Chronic Obstructive Pulmonary Disease Nursing Care

Ineffective airway clearance in Chronic Obstructive Pulmonary Disease

Discuss about the Chronic Obstructive Pulmonary Disease Nursing Care.

Ineffective airway clearance mainly results from enhanced airway inflammation and oedema. Obstruction bronchitis is major disease in Chronic Obstructive Pulmonary Disease characterised by inflammation of the bronchi and bronchioles (Bolton et al, 2013). Besides, mucus gland hyperplasia, increased goblet cell production leads to overproduction of phlegm and mucus, which damages cilia and blocks the respiratory linings.

Gaseous exchange takes place between the alveoli and capillaries in the alveoli walls and it involves oxygen delivery to tissues while carbon IV oxide is eliminated from the bloodstream to the lungs (Vestbo et al, 2013). Prolonged smoking a causative factor in Chronic Obstructive Pulmonary Disease results in destruction of lung parenchyma cells lining the alveoli. As a result alveoli walls loose the elasticity and are damaged leading to high compliance (Sallis, 2016). In addition, air is trapped in the large air spaces within the altered alveoli thus inhibiting lung deflation. Eventually, this impairs the exchange of oxygen and carbon IV oxide across the alveoli.

Healthy airways and air sacs have elastic muscles that contract and relax while breathing (Eisner et al, 2010). However inflamed and obstructed airways in Chronic Obstructive Pulmonary Disease in conjunction with   inelastic air sacs lowers the respiratory rate tidal volume thus affecting the ventilation-perfusion ratio leading to impaired ventilation.

Clogged airways in Chronic Obstructive Pulmonary disease patient’s leads to expiratory airflow limitation thus breathing will require an added effort thus increasing their resting energy expenditure (Turan et al, 2014). Because of the increased metabolic demands, calorie intake has to be increased to avoid weight loss. Moreover, decreased dietary intake because of inherent inability to eat due to coughing, anorexia and chronic mucous production contributes to imbalanced nutrition intake.

Mucous filled airways and inflammation of both the airways and air sacs impairs the innate immune system (Vestbo et al, 2013). The impairment of the innate immune system is responsible for the colonization of the respiratory tract with bacteria leading bacterial infections mainly flu and pneumonia.

Oral prednisone is a systemic corticosteroid that blocks the airway eosinophilic inflammatory markers and serum C-reactive protein thus decreasing airway inflammation to manage dyspnoea.

Ipratropium bromide via nebuliser is an inhaled bronchodilator (Bolton et al, 2013). As an anticholinergic, its administration via a nebuliser facilitated its direct entry into the lungs. It relaxes the smooth muscles around the airway increasing dilation thus improving breathing.

Gaseous exchange in Chronic Obstructive Pulmonary Disease

Oral amoxicillin is an antibiotic that was administered because the patient had developed a cold and there was risk of developing pneumonia due to the impaired innate immune system (Sallis, 2016).

Ipratropium Bromide and Sulbutamol nebulisers contain an inhalation solution consisting of a combination ipratropium bromide, a long acting anticholinergic bronchodilator and Sulbutamol, a short acting β agonist that acts on smaller airways (Hartman et al, 2014). Adult dose include one 3Ml vial by nebulisation 4 times a day with up to 2 additional 3Ml doses allowed per day(Turan et al, 2014). The amount delivered to the lungs depends on patient factors and jet nebulizer utilized. Concerns include the delivery systems, efficacy of the drugs and drug interactions. Side effects to be monitored include body aches, ear congestion and chills from hypersensitivity.

A dosage of oral prednisone of between 40mg-100mg every 6 hours is an oral corticosteroid which decreases inflammation in the airways. It is also expected to speed up recovery rate (Khdour et al, 2012).  There is low risk of relapse and decreased rate of treatment failure. Thus, vital signs like breathing should be monitored to evaluate improved breathing. The patient’s weight, blood pressure and blood sugar levels should be monitored. It is a corticosteroid hormone that increases cardiac function and as a hyperglycaemic hormone, it can lead to secondary diabetes. Adverse effects include osteoporosis and stomach ulcers.

Oral amoxicillin is a first-line antibiotic which is administered as one 500mg tablet three times daily. The oral antibiotics are administered between 5-10 days (Hartman et al, 2014). Signs of bacterial infections like flu and pneumonia should be monitored since the drug has increased resistance from β-lactamase producing bacteria such as streptococcus pneumoniae. Side effects include allergic reactions thus; skin tests to determine tolerance are necessary.

My topic of choice would be why Neville needs to stop smoking. In this regard, the specific type of information that I will explain to Neville the patient includes the relationship between smoking and chronic obstructive pulmonary disease, its adverse effects and management. I will let him understand that the disease results to respiratory failure and smoking is its major risk factor (Reticker et al, 2012). The smoke includes cigarettes, cigars as well as second hand smoke exposure. Cigars contain nicotine and tar which when inhaled move down through the trachea and eventually into the bronchi and bronchioles which contain the alveoli responsible for gaseous exchange (Bakerly et al, 2011). The patient will understand that the contents of  the smoke contributes to the stiffening of the air sacs, thickening and inflammation of the airways, increased production of mucus in the airways due to goblet cells hyperplasia causing air obstruction according to Eisner et al (2010).. These are characteristic features of emphysema and obstructive bronchitis in chronic obstructive pulmonary disease which eventually leads to persistent cough that produces a lot of mucus. Impaired gaseous exchange contributes to anorexia and dyspnoea especially during exercise.

