NURSING 7105 Acute Care Nursing I: Pathophysiology of COPD

Case:

Bill McDonald is 65 years of age and is a male patient who is diagnosed with Chronic Obstructive Pulmonary Disease (COPD). He has smoked one pack per day of cigarettes for 35 years. He has a long history of recurrent bronchial infections. He has a chronic productive cough with copious amounts of purulent sputum. On admission, the patient complains that he is short of breath even at rest and wheezing, productive coughing and lethargy more than usual.

After a few days of treatment in the hospital, Bill is going to be discharged with home oxygen at 2 litres per minute per nasal cannula. The patient’s O2 saturation on room air was less than 88% and his PaO2 was less than 55, which was obtained from an arterial blood gas (ABG) at room air.

 The nurse needs to make arrangements with the community nurse to obtain an agency to supply the oxygen equipment needed and to provide follow-up home care on a regular basis. The supplier makes arrangements to deliver an oxygen concentrator and portable tanks or concentrated oxygen and oxygen regulators and needed supplies, including 20 meters of tubing and nasal cannulas.

Analyse the case and respond to all below questions in the essay

Answer:

Pathophysiology of COPD:

Pathophysiology of Chronic Obstructive Lung Disease (COPD) can be studied in different aspects. These aspects include respiratory tract inflammation, structural changes in the respiratory tract and mucociliary dysfunction. Inflammation is the hallmark of COPD which is mainly due to cigarette smoke. This inflammation is spread over airways, respiratory tract, lung tissues and pulmonary blood vessels. Irritants present in the cigarette smoke leads to the recruitment of inflammatory cells like neutrophils, CD8 T cells and macrophages. On activation, these inflammatory cells triggers inflammatory cascade. As a result, there is secretion of inflammatory cytokines like tumor necrosis factor alpha (TNF-α), interferon gamma (IFN-γ), Interleukin-1 (IL-1), IL-6, IL-8. Also, there is release of other mediators like matrix-metalloproteinases such as MMP-6 and MMP-9, C-reactive protein (CRP) and fibrinogen. In COPD, mainly TH1 mediated inflammatory response occurs. These inflammatory mediators produce sustained inflammatory response in the respiratory tract and structural changes in respiratory tissues. These inflammatory mediators also produce systemic effects (Bonini and Usmani, 2015; Ni et al., 2015).

Structural changes produced by inflammation leads to the narrowing of the airways. Matrix-metalloproteinases such as MMP-6, MMP-9 and fibrinogen are responsible for the structural changes in the respiratory tract. Neutrophils, elastases and matrix-metalloproteinases act on the alveolar wall to induce wall destruction and act on epithelial cells to produce goblet cells hyperplasia resulting in mucus secretion. Destruction of parenchymal cells of alveoli results in the loss of elasticity of lung tissue. This results in the destruction of the supporting structure of alveoli like elastin. This condition is termed as emphysema. Tissue damage brings about small airways collapse during exhalation and it leads to obstruction of airflow. Damage to the elastin and airway obstruction produces hyperinflation of the lung and air trapping. Hyperinflation produces barrel shaped chest in COPD patients. Air trapping in the lung results in the raised functional residual capacity (FRC). Alveolar wall destruction interferes with O2 and CO2 exchange at the alveoli and capillary interface. Hence, these structural changes reduce the lung capacity. As a result of reduced lung capacity, there is reduction in the lung volume ratio of volume of air removed in first second (FEV1) and total volume of air removed (FVC) during forced expiration post maximum inhalation. Fibrinogen plays a role in occurrence of fibrosis. Due to irritants in the cigarette smoke, epithelial cells release transforming growth factor-β (TGFβ).  TGFβ  produces fibroblast and finally fibrosis of smooth muscle cells occur (Gelb et al., 2016; Hansel and Barnes, 2012).  

