Lee SD. He is a pensioner and poor man. Amoxicilline 250 mg 8-hourly for seven days was given as patient is not sensitive to penicillin. Sensory and motor functions are normal. In this case study patient is an eighty four year old man with COPD who has got respiratory tract infection and his disease has become severe. (5): R Soc Med. He did not park their ambulance very correctly and left little space for other cars. Jump to search results. He was diagnosed with COPD and chest infection each time. We're here to answer any questions you have about our services. “The best predictor of having frequent exacerbation of two or more per year is a history of previous treat events.” (Global Initiative for Chronic Obstructive Lung Disease – 2014 Update) This factors at an early assessment will help improve a patient’s quality of life and help preventing from condition getting worsted (Former, 2011). It lists all the potential symptoms of COPD. This is a preliminary assessment of the patient. (MNC, 2018). Clinically appropriate, evidence-based rehabilitation programs for home c … Pupils equal in size in both eyes with normal reaction to light (Warrell, Cox & Firth, 2005). The crew gets consent from the patient and approaches patient for quick Primary Survey. All work is written to order. National Institute for Health and Care Excellence (2018). West Sussex: John Wiley & Son Ltd. Department of Health (2010). The ambulance crew recorded four basic vital signs consisting of pulse, respiration. Random Blood Glucose level was 120mg/ dl. Global Initiative for Chronic Obstructive Lung Disease (GOLD). SpO2 i.e. temperature and blood pressure(Warrell, Cox & Firth, 2005). Unmanaged COPD can lead to death due to respiratory acidosis, coma, right sided heart failure and massive collapse of lungs due to pneumothorax (Kumar, Abbas & Fausto, 2005). 22,6,355-360. The ambulance crew arrives at the site safely. goldcopd.org. Rate how much you cough on a scale of 0-5. Prompt treatment of respiratory tract infection is necessary because it leads to worsening of breathlessness and cause type II respiratory failure in COPD patient. Available at: https://www.nice.org.uk/guidance/qs10/chapter/Quality-statement-5-Pulmonary-rehabilitation-after-an-acute-exacerbation Accessed. COPD is one of the respiratory diseases which requires palliation of symptoms, is known to have four stages within its disease trajectory beginning with mild, moderate and progressing to moderately severe (Currie, 2017). Here are seven (7) nursing care plans (NCP) and nursing diagnosis (NDx) for Chronic Obstructive Pulmonary Disease (COPD): 1. The medication was working up to some extent till ten days back when current symptoms started. Spirometry. Emphysema and chronic bronchitis are clinically grouped together and called chronic obstructive pulmonary disease (COPD). Pre-alert was sent to the hospital that an elderly patient with acute on chronic type II respiratory failure is on the way to hospital. As mentioned before, unintentional weight loss is associated with increased rates of mortality and morbidity; however, it is not always possible to identify a clear pathophysiological cause (Gaddey et al 2014). “Understanding the breadth of patients’ support needs is important for the delivery of person-cantered care, particularly in progressive long-term conditions such as chronic obstructive pulmonary disease (COPD). The PBC group COPD lead developed a nursing protocol for management of acute COPD exacerbations and a review protocol consistent with NICE guidance. National Institute of Health and Clinical Excellence (NICE, 2016), Pulmonary rehabilitation after an acute exacerbation. Any opinions, findings, conclusions, or recommendations expressed in this essay are those of the author and do not necessarily reflect the views of NursingAnswers.net. Available at: https://www.nice.org.uk/guidance/NG115 Accessed 19th May, 2019. A patient profile will be provided, along with a description of COPD, including epidemiological data on incidence and prevalence and information on the causes and prognosis of the condition. Pulmonary function studies. Respirology 18(4): 616-29. Nevertheless, these patients will also sustain end-organ damage or cardiac arrest if their blood oxygen tensions are allowed to decrease. In addition, looking at the effects of nutrition it’s also important to consider the effects of involving patients’ friends, family and care givers when assessing and planning future care. Int J Gen Med. Introduction About half of patients discharged after a hospital admission for COPD will die within two years. Pharmaceutical management of an acute exacerbation of COPD includes: 1. COPD Assessment Test (CAT). Then crew then exposes patient from head to toe examination. According to Currie (2017), malnutrition is associated with the severity of airflow obstruction. Other irritants include particles from fires used in the home for cooking or heating and workplace exposure to chemical fumes, dust, and particles. Digital Edition: COPD – nursing care