Chronic Obstructive Pulmonary Disease - Case Study Example

Chronic Obstructive Pulmonary Disease (COPD) Case Study Affiliation Clinical experience on COPD The essay seeks to analyse the clinical experience in a patient having chronic obstructive pulmonary disease (COPD). Essentially, it will cover various aspects with reference to COPD. Such areas include the disease causative factors, the clinical pattern, presentation, diagnostic patterns and management on admission. During the analysis of the experience, Driscolls reflective cycle (200) will be of utmost importance. Utilization of reflection principles in health care is the foundation and the epitome of quality health care, as one tends to work on areas of weakness on reflecting a negative act done in the previous service delivery moment. Maintaining the patient’s privacy and confidentiality is a factor the health care team must put into consideration at all times, hence in this case, none of the patient’s particulars will be disclosed. The patient at the verge of discussion will be Mr Chris, 76 years old, a chronic smoker for over 30 years. After smoking for over 30 years, Mr Chris did quit the habit four years ago. After the age of 18, he became totally dependent on smoking, consuming at least 25 cigarettes in a day. As a result of his consistent smoking, he did develop COPD, having regular chest infections, osteomyelitis and pulmonary fibrosis. The condition complicated, and he was brought to the respiratory medical team with complains of increased productive cough, difficulty in breathing, confusion and slight alteration in peripheral perfusion. All these are symptoms that come along with COPD. According to Lange et al. (2004), the basis of discerning a respiratory problem is through a comprehensive physical examination and taking a quick audit and analysis of both subjective and objective data. On assessment, Mr Chris had classic symptoms of COPD. His cough was persistent and productive. He looked tired and weary, breathless and uneasy, and appeared a little confused on initial questioning. Additionally, further examination revealed that he did use his accessory muscles during the breathing process. He talked of having lost quite some weight in a short time. on taking the vital signs, the temperature was 37.1 degree Celsius, pulse rate was 118 beats per minute, respiratory rate was 31 breaths per minutes, while the blood pressure was 135/95Mm/Hg. Oxygen saturation stood at 83% at room air oxygen concentration. A number of other tests were done to establish the extent of disease. Arterial Blood Gases dis reveal severe respiratory acidosis. It was corrected through oxygen delivery via nasal prongs. The blood tests done did reveal an increase in the C - reactive protein and neutrophils granulocytes count. A Computerized Tomography scan did reveal exacerbation of COPD. It was done to ascertain the causative factor of the rapid weight loss within a short time, and to countercheck the problem that may have led to the swell of a lymph node in the left axilla. Initially, he was put on strong intravenous antibiotics and oral steroids for five days. The initial assessment data during the first encounter with the client remains essential in making follow-ups on the treatment modalities and prognosis process. They simply act as a comparison set (Scott et al. 2006). The documents and charts that would aid in the ideal care of Mr Chris were documented. The plan of care was individualized while all the goals were laid out according to the priority. The client also did sign consenting to all the care administered to him. Such care measures would enhance the care team to detect the progress of the disease process. COPD remains a causative cause of morbidity and mortality in the world, and especially among the smokers. COPD can be used to make a clear description of all the diseases affecting the lungs. Such diseases include emphysema and bronchitis. There is a reduction in the expired air secondary to the reduced elasticity of the lungs and resistance of the airway. The lungs fail to respond in the normal air exchange mechanism (Decramer et al. 2012). All this arise due to the accumulation of the inflammatory cells in the central airway pipe. The end result is increased stimulation of the goblet cells to produce mucus. There is a tendency of scarring to the peripheral airways (Global Initiative for Chronic Obstructive Lung Disease 2011). The scarring process is a result of the restoration process occurring on the walls of the lungs. The increased scarring will result to a reduction in the ability of the alveoli to exchange gases in the ideal way. Consequently, the breathing process becomes quite difficult and burdensome (Pauwels et al. 2001). COPD do cover all the respiratory conditions that lead to air exchange obstruction. Administration of bronchodilators reverses the condition partially or fully. The condition remains burdensome to the afflicted people and society, both directly and