The aim of this essay is to explore evidence based nursing intervention in the care and management of chronic obstructive pulmonary disease (COPD) in an acutely ill patient.
The acutely ill patient involved in this essay was admitted to hospital due to cerebrovascular accident and had a past medical history of myocardial Infarction, left Ventricular failure, peripheral vascular disease and duodenal ulcer as well as chronic obstructive pulmonary disease. This essay will provide a rationale for the chosen aspect of care (COPD) and reason will be given why it is a priority.In particular the essay will examine the significance of the underlying pathophysiology of the disease relating to the acutely ill patient other conditions. The nursing intervention will focus on the measures in order to manage the acutely ill patient experiencing breathlessness. The involvement of other members of the multidisciplinary team, some of the relevant drugs, the common test and investigations will discuss as a part of the nurse holistic care process.
Main Body The author chooses chronic obstructive pulmonary disease (COPD) from a clinical perspective, as it is a long-term condition that is associated with impaired lung function and lung damage which interferes with gas exchange and ventilation in the respiratory tract, causing an acutely ill patient to experience severe difficulty with airway clearance, alterations in breathing patterns, and impaired oxygenation, as well as anxiety (Currie 2009).It also imposes a considerable burden on the acutely ill patient’s quality of life in terms of ability to live independently, financial losses due to absence from work, premature retirement and psychological well being which eventually leads to depression, and feeling of being trapped by the disease (Whittaker 2007). Chronic obstructive pulmonary disease (COPD) is estimated to be the third leading cause of mortality through out the world by 2020. The disease affected approximately 600 000 people and cause more than 26 000 death each year in the UK (Mannino 2001).
On average the disease reduces life expectancy by nearly 2 years, which has out number the other advanced diseases. Since the mid-1990s, COPD increased emergency admissions to hospital due to worsening episodes (Currie 2009). This high prevalence is a Hugh burden on health services. Hospital stays for COPD exacerbation typically last about ten days, with patient occupying beds and slowing the admission of patients from primary care for operations or other procedures (Lynes2007).Therefore, prevention or optimal treatment of exacerbations is a global priority and the author will looks at measures to prevent an exacerbation of chronic obstructive pulmonary disease.
According to (Whittaker 2007) chronic obstructive pulmonary disease (COPD) is part of a large class of lung disease in the respiratory system and the pathophysiology is not clearly identified. Although, there is a growing bodies of evidence highlights that chronic inflammation is the underlying cause of narrowing and remodeling of the airways.The lung is an organ which transfers oxygen from the air into the blood and carbon dioxide from the blood into the air. The air we breathe enters the body through the nose and mouth leading into the airways to the tiny air sacs of the lungs, called the alveoli.
In the air sacs, oxygen that we breathe passes through the walls of air into the bloodstream. Carbon dioxide passes in reverse direction, out of the bloodstream, back into the alveoli, and is then eliminated when we breathe out.Over a period of time emphysema and chronic bronchitis leads to shortness of breath, weakness, dizziness, fatigue and a persistent, productive cough (Rennard 2009). Airflow obstruction occurs as a result of loss of elasticity of the lung tissue and permanent enlargement of the alveoli due to destruction of the walls that gradually destroyed making it is difficult to absorb enough oxygen (Fehrenbach 2002).When the respiratory tissue damaged, the body’s inflammatory responses cause the lining of the airways to become swollen and thickened as a result of constant irritation that leads to an excessive mucus secretion in effort to protect the lungs from inhaled irritants such as cigarette smoking, air pollution, passive smoking, occupational dusts and chemicals (Currie 2009).
This essay will now analyze the nursing intervention that requires for the acutely ill patient to prevent an exacerbation of chronic obstructive pulmonary disease.The nurse carried out an initial assessment of a full history, taking in consideration that the patient was over 35 years of age who has been, or still is, a cigarette smoker, with vascular related diseases and had symptoms of breathlessness on exertion, chest tightness, wheezing, coughing, sputum production especially in the morning and chest infection (Currie 2009). A physical examination was done to check the patient respiration rate, depth and rhythm, blood pressure, pulse, temperature and oxygen saturation (Lynes 2007).The acutely ill patient’s respiration was between 30-34 breaths per minute, blood pressure 580/98, pulse 110 beat per minute and saturation levels 80-82%. Increase respiration indicates that the patient was in fear, pain and anxious.
