• Internal Code :
  • Subject Code : NUR241
  • University : University of Sunshine Coast
  • Subject Name : Medical Sciences

Case Study: Chronic Obstructive Pulmonary Disease

Question 1:

The first priority problem identified in the patient is shortness of breath and dyspnea as per ABCDE framework. As per ABCDE framework, breathing has issues as the patient is tachypneic and has RR 30, the SpO2 is 87%, HR- 105 that is significantly low. This is the priority issue because if shortness of breath is not addressed then this patient may suffer from organ failure because he is suffering from COPD (van der Meide et al. 2019).

The second priority problem is high temperature that is 39 degree Celsius as per ABCDE framework E (exposure). This is the problem because high temperature worsens the symptoms of COPD thus it is dangerous (Abedini et al. 2019).

Question 2:

The pathophysiology of COPD starts from the airflow restriction that is progressive and is associated with the abnormal inflammatory response produced by the lungs to noxious gases and the particles. The people with COPD has a mixed presentation of the features of emphysema and chronic bronchitis. In emphysema, the blood remains relatively well- oxygenated as ventilation and perfusion are lowered down that leads to the defect in V:Q mismatch (Kim 2017). The air is trapped due to the looseness of elastin fibres that lowers the structural support for alveoli and reduces the size of airways that leads to the collapse on expiration. The maintenance of positive end- expiratory pressure (PEEP) maintains the airways open and it also reduces the lung compliance that results in increased work of breathing and dyspnea (Brashier and Kodugle 2012).

This has a direct impact on the heart disease, dyspnea, cachexia and osteoporosis. When the stroke volume decreases, the cardiac output can be best maintained by an increase in the heart rate. The heart rate increases because as the lungs slowly starts to fail, the available oxygen supply in the blood reduces more and more and in mean while time the dangerous carbon dioxide build up. COPD also makes an individual prone to alterations in the context of oxygen and carbon dioxide levels in the lungs (Yin et al. 2019). The body starts to rapidly breathe to obtain oxygen when there is a low body oxygen level that is the partial pressure of oxygen decreases.

In the chronic bronchitis condition, there is an airway obstruction which results in hypoxia and V:Q mismatch which subsequently causes pulmonary vasoconstriction (Tuder et al. 2019). When there is high resistance in the pulmonary vasculature that results in lowered circulating blood volume and also results in right sided heart failure. The condition of chronic bronchitis is a result of an increased inflammation and mucus production that occurs in the breathing tubes and the airways. The inner lining of the airways gets disturbed thus inflamed. The tiny hairs inside the lining of airways helps the movement of mucus along the airways which is removed by the cough (Kesimer et al. 2017). The lungs are unable to move mucus easily because of the loss of functionality of these tiny hairs. This extra inflammation and the mucus inside of breathing tubes causes even more thinning of the airways thus difficulty in breathing.

Question 3:

The first priority issue identified in the patient as per his vitals and other complaints with which he has presented to the health care setting is shortness of breath. This is the priority problem because this is represented by the physical symptoms like breathless and vitals like increased respiration rate, heart rate and decreased SpO2. As per the details of assessment, the event leading to the presentation of the patient is that he was trying to shower this morning. This indicates that he gets tired and breathless during physical activities. The main nursing intervention for shortness of breath is the administration of oxygen therapy in which the correct concentration of oxygen will be administered using Hudson mask (Giamellaro et al. 2018).

This will help in achieving partial pressure of oxygen up to 92% which is very important in the patients with shortness of breath. This will also help the patient breathe normally thus lowering down the respiration rate and heart rate. This will have a positive impact on patient as it will widen the airways thus the lining of airways will allow the passage of more air (Fan et al. 2016). The nursing consideration is that the nurse will continuously monitor the vitals such as heart rate, respiration rate and SpO2. This will help in learning the improvements that will be the result of oxygen therapy that will be administered to the patients. The oxygen therapy is the first line treatment given to the patients with shortness of breath in the patients with COPD. It will affect the pathophysiological change as it will complete the oxygen demand of tissues thus saving the patient from collapse.