indirectly. The cost of seeking health care services and medications is expensive. Action on Smoking Health (2006) makes an estimate that at least 900,000 people are diagnosed with the disease, while at least 2 million people remain undiagnosed in United Kingdom. Bellamy & Booker (2004) found out that at least thirty million days are lost in the process of seeking treatment. Around the world, approximately 3 million deaths do occur every tear. World health Organization (2008) did reinstate COPD as a condition that has shown a dramatic rise in UK, causing frequent deaths. The disease is likely to become a common cause of death in the next few years, according to World health organization’s observation. Ninety Nine percent of the people with a common smoking habit fall at risk of having the condition. The condition develops over a long time, taking an utmost 20years, hence affecting most chronic smokers (Agustí & Vestbo 2011). Sometimes it is possible to find people with this condition, yet they have never smoked, while others have the condition and they have never smoked. Such are the fluctuations that exist in the epidemiology of the COPD. Tobacco usage remains a health burden in United Kingdom. According to Bronsky & Wilson (2008), there are about 10 million adult active cigarette smokers. Cigarette contributes immensely to the deaths associated with COPD. Ninety Percent of the deaths resulting from COPD have a close link with smoking habits. Moreover, it is worth noting that other factors may have a contributing effect to the development of COPD. Research done by Seamark, Blake, Seamark & Halpin (2004) did prove that only 15% of the smokers end up developing COPD. Other factors that may contribute to the development of the condition includes presence of dust, coal or general air pollution within the environment. Genetic factors and developmental patterns may also determine the fate of a person. In genetic factors, early absence of anti-protease enzymes may worsen the situation. According to Celli and Macnee (2004) classification, the factors that may predispose one to the condition includes smoking, diet, genetics, social economic status, occupation, hyperactivity of the airway, pollution, perinatal events and childhood illnesses. Booker (2005) also states that low birth weight can be can be an additional risk factor to development of COPD in later stages in life. National Institute of Clinical Excellence (2010) outlines the core cause of COPD as smoking. It further states that the probability of condition acquisition escalates as one spends more time smoking, as it does irritates the lungs resulting to the scarring process exhibited. The inflammation process may lead to a long-term change in the anatomy and physiology of the lungs. For instance, the airway tends to thicken, leading to formation of more mucus. The delicate air sacs walls are damaged. All this results to emphysema and the lungs tends to lose their normal elasticity. Other smaller airways also tend to scar and narrow, ultimately leading to reduced cilia reflex. The affected person present with symptoms of productive cough, breathlessness and phlegm (WHO, 2008). According to British Thoracic Society (2006), the narrowing of the airways causes breathlessness. There is reduction in exchange of gases, thus affecting the air distribution in the lungs resulting to altered ventilation and perfusion in the body. Such deviations can be established when utilizing the Medical Research Council scale. The patient may also present with others symptoms, such as decreased arterial oxygen levels, fatigue, depression secondary to frustration and social isolation. Chests tightness may emanate from the progressing ischemic heart disease or the straining muscles. Edema of the limbs and face may be and indicator of right sided heart failure. Wheezing may result due to the narrowed respiratory pathways, but is found in people with severe COPD. Anorexia and massive wastage may result due to increased breathing rates and energy depletion secondary to that breathing (Plant & Elliott 2003). Medical Research Council Dyspnoea scale GRADE DEGREE OF BREATHLESSNESS RELATED TO ACTIVITIES 1 Not troubled by breathlessness except on strenuous exercise. 2 Short of breath when hurrying or walking up a slight hill 3 Walks slower than contemporaries on level ground because of breathlessness or have to stop for breath when walking at own pace. 4 Stops for breath after about 100m or after a few minutes on level ground. 