Mucous glands which lines airway walls of the respiratory tract gets enlarged due to smoking and inflammation. This goblet cell metaplasia results in the replacement of normal cells with mucus secreting cells. Inflammation also interferes with the mucociliary transport system and there is accumulation of mucus in the respiratory tract. Goblet cell hyperplasia and mucus accumulation results in the interference of the airflow (Guenette, 2014).

Management plans:

Care should be provided to Bill for ineffective airway clearance. Doctor and nurse should set goal to maintain normal breath sounds and breathing pattern. Also, they should set goal for effective cough and spit out secretions. They should hear breath sounds and note abnormal sounds. They should record inspiratory and expiratory ratio. They should record extent of dyspnea, respiratory distress and anxiety, which may occur due to problem in breathing and coughing. They should advise Bill remain in comfortable position for breathing. This comfortable position can be achieved by elevating head of bed. The nurse should teach Bill for abdominal and lip breathing. They should advise Bill to consume maximum amount of water daily because it can decrease viscosity of secretions and facilitate easy expectoration. They should monitor condition of Bill using arterial blood gas (ABG) measurement, spirometry and chest X-ray. They should demonstrate him about effective coughing and deep respiration technique. They should perform chest physiotherapy by tapping on it during coughing. They should prescribe him anti-inflammatory drugs and bronchodilator nebulisation (Howcroft et a., 2016; Heffner, 2011). Medical and nursing care should be provided to Bill for impaired gas exchange. Impaired gas exchange is due to excess or deficient O2 inhalation or CO2 exhalation at the alveolar-capillary interface. Doctor and nurse should set a goal to achieve normal ventilation and sufficient supply of oxygen to tissues. Oxygen supply can be evaluated by ABG. Nurse and doctor should look for eliminating respiratory distress in Bill. They should evaluate and record respiratory rate. They should observe skin and mucous membrane color of Bill. They should observe Bill for consciousness status. They should advise Bill for rest and regular breaks during activities. They should monitor Bill for vital signs (Chow et al., 2015; Janssen et al., 2012).  

Doctor and nurse should provide intervention for ineffective breathing pattern to Bill. They should set goal to improve breathing pattern and maintain respiratory rate within normal range. They should ask Bill to keep back dry. They should provide him with supplemental oxygen using face mask. Flow rate and duration of supplemental oxygen supply should be under doctor’s monitoring.  Doctor should prescribe Bill with cough suppressants (Gulanick and Myers, 2011).

Doctor and nurse should provide him with anti-inflammatory and bronchodilator medicine. Doctor and nurse should provide intervention for risk of infection to Bill because patients of COPD are more susceptible to infection. They should monitor temperature of Bill because in infection there is possibility of increase in the temperature. They should monitor color change of sputum because sputum color changes due to pulmonary infection. They should advise Bill to maintain hygienic condition by washing hands, using gloves and disposing of sputum containers. They should advise Bill for frequent rinsing of mouth. They should order culture staining of sputum samples. Doctor should prescribe antimicrobial agents to Bill. Doctor and nurse should provide intervention for imbalanced nutrition to Bill. They should be aimed to gain body weight in Bill. They should understand nutritional requirements of Bill and provide food accordingly. They should monitor bowel sound because there can be decreased gastric motility due to hypoxemia. They should advise him to eliminate expectorated material from mouth. They should advise him to take meal in frequent intervals and rest before and after meals.  They should advise him to avoid carbonated beverages because it can diminish hunger. They should provide him with supplements of antioxidants, minerals and vitamins (Howcroft et al., 2016; Chow et al., 2015).  

