Management Of COPD Patient – Assessment, Diagnosis, And Treatment

Types of care and their effects on service users

Mr. James, a 69 years old man comes to St Bartholomew’s (Bart’s) hospital with his wife complaining of difficulty in breathing and shortness of breath. James says “ever since this cold weather started, I have been having a hard time breathing. I need my lungs to be checked”. James wife explains that James has been having a hard time recently to the extent that he could not do normal routines anymore. In addition to that, James stated that he had had persistent coughs, especially during the night. Although a cough is productive, James and his wife fail to give an estimate of the sputum produced. Sleeping in the bed has been a problem in the previous night that he spent setting his back on his easy chair. James wife further explained that it is by her effort that James was able to come to the hospital. James wife came had come with the last medical records for review.

James reported having been admitted several times in the past years. The patient was first diagnosed with Chronic Obstructive Pulmonary Disease(COPD) at the age of 65 years and admitted for one month. One year later the patient was diagnosed with type 2 diabetes and Osteoporosis of which the conditions were managed. James was on anti-diabetes medication for one year at which the condition was later managed using diet and physical exercises. From the past health records, the patient was put on biophoshates  for the treatment of osteoporosis. At the age of 67 years, the patient developed hypertension of which the condition was managed using several antihypertensives. Patient has been on a proper diet and physical exercises until recent days where he could not perform enough activities. The patient has healthy siblings.

James is married with four children of which three are girls and one boy. Patient has a forty years history of smoking cigarettes. James used to smoke one pack of cigarette daily but reduced to a quarter pack after being diagnosed with COPD. The patient explains he had not been able to quit smoking, but he is working toward it. Patient has 35 years of taking alcohol but entirely after diagnosed with diabetes and osteoporosis. Currently, the patient lives with his wife only as all the children are grownups working at long distances from home. No known allergies.

Current medication

James has been on prednisolone 30mg daily, Saltemerol inhaler 50 twice daily, Aspirin 81mg daily and tiotropium inhaler only when needed.

Impact of illness on individuals and families

Warm skin and dry with no rashes. BP170/87. RR 32, Temperature 37.5 celsius, weight-76kilograms, 5’9, pulse rate80 beats per minute, oxygen saturation 85%.No skin crackles, patient well nourished. The patient seems confused. Spirometry of FEV1 45% is predicted that does not seem to change with the use of inhaled bronchodilators. The patient is audible but unable to make full sentences. The patient has dyspnea with a productive cough with grey sputum, audible wheezing, mild chest tightness. Patient seems to adopt tripod sitting position .the use of accessory respiratory muscles and neck muscles while breathing is noted.

As an assistant practitioner, the first line in managing the Patient is by detecting and checking the presence of airway obstruction by performing the post-bronchodilator spirometry (Wise, 2016). James seems to have an air obstruction. His spirometry is FEV1 of 45 %, indicating his condition is severe(NHS, 2018). James will definitely need a formoterol 20 mcg inhaled via nebulizer in 12 hours or indacaterol 75 mcg inhaled orally daily(NHS, 2018). Musculonist agonist such as glycopronium one capsule inhaled per twelve hours using a neon inhaler can be useful(NHS, 2018).

If Long-acting beta-agonist does not work, add an added dose of inhaled corticosteroid can also be used if James continues to have shortness of breaths(NHS, 2018). This includes drugs like a high dose of budesonide powder inhalation of about 1200ug (Wise, 2016). Since James seems to have developed exacerbations, pulmonary rehabilitation should be advocated and made available to him (Wurst, Punekar, and Shukla, 2014).Management of exacerbations should be minimized by giving advices to James and his wife. In addition, the assistant practitioner should always respond immediately to any symptom of an exacerbation (Resuscitation Council,2015).  Other than that, appropriate use of inhaled corticosteroids, vaccination with pneumococcal vaccine and bronchodilators should be enhanced. Try to use noninvasive ventilation whenever indicated and advocating for the hospital at home can also be used in the management of James condition(Resuscitation Council,2015).

In addition, giving James proper education and psychological support in order to help him cease smoking completely can be one of the essential actions of James management. James should be explained the need for quitting smoking encouraged to stop and even given an offer in the process to promote positive results (Wurst, Punekar, and Shukla, 2014).

James who is at risk of having more COPD aggravating factors should be given a self-management advise which will encourage him to respond promptly and call for help when symptoms arise. James should be instructed to start oral corticosteroids whenever the breathing start interfering with daily living activities(Resuscitation Council,2015). The assistant practitioner should always make sure that antibiotics and corticosteroids are always available near the patient for a self-management strategy. The patient should be enforced with a proper education in order to ensure the adherence to the guidelines of use(Resuscitation Council,2015).

