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Nursing Management – Patient with End-stage COPD  

 

Nursing Management of the needs of a Patient with End-stage (Chronic obstructive pulmonary disease) COPD

 

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Introduction

Chronic obstructive pulmonary disease (COPD) affects over 5 percent of the population and is often linked to high mortality and morbidity. In the United States, COPD is the third leading cause of death, responsible for over 120,000 deaths annually (Kochanek et al., 2011).  In the UK, COPD is ranked the second most common form of lung disease, after asthma. Nearly 2% of the UK population has been diagnosed with COPD with the prevalence of the disease estimated at 4.5% among individuals aged above 40 (British Lung Foundation, 2017). Projections show that the burden of COPD shall escalate in the next few decades owing to an increasing aging population, coupled with the rise in exposure to COPD risk factors. Moreover, COPD is linked to a considerable economic burden. COPD is a common treatable and preventable condition that usually presents with a progressive, but persistent restriction in airflow, and is usually linked to increased chronic inflammation of the lungs and airways owing to gases or noxious particles. Causes of COPD Include smoking, air pollution, sudden constrictions of the airway triggered by exposure to inhaled irritants, and occupation exposures, such as workplace dust in gold and coal mining (WHO, 2017), among others. Genetics also plays a role. Risk factors for the conditions include an aging population, infections, nutrition, as well as socio-economic status (See, Phua and Lim, 2016). In terms of pathophysiology, toxic gases and other triggers cause abnormal inflammation of the airways, leading to its narrowing. The parenchyma may also be inflamed, thus triggering emphysema. Destruction of the parenchyma results in an imbalance of the proteinase inhibitors responsible for halting the destructive process. There are hence resultant changes in the pulmonary vascular, including deposition of collagen, and thickening of vessels, while the capillary is also destroyed. Airway limitation also causes mucus hyper-secretion, leading to sputum production and a chronic cough also develops (MacNee, 2006). The premise of the current essay is to identify a patient with end-stage COPD under nursing care and to identify and discuss 2 patient needs associated with the patient in question, including how the nurse assessed, managed, and provided support to this patient.

Detailed Case Study

The patient whose case study is being reviewed here shall be given the pseudonym Tom, in order to preserve their privacy and in keeping with the requirements of the NMC (code of nurse and midwives) regarding patient confidentiality (NMC, 2015). Tom is a 74-year-old male who came to the Emergency Department in the company of his wife complaining of fever and shortness of breath. His wife brought along medical records of her husband from his last visit to the physician. Tom’s past medical history as shown by the health records indicated that he had suffered heart failure at age 69 due to myocardial infarction. He also suffered from hypertension and COPD. For the latter condition, Tom was on 2L home oxygen. He had also been prescribed various medications, including 25 mg of spironolactone daily.  Tom’s current symptoms include the inability to speak in full sentences over the last 12 hours, based on his wife; production of cough audible wheezing for nearly 24 hours; based on his wife; dyspnea, and mild chest tightness. According to Tom’s wife, he has not had a change in terms of his mental status or alertness. Upon further inquiry, his wife indicated that Tom’s cough worsens in the morning, and is usually accompanied by gray sputum. He cannot also walk beyond 10 feet without experiencing shortness of breath. If Tom suffers from an upper respiratory infection, he also experiences episodes of wheezing. His condition does not allow him to assist with light work around the house, such as fixing things.  Upon physical examination of Tom, his vital signs were as follows: BP 89/79; Height 5ft 8 in; Temperature 38.6 °C; Weight 132 lbs; Alert and oriented, could not speak in full sentences, and also presented with audible wheezing. Tom’s nails also had tar stains. His heart had a regular rhythm without any murmurs, while his chest manifested in diffuse wheezing to auscultation.

Patient Assessment Process

Assessment of patients with end-stage COPD is essential in order to identify the disease at this stage and more importantly, institute timely palliative care to the patients, thus reducing the risk of mortality. Scullion and Holmes (2011) indicate that COPD mortality is mostly under-recognised, with the result that healthcare professionals are not able to provide the patient with proper management of the condition in the palliative stage. End-stage COPD often presents with episodes of stability which could also alternate with periods of sudden disease exacerbations, and this makes it increasingly harder to manage the disease (Leyshon, 2012). It is therefore crucial to conduct a detailed assessment process of the patients with end-stage COPD in order to implement an effective care plan.

