Assessment And Management Of Chronic Obstructive Pulmonary Disease- Nursing Case Study

Pathophysiological changes in COPD

• Explain the pathophysiological changes that occur as a result of long term health problems

• Demonstrate an understanding of the pivotal role of communication in continuing care

• Explain the relationship between attitudinal development and belief systems to the individuals perception and responses to their health circumstances  

• Analyse the role of life events and lifestyles in terms of health status and coping strategies

According to Elsherief and Noble (2011) is a chronic illness and caused due to tobacco smoking. From researches, it is found that COPD is the fifth most common cause of mortality and morbidity in the UK Elsherief and Noble (2011). The aim of this paper is to discuss about the condition of a patient who is suffering from Chronic Obstructive Pulmonary Disease (COPD) and the interaction of nurses with the patient to help him. A real life case study was taken to develop this paper. To avoid the ethical issues regarding patient’s confidentiality, an alias name is used to refer the patient (Nursing and Midwifery Council 2015). In this paper, the patient is referred as “Frank”. For assessing, planning, implementing and evaluating, the care of Frank ‘Roper, Logan and Tierney activities of daily model’ is used (McCrae, 2012). This model is used to assess, as it allows the methodical identification of potential or actual problems that the patient may face and allows the clear recognition of nursing needs (McCrae, 2012).

Frank (60 year old) from London has been admitted to the hospital with Chronic Obstructive Pulmonary Disease (COPD). Frank started his career from the age of 20 years old as a builder. He stopped working at the age of 58 to take care of his wife. His wife later died of breast cancer and his son has now lived in Australia. From the medical history, it was found that in 1989, Frank was diagnosed with prostate cancer and went through treatment. He was very depressed therefore, started smoking heavily. In 2010, he was diagnosed with COPD. After that, he has lost weight and he was becoming breathless when doing household tasks and simple exercises.

To assess the present condition of the patient, assessment tool was adapted from Roper, Logan and Tierney’s activities of the daily living nursing model. This model is used to assess, as it allows the methodical identification of potential or actual problems that the patient may face and allows the clear recognition of nursing needs (McCrae, 2012). This assessment framework is one of the most popular frameworks used in the UK and Ireland. This tool is easy to use and translate into practice (McCrae, 2012). The activities of living are often considered to have limited scope, which leads to the dissatisfaction of the model. Therefore, according to Roper, 1996 this tool should not be used as checklist, but as a nurses’ approach to the health care organization. However, the complexity of this model limited its application.

Pivotal role of communication in continuing care

The nursing treatment is an organized series of problem-solving mechanism used to recognize and to manage the health troubles of a patient (Postma et al. 2011). Activities of daily living (ADL) of Frank were assessed following steps methodically, such as assessment, planning, implementation and evaluation (Weldam et al. 2013). It is found that Frank is facing main problems related to his mobility, eating and drinking. General mobility, eating and drinking are considered as basic ADLs, since these are self-care tasks. A patient experiencing problems with basic ADLs needs intense care of the nurses. However, not only the physical condition but also the emotional aspects of the patient’s health needed to be considered. The limitation of ADL framework is, this framework does not consider the emotional aspects of the patients. Therefore, the nurses need to use their profound knowledge throughout the process to prepare changes in approach to the patient’s altering state. The nurses need to use their clinical knowledge to identify the problems experiencing by the patients. To understand the physical and psychological condition of the patient and to help them, nurses can use Maslow’s Hierarchy of Human Needs. This theory is helpful since it can explain the patient’s psychological needs, safety needs, needs of love, self-esteem and self-actualization (Thielke et al. 2012).

According to (Wilkins & Dexter, 2010), patient assessment is a conscious, organized and collaborating process that reinforces every aspect of nursing care. To recognize the patient’s needs and concern the nurses can use individualized care. Every patient is unique and so that their needs, therefore individualized care is helpful in the patient’s treatment. The process of assessment necessitates the nurse need to make precise and significant observation, to gather, confirm and put in the order data to make decisions about the care and treatment needs (Wilkins & Dexter, 2010). To assess a patient, nurse needs to consider about the patient’s physical, psychological, emotional, spiritual and cultural need.