Patient case study: Mr. James

In Management of COPD patients like James, working with other healthcare workers is the most critical role in management (Yeung et al., 2014). An assistant care practitioner should always involve all healthcare professionals in the care of people with COPD, especially when assessing the spirometry (Yeung et al., 2014).  Other than that, treatment and care should take into account patients needs and preference. James being a patient should be given an opportunity to make informed decisions about his care and treatment including a partnership with all other healthcare workers(Resuscitation Council,2015). If James cannot be able to make health care decisions, it is the responsibility of the assistant practitioner to be involved plus including other medical teams to follow the code of practice that is usually accompanied by the mental status act.

The assistant practitioner should also ensure there is a good communication between him and other healthcare workers and even with the patient(NHS, 2018). Communicating with the patient and other healthcare workers should be culturally appropriate. Other than that, family and cares like James wife should be given enough information and support they need about the patient (NHS, 2018). The assistant practitioner should always refer to specialist advice in certain levels of disease care like when exacerbations are challenging to manage. However, it is advisable to ask for advising all levels to prevent mismanagement(NHS, 2018).

Managing smoking cessation is a multidisciplinary action that requires patient, family members and other healthcare teams (Parkes, 2013). Enquire from the patient and family members the number of years the patient has been smoking in order to determine the correct therapy (Parkes, 2013). Help the patient using other health care workers like a therapist to choose the proper recommendation of smoking cessation in all opportunities the patient to have (Parkes, 2013). All multidisciplinary teams should also be included in undertaking activities which aim to avoid emergency admissions, advising the patient and educating the patient on other healthy lifestyle issues (Parkes, 2013).

There are various underlying principles used in assessing patients with COPD. This includes airway, breathing, circulation, disability, and exposure (Yeung et al., 2014).  All the above principles are needed to be done initially and regularly so as to be able to manage any life-threatening problems or complication that may arise (Yeung et al., 2014). This will still enable one to know when there is a need for extra help in order to be able to call for assistant early enough (Yeung et al., 2014).  Always remember it may take a while for treatment to work therefore it is always for the best to take few minutes before reassessing the patient (Yeung et al., 2014).

Management of COPD patients

During the initial assessment as an assistant practitioner always ensure you have adequate self-protection (McNulty, Jordan and Hopkinson, 2014). This includes wearing face mask, aprons and gloves appropriately (McNulty, Jordan and Hopkinson, 2014). In addition to that, it is always crucial to observe the patient keenly in order to assess general patient appearance (McNulty, Jordan and Hopkinson, 2014). This is done by checking if the patient is fully awake, whether he or she can speak, and his general feelings including what is his complain at the moment. Good indications of sufficient breathing can be merely be identified through checking if the patient can be able to talk or respond to general commands (Malcolm et al., 2017). However, if unable to talk or speaking is not clear, it is a good indication of some difficulty in breathing which demonstrates that the patient has developed signs of critical illness (Malcolm et al., 2017). Always use the basic resuscitation principles which involve asking general questions like patient names, looking the general appearance of the patient, listening to the patient talk and feel if the patient is breathing or not (Malcolm et al., 2017). If the patient is unresponsive or having occasional gasps always check the strength of the pulse. From the results, you start cardiopulmonary resuscitation according to resuscitation guidelines (Malcolm et al., 2017). Monitor vital signs as early as possible by attaching pulse oximeter, ECG monitor, thermometer and non-invasive blood pressure monitor (Malcolm et al., 2017). In addition, it is always advisable to Insert an intravenous cannula and take blood for investigations as soon as possible (Malcolm et al., 2017).

AIRWAY (A)

Airway obstruction is emergency and needs immediate intervention since if left untreated it can cause hypoxia leading to multiple organ damages and death (Lim et al., 2015) Treat airway obstruction as an emergency, try to check what can be causing the obstruction. In case of secretions, suction is recommended to achieve airway clearance (Lim et al., 2015). Tracheal intubation is required only where there is a complete obstruction (Lim et al., 2015).Where there is no complete obstruction, put the patient on high oxygen concentration via mask to ensure good air circulation in the body and to prevent hypoxia. Always maintain oxygen concentration at 94-98% (Lim et al., 2015).

BREATHING (B)

When assessing James breathing assistant practitioner need to look, listen and feel for the general sign of respiratory distress which includes cyanosis, sweating,  nasal flaring and breathing using accessory muscles(Resuscitation Council,2018).  Count the respiratory rate, anything above 25 breath/min is an indicator of distress as the standard rate is 12-20 breath/min.   Listen to patient’s breath sounds a short distance from his face, ratting airway noises shows the presence of secretions that can be caused by the inability of the patient to a cough(Resuscitation Council,2018). Wheeze sounds suggest of partial but severe airway obstruction.  Auscultate the chest to check if there is the presence of reduced bronchial breathing which may indicate pneumothorax or presence of pleural fluid that can cause a complete obstruction(Resuscitation Council,2018).