Healthy airways and air sacs in Chronic Obstructive Pulmonary Disease

In addition, I will let Neville understand that the inflammation of the air sacs which leads to development of air spaces within the air sacs that cause a wheezing sound while breathing and chest tightness (Reticker et al, 2012). It is important for the patient to understand that COPD is a progressive disease that has no cure. Lung damage from cigarette smoking is an irreversible process but lifestyle adjustments and some medical treatments aid in its intervention (Nguyen et al, 2015). Because of the interventions, symptoms are managed to avoid flare-ups. Management of COPD include medical treatments such as bronchodilators, glucocorticosteriods, flu and pneumococcal vaccines, pulmonary rehabilitation oxygen therapy, lung volume reduction and lung transplant.

Further, Neville will be made aware that smoking cessation is a major lifestyle intervention in COPD case management. Nicotine in the tobacco attaches to brain receptors in the brain leading to the addiction and difficulty in smoke quitting (Nguyen et al, 2015). However, interventions in smoking cessation help smokers who are trying to quit. Thus Neville should consider strategies such as use of medications which include nicotine replacement therapy, cytosine or varenicline according to Khdour et al (2012). Behavioural counselling is an important in smoking cessation and it includes assessment, advice and assistance to the patient. His supportive wife will be of help in offering home care to Neville.

Follow-ups to monitor progress and nicotine withdrawal symptoms would be necessary as part of clinical practice guideline.

There are several recommendations that nurse and doctors both in the hospital and in the home care facilities need to follow in regard to managing COPD. These include first, assessing the ddischarge status and further communicating directly to a discharge agency on patient required handling so as to ensure a seamless handover between the facilities (Reticker et al, 2012). Secondly, there is need to asses and address the patients’ psychosocial factors and even co-morbidity as they influence the expected post-intervention medication adherence. Thirdly, medical teams need to consider the probability of medication adherence on the part of the patient in order to prevent future hospital readmissions due to repeated exacerbations (Vestbo et al, 2013). Further, the medication and nursing plans need to incorporate the promotion of physical activities among patients and emphasize its positive influence on patient physical functioning and anxiety. Neville is undergoing acute flare-ups resulting from withdrawal symptoms.  Exacerbations of Chronic Obstructive Pulmonary Disease are characterised the mentioned signs which include dyspnoea, reduced respiratory rate and increased heart rate(Bakerly et al, 2011).

Clogged airways in Chronic Obstructive Pulmonary disease

I would connect the nebuliser mask and tubing to the oxygen inlet to oxygen therapy through ipratropium bromide using the nebuliser.

I would administer inhaled prednisone since it is useful in acute flare-ups. The corticosteroid drug will decrease inflammation thus improving breathing (Turan et al, 2014).

 Ipratropium bromide is a long acting bronchodilator and it opens up the central airways. The long acting anti-muscarinic agent improves lung function, dyspnoea and quality of life (Hillegass et al, 2017). The nebuliser was used to facilitate direct entry of the drugs to the lungs to facilitate faster dilation of muscles thus improving breathing.

Inhaled prednisone was necessary as an anti- inflammatory and is recommended for symptomatic patients at a high risk of exacerbation.

Neville is 62 years male presenting with severe, but established COPD. He has a long history of cigarette smoking. This patient was admitted to hospital the previous 2 days and diagnosed with worsening dyspnoea, increased purulent sputum and cough.

Neville reports that he had developed a cold several days before he was admitted. The patient also reported that his usual preventative medications could not relieve the mentioned symptoms.

Since admission, his upper respiratory symptoms improved but after being administered with salbutamol nebuliser, I noticed that Neville was restless, anxious with dyspnoea.

His pulse has increased to 110 beats per minute and has slight increase in the respiratory rate and oxygen saturation. Nasal prong oxygen remains in place.

The medical orders for nasal prong oxygen administered at 2L/min in order to the lower oxygen saturations from 88 to 92%. The patient needed; spirometry before the administration of nebulisers and after; high protein and carbohydrate diet; administration of intravenous fluids (Bakerly et al, 2011).

Current medications are ipratropium bromide nebuliser, inhaled prednisone, oral amoxicillin-clavulanate, prn paracetamol. Pneumococcal and flu vaccines have been administered.

Neville is undergoing smoking cessation. He has stopped smoking and is currently managing withdrawal symptoms. He has been admitted in our facility with health care professions who are very supportive.

References

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Eisner MD, Blanc PD, Yelin EH, et al(2010). Influence of anxiety on health outcomes in COPD. Thorax. 65(3):229-234.

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Nguyen HQ, Rondinelli J, Harrington A, et al(2015). Functional status at discharge and 30-day readmission risk in COPD. Respir Med. 109(2):238-246.

Reticker AL, Nici L, ZuWallack R. (2012). Pulmonary rehabilitation and palliative care in COPD: Two sides of the same coin? Chronic Respiratory Disease. (2):107-16. https://search.proquest.com/docview/1020122025?accountid=14375. doi: https://dx.doi.org/

Sallis R.E.(2016). Call to action on making physical activity assessment and prescription a medical standard of care. Curr Sports Med Rep.

Turan O, Yemez B, Itil O (2014). The effects of anxiety and depression symptoms on treatment adherence in COPD patients. Prim Health Care Res Dev. 2014;15(3): 244-251.

Vestbo J, Hurd SS, Agustí AG, et al (2013). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: GOLD Executive Summary. Am J Respir Crit Care Med. 187(4):347-365.

World Health Organization (2013). How to use the ICF: A Practical Manual for Using the International Classification of Functioning, Disability and Health (ICF). Exposure Draft for Comment. Geneva: World Health Organization; 2013. Web https://www.who.int/classifications/drafticfpracticalmanual2.pdf?