5 Too breathless to leave the house or breathless when dressing or undressing. There does lack stability and persistence of disease symptoms. Sometimes the condition can worsen while at times it is stable. The symptoms also vary from one person to another. Exacerbation refers to acute periods, which may range from one to four attacks times in a day. A client experiencing such acute moments necessitates hospitalization. As the disease complicates and the condition becomes severe, the client may experience more attacks daily, with the duration of each and subsequent attack becoming shorter and shorter. It is indicative of the end stage COPD. Mr Chris had several acute cases in a period of one month, and was aware that his life was at the end stage of his disease. Such stage would result to regular hospital admissions (Vestbo et al. 2013). COPD diagnosis is made upon critical evaluation of clinical presentation and symptoms. Further diagnostic evaluations such as x-ray and computerised tomography scan and laboratory investigations will confirm the presence of the condition. Spirometry is useful in evaluating the airflow evidence. Every patient who is at risk of the condition should undergo screening. There is no single existing test for diagnosing COPD. Differential diagnosis is ruled out from a combination of history taking, physical examination, and airway examination with reference to airflow and obstruction presence. For instance, auscultating the chest may reveal a reduction in breath sounds and crepitation on inspiration. Wheeze may present on expiration and inspiration. National Institute of Clinical Excellence (2010) categorizes COPD into three main classes. Severe COPD presents with wheezing, general malaise, wastage, breathlessness on exertion, productive cough, wheeze, central cyanosis, peripheral Odema, pulmonary hypertension and over inflation of the lungs. The Forced Expired Volume is less than 30% predicted normal. Moderate disease possesses a wide range of symptoms. They include cough, sputum production, acute infection, wheezing and lungs over inflation. The Forced Expired Volume is 30-50% of predicted normal values. Mild COPD is characterized by few symptoms, morning cough, shortness of breath on exertion, and recurrent respiratory infection. The Forced Expired Volume remains 50-80% of the normal values. One can do further tests and investigations to make a confirmatory diagnosis. Chest x-ray should reveal overinflated lungs. The diaphragm is flattened. Computerised Tomography reveals acute emphysema. On examining the arterial blood gases, there are low oxygen levels and very high carbon dioxide levels. Investigations done to Mr Chris did reveal clear symptoms of traction bronchiectasis and patchy fields in the left lung. National Institute of Clinical Excellence expounds on the treatment modalities given to a patient on COPD. The patients’ needs and preferences are put in place. The patient must have a chance to take part in the decision making regarding his care modalities. The relatives can represent those who are not in a position to take part in the consent signing and decision-making. The best treatment modality for COPD is the utilization of a metered dose bronchodilator inhaler. The core goal of primary supportive treatment is relieving the symptoms, maintaining functional activity levels, prevention of complications, and slowing down the disease progression (Soriano & Lamprecht 2012). Pharmacologically, the best drugs choices are bronchodilators and corticosteroids. They do aid in removal of excess secretions, hence opening the airway. In the case of hypoxic patients, supplemental oxygen remains vital. Antibiotics does aid in clearing out the infection. On discharge, Mr Chris was given the following medications: Nebulization with salbutamol 5mg four times in a day, Paracetamol 1g four times a day, doxycycline 100mg once a day for five days and carbocysisteine 375 mg three times a day. Additionally, he was put on Ipratropium Bromide 500mcg four times a day and Symbicort 400/12 breath activated inhaler twice a day. For patients with COPD, surgical management is limited. Bullectomy is quite beneficial to clients, who do exhibit short-term improvement in the airway flow, lung volumes, exercise capacity, dyspnoea, hypoxemia and hypercapnia. Prior to surgical operation, various factors have to be put into consideration. Such factors include old age, comorbid illnesses, cardiac disease, frequent respiratory infections, Forced Expiratory Volume Rates, and the size of the bullae. Additionally, those patients unable to carry out the activities of daily living should also be considered for surgical operation to improve their livelihood. Nursing management remains vital in management of the patient. The nurse should reassure the client, do a continuous close monitoring and evaluation of the recovery process. Additionally, a nursing care plan has to be drawn to enhance optimal care of the patient. The care plan incorporated the nursing diagnosis, plan of action, implementation and evaluation. All nursing diagnosis must be prioritized, specific, measurable, achievable within a certain time limit, realistic and time bound. The nurse will also give both physiological and psychological care. He will act as an educator, counselling the client on the dangers of smoking, and the value of cessation of smoking to the body wellbeing. He will also explain the treatment modalities and regimen, and the importance of