Since Frank was diagnosed with COPD, it was found that he was losing weight rapidly as well as food appetite, which in turn causes anxiety and breathlessness. Another reason behind the weight loss of Frank is the side effect of certain medicine (such as salbutamol). To measure the nutrition, reduction, the nurses checked his weight and body mass index (Sundh et al. 2011). However, many researchers advised that BMI is less consistent in the older people because of age related changes, such as ratio of muscle to fat, posture and height (Garcia-Rio et al. 2012). According to many researchers, assessment is the initial step of the nutrition care process (Sundh et al. 2011). However, it provides the foundation for the nutritional diagnosis. The researchers also mentioned that MUST (Malnutrition Universal Screening Tool) screening process is simple, quick, reliable and inexpensive. Therefore, it can be used to identify who is suffering from malnutrition. This MUST plan also consists of management guidelines, which are used to develop a care plan for the patient (van Venrooij et al. 2011). This tool is vital and beneficial to the assessment and determination of risk by looking at the patient’s BMI, psychological stress, history of weight loss or any other condition that could affect their dietary intake. However, the use of this tool is very tedious. Use of MUST tool can guide the staffs to come up with an individual score for each patient and this score is helpful to assess Frank’s condition. Since, frank is diagnosed as malnourished, he need to be referred to a dietician.

Relationship between attitude and belief systems with patient’s perception and response to health circumstances

A nutritional risk assessment was performed to find out Frank’s risk of fluid, electrolytes or acid- base imbalance. It is observed that fluid balance chart helps to calculate urine output, eating pattern, fluid intake and bowel movements of a patient. Therefore, this fluid chart can be used to assess the fluid intake rate and eating patterns of Frank. Less amount of fluid intake can cause dry mouth, which in turn may have an impact on the nutrition and health of Frank. Less fluid intake can also change his eating pattern. Therefore, it is important to measure the fluid intake of the patient by using a fluid chart. On the other hand, administration of medicines such as diuretic flurosemide (used to ease breathing) can cause dry mouth and dehydration (Layec et al. 2011)

The nurses assessed Frank’s mobility and skin condition. According to nurses’ observation, it was found that his skin was intact, dry and flaky. In addition, frank appeared to be tired and lack of energy. Considering his energy level and skin condition it could be assumed that frank is at a risk of developing ulcers. Therefore, a “Waterlow risk assessment” was carried on, which indicated the risk areas that could be faced by Frank (Kaitani et al. 2010).

The aim of the nurse was to improve Frank’s weight, a balanced diet, implementation of skin care and fluid intake. The aim was to lessen the threat of other complications related to malnutrition such as poor infection, poor mobility, low energy and poor immunity (Kelly et al. 2010). According to NICE (The National Institute for Health and Care Excellence) guidelines (2010) all patients with COPD should be referred for pulmonary rehabilitation. This rehabilitation is helpful assisting Frank to improve his physical and social performance.

The healthy human lung is made up of springy and elastic fibers that allow them to constrict and stretch during breathing, which is vital in delivering oxygen to tissues and cells of the body, and to remove CO₂ (Parent, 2015). Lung can be considered unhealthy if it is unable to empty the air out such as in Chronic Obstructive Pulmonary Disease (COPD) (Galvagno, 2013). COPD can be caused by variable factors, such as, viruses, environmental pollution and tobacco smoking, which can cause inflammation of the airways and worsen obstructions leading to expiration flow limitation (Miravitlles et al., 2012).

The decrease in expiration and inspiration difficulties can attribute to the mucosal edema, bronchospasms and sputum inspissations. In most cases, exposure to noxious stimuli due to tobacco smoking can cause COPD. It is found that COPD amplified normal inflammatory response. However, the pathogenic mechanism of this phenomenon is unknown. However, it is observed that the increasing numbers of activated polymorphonuclear leukocytes release elastases in such a way that resulted in lung destruction. In addition, free radicals in tobacco smoke can increase oxidative stress of human. Autoimmune mechanisms and aging can also be accelerated by COPD.

