Introduction to Chronic obstructive pulmonary disease (COPD):

Introduction to Chronic obstructive pulmonary disease (COPD):

Introduction

A disease condition that lasts longer than six months such as cancer, arthritis, asthma, obesity, chronic pain, diabetes or heart disease is termed as a long-term illness or chronic health condition. The incidence rate of patients suffering from long term illness or any chronic diseases are gradually rising in countries like Australia and also in other parts of the world. The factors that contribute to this rising number are lifestyle problems such as smoking, consumption of unhealthy diet and aged population etc. Among the diseases that are generally categorised as Long Term Conditions, Chronic obstructive pulmonary disease (COPD) is a worldwide problem and a most important reason behind morbidity and mortality (Global initiative for chronic obstructive lung disease, (Vestbo, et al, 2013). Among the European countries especially in Sweden, about 500,000 inhabitants suffer from COPD and the number of people who loses their lives suffering from COPD is about 2000 (Swedish Pulmonary Organization, 2017). Both innate and adaptive immune response gets generated in the patient body when the patients get exposed to obnoxious particles and gases particularly cigarette smoke (MacNee, 2006; Raherison, et al, 2009).

Pathophysiology

Smoking of cigarette can be considered as one of the significant cause for the development of COPD in Western countries (Refer Fig: 1). Cigarette smoke particles cause injury of the airway epithelium and lead to specific passage inflammation and other structural changes. Enhanced inflammation of neutrophils and, in cases of mild exacerbations, excessive numbers of eosinophils are observed. Several factors can cause exacerbations such as bacterial or viral infection, polluting agents present in air and fluctuations in ambient temperature.

The pathophysiology of COPD; ------- symbolize inhibitory effects (MacNee, 2006) Systemic effects of COPD:

The exercising capacity of the patient decreases due to the prevailing conditions such as systemic inflammation and fatigue ness of skeletal muscle along with airflow obstruction. Increasing concentration of the C reactive proteins enhances the chance of cardiovascular problems among patients. The notable features observed among patient as systemic features of COPD are disuse atrophy, cachexia, enhanced cardiovascular problem, wasting of skeletal muscles, normocytic anaemia, secondary polycythaemia, osteoporosis along with mental health disorders like depression and anxiety problems (MacNee, 2006; Sturton, et al, 2008; Lapperre, et al, 2007).

The Different principles on Nursing Practice: Components of Nursing Practice:

The principles of nursing practice describe what everyone and the patients can expect from the nursing staff members. The principles were designed by the Royal college of Nursing along with the Nursing and Midwifery Council and the Department of Health.

The staff members of the nursing community should deal everyone in their care with the required respect and dignity. They should understand the individualised needs of the patients and also should provide the necessary care, sensitivity and compassion to every patient equally irrespective of their disease and their background. This promotes the inclusion practice of the nursing as the idea is to provide respect and care to all irrespective of the diversity and this includes the individuals with the mental health disabilities, learning disabilities, the low income groups and the homeless peoples.

Principle B:

The staff members of the nursing community should take the responsibility of the care that they are going to provide to the individualised patient. They are also responsible for their own actions and are answerable for their own judgements and actions that they have taken. They should perform the activities after obtaining the informed consent of the patient, their family members and also their carers and also should meet all the requirements of the legislation and the organisational bodies.

Principle C:

Nurses and the other healthcare staff should be able to manage any sudden risk and also should be vigilant about any risk. They share the major responsibility of keeping everyone safe in the health care sector or the place where the patient is receiving the care.

Principle D:

The nurses and the staff members should keep the patient at the centre while providing the care and they should also involve the family members of the patients, the service users, their carers along with the patient to make an informed choice about the treatment procedures and the care plan that they are going to be provided. This is the integrative care approach of nurses towards the patients.

Principle E:

The nursing staffs play the major role in the communication process. They should take the charge for assessing the report of the treatment, record the details of the patient at every stage of the treatment, should be able to deal with the information sensitively and maintain the confidentiality of the patient. They should also deal with the grievances received from the patient efficiently and should be meticulous while reporting the things that bothering them.

Principle F:

The nursing staff should have up to date knowledge about the skills that they are applying to treat the patients and they should exercise the skills with proper level of intelligence and understanding keeping in mind the individual needs of the patients.

Principle G:

The nurses and the nursing staff members should work collaboratively with the clinicians and the other professional teams so that a well coordinated patient care service can be provided, which will be of quality standard and will reward with the best possible outcomes.

Principle H:

The staff member of the nursing team plays the leadership role by constantly developing themselves and this impacts the quality of the care service that are provided to the patient with respect to their individual demands (Manley, et al, 2011).

Component of Integrative care in the Nursing Practice:

According to the version of Global Health Advances in Health and Medicine, integrative care approach works in the way by keeping the patient at the centre and taking care of all the aspects that may affect the health status of the patients such as the physical, social, spiritual, emotional, mental and environmental influences. The care service is constantly evolving and should involve all the practitioners who are engrossed to deliver the optimal care to the patient by introducing newer strategies. As per the definition of WHO the integrated care approach gathers together all the parameters such as the inputs, management of services in relation to diagnosis, the treatment and the care plan, rehabilitation and the promotion of health (Kreitzer, 2015). In this present study the COPD home model will be described as an integrative care approach.