The ABCDE Approach

The ABCDE (Airway, Breathing, Circulation, Disability, and Exposure) approach is the gold standard when dealing with clinical emergencies in order to facilitate timely assessment of the patient and treatment. Moreover, the ABCDE approach has been widely accepted by the various healthcare professionals dealing with emergency medicine in that it enables them to focus more on crucial life-threatening clinical problems, thereby enhancing patient health outcomes (Thim et al., 2012). The ABCDE approach has also been recommended by the Resuscitation Council UK (2006) for use by their staff while assessing acutely ill patients. According to Macintosh and Moore (1999), the ABCDE approach enables healthcare professionals to promptly identify patients who are acutely ill and to undertake initial management of the condition.

Airway

Upon examination of Tom’s airway, partial airway obstruction was identified. The physician then ordered the patient to be administered with high-concentration oxygen. In this case, the oxygen was administered via a reservoir bag and mask.

Breathing

Assessment of breathing was then done to check for changes in levels of oxygen saturation and respiratory rate. A high level of these parameters points towards the patient’s attempt to increase levels of oxygen delivered to cells (Cuthbertson et al., 2007).  The patient also manifested in nasal flaring, the R was way above the normal rate, while a non-productive cough was also evident.

Since the patient was already receiving high-concentration oxygen, this also took care of the breathing.

Circulation

The patient’s initial observation included checking for signs of distress altered heart rate, and signs of fluid loss. The patient had no signs of haemorrhage or pulse pressure. PP was recorded at 40 mmHg.

Disability

This is meant to deal with the patient’s responsiveness to her or his state of consciousness. The patient was semi-alert, and could not respond verbally to all the questions posed to them. Exposure Macintosh and Moore (1999) opine that it is important to assess a patient’s exposure to bleeding or injury.

Activities of daily living

The activity of daily living checklist was also used to evaluate Tom’s potential independence and relative independence in undertaking various activities in day-to-day life. In this case, the patient’s independence is assessed based on a continuum that “ranges from complete dependence to complete independence” (Petiprin, 2016, n.p.). Such an assessment is important because it enables the nurse to determine the kind of interventions likely to result in enhanced patient independence, along with the ongoing support that the patient should receive to counterbalance any existing patient dependency. According to Holland et al. (2008), the independence/dependence continuum functions as a reminder that patients may not always undertake each activity of living without the need for assistance. While some people lack the skills needed, others lack the means required to perform such skills. Still, others suffer from trauma or illness, leading to their loss of ability to undertake such activities. Based on the assessment done on Tom, it emerged that he could not communicate effectively. While breathing, Tom experienced episodes of wheezing. Tom’s wife indicated that he could not eat or drink anything unaided over the past few days, not to mention that he could not also wash and dress himself. He could also not move more than 10 steps without the need to rest and catch his breath. According to Brooker, Nicol, and Alexander (2013), it is not unusual for individuals suffering from long-term conditions to experience difficulty in performing various activities of living due to the disruption in the performance of one of the daily living activities. For example, Tom was experiencing shortness of breath and this in turn compromised his ability to eat and drink, communicate, wash and clothe himself, sleep, and reach the toilet.

Patient Problems

Based on the foregoing assessment of the patient, two healthcare problems are evident: the patient is faced with an ineffective breathing pattern, and the patient has also presented with ineffective airway clearance. Ineffective breathing pattern:

Ineffective Breathing Patterns

Carpenito-Moyet (2008) has defined ineffective breathing patterns as the “state in which a person experiences an actual or potential loss of adequate ventilation related to an altered breathing pattern” (p. 540). This is usually manifested by changes in pulse rhythm, quality, or rate, as well as variations in respiratory pattern or rate from baseline. For patients experiencing ineffective breathing patterns, nursing management is often necessary, and it is intended to maintain sufficient ventilation via exercise training, breathing retraining, the use of ventilator support devices, psychological support of the patient, as well as the use of energy conservation techniques. This calls for the use of a multi-disciplinary team to assist the patient with pulmonary rehabilitation (Hoeman, 2008).  In the case of Tom, ventilation assistance was accomplished through the adoption of Pursed-Lip Breathing (PLB). Hoeman (2008) has described PLB as ‘a technique of exhaling slowly through partially closed, or “pursed”, lips.  This was meant to allow the patient to empty the alveoli to the maximum while also controlling expiration. In this way, the technique helps to reduce carbon dioxide levels, minute ventilation, and respiratory rate, while also increasing arterial oxygen pressure, and levels of carbon dioxide.

Nursing intervention is thus desirable in order to allow the patient to realise improved breathing patterns and at the same time, ensure that their respiratory rate remains within the normal limits.