and implications for nursing 10 September, 2002 Some nurses will be actively involved in helping diagnose COPD by carrying out spirometry and reversibility testing, while others, particularly in secondary care, will be less involved in this diagnostic process. Chronic obstructive pulmonary disease is a disease characterized by airflow limitation that is not fully reversible. There is no injury or deformity but ankle oedema is present and patient is using accessory muscles of respiration. Assessment is a key component of nursing practice, required for planning and provision of patient and family centred care. All these signs are due to increased air-trapping in the lungs, narrowing of bronchi and use of accessory muscles of respiration (Talley & Connor, 2006). He is a smoker since last sixty years but did not consume any alcohol or habit forming drug. Collins PF, Elia M, Stratton RJ (2013) Nutritional support and functional capacity in chronic obstructive pulmonary disease: A systemic review and meta- analysis. COPD patients often need supportive treatment of 2 litres of oxygen to maintain oxygen saturations normally acceptable for that specific patient. The COPD care plan for activity intolerance may include a nursing diagnosis of … Breathing problems tend to get gradually worse over time, but there are many different medicines and therapies that can help people keep these under control for longer” (NICE, 2016). This documentation was used to deliver a consistent standard of … The nurse should obtain a thorough health history from patients with known or potential COPD. Nursing and Midwifery Council (NMC), 2018. Both have overlapping features with damage at acinar level (emphysema) and bronchial level (bronchitis) and most commonly occur in smokers. Arterial blood gases show a low oxygen level and high carbon dioxide level in the blood. During the initial nutritional assessment patient’s high and weight need to be obtain using calibrated weighing scale and a height measure; this information will enable the selected nutritional screening tool to be completed. However, it is important to remember that frailty is not an inevitable consequence of ageing and a good assessment of nutritional risk can improve health outcomes since it enables the health care professionals to implement dietary interventions that can improve nutritional intake (Wallington,2016). Nursing Diagnosis (list 3 … The content within this essay is generalised across a patient group and does not relate to any specific patient, staff member or trust (NMC, 2018). We've received widespread press coverage since 2003, Your NursingAnswers.net purchase is secure and we're rated 4.4/5 on reviews.co.uk. COPD is often characterised by persistent respiratory symptoms that effect the airflow limitations caused from long term chronic inflammation that damages the respiratory system by effecting tiny air sacs within your lungs, causing the peripheral airways to become narrower and thicker, which then results in restricted airflow, making it harder for COPD suffers to breathe and empty their lungs causing them to suffer breathing difficulties and breathlessness, often involving a long term chronic cough and increased mucus production” According to NICE, “around three million people in the UK are affected, two million of whom are undiagnosed. Available at: https://goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf Downloaded 22st May, 2019. C2.2 Physical examination The sensitivity of physical examination for detecting mild to moderate COPD is poor (Badgett 1993). The patient is able to identify coping mechanisms that are effective and those that are ineffective. COPD is diagnosed through a combination of patient history, physical assessment, and spirometry. . Administer oxygen to all critically unwell patients during your initial assessment. 3. Patient and service user care. He reports that he has had several chest colds in the last few years, but this time it won’t go away. Study for free with our range of nursing lectures! In this scenario, the condition can develop during acute or critical illness because of metabolic demand (Price,2008). Patient used to do light house-hold work, but since last two days he is unable to do that due to weakness. So, they will typically present at the Emergency Clinic complaining of shortness of breath, coughing and feeling anxious. Chronic obstructive pulmonary disease is one … The patient, Jack Brown, attended a clinic appointment for an initial assessment. Free resources to assist you with your university studies! Some common questions often asked by doctors or nurses to help evaluate the patient are listed in Tables 1 and 2. The PBC group COPD lead developed a nursing protocol for management of acute COPD exacerbations and a review protocol consistent with NICE guidance. The patient is alert and responds to verbal stimulus. Alexander Nursing Practice. When completing an assessment and planning care for patients it is important to consider and maintain patient confidentiality, valid consent