The COPD Home Model:

• According to the guidelines of GOLD report recommendations the integrated care approach should include the following components:
• Education about the disease; 2) developed coordinated care levels; 3) the increased accessibility; 4) a well developed management plan.
• The COPD home interventions help the patients and the nurses to monitor and implement the self management strategies during the stable phase and while controlling the exacerbations of the COPD patients.

Education provided by the education programme to the patients:

The home care nurses attend the DTM for a period of 2 days and a 3 hour training programme that covers the following topics:

• The detailed information about the COPD which includes the pharmacological and the non pharmacological interventions, the care plan of the nurses and the follow up required.
• Training with the observation form, the plan for the implementations of the non pharmacological and pharmacological interventions and PiKo-1 (Electronic Peak Flow metre) which helps to monitor the forced expiratory volume (FEV1).
• The patient also attends a 15 minutes e-learning strategy on COPD concerning the self management strategies during the stable phase and the measurement required to control the exacerbations.
• In addition patients are also advised of a consultation with a specialist nurses regarding the individual patients opinions and questions.
• When the specialist nurses visit the patient home, they should perform the following functions: disseminating the knowledge about the pharmacological interventions of the disease and about the symptoms to detect the start of exacerbations.
• The follow up visits includes the examination of the patient, alterations in the care plan and strengthening of the required behaviours.

The self management strategies:

The patient centred self management strategies are educated to the patient during their first visit after the hospital stay.

The home care nurses and the patient should use the observation form to monitor the daily lung functions (FEV1 on the device PiKo 1) and the other parameters such as the physical, mental, the amount or colour of the sputum, the respiratory rate and the temperature of the patient.

Management of COPD and the exacerbations:

The strategies of the self management include the non pharmacological interventions such as the rehabilitations, the smoking cessation programmes, the groups for training and education and the management of the disease by self. The aspect of nutrition and vaccination are also incorporated within the treatment process. The patient along with the specialist nurse designs a personal plan for the non medical interventions and should offer the support strategies throughout the follow up. The home care nurses may also participate in designing the follow up plan.

For the management of the exacerbations the patient follows an individual plan for the pharmacological interventions by applying the traffic light system. It also includes the usual medications when the sputum is green in colour, stepping up the medication in each case when the colour of the sputum is yellow or red. The patient needs to follow the treatment plan as designed by the hospital during the discharge of the patient. If the patient is unable to record the observations by itself then the home nurse can do it for the patient. The self management techniques also include the necessary telephone numbers and the information for the COPD patient and their families (Connors, et al, 1996; Bonten, et al, 2016).

A 56-year-old male patient was diagnosed with mild/severe COPD along with chest infection

A 56-year-old male plumber suffering from chest infection made an appointment with GP. He is suffering from upper respiratory tract infection for the past 15 days. Other symptomatic features were the production of cough consisting of green coloured sputum, extreme breathlessness and tiredness due to which the person is unable to work. He had complained to his doctor about the same problem about two to three times every year for the past decade. He was diagnosed with COPD and was kept on short-acting β2-agonist. Although the drug helped him to carry on with his work, the breathing problem is constantly interfering with his day to day life activities. The recovering speed of the patient has also slowed down often taking about 2 weeks to recover from exacerbations and this is constantly hampering his profession. The patient reduced his workload as he cannot think of retiring. He underwent check-up for COPD about six months ago and he was predicted with 52% of FEV1. He was also advised not to smoke and was prescribed with drug varenicline for 12 weeks. His symptoms again relapsed after few days but he didn’t respond to the follow-up routine. Every year he attends for his flu vaccination and was advised to take ACE (angiotensin-converting enzyme) inhibitor as his only medicine for hypertension (Rahman, et al, 2006; Maestrelli, et al, 2003; Goven, et al, 2008; Politis, et al, 2018).

Management of the problem:

The symptoms of dyspnoea, the enhanced sputum purulence and the increased volume of the sputum were all present in the patient. The management of the acute exacerbations of the patient were treated with antibiotics, oral application of the steroids, short acting bronchodilators. The attention was given on the ongoing treatment to prevent the episodes of exacerbations. Use of the systemic corticosteroids for a short span of time and antibiotics usage shortened up the recovery of the patient and also improved the functioning of lungs. The short acting β2-agonists when inhaled with or without short acting anti-muscarinics were the recommended bronchodilators applied for the treatment of acute forms of exacerbations (Wilkinson, et al, 2004).