Home care considerations:

Bill should be taught with effective breathing techniques. Nurse should teach him lip breathing which can be helpful in reducing respiration. Nurse should tell Bill that slow expiratory phase delays airway collapse and minimizes air trapping which occurs with the forced expirations. Nurse should advise him to take tripod position because it minimizes work of breathing. Nurse should advise him to take help of others in performing daily activities, in case if he is facing problem of breathing while doing these activities. Nurse should advise him to conserve energy because he may develop fatigue due to improper breathing and coughing. Nurse should advise him to take maximum rest, frequent breaks during activities and use accessories for performing activities. Nurse should demonstrate use of inhaler and teach him maintenance of inhaler. Nurse should tell him that he should not miss inhalation dose and it should be according to schedule. Nurse should tell him that he should not increase the dose of inhaler until and unless directed by doctor. Nurse should tell him precautions to be taken during serious condition of insufficient breathing. He should not be panic and he should keep himself calm. Nurse should advise him to contact doctor immediately in case of serious breathlessness (Neal-Boylan, 2011; Fromer, 2011).

Nurse should advise him to take enough water at home. Nurse should advise him to take small quantity food at regular intervals. Hence, stomach would not be completely full and little empty stomach would be helpful in improving breathing pattern. He should consume food with more amount of energy. Nurse should teach him how to warm up his chest. He should massage his chest for warming up and it would be helpful in improving breathing. Nurse should advise him to take his prescribed long term drugs on daily basis. Nurse should warn him not to smoke because smoking can adversely affect his condition irrespective of the medication he is consuming. He should keep himself away from the smokers because passive smoking may also adversely affect his condition. He should keep himself away from the strong odors. Nurse should advise him to perform breathing exercises on regular basis because breathing exercises would be helpful in clearing his airway passage and improve breathing pattern. Nurse should advise him to maintain hygienic condition to protect himself form infection because COPD patients are more susceptible to the infections. He should wash his hands on regular basis. Nurse should advise him to keep himself away from crowd and ask visitors to keep face mask whenever they come to his room. Nurse should advise him to keep himself active at home. He should try to walk a little on daily basis and should not walk when he experiences breathing problem. Nurse should advise him to build strength when he is sitting position. He can build strength by lifting small weights and performing light exercises (Brown et al., 2015; Fromer et al., 2010).        

Education plan:

There are organizations available which deals with COPD. Few of the organizations are as follows : American Association of Respiratory Care,  Americal College of Chest Physicians, Emphysems Foundation for Our Right To Servive, The Global Initiative for Chronic Obstructuve Lung Disease, Amercian Lung Association, Medline Plus, National Heart, Lung and Blood Institute,, National Institute of Health, Pulmonary Education and Research Foundation, Portable Oxugen : A User’s Perspective, European Respiratory Society, Touchrespiratory, Alpha 1 foundation and Alpha 1 association. These organizations are useful for both healthcare providers and patients. These organizations provide information to doctors about the recent trends in the research of COPD. These organizations also provide services to patients.

Before preparing education plan for Bill, nurse should know learning needs of Bill. Nurse should ask him knowledge about COPD and reasons behind occurrence of COPD. Nurse understood that Bill is not aware of this. Nurse should also know his approach for managing this chronic disease condition and his past experience in managing this disease. Nurse understood that he is not clear about management of disease. Nurse understood that Bill can’t understand complex medical terminologies, hence nurse should make education plan in simple language. Bill is on oxygen supplementation with 2 l per minute oxygen level. He wants to know, if he increases speed of oxygen, can he start breathing independently because he wants to get rid of this as early as possible. Nurse should teach him according to his learning needs. Nurse should tell him that it is not possible to increase speed without expert supervision. Nurse should explain him about oxygen saturation and how to increase oxygen saturation level. Consequently nurse should explain him different techniques of improving oxygen saturation. These techniques comprises of use of breathing techniques, correct use of inhalers, coughing to expel secretions, increasing strength by performing tolerable exercise and maintenance of sufficient hydration and nutrition. Nurse should inform Bill about problems of inhaler use like candidiasis and harshness of voice. Nurse should tell him that use of spacer and regular rinsing of mouth can prevent it. There is possibility that Bill may feel depressed due to disease condition. Nurse should give him mental strength and tell him that his disease condition can improve if he follows all the instructions and consume medication on regular basis. Nurse should tell him that he needs to consider behavioral changes as well as lifestyle changes along with consumption of medication for improving breathing pattern. Nurse understood that he lost his appetite. Nurse should advise him to consume energy enriched liquids to maintain proper nutritional balance (Scullion, 2010; Smeltze et al., 2010).  