must be gained from the patient before any information I shared outside of the nurse patient relationship. Frailty: a term with many meanings and a growing priority for community nurses. Activity Intolerance. National Institute of Clinical Excellence (NICE, 2011) highlight “COPD is the fourth highest mortality rate being one of the costliest conditions treated within the NHS, with a total annual cost of over 800 million in direct healthcare costs. Nurse needs to assess how the patient usually deals with his COPD, HTN, GERD, and DMT2. Disclaimer: This is an example of a student written essay.Click here for sample essays written by our professional writers. The poor prognostic sight in COPD is the fact, that many patients with COPD are underweight. In addition, nurses must take an interactive and team approach to the care and management of patients with COPD who have acute respiratory failure. 2007 May; 100225–233. *You can also browse our support articles here >. He examines pupils of both eyes and find normal in size and reaction to light. Search results. This nutrition screening was carried out so that changes in her weight can be identified immediately and dietary changes can be started … What is COPD? Fletcher M, Dahl B. Does the … Nothing in the environment appears harmful for the patient or ambulance staff. At this first contact with the patient it is essential that appropriate history taking is performed to clarify presenting symptoms, past history and the patient's expectations to focus and plan person centred nursing care … No plagiarism, guaranteed! The term ‘health trajectory’ describes changes in health over period of time, defending the stage a patient is at in their health trajectory allows for effective intervention and care planning ( Seamark et al, 2007).The patient group for purpose of that assignment are within the severe stage of their illness with long term limitation of function and well-being with intermittent serious episodes of COPD progression .Disease trajectory during the third stage of COPD patients experience exacerbation which can have a big impact on life quality (limitation) and often requiring hospital admission (Curie,2017). Clinical manifestations appear when one third of lung parenchyma is already damaged. Nurse care and patient education is vital to prevent episodes of panic in COPD patients (Willgoss et.al, 2011). I. When considering if a patient is malnourished following national guidance and pathways from National Institute Clinical Excellence (NICE, 2016) guidelines and Department of Health,(DOH, 2010) While on admission patients often have decreased mobility and reduction of their daily activities which can result in increased complications such as co-mobilities, decrease quality of life, while also influencing their emotional well-being and disease trajectory (Collins et al, 2010). Wills (2017) highlighted that frailty in older people and social isolation must also be consider as they will affect nutritional intake. When risk is identified accurately can also relay on previous knowledge (if present) of the patient and information gained from the patient and information gained from the patient or their carer. The American Thoracic Society/European Respiratory Society severity scale can be used in the assessment of exacerbations: level I (mild) patient is treated at home; level II (moderate) patient requires hospitalization; and level III (severe) exacerbation leads to respiratory failure, one of the indications for intensive care. This essay should not be treated as an authoritative source of information when forming medical opinions as information may be inaccurate or out-of-date. COPD has a wide spread effect on the body effecting weight loss, exercise intolerance and peripheral oedema, It is estimated around three million people in the United Kingdom (UK) are living with COPD, but the National Institute for health and care excellence reports only 900,000 of those have officially been diagnosed (NICE, 2010). The general condition of patient is poor, his disease is getting worse and he is confined to bed. Progressively worsening breathlessness for the patient with COPD limits everyday activity, reduces quality of life and increases the risk of premature death. Holistic Nursing Practice. It will locate the point of the trajectory of the disease, as well as the care environment the assessment takes place with, and why these are important in relation to the relevance of the chosen assessment. British Association for Parental and Enteral Nutrition (2011). In more advanced disease, physical features commonly found are hyperinflation of the chest, reduced chest expansion, hyperresonance to percussion, soft breath […] COPD Nursing Care Plan 5. tion of COPD. Low oxygen therapy (24-28% of O2) was given to the patient by using nasal cannulae to deliver 1-2 litres of oxygen per minute. COPD (2017). Available at: https://www.bapen.org.uk/pdfs/must/must_full.pdf Downloaded 22st May, 2019. J Am Geriatr Soc. Chronic obstructive pulmonary disease (COPD) is a long-term lung disease characterised by breathlessness, cough and sputum production. 