Research proposal

Introduction to Chronic obstructive pulmonary disease

Introduction

A disease condition that lasts longer than six months such as cancer, arthritis, asthma, obesity, chronic pain, diabetes or heart disease are termed as 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, (GOLD 2016). Among the European countries especially in Sweden, about 500,000 inhabitants suffers from COPD and the number of people who loses their lives suffering from COPD are about 2000 (Swedish Pulmonary Organization 2017). Both innate and adaptive immune response gets generated in the patient body when the patients gets exposed to obnoxious particles and gases particularly cigarette smoke (MacNee, 2006).

In general cigarette smokers suffer from inflammation in their lungs whereas COPD patients develop an anomalous response after inhalation of toxic particles. The pathophysiological response observed are generally hypersecretion of mucus known as chronic bronchitis, tissue destruction also known as emphysema, and disturbance of routine repair and defence mechanisms resulting in small air passage inflammation and fibrosis (bronchiolitis).. Due to the above mentioned pathophysiological changes resistance of airflow in the small conducting airways passage occurs. The other typical features include air trapping, increased compliance in the lungs and progressive air flow obstruction (MacNee, 2006).

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 leads to specific passage inflammation and other structural changes. Enhanced inflammation of neutrophils and, in cases of mild exacerbations, excessive numbers of eosinophils are observed. There are number of factors that can cause exacerbations such as bacterial or viral infection, polluting agents present in air and fluctuations in ambient temperature.

During mild exacerbations, obstruction to airflow gets slightly altered or remains unchanged. Incase of severe exacerbations worsening conditions of pulmonary gas exchange occurs because of enhanced inequality between ventilation and perfusion process which eventually results in fatigueness of respiratory muscle. Worsening conditions result in inflammation of air passage, hypersecretion of mucous, oedema and finally bronchoconstriction. Bronchoconstriction results in reduced ventilation resulting in vasoconstriction of pulmonary arterioles in hypoxic conditions. Several pathophysiological conditions are observed due to fatigueness of respiratory muscle and alveolar hypoventilation such as hypercapnia respiratory acidosis, hypoxaemia ultimately directs to severe respiratory failure and death. Pulmonary vasoconstriction gets induced by conditions such as hypoxia and respiratory acidosis which aggravates the worsening conditions and the hormonal changes also contributes to the above changes (MacNee, 2006; Barnes 2008; Willemse et al, 2005) .

Systemic effects of COPD:

The exercising capacity of the patient decreases due to the prevailing conditions such as systemic inflammation and fatigueness 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).

A case study

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 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 work load 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. 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 inhibitor as his only medicine for hypertension.

Components of Nursing Practice:

The components of nursing practice on environmental factors affecting our health and causing diseases are omnipresent and fundamental in nature. It includes proper diagnosis, interference, preparation, and assessment. The environmental factors which affect the health of the patients are sometimes overlooked during the routine assessment procedures. Therefore the environmental health factors are not taken into consideration, the factor which supports prevention are missed and as a result the public health service gets compromised. The following actions that are considered as part of central of all nursing actions are diagnosis, scheduling/outcomes, intervention and evaluation. Generally a purposeful, logical and reasonable attitude is taken into consideration for problem solving during systemic practice of nursing. The systemic practice includes constant input from patients and their family or community throughout the treatment for correct evaluation. The components such as planning, diagnosis and involvement can be altered based on the availability of any new information from patient or from any other sources. The patient should also have a dynamic and identical role throughout the assessment phase of nursing process though certain limitations are also there such as emotional and physical constrains upon their efficiency to perform. Based on the guidelines provided by American Nurses Association (ANA), three basic guidelines that are broadly included in the topic affecting the environmental impact upon health and disease of the patients as a preventive approach are: (1) Restorative practice which modifies the outcomes of the disease; (2) Supportive practice which basically changes or modifies the surroundings and relationships to improve the health conditions of the patients; (3) Promotive practice gather together all factors that promote quality living, encourages the familial and all personal developments and also sustain self – defined objectives of any individual, family and as a whole community. Therefore the chief and necessary activities required to deal with environmental factors that manipulates the health conditions of the populations are included in the scope of nursing practice as defined by ANA (Pope, 1995).

