Patient Presentation with COPD - Essay Example

Chronic obstructive pulmonary disease, otherwise known as COPD is a general term used in a disease characterised by progressive limitation and obstruction of the airflow and is associated with chronic cough, dyspnoea on exertion, expectoration and wheezing. COPD is partially irreversible and its symptoms are associated with hyper-responsiveness of the airways. The aforementioned conditions are recognized as a major disability causing a progressive chronic airway obstruction or narrowing that frequently occur as one entity. In the United Kingdom (UK), the prevalence of COPD affects both men and women more commonly in their fourth decade of life. Differential diagnosis of COPD includes asthma, congestive heart failure, bronchiectasis, tuberculosis, obliterative bronchiolitis, and diffuse panbronchiolitis. Nonpharmacological and pharmacological management are considered in treating the patient. Other treatments include rehabilitation, oxygen therapy, and ventilatory support. Patient Presentation with COPD A Brief Introduction: This paper discusses chronic obstructive pulmonary disease (COPD) and its significance in the family and community settings, its socio-economic and cultural background, past medical history, differential diagnosis, and current guidelines relating to pharmacological and nonpharmacological patient management. The analysis of psychosocial impact of COPD to the patient and her family as well as strategies for patient education, and the context of multidisciplinary care team are also will be discussed in the paper. Short Background on COPD: Chronic obstructive pulmonary disease, otherwise known as COPD is a general term used in a disease state characterised by progressive limitation and obstruction of the airflow and is associated with chronic cough, dyspnoea on exertion, expectoration and wheezing (Mannino, 2001; COPD International, 2011; British Medical Journal, 2012; World Health Organization, 2012; and GOLD, 2012). Mannino (2001) stated that COPD is partially irreversible and its symptoms are associated with hyper-responsiveness of the airways. The aforementioned conditions are recognized as a major disability causing a progressive chronic airway obstruction or narrowing that frequently occur as one entity (Patient.co.uk, 2012 and Sharma, 2012). Nursing Assessment: Patient, JC, is a 76 year old female patient with a ten year history of chronic obstructive pulmonary disease (COPD). JC, white female, now 76 years old was 66 year old when diagnosed with COPD in 2002. In the United Kingdom (UK), the prevalence of COPD affects both men and women more commonly in their fourth decade of life (NICE, 2010). It is associated with high rate of mortality and significant healthcare system cost (Raherison and Girodet, 2009). Epidemiological studies note a close association between chronic bronchitis prevalence and low socioeconomic status (Viegi, et al., 2001). COPD is classically thought to be a combination of chronic bronchitis and emphysema, even though in COPD patients, only one of the previously mentioned conditions is present (MayoClinic, 2011; CDC, 2011; and British Medical Journal, 2012). Sharma (2012) defined chronic bronchitis as persistent productive cough for more than three months each year in a period of two consecutive years. The mucous glands in lungs of individuals with chronic bronchitis are enlarged, the airways are inflamed, and the bronchial walls are thickened with subsequent changes and loss of supporting alveolar connection, which results to narrowing and deformity of the lumen of the airway and eventually causes limitation of airflow (Sharma, 2012). On the other hand, emphysema, one of the causative agents of COPD is defined as an abnormal and permanent alveolar enlargement of the terminal bronchioles that results to destruction of the airspace wall (Sharma, 2012). The patient has her own home; she is married with two children and one grandchild. Prior to her diagnosis, the patient worked in an office for most of her working life. She was a known cigarette smoker for 37.5 pack years (Appendix 1). It is generally known that COPD can be caused by smoking, although not exclusively (Patient.co.uk, 2012; GOLD, 2011; and Sharma, 2012). The patient has a dog, which has free run in all areas of her house. She walks the dog twice each day, with no shortness of breath. COPD develops when the airways overreact to irritant present in the air, causing hyper responsiveness of the airway (GOLD, 2011 and Sharma, 2012). Aside from the previous history of smoking, the patient was also exposed to a lung irritant, which is the fur of her pet dog. Past Medical History: December 2, 2004, patient was hospitalised due to worsening shortness of breath and productive cough unresponsive to amoxicillin and prednisolone treatment. On admission, clinical examination revealed widespread wheezing on both lung fields, reported oxygen saturation of 89%, noted to be hypoxic, and treated with nebulisers, doxycycline, and prednisone. Following treatment, she settled rapidly and was discharged. Follow up was in the chest clinic, sputum investigation revealed presence of Moraxella organism. According