Research proposal

Introduction to COPD

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.

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.

Pathophysiology:

Smoking of cigarette can be considered as one of the significant cause for the development of COPD in Western countries. 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.

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.

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:

Environmental determinants of health and disease are pervasive and integral to the assessment, diagnosis, intervention, planning, and evaluation components of nursing practice. However, environmental factors that affect health are commonly overlooked in routine patient assessments. When environmental health concerns are missed, an opportunity for prevention is lost, and public health is less well served. The nursing process, consisting of assessment, diagnosis, planning/outcomes, intervention, and evaluation, has been described as the core and essence of nursing, central to all nursing actions. It is a deliberate, logical, and rational problem solving process whereby the practice of nursing is performed systematically. The nursing process includes continuous input from patients, their families, or communities through all phases from assessment to evaluation. Diagnoses, planning, and interventions may be altered at any stage based upon new information from the patient or any other source. As far as possible, the patient should have an active and equal role in the nursing process, constricted only by physical or emotional limitations on their ability to participate.

The American Nurses Association (ANA) describes three basic nursing activities that explicitly include issues related to the environment and health, a preventive approach to health, and concern for populations as well as individuals:

• Restorative practices modify the impact of illness and disease.
• Supportive practices are oriented toward modification of relationships or the environment to support health.
• Promotive practices mobilize healthy patterns of living, foster personal and familial development, and support self-defined goals of individuals, families, and communities.

Thus, major concepts and activities necessary to address environmental factors that can affect the health of individuals and populations are within the scope of practice and definition of nursing set forth by the ANA.

During the assessment phase of the nursing process, data are gathered to determine a patient's state of health and to identify factors that may affect well-being. This activity includes eliciting a health history to identify previous illnesses and injuries, allergies, family health patterns, and psychosocial factors affecting health. Environmental health components of history taking can be integrated into the routine assessment of patients by including questions about prior exposure to chemical, physical, or biological hazards and about temporal relationships between the onset of symptoms and activities performed before or during the occurrence of symptoms. During an assessment, the nurse should be alert to patterns of co-morbidity among patients, family members, and communities that are indicative of environmental etiologies. Nurses also conduct assessments during visits to patients in their homes and places of work, gaining first hand information about environmental factors that may adversely affect health.

Diagnosis occurs with the culmination of objective and subjective data collection. In this phase of the nursing process health problems are identified and described. Depending upon their practice setting, nurses may use the diagnostic terms established by the North American Nursing Diagnosis Association (NANDA) or medical diagnostic terminology, as is often the case with APNs who are nurse practitioners. Routine consideration of environmental factors that affect health is essential in the diagnostic phase of the nursing process; without knowledge of such factors, problems may be misdiagnosed and subsequent interventions will address environmental issues haphazardly, if at all.

Prevention and management of exacerbations of the disease

Exacerbations are common, particularly in the wintertime, and it is sensible to recommend an annual influenza vaccination (Calman, 1993). Many COPD patients are offered pneumoccocal immunisation despite the lack of evidence of its effectiveness in COPD (BTS, 1997). Teaching patients how to recognise exacerbations and to seek help early may reduce the need for hospital admission. The symptoms of an exacerbation of COPD are listed in Fig 1. Treatment should be aimed at maximising bronchodilation, treating any underlying infection and reducing inflammation. Although most exacerbations are not bacterial in origin, antibiotics are commonly used. Short courses of oral steroids reduce recovery times and improve lung function during an exacerbation, and are recommended for all patients with an acute exacerbation who do not have significant contraindications (MacNee, 2002).

Some patients may wish to have a supply of antibiotics and oral steroids at home. In such cases, clear written guidance must be given on how and when to start treatment and whom to contact if advice is wanted at any time. Patients with worsening symptoms and signs may need to be admitted to hospital, so the importance of seeking advice needs to be explained.

It may become apparent during admission of a patient to hospital that he/she needs to be considered for long-term oxygen therapy. Assessment for this treatment, which involves having supplemental oxygen for a minimum of 15 hours a day (Medical Research Council Working Party, 1981) should be carried out on two separate occasions when the patient is stable, usually four to six weeks post-admission. The criteria for long-term oxygen therapy are listed in Fig 2.

Patients who use long- or short-term oxygen therapy should not smoke, as this negates any treatment benefit and, moreover, is a fire hazard. Oxygen concentrators rather than oxygen cylinders should be used if possible, as these offer a much cheaper and more convenient means of providing oxygen.

Helping patients help themselves

However severe the disease, smoking cessation will lengthen life (BTS, 1997), as cessation slows the accelerated decline in lung function. Unfortunately, lost lung function cannot be regained, so patients need to be aware that stopping smoking will not return them to health. Some patients may feel that the years gained may not be worth the effort, especially if they are already severely disabled.

Smoking cessation is difficult, and most smokers try several times before they succeed. Nicotine replacement therapy and bupropion do increase success rates (Silagy et al., 2002) and both are now readily available on prescription. Most nicotine replacement products are safe to use in COPD.

The inclusion of smoking cessation services as part of the National Service Framework for Coronary Heart Disease has benefited respiratory patients considerably (DoH, 2000). These services have developed over the past three years, and smoking cessation clinics and specialist advisers have now been established in every health authority. Smoking cessation guidelines (Raw et al., 1998; West et al., 2000) give clear and structured guidance for health professionals: all patients should be asked if they smoke, advised to quit if they do, offered help with quitting, and followed up.

Helping COPD patients to stop smoking is a vital part of the nurse’s role even if that help is referring the patient to specialist services. Many practice nurses have been trained in smoking cessation techniques and can offer patients a great deal of support. Similar skills are now developing in secondary care, although it may be more difficult to offer ongoing support in hospital.

Nutrition

Many patients with advanced COPD are underweight, while some are overweight. Obesity increases the workload of breathing, and reducing weight will help patients cope with disability (BTS, 1997). Measuring body mass index (BMI) is simple and should be a routine part of assessing patients with COPD. A low BMI suggests a poorer prognosis (Landbo et al., 1999), especially in those whose disease is advanced, while an increase in BMI with treatment improves prognosis (Schols et al., 1998). Why patients lose weight is not clear, although it is widely accepted that weight loss occurs when energy demands exceed energy intake. Dietary supplementation may help, but this should not replace a normal diet. Patients with severe disease should be advised to eat little and often, particularly if eating increases the sensation of breathlessness.

Exercise

Keeping active maintains general fitness and wellbeing. Breathlessness is very distressing, and the natural reaction is to stop the activity causing the breathlessness. Patients need to be reassured that, although it is distressing, breathlessness is not dangerous, and they should carry on with activities and interests (BTS, 1997). Many patients with moderate disease will be able to continue to work and should be encouraged to do so. Patients may need advice on pacing their activities, and housebound patients need to be encouraged to maintain upper and lower limb strength through simple exercise programmes so that simple but important tasks such as going to the toilet are manageable.