Spirometry and diagnosis

CIRCULATION (C)

In most of the medical and surgical emergency,  hypervolemia is the most cause of shock unless proven otherwise (Punekar, Shukla and Muellerova, 2014).  Unless James circulation has any cardiac cause,  give intravenous fluids if the patient has cold extremities and fast breathing (Punekar, Shukla and Muellerova, 2014).Assess for cyanosis especially from the extremities and treat the underlying causes to prevent further complications (Punekar, Shukla and Muellerova, 2014).

DISABILITY (D)

Common causes of unconsciousness are hypoxia, cerebral hypoperfusion, hypercapnia or use of sedativesJames general assessment should be done which includes checking the patient alertness, if he responds to vocal response and painful stimuli or if he is unresponsive to all stimuli. Glasgow coma scale( GCS ) score can also be used to assess the level of consciousness. Blood sugars should also be taken and recorded to exclude hypoglycemia (Resuscitation Council,2018).   In case James has hypoglycemia you should correct blood glucose levels using glucose solution intravenously(Resuscitation Council,2018). Be cautioned not to raise too much of blood sugars as James had a history of diabetes type 2. The unconscious patient should be managed in a lateral position where the airway is not protected(Resuscitation Council,2018).

EXPOSURE (E)

Perform a head to toe exam when assessing the patient. During assessment remember to respect patients dignity and minimize the heat loss (Davidson, 2013). Take a detailed clinical history of James and his wife (Davidson, 2013). Review your patient regularly and do the recording of patients responses. Treat any other underlying condition that may lead to the respiration distress (Davidson, 2013)

NURSING CARE PLAN

Ineffective Airway Clearance related to bronchospasm, increased production of secretions as evidenced by patient complaining of difficulty breathing and presence of abnormal breath sounds (wheeze) (Hertel et al., 2012).

Expected outcomes

 James will maintain a patent airway with clear breathing sounds, be able to expectorate secretions effectively (Hertel et al., 2012).

interventions

Rationale

Assess and monitor respiration rate and sounds such as wheeze and crackles Auscultate for breath sounds Suction can be done to remove excretions. (Hertel et al., 2012)  Elevate the head of bed and patient to assume the lean position. Keep the environment clean from pollution such as dust Observe cough characteristics and assist with a measure to improve the effectiveness Administer bronchodilators as prescribed (George et al., 2013)

Tachypnea and dyspnea is usually present and can be realized on admission To detect any breathing obstructions present. Removal of secretions will reduce resistant to air movement in the bronchi  (Hertel et al., 2012) The lean position will ease breathing and facilitates respiratory function by use of gravity. Precipitation of allergic reactions can trigger COPD exacerbations. Persistent coughing may lead to discomfort. To maintain airway patency (George et al., 2013)

 Impaired Gas Exchange related to altered perfusion ( obstruction  of the airway by secretions, bronchospasm ) as evidenced by dyspnoea, abnormal  breathing, changes in vital signs and cyanosis (George et al., 2013)

Expected outcome

 James will present with improved ventilation and tissue perfusion and free from symptoms of respiratory distress within 1 hour.

Interventions	Rationale
Acquire and assess the respiration rate Administer oxygen in a higher concentration Elevate the head of the bed Monitor skin color (George et al., 2013)	Respiration rate is useful in evaluating the degree of respiratory distress. Oxygen supply with aid in tissue perfusion Elevating the head of the bed will ease the breathing. Cyanosis may be present which indicate advanced hypoxia (George et al., 2013)

Nursing Diagnosis

 Imbalanced Nutrition Less than the body requirement related to dyspnoea as evidenced by weight loss reported altered taste sensation and lack of interest in food (George et al., 2013).

Expected outcomes

James will demonstrate progressive weight gain  appropriately and regain food appetite

Interventions	Rationale
Assess understanding of individual nutrition needs and dietary habit of the patient. Acess the dietary habits and recent food intake	This to determine the informational need and how to improve. Many COPD patients eat poorly due to dyspnea, and they may develop malnutrition

 Nursing diagnosis

Medications for COPD management

 Risk of infection related to inadequate primary defense (stasis of  secretions) (George et al., 2013) 

Expected outcome

James will have reduced chances of infection during the treatment period

Interventions	Rationale
Monitor body temperatures Administer antibiotics prophylaxis (George et al., 2013)	the temperature will be high in case of infection  Antibiotics Prophylaxis is a good measure when preventing infections. Antibiotics kill any introduced bacteria in the body thus preventing infections to occur. (George et al., 2013)

MEDICATION

The aim of the therapy is to control the symptoms, reduce the risk of complications and exacerbations, and improve your ability to lead an active life (Thomas et al., 2013).

