Nursing Case Studies on COPD
In this reflective piece of writing I will be explaining how chronic obstructive pulmonary disease (COPD) affects the patient physically, psychologically ,and socially ,I will also explain how the disease affects his daily routine and how it impacts on his family life. I will give an overview of the clinical signs and symptoms, how the disease alters the pathphysiology of the lungs, and what these changes cause within the body. I will be using the reflective model “What, So What, Now What “ (2007). The patient I have chosen to write about is a seventy year old male who has been married for nearly fifty years.
He has two grown up sons, both married with children of their own. Mr Woods has Chronic Obstructive Pulmonary Disease diagnosed ten years ago. Prior to this disease Mr Woods was a lifelong smoker, beginning at the age of fourteen years, smoking up to thirty cigarettes per day. Mr Woods condition has progressively worsened over the past few years, and he now requires home oxygen therapy. A patient was brought into the emergency department by the paramedics complaining of difficulty in breathing. On arrival he was tachypnoeic, had a respiratory rate thirty two and was found to have an audible wheeze.
He stated that he had a productive cough and was expectorating green coloured sputum. The patient felt warm to touch. He looked pale, was sat upright, slightly leaning forward in a rigid posture on the ambulance stretcher. I was delegated the role of undertaking Mr Wood’s initial assessment, which included ensuring the patient was undressed ready for examination by a doctor, and also carrying out a baseline set of observations. I was happy to undertake this task, because I had the required training, skills and was deemed competent to carry out the necessary care required to look after Mr Woods.
The nurse in charge informed me of Mr Woods medical history prior to me entering the cubicle, including what had precipitated his attendance to the emergency department which on that particular day had been his worsening shortness of breath. On entering the cubicle, I helped Mr Woods get undressed and into a hospital gown because any slight exertion made him more short of breath. I carried out a baseline set of observations. His blood pressure was 165/95, he had a pulse rate of 125 beats per minute, a temperature of 38. c, a respiratory rate of 32, on 2 litres of oxygen his saturation level was 88%, and his blood glucose level was 4. 4mmol/l. Although some of these observations are not within ‘normal’ range, for a person with COPD some of these observations maybe acceptable because the disease affects the path physiology of the lungs. The airways leading to the lungs, the bronchi, become inflamed. The inflamed airways produce too much mucus (sputum) which can lead to a persistent cough, wheeze and increasing shortness of breath.
This happens because the air sacs (alveoli) become overstretched, rupture and merge which causes them to lose their elasticity. This causes the oxygen absorbing surfaces to be reduced, and with the narrowing of the airways gas exchange is less efficient (Parker, 2009). The lungs over inflate which reduces the air volume moving in and out of the lungs which can lead to tachypnoea (abnormally rapid rate of breathing), breathlessness on exertion, respiratory distress, abnormal posture I. e. leaning forward to help open the airways (Nursing Standard, 2001).
Patients with Chronic Obstructive Pulmonary Disease can have a tendency to have low oxygen saturation levels, usually around 88% on air. In healthy patients their levels are usually between 95%- 100%. COPD patients often need supportive treatment of 2 litres of oxygen to maintain oxygen saturations normally acceptable for that specific patient. However oxygen therapy higher than 2 litres may cause their carbon dioxide (CO2) levels to rise (Abrahams, 2009). As Mr Woods COPD had progressively worsened he had been commenced on home oxygen which he uses throughout most of the day.
This helps him to undertake the most simplistic of daily activities of living. Mr Woods lives at home with his wife who, due to the impact of this disease on Mr Woods, has now become his main carer. She helps her husband with his daily activities such as washing, showering and preparing his meals. He needs help mobilising to the downstairs shower room, and, once there, needs assistance to get undressed. Whilst in the shower room Mr Woods needs to sit on a shower stool because he cannot manage to stand for any length of time due to breathlessness.
He is also unable to walk upstairs because he gets short of breath on exertion so he has had a stair lift installed which enables him to go upstairs to bed. This enables Mr and Mrs Woods to fulfil both the physical and psychological aspects of their relationship. COPD can affect the psychological wellbeing of the sufferer. Before Mr Woods condition deteriorated he was able to go out, he used to enjoy going fishing with his sons and playing with his grandchildren. Because of his condition, Mr Woods is prone to feelings of inadequacy and depression.