Anxiety causes stimulation of sympathetic nervous activation which forces bronchioles constriction causing increased in depth and respiration rate.The nurse listens for abnormal sounds in the lungs and looks for symmetry of chest, effort of breathing and use of accessory muscle, abdominal muscles and the muscles of the neck and shoulder. Respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties (Brooker et al 2004). The most well known and reliable method used to diagnosis chronic obstructive pulmonary disease (COPD) are careful history taking and a thorough physical examination, supported by spirometry (Blackler et al 2007).Differential investigations should also considered such as simple laboratory tests: a blood cell count to detect anaemia or polycythaemia secondary to chronic hypoxia, a routine chest x-ray examination to exclude alternative diagnosis, lung function test maybe helpful in cases where diagnosis is unclear or where symptoms appear out of proportion to the abnormalities seen on spirometry, sputum microscopy and culture to indicate viral infections and an electrocardiogram to prompt further cardiac investigations in an advanced COPD patient.
A minority of patients may have computed tomography (a CT lung scan) of their chest arranged if the diagnosis is uncertain and the chest X-ray shows some concerns (Booker et al 2004). COPD has no cure so the nurse advised the patient to stop smoking with help of smoking cessation aids include counseling, nicotine replacement patches and various pharmacological therapies which can lead to substantial symptomatic relief and reduction in complications. The doctors prescribed the acutely ill patient a reliever inhaler for use on an as required that opens up the airway called short-acting bronchodilator.Short-acting beta 2 agonists are salbutamol and terbutaline.
The only short-acting anticholinergic is ipratropium, and may be used alone or together in the same inhaler device, but may cause tremor of hands or palpitations, dry mouth, nausea and constipation (Blacker et al 2007). The assessment revealed an increase in respiration rate, causing the acutely ill patient’s to be experiencing difficulties in breathing. The goal is for the patient to breath comfortably and effectively within four hours.The nurse would ensure the patient is positioned upright in bed, well supported with pillows, arms resting on the bed or table to allow maximum lung expansion, facilitating ventilation and to reduce pressure from the abdomen on the diaphragm. Give maximum reassurance and calm support as patient will be constantly striving for breath.
Sitting forward and resting the arms on the thighs with the wrists relaxed assists relaxation of the upper chest muscles and encourages freer use of the diaphragm (Fehrenbach 2002).Administer prescribed oxygen as required via a nasal mask, usually 24-28% as low concentration of oxygen is used to treat patients with COPD. Measure and record pre peak-flow level prior to administration of bronchodilator treatment. Administer bronchodilators as prescribed via oxygen driver nebulizer. This is to dilate bronchioles and reduces bronchiospasms.
Perform post peck flow 20-30mins after administration of bronchodilator and compare with pre peak flow recording to determine the effectiveness of drug. Administer antibiotics as prescribed to combat infection (Booker et al 2004).Measure and record all vital signs every hourly to detect any abnormalities for immediate intervention. Observe for signs of cyanosis, change in mental state such as agitation, confusion and restlessness.
Liaise with physiotherapists regarding chest physiotherapy to help sputum expectorate and breathing exercise. This is to reduce the risk of chest infection and sputum retention. Encourage the patient to mobilize as soon as possible. Mobilization stimulates ventilation, increases perfusion, clearance of secretion and oxygenation (Fehrenbach 2002).The nurse referred the patient to the respiratory specialist nurse to help the patient with better understanding and knowledge of COPD and its management, pharmacist provide advice on how to use inhalers correctly, potential side effects, ways to stop smoking and information on changes of prescription and changes, dieticians may advise the patient regarding the best diet and the provision of high-energy drinks supplement, where necessary, early referral is essential for an expert assessment to be performed and strategy identify (Currie 2009).
Following discharge from hospital admission, a review of the patient by any healthcare professional such as occupational therapists, social workers presents an opportunity for further assessment. This includes a chance to assess the patient ability to cope at home and to provide education regarding their disease and its management, and advice on preventative strategies. Self-management approaches patient education, aim to help patients and families and carers to recognize early changes and seek help or instigate early treatment.Early intervention can be achieved by supplying patients with emergency supplies of corticosteroids and antibiotics (Barnett 2005). In my conclusion, COPD is a condition characterized by airflow obstruction that is not fully reversible and it is the most common respiratory disorder, affecting patient quality of life causing morbidities and mortality worldwide (Mannino 2001).
Living with COPD can impact on the patient and family in a number of different ways and more likely they experience symptoms for longer, having significantly worse limitations of activities of daily living and physical, social emotional functioning.These patients need holistic assessment and good care planning involving other members of the multi-disciplinary team (Lynes 2007). Recognizing the importance of preventing exacerbations and initiating early treatment is likely to help prevent worsening symptoms and the need for admission. With early treatment, the length and severity of an exacerbation can reduce.
Patients will be given an emergency supply of antibiotics and bronchodilator to take home, which enables them to start treatment early (Barnett 2005).