Assessment and Diagnosis Phase of Nursing Practice:

The purpose of the assessment phase of the nursing process is to gather data that determines the patient health condition and the factors that may affect the well-being of the patient. During this particular phase detailed health histories are noted to categorize any past illness or injuries, health status of the family and the metal and physical factors that affects the health. Routine assessment of the patient includes questions as a part of environmental health components such as any previous exposure to hazardous chemical, physical or any biological substance. It may also include about the sequential relationships between the inception of symptomatic features and any activities undertaken during or before the appearance of symptoms. Throughout the assessment process nurse should be aware about any prototype of co-morbidity of patients and their family members, communities that will point towards any environmental factors. Gathering information during any occasional visit to residential places of patient including their work place helps in gaining useful insights about several environmental factors that have an adverse impact upon the health of the patient.

Proper diagnosis is manifested when both the objective and subjective data collection are considered together. The identification and in depth description of the health problems are done during this phase. Nurses may use the diagnostic terms as mentioned by the North American Nursing Diagnosis Association (NANDA) or they may also use medical terminologies as used by APN , the nurse practitioners depends upon their own practice setting. The routine assessment of environmental factors are taken into consideration that may affect the health status of the patient is an integral part of the diagnostic phase because without intimation of any such factors the problem may get overlooked or misdiagnosed and subsequent interference will not address the environmental issues properly (Pope, 1995) .

Role of Nurses to facilitate safety, dignity and respect for the patient:

Several academic fields such as philosophy, nursing, social science, medicine, politics and ethics have considered human dignity as a subject of extensive research. In this 21st century several countries have considered the subject of human dignity and patient dignity protection as a matter of high significance in the health care sector for providing quality care. In nursing practice respect of patient dignity is considered to be a significant principle which in turn builds up trust for health care services and also promotes patient satisfaction. Several advantages can be achieved such as it establishes a stable patient staff-relationship, ensures a feeling of safety and security and in turn reduces the duration of hospital stay by taking care of mental health problems, reduction in costs and also motivates staff. On the contrary infringement of patient dignity by the nurses generates sudden emotional response such as hatred, anger and sadness and can also aggravate profound long-lasting emotion such as feeling non worthy, isolation from society, exhaustion, unfriendliness and ultimately a strong desire to commit suicide. Several research studies have demonstrated that nurses give respect to patient dignity upto a satisfactory level. Unfortunately similar scenarios are not observed in public hospitals and other emergency departments. Therefore policy makers and nursing authorities are suggested to initiate appropriate methods to progress the present conditions (Raee et al, 2017).

How to prevent and manage exacerbations of the disease:

Exacerbations are commonly manifested during the wintertime, and recommendation of yearly influenza vaccination is done. Though pneumoccocal immunisation failed to provide any substantiation of its efficacy still it is prescribed to COPD suffering patients. The primary role of the nurse to teach patients to recognize exacerbations and to ask for early medical help which will eliminates the chances of hospital admission by certain percentage. During mild exacerbations, obstruction to airflow gets slightly altered or remains unchanged. Incase of severe exacerbations worsening conditions of pulmonary gas exchange occurs because of enhanced inequality between ventilation and perfusion process which eventually results in fatigueness of respiratory muscle. Worsening conditions result in inflammation of air passage, hypersecretion of mucous, oedema and finally bronchoconstriction (Judith, 2002).

Treatment Prescribed:

Prescribed mode of treatment includes enhancing bronchodilation, lowering the chances of inflammation by taking care of any basic infection. There are number of factors that can result in exacerbations antibiotics are generally prescribed. Patient suffering from an acute exacerbation and donot show any significant contraindications are kept on short course of oral steroids which effectively improves lung function and in turn recovery time.

The in-patient management process is similar in approach and they also include evaluation of gases of blood with advanced support and monitoring. 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 end stage category of disease may oppose ventilation although non invasive method of ventilation can be a comfortable approach for them. Patient may be advised to stay on oxygen therapy for a long term during admission to the hospital and that his/her condition needs to monitored. The treatment during this assessment phase involves supply of oxygen for at least 15hours a day (Medical Research Council Working Party, 1981) 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 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).