Conclusion:

Bill is suffering through COPD. He is exhibiting symptoms of COPD like productive cough, wheezing and lethargy. He is supplemented with O2 to maintain normal level of oxygen saturation. These symptoms are observed in Bill due to pathological changes in the respiratory tract. These pathological changes include inflammation, bronchoconstriction, mucus deposition and insufficient breathing. Nursing and medical intervention should be provided to Bill to reduce inflammation, to aid ineffective airway clearance, to improve breathing pattern, to produce effective cough and to maintain normal oxygen saturation level. Nurse should consider home care for Bill in terms of improving breathing pattern, utilization of inhaler, maintaining hygienic condition, smoking cessation and physical exercise. Nurse should educate him about COPD, its causes and management. In conclusion, effective implementation of nursing interventions comprising of medical, physical and person centered aspects would definitely provide holistic cure to Bill.

References:

Bonini, M., and Usmani, O.S. (2015). The role of the small airways in the pathophysiology of asthma and chronic obstructive pulmonary disease. Therapeutic Advances in Respiratory Disease, 9(6), 281-93.

Brown, D., Edwards, H., Seaton, L., and Buckley, T.  (2015). Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.

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Fromer, L. (2011).  Implementing chronic care for COPD: planned visits, care coordination, and patient empowerment for improved outcomes. International Journal of Chronic Obstructive Pulmonary Disease, 6, 605–614.

Fromer, L., Barnes, T., Garvey, C., Ortiz, G., Saver, D.F., and Yawn, B. (2010).  Innovations to achieve excellence in COPD diagnosis and treatment in primary care. Postgraduate Medicine,  122(5), 150-64

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Guenette, J.A. (2014). New insights into the pathophysiology of mild chronic obstructive pulmonary disease. Canadian Respiratory Journal, 21(1), 25-7.

Gulanick, M., and Myers, J. L. (2011). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier Health Sciences.

Hansel, T. T., and Barnes, P.J. (2012). Recent Advances in the Pathophysiology of COPD. Springer.

Heffner, J.E. (2011). Advance care planning in chronic obstructive pulmonary disease: barriers and opportunities. Current Opinion in Pulmonary Medicine, 17(2), 103-9.

Howcroft, M., Walters, E.H., Wood-Baker, R., and Walters, J.A. (2016). Action plans with brief patient education for exacerbations in chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews, 12:CD005074. doi: 10.1002/14651858.CD005074.

Janssen, D.J., Engelberg, R.A., Wouters, E.F., Curtis, J.R. (2012). Advance care planning for patients with COPD: past, present and future. Patient Education and Counseling, 86(1), 19-24. doi: 10.1016/j.pec.2011.01.007.

Neal-Boylan, L. (2011). Clinical Case Studies in Home Health Care. John Wiley & Sons.

Ni, Y., Shi, G., Yu, Y., Hao, J., Chen, T., and Song, H. (2015). Clinical characteristics of patients with chronic obstructive pulmonary disease with comorbid bronchiectasis: a systemic review and meta-analysis. International Journal of Chronic Obstructive Pulmonary Disease, 10, 1465-75.

Scullion, J. (2010). Helping patients with chronic obstructive pulmonary disease adhere to regimens. Primary Health Care, 20(5), 33-39.

Smeltzer, S.C., Bare, B.G., Hinkle, J.L., and Cheever, K.H. (2010). Brunner and Suddarth’s Textbook of Medical-Surgical Nursing. Lippincott.