to Barreirro, et al., (1992), Moraxella catarrhalis is an “aerobic Gram-negative diplococcus which has been regarded traditionally as a commensal organism in the oropharynx.” Recently, it was identified as a pathogen of infections in the bronchopulmonary area (Barreirro, et al., 1992). Arterial blood gases (ABG) obtained from the patient revealed type 1 respiratory failure with pO2 of only 8.95. Arterial Blood Gases, ABG, is a test used to measure the acidity and oxygen and carbon dioxide “in the blood from an artery” (WebMD, 2010). This test is used to “check how well your lungs are able to move oxygen into the blood and remove carbon dioxide from the blood” (WebMD, 2010). Patient subsequently was diagnosed with COPD, moderate airflow obstruction, and ex-smoker. Medication on discharge were Tiotropion 1 puff OD, seretide 500mg 1 puff BID, and ventolin on as needed basis. At her next review in the clinic she was reported to have some reversibility to salbutamol on pulmonary function tests performed at the time. She has a good exercise tolerance as exemplified by her ability to walk her dog twice daily with no apparent complaints of shortness of breathing. It was reported that patient was settled on her medication to date. December 15, 2005, spirometry results (Appendix 3 and 4) were better than the previous year with an FEV1 of 1.47 and FVC of 2.54 and an FEV1/FVC ratio of 58%. In October 2004, her baseline FEV1 was 1.37 and FVC was 3.03 and the FEV1/FVC ratio was 45%. Her predicted levels are FEV1 of 1.88 and FVC of 2.2.7. The improvement in lung function is supported by her clinical condition, she is maintaining a good exercise tolerance, although walks slightly slower than she did previously. There is improvement in her sleeping habit, she can sleep through at night and is not disturbed with breathlessness. There were instances of disturbed sleep pattern, when she had bouts of viral infection, but in general, the patient was rated deemed to be very stable and as such discharge to the care of her GP. Physical Examination Findings include: Height: 157 cm, Weight: 56kg, BMI: 22.7, Pulse Rate: 70 BPM, Respiratory Rate: 26/minute, and Blood Pressure: 120/80 mmHg Skin: Pale, cold clamming extremities HEENT: Nasal flaring Lung: Use of accessory muscle of respiration, diminish breath sounds (both lungs), presence of thick and yellowish sputum One must consider other possible differential diagnosis, including: Asthma: Commonly mistaken with COPD; however, following characteristic of asthma must be noted so that management for COPD is easy: (1) generally, onset of asthma occurs earlier in life than COPD, (2) varied symptoms which disappears in between attacks, (3) presence of familiar history of asthma, (4) commonly accompanied with allergy, rhinitis, and eczema, and (5) essentially reversible airflow limitation (Leader, 2011; Price, et al., 2011). Congestive Heart Failure: COPD and CHF basically share the same characteristic symptoms; however, fine crackles at both lung bases through auscultation, dilatation of heart muscle, pulmonary oedema on CXR, and volume restriction on pulmonary function testing are unique features of CHF (Leader, 2011; Price, et al., 2011). Bronchiectasis: Tenacious, purulent sputum, bouts of recurrent bacterial infections, coarse crackles, dilatation of bronchial tubes and walls of the bronchus on x-ray, and clubbing of the fingers are noted in patients with bronchiectasis (Leader, 2011; Price, et al., 2011). Tuberculosis: Occurs at an early stage and CXR shows air spaces filled with pulmonary infiltrate and nodular lesion (Leader, 2011). Obliterative Bronchiolitis: Generally occurs at a younger age even if patient is non smoker (Leader, 2011; Price, et al., 2011). Diffuse Panbronchiolitis: Primarily occurs among males, who are non-smoker, patients with long term sinusitis, and hyperinflated lungs visible in chest x-ray and CTscan (Leader, 2011; Price, et al., 2011). Current Non-pharmacological and Pharmacological Management of COPD: GOLD (2011) current guidelines set for nonpharmacological management for patients suffering from chronic COPD include: Cessation from smoking: Our patient JC, and other patients, are encouraged by health care providers to stop from smoking. As mentioned previously, the natural history of COPD is greatly influenced by smoking cessation (GOLD, 2011). Counselling: Patient counselling delivered by physicians and other health care professionals even in a 3- minute period result to 5-10 percent of patients who stop from smoking compared to the self-initiated strategies (GOLD, 2011). Nicotine Replacement Therapy: Nicotine replacement therapy In the form of nicotine gum, inhaler, nasal spray, transdermal patch, sublingual tablet or lozenges increases long term abstinence rates from smoking and is reported to be more significantly effective compared to the placebo (GOLD, 2011). Smoking Prevention: A 50 percent reduction rate of lung function is observed among COPD patients who abstained from smoking. Smoking is the only known effective intervention in modifying COPD (Sutherland and Cherniack, 2004). Work with officials in the government to pass legislation to establish schools, facilities