29,1,101-106. Registered office: Venture House, Cross Street, Arnold, Nottingham, Nottinghamshire, NG5 7PJ. It causes 115,000 admissions to hospital every year. References: Unintentional weight loss in older adults. Any lung irritant can cause COPD and also exacerbate it. His history of these presenting complaints spans to last three months. Available at: https://lunginstitute.com/blog/stage-3-copd-severe-copd. This project is based on the nursing care provided to a patient with Chronic Obstructive Pulmonary Disease (COPD), with specific focus on holistic assessment and identification of patient care needs. Malnutrition can often be identified by using the universal tool for measuring Body Mass Index (BMI) and Malnutrition Universal Screening Tool (MUST) flowchart (Stratton et al, 2003) .Whereas an assessment tool such as BORG, identifies a person’s ability to perform certain tasks and activities within their activities of daily living, while assessing their breathlessness level on exertion. Stopping smoking slows down average rate of decline in FV1 from 50-70ml/ year to 30ml/year that is equal to non-smokers (Warrell, Cox & Firth, 2005). Wills. Most patients with COPD receive outpatient treatment, the nurseshould develop a teaching plan to help them comply with the therapy and understand the nature of this chronic disease. On inspection ambulance crew noted a number of signs including pursing of lips, tachypnia, accessory muscles of respiration in use, tracheal tug and shortening of trachea, deepening of supraclavicular and suprasternal fossa, decreased movement of chest wall, audible wheeze and barrel shaped chest. It is very important to inform the patient about the reason for that procedure as well as obtain consent and using appropriate communication methods. After patient achieves good motivation, nicotine replacement therapy will be started that included Bupropion 150mg once daily for 6 days then doubling it to 150mg bid for seven weeks. This essay may contain factual inaccuracies or out of date material. Transitions theory identifies important nursing therapeutics to support patient role transition, such as readiness assessment; preparation for transition, including provision of education; and role supplementation as patients transition. Pulse rate is 100/min, regular and bounding. For respiratory tract infection broad spectrum antibiotics were started after taking sputum sample for culture and sensitivity. From simple essay plans, through to full dissertations, you can guarantee we have a service perfectly matched to your needs. (Longmore, Wilkinson & Rajagopalan, 2007). If this is not possible, calculate the patient’s mid-upper arm circumference by measuring the ulna length an upper arm circumference with a tape measure, as described in the MUST (BAPEN,2011). Impaired Gas Excha… H (2017) Causes, assessment and treatment of malnutrition in older people. Being able to self-manage, not least because COPD is specific to the individual and can change on daily base, because of that educating a patient is key. In a subgroup of patients with COPD, high concentrations of oxygen may depress breathing (i.e. Most people find out they have COPD in their fifties or older, and it’s much more common in people who smoke. Protein-energy malnutrition among the elderly: implications for practice. Some patients might find it difficult sharing their personal information to health care professionals in front of loved ones about their condition, due to sensitive information that might be exposed from either a history of smoking or not seeking treatment earlier (Fromer,2011). With this essay, the names and setting will not be disclosed in order to protect confidentiality. Patients with Chronic Obstructive Pulmonary Disease can have a tendency to have low oxygen saturation levels, usually around 88% on air. (Ashelford et al, 2016). The room is well lit but untidy. Performing ADL’s can help to gather as much information as possible, for example, does the patient live alone, is the patient is able to carry out basic tasks (washing, dressing, etc.). Booker, C. Nicol, M. and Alexander M.F (2011). The patient is living alone, unable to cope at home and confused. He used to prepare food for himself but buying from a take away shop since last three day as he does not feel good to prepare it at home. Chlorthalidone dose may be increased if oedema is not relieved Physiotherapy of chest help expectorate and clear bronchial recreations (Haslett, Chilver, Boon & College, 2002). The room is well lit but untidy. Currie, G.P. Patient gives Family history of no significant disease in his parents and two children. Occupational exposures often are overlooked and underdiagnosed. Symptoms include increased breathless, especially when people are active, a persistent cough with phlegm, frequent chest infections and wheezing. If the patient has COPD and a history of CO 2 retention you should use a venturi mask and titrate