Cessation of Smoking

Smoking has a profound impact upon COPD patients. Cessation of smoking lengthens life in severe diseases patients also as because it diminishes the rapid decline of lung function. Patients should be educated about the fact that the function of the lungs that has stopped due to smoking cannot be regained and only cessation of smoking can return them to health. The disease can cause severe impairment of function and therefore the life span gained may not be as worthy to the patients to live. The addiction to smoking is a huge problem for COPD patients and most smokers couldnot give up in one turn. Several therapies such as replacement of Nicotine and and administration of bupropion enhances the success rates and both the therapies are now readily available if prescribed. Several products prescribed as nicotine replacement therapy are absolutely safe regarding COPD patients.

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 kind 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 a well structured guidance for all health professionals. Every patients 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)

Nutrition

Many patients suffering at an advanced stage of COPD are generally underweight, though few overweight patients are also available. Obesity causes several problems such as enhances the workload during breathing. Therefore reduction in weight will definitely help patients to deal with this disability. Measurement of body mass index (BMI) is suggested as a routine part of assessment for COPD patients. Lower BMI indicates poorer conditions and it is found in those patients suffering from advanced stage of the disease, whereas a rise in BMI along with treatment improves conditions. It is still not clear that why there is loss in weight among patients, though it well known that burning of calories occurs when our body demands excess energy. Dietary supplementation can be suggested without replacement of a normal diet for the patients. Moreover, patients with acute form of the disease should be given little to eat for several times, only if eating enhances the problem of breathlessness (Judith, 2002).

Exercise

For maintaining general fitness of the body the patients need to be in an active state. The breathlessness condition is very stressful, and as a natural response one has to stop the activity responsible for breathlessness. Patient has to be constantly convinced about the fact that though breathlessness is a stressful condition, it is not fatal, and they should go on with their normal course of activities. Patients with moderate level of the disease can continue to work and proper encouragement should be given to do so. Proper advice on continuing the activities with speed and for patients staying at home needs to be encouraged to maintain strength at their upper and lower limbs through simple exercise programmes so that patients can manage simple task such as going to toilet (Judith, 2002).

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

One of the important factors of the nursing community about facing challenges during caring for 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 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).

Role of Healthcare Team during Patient Care:

As a healthcare team they have profound roles such as they accelerate without extending the services, nursing skills gets utilized more appropriately and also facilitate expenditure containment. The training and supervision they provide are considered as time concentrated, which demanded more commitment. Patient safety is considered as a significant concern, and compromise in this regarded has been ever reported. Patients are considered as neutral or positive. Several typical benefits includes reduction in the workload of nurses, reduction in the pressure on reception people, increase in the available opportunities for the nurses to build up their function; general improvements can be observed in the overall functioning and performance which facilitates the attainment of targets. Overall a healthcare team provides a streamlined process for patients with the availability of new or extended area of services (Petrova et al., 2010).

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. 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.

References

• Global initiative for chronic obstructive lung disease, GOLD (2016). Global strategy for the diagnosis, management and prevention of COPD.
• Swedish Pulmonary Organization (2017). Nationellt vårdprogram för KOL [National care program for COPD].
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• Willemse BW, ten Hacken NH, Rutgers B, et al. (2005) Effect of 1-year smoking cessation on airway inflammation in COPD and asymptomatic smokers. Eur Respir J; 26: 835–845.
• Pope AM, Snyder MA, Mood LH (1995). Institute of Medicine (US) Committee on Enhancing Environmental Health Content in Nursing Practice; editors. Nursing Health, & Environment: Strengthening the Relationship to Improve the Public's Health. Washington (DC): National Academies Press (US); 3, Nursing Practice.
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• Mila Petrova, Laura Vail, Sara Bosley, Jeremy Dale (2010). Benefits and challenges of employing health care assistants in general practice: a qualitative study of GPs’ and practice nurses’ perspectives, Family Practice, 27(3):303–311