in the public, and work environments that are smoke-free and encourage patients to keep homes as smoke free as possible. This tobacco control policies and programs must be comprehensive with clear, consistent, and repeated messages about non-smoking (GOLD, 2011). Occupational Exposure: This is achieved through surveillance and early detection by eliminations or reduction of exposure to various substances present in the workplace (GOLD, 2011). Indoor and Outdoor Air Pollution: Measures in reduction or avoidance of burning biomass for cooking and heating in dwellings that are poorly ventilated must be implemented (GOLD, 2011). Physical Activity: Regular physical activity must be encouraged in all COPD patients since being physically active is beneficial to them. This theory is born out in our patient JC in her regular walks with her dog. Pharmacologic Therapies for Stable COPD based from GOLD (2011) guidelines are the following: Bronchodilators: To prevent or reduce symptoms, bronchodilators are prescribed on a regular or on as needed basis to provide symptomatic management in COPD. GOLD (2011) stated it is more convenient and effective to use long – acting inhaled bronchodilators compared to short acting bronchodilators at producing maintained relief of symptoms. Inhaled Corticosteroids: With regular treatment, the symptoms, lung function, and quality of life in COPD patients with FEV1 [Accessed at 25 February 2012].   Barreiro, B., Esteban, L., Prats, E., Verdaguer, E., Dorca, J., and Manresa, F., 1992. Moraxella catarrhalis respiratory infections. European Respiratory Journal, 5(6), pages 675-679.   British Medical Journal, 2012. Interventions. [Online] Available at: [Accessed 14 February 2012].   Buist, S., 2007. Epidemiology of COPD and its Co-morbidities. [Online] Available at: http://www.pneumologiamo.it/materiale/marzo2007/09_venerdi/06.%20Buist.pdf [Accessed 16 February 2012].   CDC, 2011. Chronic Obstructive Pulmonary Disease. [Online] Available at: [Accessed 16 February 2012].   COPD International, 2011. [Online] Available at: [Accessed 16 February 2012].   GOLD, 2011. Global Initiative for Chronic Obstructive Lung Disease. [Online] Available at: Accessed [15 February 2012].   GOLD, 2012. New Global Strategy for COPD Emphasizes Diseases Effect’s on Patients. [Online] Available at: [Accessed 15 February 2012].   Kelly, C., 2008. Psychological Effects of Chronic Lung Disease. [Online] Available at: < http://www.nursingtimes.net/nursing-practice-clinical-research/psychological-effects-of-chronic-lung-disease/1940860.article> [Accessed 17 February 2012]. Leader, D., 2011. Differential Diagnosis of COPD. [Online] Available at: [Accessed 14 February 2012].   Mannino, D., 2001. Chronic Obstructive and Pulmonary Disease: Epidemiology and Evaluation. [Online] Available at: [Accessed 14 February 2012].   MayoClinic, 2011. COPD. [Online] Available at: [Accessed 16 February 2012]. Mehuys, E., Boussery, K., Adriaens, E., Bortel, L., Bolle, L., Van Tongelen, I., Remon, J., and Brusselle, G., 2010. 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European Respiratory Review, 18(114), 213-221. Respiratory Health Network, 2008. Chronic Obstructive Pulmonary Disease Model of Care. [Online] Available at: [Accessed 17 February 2012]. Sharma, S., 2012. Chronic Obstructive Pulmonary Disease. [Online] Available at: < http://www.emedicinehealth.com/chronic_obstructive_pulmonary_disease_copd/article_em.htm> [Accessed 13 February 2012]. Sutherland, R., and Cherniack, R., 2004. Management of Chronic Obstructive Pulmonary Disease. The New England Journal of Medicine, 350(2004): 3689-3697. Viegi, G., Scognamiglio, A., Baldacci, S., Pistelli, F., and Carrozzi, L., 2001. Epidemiology of Chronic Obstructive Pulmonary Disease (COPD). International Journal of Thoracic Medicine, 68(1), page 16. Viegi, G., Pistelli, F., Sherrill, D., Maio, S., Baldacci, S., and Carrozzi, L., 2007. Definition, Epidemiology, and Natural History of COPD. European Respiratory Journal, 30(5), pp. 993-1013. WebMD, 2010. Arterial Blood Gasses. 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[Online] Available at: [Accessed 16 February 2012].     Appendix 1: Computation of Number of Pack Years: Number of Cigarettes per day x number of years smoking = Pack years   Appendix 2: Past History of Exacerbations and Treatment of JC: August 23, 2010 – Amoxicillin 500 mg 3x a day for 21 days October 9, 2008 – Amoxicillin 500 mg 3x day for 21 days and Prednisolon 30 mg once daily for 30 days April 20, 2008 – Cefaclor MR 359 mg 2x a day for 14 days March 25, 2008 - Amoxicillin 500 mg 3x day for 21 days and Prednisolon 30 mg once daily for 30 days March 25, 2007 – Amoxicillin 500 mg 3x a day for 21 days October 8, 2007 – Amoxicillin 500 mg 3x day for 21 days September 5, 2007 - Amoxicillin 500 mg 3x day for 21 days and Prednisolon 30 mg once daily for 30 days Appendix 3: Spirometry Result     Appendix 4: Spirometry Result Appendix 5: What is Nicotine Replacement Therapy (NRT)? Nicotine replacement Therapy is a substitute of smoking where nicotine gets into the bloodstream. These include nicotine gums, patches, inhalers, tablets, lozenges, and sprays (Patient.co,uk).   Read More