compliance to the same medications. Essentially, the nurse will remain a vital tool in provision of care to the patient, primarily advising the client on the importance of behavioral change in prognosis of the disease. Mr Chris did receive a referral letter to the smoke cessation team where he was commenced on daily nicotine patch. Additional measures such as patient counselling on energy conservatory measures would also benefit the patient. Nutritional recommendations and counselling is also significant to prevent muscle wasting. Patients having COPD may suffer from malnourishment secondary to an increase in the breathing work. They are also breathless to chew well. That was the reason behind Mr Chris body wastage and emaciation. Malnutrition remains a late signal of COPD. The choice of food remains critical to the management of the sick patient. Consumption of small regular feeds and utilization of oxygen via nasal prongs aids in energy recovery. National Institute of Clinical Excellence states that Body Mass Index assessments remain crucial in weight management. Nutritional supplements are important to increase the total calories intakes. Mr Chris initial Body Mass Index was quite low. The referral to dietician was important as a prescription of Calcium drink was given which meet his nutritional needs. Physical exercises are also crucial. The physiotherapist should be involved in redesigning a program that will enhance continuous fitness maintenance. The duration of the exercise should be ideal in such a way that the patient can tolerate it. Physical exercises ensure that the patient remains fit, and there is no accumulation of secretions in the chest. The patient should be educated on the methods of chest cleaning and sputum removal. Raising the head of bed during rest times, education on the various range of movements to aid in sputum expectoration and forced coughing are beneficial mechanisms (O’Donnell & Parker 2006). Patients with chronic conditions should have individualized care plans. The client should also have autonomy and participate in decision making during the care delivery process. For instance, Mr Chris has to undergo continuous energy expenditure assessments. He must be in a position to perform the basic Activities of Daily Living. With reference to that, he was referred to a physiotherapist to monitor his body activities, an occupational therapist and a social worker. Three days after, he did receive a discharge letter, with referral to the community respiratory nurse to monitor his recovery process. The hospital respiratory team would also conduct follow-up visits in his residence, for counselling, community diagnosis and assessment and further family education. Despite the fact that COPD affects the lungs majorly, the disease can also create an overhaul of emotional challenges. It may cause limitation or one’s ability to be happy and jovial in life. Anxiety, panic and distress is at the verge, since the client is always worrisome of the next shortness of breath attack. The mind can even have a perception that the next attack may lead to suffocation and eventual death. When one is at end stage of the disease, feelings of hopelessness, depression and regret may crop up. Profound loneliness may also chip in, as the family members are likely to desert them, blaming their health condition on their smoking behavior. Establishment of social supports improves their psychological status greatly. When they are involved in community activities, feelings of social isolation are eliminated. In summation, it is worth noting that COPD, if not well managed it can lead to other complications. Such complications include acute heart exacerbations, heart conditions such as stroke, lung cancer, pneumothorax, depression and severe malnutrition. The main goal in monitoring and providing the best care to Mr Chris was to ensure that such complications do not arise. The essay did expound in details the etiology, pathophysiology and first hand care and intervention received by Mr Chris. Behavioral modification remains the sole important nursing interventions focusing on improve the health status of the client. Counselling is also vital, ensuring that one is not at the verge of emotional stress overwhelming due to stress, denial and social isolation. Patient and family health education is the cornerstone of continuity of care upon discharge process. The patient and family must have skills on drug administration, method of administration and importance of complying with the treatment modalities. The essay writer will take the mandate of updating self on the most recent evidence based care modalities to the client suffering from COPD. References ASH (2006). Fact Sheet no 1: Smoking Statistics: Who smokes and How Much. http://www.ash.org.uk/html/factsheets/html/fact01.html Agustí, A. & Vestbo, J., 2011. 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WHO report on the global tobacco epidemic: The MPOWER Package. Geneva: WHO. Read More