COPD: A Worldwide Menace to Health

Introduction to Chronic obstructive pulmonary disease (COPD):

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 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).

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 is 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, the resistance of airflow in the small conducting airways passage occurs. The other typical features include air trapping, increased compliance in the lungs and progressive airflow 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 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.

During mild exacerbations, obstruction to airflow gets slightly altered or remains unchanged. In case of severe exacerbations worsening conditions of pulmonary gas exchange occurs because of enhanced inequality between ventilation and perfusion process which eventually results in fatigue of respiratory muscle. Worsening conditions result in inflammation of air passage, hypersecretion of mucus, oedema and finally bronchoconstriction. Bronchoconstriction results in reduced ventilation resulting in vasoconstriction of pulmonary arterioles in hypoxic conditions. Several pathophysiological conditions are observed 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; Battaglia, 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.

Principles A:

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 (Manley, et al, 2011).

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 (Manley, et al, 2011).

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 (Manley, et al, 2011).

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 (Manley, et al, 2011).

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. The NMC code described the ethical and legal issues of “Prioritise People” as the individual right should be maintained and respect throughout the process of treatment (NMC, 2015). Therefore, to maintain the confidentiality of the patient a pseudonym has to be used instead of the correct identity of the patient. Moreover, the patient location and name of the person should be anonymised to protect the patient from any abuse or probable harm which may happen after revealing their age and location (Manley, et al, 2011).

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 (Manley, et al, 2011).

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 (Manley, et al, 2011).

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:

1) 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.

The patient should be informed about the lung function and recoding the observations on the observation form and also how to use the COPD call centre for decisions and support interventions.

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 (Connors, et al, 1996; (Kreitzer, 2015).

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 case study

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

Mr. John (pseudonym) is 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. He lives alone in his apartment as his wife expired about 5 months ago. After her death, he used to manage the conditions of his disease by self. The clinical manifestations of his disease 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). Among the other sociological parameters he is little untidy or clumsy in his behaviour and also started smoking recently. This may be due to the alteration in the mental status of the patient after the death of his wife. His only daughter currently lives outside the country with her husband. So he is leading a lonely life.

The social and psychological challenges of the patient:

The condition of COPD makes the patient unfit for leading a healthy social life due to the acute problem of breathlessness. The shortness of breath hinders the person to talk to someone spontaneously and travel distance through walking. Thus the diseased condition confines the patient to lead a lonely life as he is unable to keep proper contact with his friends and relatives. Moreover, due to the limitations induced by his physical condition the patient was unable to attend the social gathering which eventually forced the person to lead a lonely life.

In this case the patient was depressed not only because of the social limitation caused due to the acute health condition of COPD but also due to the recent death of wife of the patient. The patient was unable to share his emotions with anyone and due to the depression the patient again got addicted to smoking which he thought could alleviate his stress level. It is evident that the presence of COPD, a long term condition results in the development of anxiety and depression as the patient is unable to lead a quality life and always need the support of other people for executing any activities. In the present case also, Mr John also was suffering from depression and anxiety as he could not lead a healthy social and professional life due to his acute health condition and also because he had recently gone through a stressful phase in his relationship due to her death (Kouijzer, et al, 2018; Tselebis, et al, 2016).

Management of the problem using the holistic approach of nursing:

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). Mr John was also made to attend the group counselling for the cessation of smoking. The smoking cessation services have been included as part of the National Service Framework for Coronary Heart Disease and it has immensely benefited patients suffering from respiratory problems. Guidelines on Smoking cessation demonstrate well-structured guidance for all health professionals. 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). Thus according to NICE guidelines varenicline was provided to him to help quit smoking to control his health condition (NICE, 2017).

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 the patient who is 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. As mentioned above for the management of the diseased condition of the patient, the nurses should provide the bronchodilators which will dilate the bronchioles of the patient and the patient will experience better while breathing. The blood oxygen level will be successfully monitored by using pulse. Mr John was advised to stay on oxygen therapy for the long term during admission to the hospital and that his condition needed to be monitored. The treatment during this assessment phase involves the supply of oxygen for at least 15 hours a day and it has to be carried out in two separate phases when the condition can be considered to be stable usually after about six weeks after admission. During the oxygen therapy Mr. John was advised not to smoke as it diminishes any treatment benefit and cigarette can also be considered as a fire hazard. Nurses and the healthcare team educated Mr. John about the self management strategies of COPD during the time of release from the hospital stay. Moreover, he was informed as per the aspect of the model, when and where to ask for help if he was unable to manage his own health or experienced any issues with care delivery. Thus, the nurses around Mr John were there to provide counselling to help him get over the grief and were also referred to respiratory nurse specialist who informed him regarding the way he could control his replaces COPD symptoms to ensure normal breathing. Therefore, for the health promotion of Mr. John, nurses provided the high quality services marinating all the principles of nursing concerning the smoking cessation, lowering his depression and provided him with better carers to give him support which valued his dignity gave respect to the patient. Impassionate services of the nurses makes the patient feel lack of value and dignity and eventually the patient avoids the care services of the nurses (Judith, 2002; Boschetto, et al, 2003; Domenech, et al; 2013; 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. 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).

Role of the Multidisciplinary 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 for the patient. An assessment of Mr John’s mental health such as the presence of anxiety disorders and depression and about the coping skills was included within the medical plan. Dietary habits of patient were monitored as there is a strong association between COPD condition and weight loss. Weight loss diet should be advised for obese COPD patient which may help to decrease the breathlessness problem. Pulmonary rehabilitation should also be provided to patients if needed. In the present case, Mr. John was educated about the smoking cessation process, travelling, support groups, advanced directives and community resources by the nurses and the healthcare team in a collaborative approach. Regular follow up of the patient and communication between all members of the health care team were ensured for the efficient management of COPD patient (Kuzma, et al, 2008). For the pulmonary rehabilitation of the patient, the strength, flexibility, gait orthopaedic and musculoskeletal limitations need to be addressed to tailor a patient centred exercise program which may act as a barrier to success.

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 discussed.

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