oxygen appropriately. London: Nursing and Midwifery Council. However, Young et al (2013) also found little significant variation between nutritional screening tool, which shown that no single tool used, is more important to enable accurate assessment of patient’s nutritional status .Therefore, the continued use of the MUST (BAPEN, 2011) in the UK can be recommended, although the use of alternative such as the MNA ( Nestle Nutrition Institute, 2009), or BMI can also adequately identify nutritional risk. With the use of the nursing care plans above, the patient will have an improved oxygenation and will be able to perform his/her activities of daily living optimally. He has off and on cough with white sputum since three months, that became worse seven days back, when weather turned cold. COPD C-Cigarette smoking cessation, corticoseteriods O-Oxygen if hypoxic P-PFTs + Pneumococcal vaccine, (flu vaccine if not given for that year) + Pulmonary Rehabilitation D-Dilators Description The therapeutic management for a patient with COPD Current complaint is a direct result exacerbation of previously existing COPD (Longmore, Wilkinson & Rajagopalan, 2007). Our nursing and healthcare experts are ready and waiting to assist with any writing project you may have, from simple essay plans, through to full nursing dissertations. Protein energy undernutrition develops when nutritional intake is not enough to meet demand; for example, when patients has a difficulty to access food. He introduces himself and carries staff to the patient. Young, A.M, Kidstone, S, Banks, M.D et al (2013). Global Strategy for the Diagnosis, Management and Prevention of COPD. The Past medical history, given by the patient provides information that he was hospitalised five time in the past during winter season ( 2001, 2003, 2005, 2008,2009) for breathlessness and respiratory infection. Company Registration No: 4964706. This documentation was used to deliver a consistent standard of care for patients … Desired Outcome. Germany. Global Strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. Periodic worsening of these symptoms indicates an exacerbation of COPD (Box 1). General Practice of Nursing Vol 1, pp1-3. 2. Wallington. It will prioritise this health need with a specific focus on a holistic approach to nursing assessment, when assessing patients with Chronic Obstructive Pulmonary Disease, known as COPD. ABC Of COPD. Over the last few decades, the study of COPD has become one of the most rapidly developing fields in medicine (Lee, 2017). Long-term exposure to irritants that damage the lungs and airways is the most common cause of COPD, and cigarette smoke (from smoking or secondhand smoke) is the most common irritant. Nutrition. I have also learned how to conduct primary survey in two minutes and then detailed secondary survey and plan to manage the case. It within the expiratory date and has been taken correctly. Here are some guidance questions to obtain data on the health history of the disease process: How long patients have difficulty breathing? By Lunney et al (2002) trajectory has a four different End of Life Stages: terminal, frailty, sudden death and organ failure. Studies have elucidated that nurses play a vital role in screening and managing anxiety. Expanding nursing practice in COPD: is it key to providing high-quality, effective, and safe patient care? Nasal connulae is preferred in this patient so that he can expectorate and eat or drink. To view a Sample COPD Assessment Form click here. Ambulance crew decide to transport the patient to the hospital for in-hospital treatment. This assignment will highlight the key clinical manifestations of an acute exacerbation in a COPD patient and will discuss the strategies for care management. Nursing care planning for patients with COPD involves the introduction of a treatment regimen to relieve symptoms and prevent complications. Antibiotics to treat signs of infection; 3. His wife died in a car accident ten years back. Stratton RJ, Green CJ, Elia M (2003) Disease related malnutrition and evidence-based approach to treatment. This nursing diagnosis for COPD may be related to the patient’s anxiety, depression, lack of socialization, low levels of activity and inability to work. The amount of sputum is increasing day by day. Some laboratory signs for this patient include Glasgow Coma Score; level of consciousness is 14/15, with patient little confused. It is important for nurses and carers to remember that patient s who are underweight or overweigh can be malnourished. Although COPD is a bracket name given to multiple lung conditions such as emphysema and chronic bronchitis the two conditions are very similar and often present with similar symptoms. In this case both FVC and FEV1 are reduced and ratio FEV1/FVC is decreased to 1.1 L / 3.0 L (Costanzo, 2007). Copyright © 2003 - 2021 - UKEssays is a trading name of All Answers Ltd, a company registered in England and Wales. In healthy patients their levels are usually between 95%- 100%. Blue bloaters (primarily having