refers to: A sudden deterioration of kidney function in a person who already has chronic kidney impairment.
It often results from:
Dehydration or volume loss
Infections (e.g., sepsis, UTIs)
Nephrotoxic drugs (NSAIDs, contrast dye)
Obstructive uropathy (e.g., enlarged prostate)
Heart failure or hypotension
🩸 Clinical Signs:
Sudden rise in creatinine and urea
Oliguria or anuria
Fluid retention
Electrolyte disturbances (especially hyperkalaemia)
Possible mental status changes
✅ 3. Nursing Management of Acute on Chronic Kidney Disease
🧾 A. Assessment and Monitoring
Action | Why it matters |
|---|---|
Monitor vital signs (especially BP, HR) | Detect fluid imbalance or hypotension |
Track fluid status (I&Os, daily weights) | Guide fluid management |
Monitor serum creatinine, urea, potassium | Assess renal function and electrolyte stability |
Assess for signs of overload (e.g., crackles, oedema, SOB) | Prevent pulmonary complications |
Evaluate neurological status | Detect uraemic encephalopathy or electrolyte-induced confusion |
💊 B. Medication Management
Action | Rationale |
|---|---|
Withhold or adjust nephrotoxic drugs | Prevent further renal damage |
Administer diuretics (if fluid overloaded) | Help remove excess fluid |
Manage hyperkalaemia | Urgent if potassium >6.0 mmol/L (use insulin/dextrose, calcium gluconate) |
Dose-adjust antibiotics and antihypertensives | Prevent toxicity |
💧 C. Fluid & Electrolyte Balance
Restrict fluid intake if overloaded
Manage sodium and potassium intake per dietitian guidance
Prepare for possible dialysis if indicated
👂 D. Person-Centred Support
Explain the condition and treatment clearly to reduce anxiety
Involve the patient in decision-making (e.g., dietary choices, dialysis consent)
Offer emotional and psychological support
Encourage family/carer involvement (with consent)
🧠 E. Multidisciplinary Coordination
Collaborate with:
Nephrologists
Dietitians (renal-friendly diets)
Pharmacists (drug adjustments)
Social workers (transport, finances, support at home)
Acute Kidney Injury (AKI)
✅ What is Acute Kidney Injury (AKI)?
Acute Kidney Injury is: A sudden decline in kidney function, leading to an accumulation of waste products (urea, creatinine), disturbances in fluid, electrolyte, and acid-base balance, and decreased urine output.
AKI can develop within hours to days, and is often reversible if treated early.
⚠ Causes of AKI
Grouped into three main categories:
Pre-renal (most common)
Due to reduced blood flow to the kidneys
Causes: dehydration, blood loss, heart failure, hypotension
Intra-renal (intrinsic)
Due to direct damage to kidney tissues
Causes: acute tubular necrosis (ATN), nephrotoxic drugs, infections, glomerulonephritis
Post-renal
Due to obstruction of urine flow
Causes: kidney stones, enlarged prostate, tumors
🔄 Three Phases of Acute Kidney Injury
🟥 1. Initiation Phase
Triggering event occurs (e.g., dehydration, sepsis, drug toxicity)
Subtle or no symptoms
Decrease in urine output may begin
Early intervention can prevent progression
🟨 2. Oliguric (or Maintenance) Phase
Occurs within 1–7 days of the insult
Urine output <400 mL/day
Symptoms:
Fluid overload (edema, crackles, hypertension)
Hyperkalaemia, metabolic acidosis
Uraemia (fatigue, nausea, confusion)
Labs: ↑ creatinine, ↑ BUN, ↑ potassium
🟩 3. Recovery (Diuretic) Phase
Gradual increase in urine output (up to 3–5 L/day)
Kidneys begin to recover
Monitor for dehydration and electrolyte loss
Eventually, renal function improves, but may not return to baseline
👩⚕ Nurse’s Role in Caring for Patients with AKI
🔎 1. Assessment & Monitoring
Nursing Action | Why it matters |
|---|---|
Monitor vital signs | Detect hypotension or signs of overload |
Track intake & output accurately | Essential to monitor progression |
Daily weights | Detect fluid retention or loss |
Monitor labs: urea, creatinine, potassium, sodium | Evaluate kidney function and electrolytes |
Assess for edema, breath sounds, JVP | Signs of fluid overload |
Watch for confusion, fatigue, nausea | Indicators of uraemia |
💊 2. Medication & Fluid Management
Withhold nephrotoxic drugs (NSAIDs, contrast agents, some antibiotics)
Ensure correct dosing for renally-excreted meds
Administer diuretics or fluids only if prescribed and indicated
Prepare for dialysis if required
🍲 3. Nutritional & Electrolyte Support
Collaborate with dietitian for renal-safe diets (low potassium, low phosphate, fluid restriction)
Monitor for signs of hyperkalaemia: muscle cramps, ECG changes
Educate on sodium and fluid restrictions
🤝 4. Person-Centred Care
Explain the condition and tests in clear, supportive terms
Offer emotional support—patients may feel anxious about kidney failure
Involve patients in decisions about care and dietary changes
Support family/carer understanding (with patient consent)
👥 5. Multidisciplinary Collaboration
Work with:
Nephrologists
Pharmacists
Dietitians
Social workers (for support post-discharge)
Here’s a detailed breakdown of the ABCDE approach to assessing a deteriorating patient, your role as a Registered Nurse (RN), when to begin a secondary assessment, and how to reflect on your learning needs.