The nursing intervention for the management of shortness of breath in this patient is to demonstrate chest physiotherapy in which there will be bronchial tapping when the patient will cough and will also include proper postural drainage (iFiguls et al. 2016). Apart from this chest physiotherapy, the nurse will administer the bronchodilators as prescribed by the doctor. The rationale for using chest physiotherapy in the patient is that this technique will avoid the possible aspirations and will also prevent any untoward complications. The management of shortness of breath is very important because it may lead to organ failure and in the worst cases the patient may die (Walker et al. 2019).

The effective coughing and deep breathing exercises after the administration of oxygen therapy will help the patient in maximizing the ventilation. These exercises along with abdominal or pursed lip breathing exercise will provide the patient to cope from dyspnea and these exercises will also reduce the air- trapping (Permadi and Putra 2018). This intervention of administration of oxygen therapy can be evaluated by continuously monitoring the vital signs so that the improvement can be measured and in case there is worsening of the symptoms or the vitals then it can be reported to the doctor.

The second priority health issue identified in the patient is high temperature. The patient assessment details reveals that the body temperature of the body is 39 degree celsius and this needs to be managed using nursing interventions. The nursing intervention for the management of elevated temperature in the patients with COPD includes the treatment of infection that is treatment of the respiratory infection (Farias et al. 2019). The nursing intervention is the administration of antimicrobial medication for the treatment of respiration infection. The elevated temperature of the body is representation of the infection in body as it the immune system gets activated when the person gets infected.

The antibiotic amoxycillin will be administered as prescribed by the doctor. This medication competitively hampers the binding of high molecular weight penicillin and also the penicillin binding protein 1 that are responsible for glycosyltransferase and transpeptidase reactions. These reactions results in the cross linking of D- alanine and D- aspartic acid that takes place inside the bacterial cell walls. The bacteriocidal action takes place when the bacteria upregulates autolytic enzymes without the actions of these penicillin binding proteins (DrugBank, 2020). Thus, they are unable to build and repair the cell wall that leads to bacteriocidal action. This is the preferred treatment in the patients having respiratory infection due to COPD.

It has a high clinical cure rate and can be given from short duration of time about five days to longer duration of time that is for ten days. It effects the pathophysiological change in COPD patients thus treating their respiratory infection (Manchukonda et al. 2016). In these patients, when an infection is treated the temperature comes down to being normal thus this is an effective intervention for management of elevated temperature. This intervention can be best evaluated by continuously monitoring the temperature and recording it after every four hours. This will prove the effect of medication as the lowered and normal temperature will be recorded. The elevated temperature can also be managed using hot and cold strips but for a short duration of time.

The discharge planning of the patient begins the moment patient is admitted into the health care setting. The discharge planning of this patient will be based on social justice framework. Based on social justice principles, the nurses will reflect on the rights of people by evaluating the organisational structure for resources, disparities and so on (Bond 2018). The nurses have a role to play in advocating for reinventing the discharge planning process due to big disparity and complexity of the health care system. For this patient, the nurse will plan and design a discharge plan based on his rights and addressing all the disparities. The discharge plan will include everything from self- care to the care that should be taken at the home.

The nurse will educate patient on the importance of self- care, staying away from infection, adhering to medication regime, joining COPD rehabilitation centre, calling the doctor in case of emergency and on the follow- up sessions (Di Martino et al. 2017). The social justice framework will allow the nurse to advocate on the behalf of patients who have no voice due to their worsened health condition. The nurse will put forward the care technique for this patient that will facilitate better care services at his home because he has highly disturbed vital signs data.

The nurse will educate patient on taking quick- relief inhaler when he feels shortness of breath and will guide him on taking his medications (Weldam et al. 2017). The appropriate discharge planning will include the multidisciplinary team that will involve physiotherapist, dietitian, geriatric specialist and the doctor. He will be educated on the importance of smoking cessation because this is very important for his lungs that are in worst condition. His discharge plan will include every aspect from his diet to his medicines so that a holistic care can be taken. The nurse will facilitate the allocation of resources and other practitioners who will take his follow- up sessions.

References

Abedini, A., Kiani, A., Emami, H. and Touhidi, M.H., 2019. Serum Procalcitonin Level as a Predictor of Bacterial Infection in Patients with COPD Exacerbation. Tanaffos, 18(2), pp.112-117.

Bond, S., 2018. Care-leaving in South Africa: An international and social justice perspective. Journal of International and Comparative Social Policy, 34(1), pp.76-90.