 Encourage the patient to stop smoking and offer to help. Unless where it is contraindicated, offer varenicline or bupropion as appropriate and combine with a support programme (Thomas et al., 2013).  Varenicline is only recommended where the patient express a desire to quit smoking and it is only prescribed as part of support programme of behavioral change (Thomas et al., 2013).

Bronchodilators

Inhalers that containing vasodilators and muscle relaxants around the airways easing breathing and relieve a cough, according to the severity of the disease one can use short acting or long acting for daily use (Thomas et al., 2013). There are two types of short-acting bronchodilator inhalers which Include Beta 2 agonist inhalers such as salbutamol and antimuscarinic inhalers such as ipratropium (Thomas et al., 2013). Short-acting inhalers should only be used where there is shortness of breath to a maximum of four times a day.

Long-acting inhalers should only be recommended where symptoms persist throughout the day (Rothnie et al., 2017). These inhalers work similarly as short-acting inhalers only that their action last for at least twelve hours (Rothnie et al., 2017). Therefore long-acting inhalers should only be used once or twice a day. There are two types of these inhalers which include beta 2 agonist inhalers such as salmeterol and antimuscarinic inhalers such as tiotropium (Rothnie et al., 2017) .

 Steroid Inhalers

These are corticosteroids medications that reduce inflammation and prevent exacerbations(NHS, 2018). Steroids inhalers can only be used when long-acting inhalers fail to work (Hertel et al., 2012). These types of medications normally help to reduce inflammation along the airway pathways and are usually used alongside with long-acting inhalers as combination therapy. A good example is budesonide inhalers (Hertel et al., 2012).

 Oral steroid

  This medications should not be used for a long time due to there side effects, for example, they increase the risk of weakened bones (osteoporosis), diabetes and catarac (Gruffydd-Jones and Loveridge, 2015)t. A 7 to 14 days treatment is usually recommended. Long-term prescription can only be prescribed by COPD specialist (Gupta, Allen-Ramey and DiBonaventura, 2012). These oral steroids prevent inflammations of the airways. A good example of commonly used oral steroid is prednisolone (Gupta, Allen-Ramey and DiBonaventura, 2012).

Management of COPD exacerbations

Antibiotics

 Antibiotics are only prescribed where there are symptoms such as fever, coughing up yellow sputum, rapid heartbeat, and chest pains (Gruffydd-Jones and Loveridge, 2015).

Theophylline Tablets

This medication normally opens up the airways and it is usually taken twice a day. Blood tests are recommended when taking theophylline in order to check the level of medication in the blood. This helps to reduce side effects such as headaches, insomnia, and palpitations (Gruffydd-Jones and Loveridge, 2015).

References

Davidson, C. (2013). NICE COPD update: a good reminder of best practice. Prescriber, 21(20), pp.6-9.

George, P., Stone, R., Buckingham, R., Pursey, N., Lowe, D. and Roberts, C. (2014). Changes in NHS organization of care and management of hospital admissions with COPD exacerbations between the national COPD audits of 2003 and 2008. QJM, 104(10), pp.859-866.

Gruffydd-Jones, K. and Loveridge, C. (2015). The 2010 NICE COPD Guidelines: how do they compare with the GOLD guidelines?. Primary Care Respiratory Journal, 20(2), pp.199-204.

Gupta, S., Allen-Ramey and DiBonaventura, M. (2012). Patient characteristics, treatment patterns, and health outcomes among COPD phenotypes. International Journal of Chronic Obstructive Pulmonary Disease, p.779.

Hertel, N., Kotchie, Samyshkin, Radford, Humphreys and Jameson (2012). Cost-effectiveness of available treatment options for patients suffering from severe COPD in the UK: a fully incremental analysis. International Journal of Chronic Obstructive Pulmonary Disease, p.183.

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McNulty, W., Jordan, S. and Hopkinson, N. (2014). Attitudes and access to lung volume reduction surgery for COPD: a survey by the British Thoracic Society. BMJ Open Respiratory Research, 1(1), p.e000023.

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Parkes, G. (2013). Asymptomatic COPD and NICE guidelines. British Journal of General Practice, 61(585), pp.294-295.

Pharmacy COPD (2014) screening could save the NHS £264m. The Pharmaceutical Journal.

Punekar, Y., Shukla, A. and Muellerova, H. (2014). COPD management costs according to the frequency of COPD exacerbations in UK primary care [Corrigendum]. International Journal of Chronic Obstructive Pulmonary Disease, p.247.

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