Nursing Care Example Patient Examination

A 61-year-old male with chronic obstructive lung disease is the subject of the case study (COPD). COPD is becoming a significant expense in the UK and around the world’s healthcare budgets. COPD is an umbrella term for progressive lung disorders such as refractory asthma and chronic bronchitis that cause shortness of breath. COPD causes inflammation and damage to one’s air sacs. The injury causes further constriction of the airways, causing the patient to have trouble breathing in daily life. Aside from an increase in breathlessness, the patients experience tightening chests, wheezing and recurring coughs (Price et al, 2014, p. 889). The inhalation of pollutants is ascribed as the main cause of COPD cases. Smoking, inhalation of fumes, dust are causative factors for the disease. Genetics has also been i9dentified as an influencing factor to the contraction of the disease. However, smoking is a top cause of the disease while workplace exposure is responsible for 15% of COPD cases in the UK (Edward et al, 2016, p.285a). The prevalence of the COPD escalates with the aging population. The patients that are over 65 years old are five times more likely to contract COPD than those that are under 40 years of age. The Department of Health estimates that nearly 4.5% of the people aged above 40 have been diagnosed with the disease (Gilkes et al, 2016, p.739).

The common types of COPD are Chronic Bronchitis and emphysema. The disease affects over 1.2 million people in Great Britain. The disease affects nearly 2% of the U.K population and is likely to grow as the population ages. Thomas et al (2016) estimate that nearly 25,000 annual deaths in the UK can be attributed to COPD. The average OECD expenditure on long-term diseases is 1.4% of the GDP as of 2017. The UK spends 1.2% of its GDP on long-term care which is below the OECD average. However as the UK and the rest of the OECD continue having a growth in the aging population, the expenditure is expected to rise (Kayyalli et al, 2015, p.2831).

Jakes case was important to explore due to the increasing prevalence of COPD. The world has increased its pollution levels, and more people are smoking in the UK. The rate of occurrence of COPD has been increasing by more than 2% in the UK and the globe (Haughney et al, 2014, 997). As the UK continues to be composed of an aging population, more cases of COPD will emerge. In essence, the case study was selected because of the increasing prevalence rate of COPD in the country. It is, therefore, the important field of inquisition since it is a condition that nursing students are likely to meet once they are in the field. Furthermore, the case study was selected since it involves treatment approaches for long-term conditions and chronic diseases that are increasingly becoming an issue in the medical field, both in the UK and the world. Jake’s case was specifically selected since it was my first COPD case.

Case study

Confidentiality Statement

The case study has been written to comply with the NMC code on confidentiality (Dean 2017, p.13). Though the case is real, the names of the individuals mentioned are fictional. The names of the participants in the case study and the locations are anonymised. Note that any familiarity of the names to an actual character is purely coincidental.

Jake Branson came to the hospital complaining to have been sick for over a week. Jake was 61 years old at the time and lived with his wife who was 57 years. On the initial trip Jake had come alone, but after that, he was frequently accompanied by his wife, Mary. Jake claimed to have had difficulty in breathing especially in the morning and his wheezing had increased. Jake said that he was also experiencing some difficulty in his walk and could only manage a few meters at a time. Jake claims that his father had died of myocardial infarction at the age of 63 and he was becoming worried. His mother had died of natural causes and did not have a history of heart conditions. His sibling also has yet to present any heart failures, but Jake claims that he is the oldest.

Jake did assert that he had worked in a coal mining plant for 26 years before retiring. Jake was also an active smoker from his teenage years. Aside from smoking, Jake did not partake any other drugs including alcohol. Jake has four children that are healthy and live away from home. There is no record that Jake had suffered any major respiratory disease in his time. At the time of admission, Jake had been going to his general practitioner at his local clinic. The condition had been mild for the past one and a half years and had only turned worse in the past weeks. In his life Jake had not had a major operation nor did he exhibit a case of serious allergies.

A cough had been disturbing Jake for a while. His cough was producing coloured sputum, and the wheezing was audible in the night. Jake had a feeling tightness in his chest, and he had some difficulty in breathing. He claimed that his wife informed him that he had been less alert in the preceding days. In the past year, he was identified to be wheezing whenever he had a mild ailment. His walking was mostly limited to five meters. However, Jake was still able to perform some chore around the house. From his history and symptoms, Jake was determined to have a case of COPD. The diagnosis was confirmed once further medical tests were performed.

Pathophysiology

The diagnosis can be performed by studying the symptoms exhibited by the patient. The formal diagnosis is made through a spirometry test. The test determines the degree of obstructiveness defect in the airways. When the ration of forced expiratory volume (FEV) to that of forced vital capacity (FVC) is less than 70%, the presence of COPD is ascertained (Sehgal, P. and D’Urzo,2014, p.143). For Jake, his reading was at 51% which was a stage two. It was moderate, but it was nearing stage 3 which begins at FEV1/FVC 49%.