Treatment Prescribed:

Nurses should give neat manual guidance on how and when to start treatment and about the contact person for any advice if needed any time for those patients who are willing to have the supply of antibiotics and oral steroids at their home. Those who are revealing deteriorating symptoms and signs should be immediately hospitalised stating the importance of the contact person for seeking medical help. The in-patient management process is similar in approach and they also include evaluation of gases of blood with advanced support and monitoring. The blood oxygen level can be successfully monitored by using pulse but it fails to detect hypercapnia. Some patient may need ventilation and it will be of immense help if they know this aspect of patient care also. Patients suffering from the end-stage category of the disease may oppose ventilation although the non-invasive method of ventilation can be a comfortable approach for them. The patient may be advised to stay on oxygen therapy for the long term during admission to the hospital and that his/her condition needs to monitor. The treatment during this assessment phase involves the supply of oxygen for at least 15hours a day and it has to be carried out in two separate phases when the patient conditions can be considered to be stable usually after about six weeks after admission. Patients undergoing oxygen therapy for a long or short period of time should never smoke as it diminishes any treatment benefit and cigarette can also be considered as a fire hazard. Instead of oxygen cylinders, one should use oxygen concentrators if possible, as it can be considered as a cost-effective method and beneficial method of providing oxygen (Judith, 2002; Boschetto, et al, 2003; Domenech, et al; 2013; Barnestein, et al, 2010; Donohue, et al, 2011).

Other roles of Nurses: Cessation of Smoking

Therefore smoking cessation services has been included as part of the National Service Framework for Coronary Heart Disease and it has immensely benefited patients suffering from respiratory problems. The awareness about these kinds of services have started about three years ago, and therefore clinics for smoking cessation including specialist advisers have been developed in every health care sector. Guidelines on Smoking cessation demonstrate well-structured guidance for all health professionals. Every patient should be queried about their smoking habits and they are, advised to quit if they are found to smoke, they will be given help with quitting, and should be followed up at regular intervals. Now the role of nurse regarding the COPD patient is to help them to quit smoking by referring the patient to specialist services. Moreover, many nurses are now trained with the techniques required for smoking cessation and this helps the patient immensely. Such arrangements are now available in secondary care hospital also though it is a difficult task (Judith, 2002; Celli, et al, 2004; Barnestein, et al, 2010; Donohue, et al, 2011).

Challenges Faced by the Nursing Community during caring for a patient with COPD:

Nurses play a key role in the supervision of COPD patients as they are the “first point of contact” and remain involved in all stages of patient care. Though few pieces of research have been conducted to explore the role of nurses for COPD patients, it is evident that their consultation and interventions can improve the quality of life of the patients. Nurses perform the role from prevention to manage the “end-of-life care”, of patients both in the hospital and in their community. Role of nurses in new care models depending on various types of telemedicine support has also been established. Consultations given by nurse generally includes tasks that were previously considered to be carried out solely by physicians like physical examination of the patient, diagnosis and also prescribing medicine in some countries like United Kingdom. They also play a role in guiding and educating the patient regarding self-management process by improving their behaviour, cessation of smoking, rehabilitation programmes. Based on studies it can be stated that nurses can deliver care as efficiently as provided by doctors (Fletcher, et al, 2013). One of the important factors of the nursing community about facing challenges during caring for a patient with COPD based on literature data is the relationship between patient and nurse. The patient-nurse relationship category deals with the challenges of communicating with the patient and how care gets compromised when the connection failed. They experienced problems regarding individual care and while structuring visits as per the patient requirements (Gustafsson, et al, 2018).

Ethical issues faced by the nurses:

As COPD is a progressive disorder with frequent episodes of respiratory failure ethical issues arises to initiate the mechanical ventilation in patients. No ethical issues exist from any organisational bodies particularly for these patients. Therefore to make any decisions regarding the withholding of support for the COPD patients demands detailed communication between the physician and the patient itself based on the health needs of the patient. Therefore patient should be educated about the current status of their health so that they can take the end of life decision making (Heffner, et al, 1996).

Role of Healthcare Team during Patient Care:

Healthcare team for managing COPD patients generally consists of a physician, dieticians, nurses, social workers and exercise specialists. The team aims to provide education and strengthening the suggested medical plan. The medical plan has a detailed instruction on the medications to be prescribed, capability assessment of the patient regarding the utilization of the device and also about when to prescribe the medications. An assessment of patient's mental health such as the presence of anxiety disorders and depression and about their coping skills should be included within the medical plan. Dietary habits of all COPD patients should also be monitored as there is a strong relation between COPD patients and weight loss. Weight loss diet should be advised for obese COPD patient which may decrease the breathlessness problem. Pulmonary rehabilitation should also be provided to patients if needed. Patients should be educated about the smoking cessation process, travelling, support groups, advanced directives and community resources by the nurses. Regular follow up of the patient and communication between all members of the health care team ensures efficient management of COPD patient (Kuzma, et al, 2008).

Conclusion:

In this report a detailed discussion on components of nursing activity has been discussed how it impacts on a patient suffering from a long term disease such as Chronic obstructive pulmonary disease has also been taken into consideration. The evidence-based fact has been evaluated. The role of nurses in maintaining dignity, safety and respect for the patient is thoroughly overviewed. At last, the role of a healthcare team on patient care and well being was also critically analysed.

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