Role of life events and lifestyles in determining health status and coping strategies

The lungs are composed of the bronchi and contain approximately 300 million pulmonary air sacs called alveoli where gaseous exchange takes place – a process known as diffusion (Peate and Nair, 2015). Both capillaries and the alveoli have cell-thick walls, which facilitate gaseous exchange via diffusion through the respiratory membranes (Khurana, 2013). It is observed that surfactant fluid (secreted by septal cells) prevents the alveoli from drying out and the subsequent reduction in the surface tension that prevents the alveolar from collapsing during expiration (Khurana, 2013). In respiration, oxygen is absorbed into the blood stream from the air sac and the carbon dioxide is transferred into the air sac from the lungs. Since, Frank started smoking excessively, the elimination of carbon dioxide from his body will be restricted. It is found that the excess presence of excess carbon dioxide in the body may lead to the decrement of hydrogen potential (pH) in blood. In addition, excess CO² can dissolve in body water to create carbonic acid, which can make Frank’s blood more acidic. The normal pH of the human body is 7.35 to 7.45, which is slightly basic (Seimetz et al. 2011). Therefore, it is certain that frank is going to face health related problem due to pH change of the body, in the future.

Peterson (2012) informs that healthy lungs are porous like a sponge and springy to touch and have a reserve capacity where a person rarely breathes deep enough to fill the lungs completely. While, during expiration stretched lungs have an elastic recoil tendency to spring back into shape, which provides the required force for the satisfactory expiratory flow (Seimetz et al. 2011). Irreversible and progressive damage to the lungs in patients with COPD can lead to the inability to exchange oxygen for carbon dioxide (due to the accumulation of carbon in the lungs); therefore, Frank may face shortness of breath (dyspnoea) in the future. In addition, Breathlessness or dyspnoea is correlated with reduced nutritional intake, which can lead to malnutrition because of elevated energy output associated with labored breathing (Parshall et al. 2012). Obstruction of the airways is the final stage of lung damage in COPD due to the loss of elastic recoil, airway narrowing, inflammation and too much mucus, which traps air in the lungs during exhalation. The degree of airflow obstruction in COPD is due to increased airway resistance and the reduction of lung elastic recoil. If COPD is not treated in its early stage then it can lead to the death of the patient. However, it is found that symptoms are reduced when the patient stops smoking tobacco (Parshall et al. 2012).

Roper, Logan and Tierney’s activities of daily living nursing model

Self- care of patient includes the patient’s capability to endure with their treatment and long-term condition or generate suitable lifestyle changes. From previous researches, it is found that patients do not like to stay in hospital unless it is necessary (Goeschel et al. 2010). Successful implementation of self-care is efficient to decrease the frequency of hospital admission. Self-care is, when a patient takes responsibilities for their own health and wellbeing, with additional support from their family and healthcare workers. However, from the family history of Frank it is observed that His wife is dead and his only son lives in Australia, therefore practically he does not have any family member to support him in self-care. Therefore, Frank need to rely on his health care professionals (nurses). On the other hand, Dieticians can understand the unique goals and challenges of a patient, therefore, Frank need to consult with a dietician. Frank is suffering from malnutrition and the need to change his eating habit. A dietician can help him to establish a healthy eating pattern. However, dietician and Frank need to work together and decide what he would like to accomplish with a better diet. According to previous researches weight, maintain is very important for COPD patients, since COPD is one of the main reasons to the reduction of weight, which in turn may lead to the health related problems in future (Farooqi et al. 2011).

The dietician need to gather all the information they need to help the patient (Frank) and the next step is to create an eating action plan especially for him by considering his all health related factors (Farooqi et al. 2011). According to other researchers, this step should be taken by the dieticians, not only for the COPD patient, but also for the other patients who are suffering from diabetes or high blood pressure. The development of eating plan should reflect Frank’s eating patterns, that is, whether he prefers three smaller meals throughout the day. Since, Frank is appeared as tired and lack of energy, the dietician can encourage him to consume glucose polymers in powder or liquid regularly so that he can have a boost of energy whenever needed. Addition of glucose can increase the energy content in diet chart.

Foods charts are vital since the necessary information needed to form the basis of a nutritional assessment. Food chart is used to indicate the valuable resources for the patient (Farooqi et al. 2011). The food chart is essential to assess if Frank is eating and drinking enough, thus allowing an action to be taken to support him with reduced dietary intake. Frank’s food chart demonstrate that he is consuming less colorized food. Therefore, dietician needs to include high calorie food in Frank’s diet chart, which will help him to recover from malnutrition. On the other hand, he is also suffering from dehydration. Therefore, dietician needs to take care of the fluid consumed by the patient (Frank).