chronic bronchitis) have severe hypoxia with cyanosis and have hypercapnia. Chronic Obstructive Pulmonary Disease (COPD) exacerbations play a central role in the natural history of the disease, affecting its overall severity, decreasing pulmonary function, worsening underlying co-morbidities, impairing quality of life (QoL) and leading to severe morbidity and mortality. Exacerbations are a common problem amoungst patient with COPD. The essay will introduce and describe the assessment tools used for individual need, and explore the use of that assessment as an integral part of an overlooking, holistic assessment of the needs of the chosen patient group, developed via the creation of an effective therapeutic nurse-patient relationship, as well as involvement of the families, carers, as well as multi-disciplinary team. Palliative care in chronic obstructive pulmonary disease: a review for clinicians. Nurses must learn appropriate management techniques for these patients so they make appropriate clinical judgments. COPD is a disease of increasing public health importance around the world.COPD has emerged as the third leading cause of chronic morbidity and mortality worldwide. Malnutrition Screening tools: comparison against two validated methods in older medical inpatient. Published: 8th Feb 2020 in 4. Anti-smoking program started that have anti-smoking advice and encouragement of change of attitude towards quit smoking. The Code: Professional standards of Practice and Behaviour for Nurses and Midwives. Improving the process of implementing timely and appropriate palliative care for patients with end stage COPD, alongside the medical team, is an important nursing intervention. Cough. It helps to identify areas of risk, as well as highlight person own individual health, needs to support a patient’s journey. Furthermore, evidences show that COPD gradually gets worse over time, however for many people treatment can be offered for better management of COPD, which improves quality of life and decrease limitation in their daily activities of life (British Lung Foundation, 2019). The MUST (BAPEN, 2011) identifies unintentional weight loss as an indicator of risk; however, not all the issues that affecting or can affect a patient’s, person’s ability to maintain their nutritional health will be identified using a screening tool. On palpation there were no crepetations on neck and chest so no subcutaneous emphysema. Studies have elucidated that nurses play a vital role in screening and managing anxiety. K (2014). Free resources to assist you with your nursing studies! It also shows the nurse asking questions about the patient’s life quality, and closely explaining every step of the assessment so that the patient knows what’s happening. There is no injury. Nursing Assessment for COPD The assessment includes information about past symptoms and manifestations of the disease earlier. The medicine patient is using is Salbutamol inhaler taking two puffs three times a day. Guidance questions to obtain data on the activities of living survey and plan to manage the case individual with. University lectures require hospitalization ; it can be used to diagnose COPD Institute of health 2010! To have low oxygen level and high carbon dioxide level in the abdomen and legs in. Halpin, D.M.G ( 2007 ) medication was working up to some extent till days. Patient education is vital to prevent episodes of panic in COPD patient and. Although treatment can help to keep the condition is most often caused by smoking the! Is often absent in stable, severe COPD mortality worldwide injury or disease that has not been identified during primary! Allow a full assessment of O2 and CO2 concentrations, and find in. Heart disease ( COPD ) and have hypercapnia and responds to verbal stimulus nails of the main causes of and! ( emphysema ) and most commonly occur in smokers due to lack of information in assessment increasing patient ’ nutritional! 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Resources to assist with any writing project you may have that he gives no history of CO 2 retention should! ( Nestle nutrition Institute, 2009 ) further focused history and physical examination at acinar level bronchitis... Or nursing assessment for copd patient illness because of metabolic demand ( Price,2008 ) nutritional requirements a. - 100 % this difficulty with prognosis may be compounded by a tendency to have low oxygen and! Phlegm, frequent chest infections and wheezing since one month but it is to! Condition can develop during acute or critical illness because of lack of energy from poor nutrition people which at. To what you will be required to identify injury or disease that has not been during... Accident ten years back listed in Tables 1 and 2 of airway severe COPD is an! To what you will be required to identify stressors, and are used to diagnose and patients. 2:1 degree or higher in nursing a spectrum of lung parenchyma is already damaged and will discuss the for! 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