Cigarette smoking has been identified as a leading cause of COPD in the UK (Dhariwal et al, 2014, p. 1008). The noxious agents in the cigarettes damage the airway epithelium and result to specific airway inflammations. Other sources are other pollutants such as chemicals and the pollutant elements in mines. It is considered that the airways can be cleared and a repair process initiated for the damaged airways. The chronic airflow results if the clearing process is inadequate. The inflammation might persist even if one stops smoking. The failure of the inflammation to erode leads to the damage of the airways. It has been established that all cigarette smokers have inflammations in their lungs. Those that develop COPD have an enhanced response to the inhalation of a toxic substance. The amplified response to the toxic substance leads to a hindrance to the normal repair and defence of the airways.

COPD is exhibited by a chronic inflammation of the airways, central and peripheral, the pulmonary vasculature and the lungs. The airways are then narrowed while the mucus-secreting glands are enlarged (Malhotra and Olsson 2015, p. 155). The changes result to pulmonary hypertension that results in the pathological symptoms of COPD. An inhaled stimulus results to an inflammatory reaction that inflames the organs mentioned above. The inflammation result to ciliary dysfunctions that lead to the increase in number and size of the goblet cells. As the goblet cells enlarge and their number increases, there is an excessive secretion of mucus.

The normal protective responses in the airways are the main reasons that result in the development of COPD. The response to the inhalation of the toxic substance is usually the inflammation of the airways and the secretion of mucus (Robert et al, 2015, p.268). For people that develop COPD, these responses are intense and result to excessive mucus excretion, breathing difficulty and coughs. There are systemic effects, pulmonary hypertension, and abnormalities in the exchange of gases. The abnormalities in gas exchanges are responsible for wheezing (Castaldi and Anil, 2016, 1191).

The changes result to decreased airflow that is evidenced by the patient’s breathing difficulties (Conley and Kelechi, 2017, p.26). Jake had been experiencing difficulties in breathing. That is probably because his breathing organs had been inflamed. Given that the conditions were mostly experienced in the morning, the key stimuli must be the cold or the dust as he walked outside. The enlargement of the goblet cells has been identified as to lead to hypersecretion (Mitchel 2015, p.174). This is a symptom that was evidenced in Jake. His wife asserted that his mucus secretion had increased. The inflammation of the organs is also said to cause a chronic cough.

Nursing Care

The management of the condition is dependent on the stage of infection (Bertella et al, 2013, p. 24). The risk factor reduction is deemed to be very helpful at every stage of the condition. People that smoke needs to stop smoking and those that live or work in highly polluted areas need to relocate. Jake had already retired, and the only thing he needed to do was cease smoking (Kasaburi and Duvall, 2014, p.149. The early stages require a short-acting bronchodilator and cardiopulmonary rehabilitation. For Jake, these two were enough for his care. But those with advanced stages of the condition will require glucocorticoids and long-term oxygen therapy. In some instances, surgery is necessary for lung implants and lung volume reduction.

It is common for the pulmonary rehabilitation to be more simplified. There is the need for educating the patient and the family on the condition (App et al, 2016, p.1523). The patient has to stop smoking and avoid the exposure to toxic pollutants. There are other medical management options like immunization and oxygen therapy (Sanders 2014, p.23). The patient can also have respiratory physiotherapy as well as chest physiotherapy. The physical therapy could involve vocational rehabilitation or exercise. The NHS advice on the rehabilitation to reduce the symptoms of COPD as well as improve the quality of life of the patient (Jones et al, 2015, p. 217). The patient has to be educated on the needs to adhere to the physical therapy. To ensure that the patient can continue with the nursing plan provided, they have to be educated. For Jake, he will be informed about the disease and his family, especially the wife, will also be introduced to Jakes rehabilitation routine. In most cases, the rehabilitation works.

It is only in extreme cases that physical therapy is toned down. In those instances, medication or surgery is advised. For other patients, there is need to maintain an oxygen tank. The air in the tank has to be 88% pure (Kon et al, 2014, p.796). There are other medications that reduce the congestion of the airwaves. However, the medication is likely to cause dizziness in the patients.

Regulation

The NHS regulates long-term conditions through the House of Care. According to England NHS (2014) House of Care is a framework that oversees the way the health industry addresses long-term conditions like COPD. The framework veers towards a model that focuses on the resources of the patients and their communities. It is a holistic approach meant to provide the patients with the best possible care (Coulter et al, 2016, p.288). The House of Care provides an integrated care system that involves the society to ensure that the patients obtain the best care available. It is person-centred and encourages self-care with the partnership of health professionals. NHS England with its partners provides quality person0centered care by following the House of Care model.