Use of Maslow’s Hierarchy of Human Needs for patient care

On the other hand, Frank also needs the help of a physiotherapist as he is experiencing mobility problems. Physiotherapy helps to reinstate function and movement when someone is affected by disability, illness or injury (Tang et al. 2010). Therefore, physiotherapy will be helpful to restore his movement and function. It takes a holistic approach that involves the patient directly in their care. The duty of a physiotherapist is to take care of people of all ages, assisting them to manage their pain, using a variety of methods to assist recovery. According to Tang et al. 2010, physiotherapist treats physical problems that are a link to the body system. It can be assumed that the proper treatment from physiotherapist will help to resolve problems of bones, joints and soft tissues, which in turn will help to reduce the respiration problem, experienced by Frank. The Occupational therapy is focused on general life skills, such as the ability to help him function independently, from personal hygiene to shopping. The therapist can suggest Frank things like safety rails next to the toilet or tub. They also need to educate Frank on how to maneuver and make changes in his home to accommodate it. The occupational therapist can show him energy saving techniques if they are exhausted to bath and dress and recommend a shower chair or safety mats, if situation demand. This will help him to ease his movement and lead a better and safe lifestyle. 

Communication is considered as the act of transferring information between two men (de Vito 2013). The fundamental skills used by a nurse to communicate with a patient are questioning, listening, explaining and reflecting (McCabe & Timmins 2013). These skills should be put into practice, to achieve the best outcome, and this can achieved through teamwork and collaboration between the patient and the nurse. Communication skills are important while providing treatment to a COPD patient. Frank a patient diagnosed with COPD is also suffering from depression and other associated diseases. It is observed that patients suffering from depression not only needs clinical treatments, but also need care and respect from the nurses. Therefore, nurses need to give their full attention to listen Frank’s problem and then help him out. Nurses in the health care system should use an excellent communication skill such as talking with him more patiently to gain his trust as well as providing him a friendly environment. Being a patient it, is important to listen the patients since listening to a patient concern is the most caring acts and an important aspect of being a nurse. Verbal communication is very important because if a nurse fails to communicate with the patient verbally, then the patient could feel more depressed and in turn, it may affect the proper diagnosis of the patient. It is observed that without communication, nurses would be unable to provide the correct care. Therefore, nurses need to talk with Frank more patiently to learn details about the symptoms or the experience faced by him, so that they can provide proper interventions for him (McCabe & Timmins 2013). To develop the communication skill and gain proper information from Frank the nurses need to frame questionnaire format, which consists of short but open-ended questions. Open-ended questions are helpful to acquire information from the patient, since this questionnaire format provides space to express the feelings of the patient in detail. This is helpful because Frank will have opportunity to express his feelings and experience of physical illness to the nurses, which in turn will be helpful to diagnose him in a better way.  On the other hand, close-ended question is helpful to narrow down the potential answer of the patient, which is helpful to acquire information from Frank and evaluate his situation rapidly (McCabe & Timmins 2013). From previous researches, it is found that the poor communication with patients can contribute a negative response, such as affecting decision-making and quality of life (Gardiner et al. 2010). In addition, different communication methods were used to reassure Frank such as providing companionship, friendly environment, making appropriate eye contact and low tone of voice while talking with him, etc. Communication between Frank and the nurses becomes vital since, Frank has no family members to talk. Therefore, he needs to talk with someone and express his feeling, which important to recover him from his state of depression. Only nurses have the chance to talk with him, encourage him to lead a healthy life and help him to recover from depression. Through proper communication, the nurses will be able to teach him about his physical condition, which in turn may encourage him to quit tobacco smoking (Gardiner et al. 2010).

Importance of individualized care in patient treatment

Conclusion

Smoking cessation is the most important intervention to slow the disease progression of COPD. There are many different ways to help a patient to stop smoking. However, the help of family members is important to recover him from his current situation. From the case study it is found that Frank has no family to take care of him. His wife is dead and his only son is now in Australia. Therefore, nurses need to provide him company and talk with him to resolve his problem. The nurses also need to reserve him in conversation and teach him about his physical condition so that he can recover from his depressed condition and lead a healthy life.

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