Brashier, B.B. and Kodgule, R., 2012. Risk factors and pathophysiology of chronic obstructive pulmonary disease (COPD). J Assoc Physicians India, 60(Suppl), pp.17-21.

Di Martino, M., Ventura, M., Cappai, G., Lallo, A., Davoli, M., Agabiti, N. and Fusco, D., 2017. Adherence to long-acting bronchodilators after discharge for COPD: how much of the geographic variation is attributable to the hospital of discharge and how much to the primary care providers?. COPD: Journal of Chronic Obstructive Pulmonary Disease, 14(1), pp.86-94.

DrugBank. (2020). Amoxycillin. Retrieved from https://www.drugbank.ca/drugs/DB01060

Fan, V.S., Gylys-Colwell, I., Locke, E., Sumino, K., Nguyen, H.Q., Thomas, R.M. and Magzamen, S., 2016. Overuse of short-acting beta-agonist bronchodilators in COPD during periods of clinical stability. Respiratory Medicine, 116, pp.100-106.

Farias, R., Sedeno, M., Beaucage, D., Drouin, I., Ouellet, I., Joubert, A., Abimaroun, R., Patel, M., Rjeili, M.A. and Bourbeau, J., 2019. Innovating the treatment of COPD exacerbations: a phone interactive telesystem to increase COPD Action Plan adherence. BMJ Open Respiratory Research, 6(1), p.e000379.

Giamellaro, A., Oliveira, E.A., Rodrigues, E.C. and de Andrade, N.V., 2018. Avaliação das variáveis cardiorrespiratórias após o uso da terapia de rede de descanso em recém-nascidos pré-termo ventilados mecanicamente e sob oxigenoterapia/Evaluation of cardiorespiratory variables after the use of hammock position in mechanically ventilated preterm newborns and under oxygen therapy. Arquivos Médicos dos Hospitais e da Faculdade de Ciências Médicas da Santa Casa de São Paulo, 63(3), pp.173-178.

i Figuls, M.R., Giné‐Garriga, M., Rugeles, C.G., Perrotta, C. and Vilaró, J., 2016. Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. Cochrane Database of Systematic Reviews, (2).

Kesimer, M., Ford, A.A., Ceppe, A., Radicioni, G., Cao, R., Davis, C.W., Doerschuk, C.M., Alexis, N.E., Anderson, W.H., Henderson, A.G. and Barr, R.G., 2017. Airway mucin

concentration as a marker of chronic bronchitis. New England Journal of Medicine, 377(10), pp.911-922.

Kim, E.K., 2017. Pathophysiology of COPD. In COPD (pp. 57-63). Springer, Berlin, Heidelberg.

Manchukonda, R.S., Thippeswamy, C., Krishnegowda, N. and Muthahanumaiah, N.K., 2016. Amoxycillin and clavulanic acid induced Stevens-Johnson syndrome: A case report. International Journal of Basic & Clinical Pharmacology, 5(3), p.1140.

Permadi, A.W. and Putra, I.M.W.A., 2018. Comparison of respiratory training methods for chest wall expansion in patients with chronic obstructive pulmonary disease. Journal of Physical Education and Sport, 18(4), pp.2235-2239.

Tuder, R.M. and Cool, C.D., 2019. Pulmonary Arteries and Microcirculation in COPD With Pulmonary Hypertension: Bystander or Culprit?. Chest, 156(1), pp.4-6.

van der Meide, H., Teunissen, T., Visser, L.H. and Visse, M., 2019. Trapped in my lungs and fighting a losing battle. A phenomenological study of patients living with chronic obstructive and pulmonary disease. Scandinavian Journal of Caring Sciences.

Weldam, S.W., Schuurmans, M.J., Zanen, P., Heijmans, M.J., Sachs, A.P. and Lammers, J.W.J., 2017. The effectiveness of a nurse-led illness perception intervention in COPD patients: a cluster randomised trial in primary care. ERJ Open Research, 3(4), pp.00115-2016.

Yin, M., Wang, H., Hu, X., Li, X., Fei, G. and Yu, Y., 2019. Patterns of brain structural alteration in COPD with different levels of pulmonary function impairment and its association with cognitive deficits. BMC Pulmonary Medicine, 19(1), p.203.

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