The NHS mandate was published in 2012 and provides the goals to be achieved by NHS England (Fuller 2015, p.23). The mandate requires NHS to make the life of people with long-term conditions better. One of the guidelines is to provide the patients with the necessary knowledge that will assist them to manage their health. The mandate helps the patients avoid being heavily reliant on the caregivers (Pollock 2013, p.388). The mandate further requires that the NHS agrees with the patient on the type of care they are to receive. The third requirement of the mandate is that the NHS should ensure that the care provided is better coordinated. The three requirement of the mandate encourages the participation of all parties in the provision of care to patients with long-term conditions.

Integrated Care

The management of COPD patients is often inefficient if it is fragmented despite the technological advancements in the medical industry. Kruis et al (2014 assert that Medical experts have considered that to optimize COPD treatment, fragmentation of healthcare provision has to be abandoned. The parties involved have to be proactive, and the process has to be centred on the patient (Hernández et al, 2015,p.15022). To ensure that the patient has the best treatment outcome, the care provided has to be defragmented and integrated. In most cases, the pain that emanates from COPD results in the patients being socially isolated making them inaccessible to the health institutions. The flexibility and focus oriented angles make integrated care models necessary in combating the condition on a larger scale.

Integrated care models are mostly multi-disciplinary, involves several sectors and are aimed at different chronic diseases which often include COPD (Sunde et al, 2014, p.472). One of the tested models is the Home Model approach. The Integrated home model ensures that most of the treatment occurs at the premises of the patient. The model is, however, week in a sense since studies indicate that the survival time of the patients is reduced. The model only reduces hospital utilization time but does not result in efficient care. The best models in integrated care have to ensure that there is constant interaction between the patient and health professionals (Berry et al, 2014, p. 93). That implies that the patient has to make several hospital visits to access the services of the caregiver (Williams et al, 2016, p.15).

The use of an integrated approach is relevant to improve the clinical care of COPD patients by addressing the deficiencies of the commonly used acute care model (Gamer et al, 2017, p.1653). The acute care model tends to favor treating patients when the situation has deteriorated. In the model, the patient is treated for the symptoms. This model is efficient in the treatment of diseases that are not chronic or those that are not long term. The model mostly considers the immediate treatment of symptoms and fails to consider long-term effects of the condition. The House of Care model by the NHS has considered the deficiencies of the acute care system. The House of Care model tries to undertake measures that limit the prevalence of the condition. It encourages communication that results to the self-efficacy of the patient. The collaboration of the professional, family members and the patient is insisted. In essence, the House of care model prefers integration over acute treatment model.

Several disease management programs have been developed to facilitate integrated care across the healthcare system. The integrated system needs to be flexible in the provision of healthcare (Davis et al, 2015, p.39). The flexibility of the system should include the provision of social services as well as encourage patient involvement. The system is not to be rigid since it should allow for more patient involvement when the need arises. For an integrated system to be successful, the nurse and other healthcare practitioners have to be proactive. The health professional has to consider a follow up on the patient and be highly participative in the care provision process. The other success factor is the provision of information in the system. For assured success in an integrated system, all the parties involved need to have all the relevant information. The relatives of the patients are among the group that requires frequent information. The patients, as well as their relatives, have to be appraised on the progress while being provided with adequate information relating to the condition. Essentially, a successful integration program relies on coordination and professional cooperation.

To improve the provision of healthcare, it has been advocated that the integration program should involve a care coordinator. The telehealth solution is also considered helpful for household patients. The emphasis is on information technology assimilation to improve the level of coordination. The increased use of advanced technology enables a patient to access the best information available on COPD. The use of better technology is efficient in updating the patient and their family members on new treatment options as well as the progress of the patient. As suggested by Moreo et al (2016) information technology should further be assimilated to foster inter-professional cooperation. The integrated approach uses several professionals to attend to one patient. The coordination of the professional regarding the type of treatment provided and the progress of the patient is important. It is difficult to provide personal meetings to the professionals due to the different schedules and high costs. Some of the professionals do no eve share the same geographical location. To ensure that the patient is provided with optimal care the professionals need to coordinate. The best way to coordinate is the use of superior communication technologies.

Psychological effects

Aside from COPD affecting one’s physical capabilities, it also results in psychological challenges. The emotional stress created by the condition limits ones zeal in life. According to researchers, those individuals that are affected by COPD are more likely to be depressed than the individuals with other chronic diseases. There is a 40% likelihood that an individual with COPD will have depression (Pumar et al, 2014, p.1615). Furthermore, anxiety issues often affect COPD patients. Jake had his share of anxiety. He did not, however, show depression signs. Perhaps the reason Jake did not have depression is the immense support he obtains from his wife and children. His wife did, however, suggest that Jake had anxiety issues. Whenever he experienced breathlessness, he would become anxious and lead to more breathlessness. To the patients, anxiety drains the physical energy they possess at those times of attack.