The nurse also trained the patient to ensure that he leaned forward with his head at 16-18 degrees during exhalation. This was meant to permit the exiting of more air from the lungs during exhalation.  Breathing efficiency was also achieved by encouraging the patient to perform abdominal breathing. This was achieved by having a pillow placed against the patient’s abdomen while he exhaled. Additionally, Tom received training in diaphragmatic breathing as it has been shown to enhance alveolar ventilation, and reduce the rate of respiration, while also aiding in the maximum expulsion of air during expiration (Corhay et al., 2014). Diaphragmatic breathing also helps to increase a patient’s oxygen levels, in addition to facilitating in relaxing of muscles.

The nurse also ensured that the patient was placed with proper body alignment as a means of achieving maximum breathing pattern. This is because a sitting position has been shown to allow for maximum chest expansion and lung excursion. The nurse further encouraged the patient to take sustained deep breaths through demonstrations. In this case, deep breaths were achieved via slow inhalation, holding of the breath for a few seconds, followed by passive exhalation. Furthermore, the nurse also encouraged the patient to yawn. These techniques of breathing are known to be effective in promoting deep inspiration. This not only enhances oxygenation but also overcomes atelectasis.  Besides, sustained passive expiration overcomes air trapping.

Activity Intolerance

After respiratory muscles experience fatigue, it is important to ensure they are rested. Walsh and Crumbie (2007) opine that interventions are aimed at enhancing individual tolerance while also reducing the work of breathing. Patients with COPD frequently experience gradual intolerance to exercise and activity. The COPD care plan that a nurse could adopt in order to deal with a patient’s activity intolerance may entail diagnosing the patient as having insufficient energy to accomplish or endure the various daily activities they are involved in (Qureshi, Sharafkhaneh and Hanania, 2014). These could be related to debilitation and dyspnea as a result of COPD. The goal of a care plan for activity intolerance is to ensure that the patient is in a position to maintain optimal activity levels (Walsh and Crumbie, 2007). In addition, the care plan is intended to enable the patient to pace his/her activities. Moreover, the COPD care plan was intended to allow Tom to plan for the simplification of his daily activities and to enable him to partake in exercise programs or muscle-conditioning exercises at home.

Nursing education is thus important given its focus on rehabilitative therapies whose goal is to promote patient independence in going about their activities of daily living (Paul and Williams, 2009). To begin with, the nurse started by assessing Tom’s activity tolerance, along with the teaching strategies and limitations in order to enhance the patient’s independent activities of daily living.  The nurse encouraged Tom to partake in specific muscle training and general exercises for conditioning. In this case, specific muscle training was deemed important so that the patient could strengthen his muscles. Given Tom’s condition, the nurse also encouraged the patient to not rush into increasing his level of activities but rather, to increase it gradually. The nurse’s role was also vital in enabling the patient to find a balance between exercising and rest as this is crucial in the regulation of energy and expenditure. Moreover, the nurse was also required to periodically assess the patient’s breathing and sleep patterns.  It may also be necessary to administer inhaled medication as it assists in the dilation of the bronchial airways, thus subsidising the inflammation. Consequently, the patient experiences relief in breathing.  Tom was already on inhaled medication that his previous physician had prescribed. This was 25 mg of spironolactone daily. Levalbuterol MDI was also further prescribed at a rate of two puffs per 4 or 6 hours, as necessary. This was aimed at preventing the occurrence of acute exacerbations.  Irwin and Rippe (2008) report that the use of levalbuterol among patients manifesting with acute exacerbation of COPD leads to a reduction in length of stay and usage. Enhancing activity tolerance breaks a patient’s vicious cycle of reduced activity and isolation, resulting in such desirable benefits as reduced fatigue and dyspnea, enhanced exercise tolerance, enhanced physical activity, and a decrease in the utilisation of health care facilities such as bed (Corhay et al., 2013).

Conclusion

COPD is characterised by high mortality and morbidity rates and is the third leading cause of death in the United States. The burden of disease due to COPD is likely to escalate owing to a rise in the aging population and increased exposure to risk factors. This paper is based on the case study of Tom (not his real name), a 74-year-old male who presented to the ED with shortness of breath and fatigue. The patient’s assessment was done in order to identify the diseases and undertake timely palliative care. An ABCDE Approach and Activities of daily living revealed two patient problems: ineffective breathing patterns and activity intolerance. the nursing intervention was thus deemed appropriate in order to improve the patient’s breathing pattern and normalise respiratory rate. In addition, nursing education was also deemed necessary to promote patient independence in undertaking activities of daily living.

References

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