He also feels guilty because of his growing dependency on his wife for the simplest of daily tasks such as making a cup of tea or answering the door. Because of the growing demands of her husband’s worsening condition Mrs Woods now has to depend on other family members to facilitate her with tasks that Mr Woods can no longer undertake due to his COPD, and frequent visits to the hospital with recurrent chest infections. Whilst Mr Woods was in the emergency department it was my responsibility to make sure Mr Woods was comfortable and that his observations were done regularly and documented.
I was happy to do this as I am deemed competent and have the required training to carry out these duties. I made sure Mr Woods was sitting upright as this would help him with his breathing by improving his lung capacity and making sure oxygen was prescribed by the doctor and administered via nasal cannulae as per trust policy. I noticed Mr Woods remained tachyponeic, so repeated his observations. Even though on 2 litres of oxygen his saturation levels still remained low so I informed the nurse in charge that Mr Woods observations remained unstable.
A doctor was notified and the patient assessed which involved listening to his chest. The doctor then prescribed nebulisers, oral steroids and paracetamol. A chest x-ray was also requested. I had to ask a qualified member of staff to administer Mr Woods medication, because I am not qualified to dispense drugs to a patient as a student assistant practitioner as this does not fall within my scope of practice or within the boundaries of my role. I think the fact I know my limitations and boundaries make me a safe practitioner.
I made sure I had documented Mr Woods observations and that I had informed the nurse in charge of his condition making sure that I had dated, timed and signed what I had written. I got my documentation countersigned by a qualified member of staff as stated by the Nursing and Midwifery Council (NMC, 2008). The doctor asked me to cannulate and take some blood from Mr Woods. I was comfortable with this request because I am qualified to undertake the task. I explained to Mr Woods that I needed to put a needle in his arm and take some blood and that I would be leaving the cannula in his arm for any medication his may require later.
I put the equipment together that I needed to cannulate, making sure that it was on a clean trolley and that I had a sharps bin. I then washed my hands, put on my apron and gloves following universal precautions. I then proceeded to cannulate Mr Woods explaining everything I was doing throughout the procedure. Once the cannula was in I disposed of my sharp in the sharps bin and put my dirty equipment in the clinical waste and then washed my hands. Mr Woods was then taken for his x-ray. Once labelled I then gave the blood to the doctor to send of to the path lab.
I then filled in the cannulation documentation form as per hospital trust policy. I was pleased that I managed to get the cannula in on my first attempt because Mr Woods had terrible veins and I did not like the thought of having to put him through the procedure again as it can be quite painful and distressing. Mr Woods x-ray showed he had a chest infection for which he was prescribed intravenous antibiotics. Mr Woods was then transferred to the Medical Assessment Unit for further treatment by the medical doctors. Reflecting back I believe I have developed my knowledge about chronic obstructive pulmonary disease.
Reading articles, text books and trust policies on COPD has allowed my to enhance my ability to recognise when patients are clinically unwell and have the confidence to highlight these abnormalities to the relevant members of the multidisciplinary team I. e. the nurse in charge and doctor, so the patient can be managed promptly and appropriately. Also the information I gained from talking to Mr Woods was invaluable in allowing me to gain insight and therefore a greater understanding of how the disease affected not only the patient but also his family on a day to day basis.
Witnessing first hand the debilitating affects the disease process has on an individual such as Mr Woods and his family left me feeling a little sad due to the fact that my role as a student assistant practitioner limited my involvement in his treatment. Having been the first member of staff to attend to Mr Woods on his arrival to the department and to have spent time developing a therapeutic relationship with him I felt that involving another member of staff to carry out an aspect of care may make him question my abilities to look after him as I could not administer his medication.
I could address this issue by explaining to the patient that my role as student assistant practitioner does not allow me to give medication but explain that I am competent in carrying out all other aspects of care. Developing my existing knowledge on the psychological and physiological affects of Chronic Obstructive Pulmonary Disease has been consolidated by caring for a patient that has attended the emergency department with this chronic long term condition.
Extending my knowledge base on this condition and the long term effects it can have on the individual will ensure that I treat each patient on their needs rather than just on their condition. Also looking back on this assessment I believe I acted professionally, promptly and efficiently. I feel I carried out my duties to a high standard of care within the boundaries of my role as a student assistant practitioner which in turn enabled Mr Woods to receive the treatment and medication he required to ensure the best possible outcome.
Looking after Mr Woods has shown that I can work effectively as a member of the multidisciplinary team. I am able to assess, implement and evaluate my care which has enabled other members of staff to witness my holistic and high level of care delivery within the emergency department. I believe this can benefit not only the patients attending the department but also help develop my role within the team.