Physical Impact

For other patients, the disease leads to hopelessness and they eventually become depressed. The signs of depression are often manifested in fatigue and sleeplessness. The depression is influenced by the physical limitations of the disease (Gimeno-Santos et al, 2014, p.734). Some individuals might be secluded from the public since they do not want to experience the coughing spasms in public view. Some might be required to carry oxygen tanks and use wheelchairs. Such requirements could lead to depression on people who were not used to be viewed as disabled. Perhaps Jake was not depressed since he was yet to be subjected to the wheelchair or oxygen tank. He was however exposed to the risk of depression if his condition was to worsen

Socioeconomic effects

Stigmatisation is a common social effect for patients with COPD. Their condition distinguishes them as a consequence in the eyes of the society (Barton et al, 2014, p.693). They are inherently devalued in the eyes of their peers. To that extent, the patients tend to avoid socialization since their earlier social standing becomes diminished by their condition. At times the public might not consider their conditions serious if COPD is at its early stages. The patients might also be affected their social interaction with their families. For Jake, his social life had been impacted since his condition did not allow him to frequent public places as he once did.

On an economic aspect, COPD patient might be required to leave their jobs. This could limit the level of family earnings. Jake is already retired, and therefore this did not impact him. The economic effect arises from the high medical expenditure. The patient might require extra funds to adhere to some costly treatment that might not be afforded by his insurance cover.

Health Promotion and Patient Empowerment

The biomedical model has its prevalent use. The model only requires the physician of their ailment and follow the treatment plans provided to the latter. The empowerment model usurped the biomedical model by trying to encourage patients to be more active in their treatment. The model provides the patient their right in determining the type of treatment they prefer (Disler et al, 2016, p. 11). The model is highly in favour of the patient since they are the ones that have the condition and they are the ones that will have to implement the treatment plan suggested by the physician. It is a chance for those suffering from a long-term decision to play the role of primary decision makers.

The patients will make sound decisions if they have appropriate and adequate information relating to their case. The patients need to understand their conditions; they need to be informed of the available treatment options. The patient with OCPD has to understand the consequence of each treatment plan and be informed of the consequences that could arise if no treatment plan is undertaken. The nurse has to provide the patient to express them. The patients are the experts of their illness since they are the ones that experience the symptoms. The empowerment model considers that the patients understand their suffering while the medical expert has information on the medical condition, its management, and the necessary resources (Disler et al, 2016, p.16). A united plan reached by both the care and the patient is likely to be optimal since each party provides valuable information.

The empowering approach has been proven to be efficient by several pieces of research. The participation tends to encourage self-management and results to a higher rate of therapy adherence. The patients that have had an active participation in their therapy have proven to have better outcomes than those that are not actively involved. The main rationale for the model is that it is the patients and their families that undertake most of the care process. The medical fraternity, therefore, tries to provide information to the patient and their families at the hospital as well as through the internet in their medical websites.

There are several factors that influence the success of empowerment. One of the supported approaches is that of pulmonary rehabilitation. Furthermore, social support has been identified as key in health management of COPD patients. There are several avenues that also increase the reach of information to the patients. Telehealth services and web-based interfaces have been deemed effective. These interfaces supplement information that is provided by the caring physician. The interfaces can be accessed by many individuals including the family and social circle of the individual that are effective in providing social support to the patient. The process empowers patients to understand and embrace their strengths. The treatment complexity and the health literacy of the patients have an impact on the treatment. Complex treatment and low health literacy downplay the efficiency of the empowerment approach. The broadness and availability of information do however address this deficiency to encourage the effectiveness of the process. The economic capabilities of an individual also influence the process as it determines the type of treatment regimen and the ability of the patient to access quality information. Despite the setbacks, collaborative treatment results to a better outcome for the patient.

Conclusion

It is apparent that the cases of COPD are on the rise in the UK and also on a global scale. The common symptoms of the condition are wheezing, breathing difficulties, tense chests and chronic coughs. It mostly affects the elderly which is a risk to the aging population in the UK. The condition is mostly caused by abnormal inflammations in the airwaves that are caused by the inhalation of toxic substances. The causative factors are pollutants with smoking being a key cause. Pulmonary rehabilitation and physical therapy are the key treatment approaches. Since it is a chronic disease, integrated care has been identified by the NHS to be the most effective. It is therefore recommended that the care for COPD patients should be integrated to obtain optimal results (Hornick 2014, p. 88). Furthermore, information technology should be assimilated to the care of the patients to facilitate the interaction of the patients and health professionals. Since integrated care is advised, a coordinator should be appointed to guide the care team.

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