✅ ABCDE Approach for a Deteriorating Patient
The ABCDE framework is a structured, systematic method used to assess and treat life-threatening conditions in order of priority. It allows for early recognition, rapid intervention, and communication in clinical emergencies.
🅰 A – Airway
Is the airway open and patent?
Look for signs of obstruction: stridor, gurgling, use of accessory muscles
Interventions:
Perform a head-tilt, chin-lift (or jaw-thrust if trauma suspected)
Suction if needed
Insert airway adjuncts (e.g., oropharyngeal airway)
Escalate to medical team or MET (Medical Emergency Team) as required
🅱 B – Breathing
Assess respiratory rate, effort, SpO₂, chest symmetry
Look for: tachypnoea, cyanosis, reduced breath sounds
Interventions:
Administer oxygen if SpO₂ < 94% (or target range based on condition)
Position upright
Support with nebulisers or escalate for NIV/ventilation if needed
🅲 C – Circulation
Check heart rate, blood pressure, capillary refill, peripheral pulses
Look for signs of shock: cold, clammy skin, low urine output
Interventions:
Administer IV fluids if hypotensive (as per orders)
Obtain blood samples
Prepare for potential advanced life support (ALS)
🅳 D – Disability
Rapid neurological assessment using AVPU or GCS
Check pupils, blood glucose, and signs of seizure or confusion
Interventions:
Correct hypoglycaemia if glucose is low
Protect airway if altered consciousness
Escalate rapidly to senior clinicians
🅴 E – Exposure
Fully expose patient to examine for:
Rashes, injuries, signs of bleeding or infection
Check temperature
Preserve dignity and warmth after assessment
Role of the RN in ABCDE Assessment
Perform initial and ongoing assessments
Recognize early warning signs using tools like MEWS or NEWS2
Initiate immediate interventions within your scope (e.g., oxygen, fluids)
Escalate care as per hospital emergency protocols (e.g., MET call)
Document findings clearly and communicate using ISBAR
Support patient and family through reassurance and updates
⏱ When to Commence Secondary (Full Systems) Assessment?
You begin the secondary assessment after the patient is stabilized from the primary ABCDE assessment.
This includes:
Full head-to-toe assessment
Detailed history (AMPLE: Allergies, Medications, Past history, Last meal, Events leading up)
Focused assessments based on symptoms (e.g., chest pain → ECG, labs)
Do not delay treatment during primary assessment; treat as you go.
Absolutely! The DRSABCD acronym is a vital part of first response and basic life support. It’s a systematic approach used in emergency situations to assess and manage someone who has collapsed or is unresponsive. Let’s walk through each step:
🆘 DRSABCD – First Aid Response Framework
🔤 D – Danger Ensure the area is safe for yourself, the patient, and bystanders.
Look for hazards (e.g., electricity, fire, traffic, bodily fluids, sharp objects).
Don’t rush in—you can’t help if you become a victim yourself.
🔤 R – Response: Check if the person is responsive.
Gently shake their shoulders and shout:
“Can you hear me?” “Open your eyes!”Use AVPU:
Alert
Voice responsive
Pain responsive
Unresponsive
If they don’t respond → continue to the next step.
🔤 S – Send for Help
Ask a bystander to call immediately and get a defibrillator (AED) if available.
If alone: Call for help before starting CPR if the person is unresponsive and not breathing.
🔤 A – Airway: Open and check the airway.
Look for obstruction (tongue, vomit, food).
Use the head-tilt, chin-lift technique unless trauma is suspected.
If something is blocking the airway:
Roll the person onto their side (recovery position) and clear the mouth with a finger sweep if visible.
🔤 B – Breathing: Check if they are breathing normally.
Look: chest movement
Listen: for breath sounds
Feel: air from the nose/mouth on your cheek
Abnormal breathing (gasping) is not considered normal.
⛔ If not breathing or breathing abnormally → begin CPR.
🔤 C – CPR (Cardiopulmonary Resuscitation)
Push hard and fast in the centre of the chest (at least 5 cm deep)
Start CPR: 30 compressions : 2 breaths
Aim for 100–120 compressions per minute
Give 2 rescue breaths after every 30 compressions (if trained and able)
If not confident with breaths, continue with compression-only CPR
Keep going until help arrives, the person starts breathing, or you’re physically unable to continue.
🔤 D – Defibrillation:
Attach an AED as soon as possible (if available)
Turn it on and follow voice prompts
Ensure no one is touching the person when delivering a shock
Continue CPR between shocks if advised