Respiratory Assessment of Patients Presenting with COPD - Essay Example

Introduction With the different cases that a nurse in the ER can encounter, it is imperative that he or she is knowledgeable about the different diseases, especially the symptoms particular to certain ones, as it will be helpful in contributing information to the medical team as a whole. A nurse is, for most of the time, the first contact of medical care for patients admitted in the emergency room for exacerbations of many diseases, including asthma and Chronic Obstructive Pulmonary Disease. COPD “is an umbrella term covering a range of conditions including chronic bronchitis and emphysema. It is a long term condition that leads to damaged airways, causing them to become narrow, making it harder for air to get in and out of the lungs” (COPD National Service Framework, 2008). There are “currently 300 million people have asthma; 210 million people have chronic obstructive pulmonary disease (COPD) while millions have allergic rhinitis and other often under-diagnosed chronic respiratory diseases” (World Health Organization, 2008). Therefore, a sound knowledge of respiratory disease and skills to effectively manage these patients are essential in the delivery of care. In line with this, I have chosen two pieces of evidence regarding COPD. For the first piece of evidence, we will be looking into the subjective and objective respiratory assessment of patients with common respiratory disorders such as asthma and COPD. Furthermore, on the second piece of evidence, I have chosen to deal with acute breathlessness due to exacerbation to COPD as well as its possible medical interventions. I will also take into consideration the psychosocial impact/s of this disease to the patient and also about patient education for self-management initiative. First Piece of Evidence: Respiratory Assessment of Patients with Respiratory Disorders such as Asthma and COPD “Respiratory diseases kill one in five people in the UK and has a mortality rate higher then coronary heart disease” (British Thoracic Society, 2006a). Respiratory diseases accounts for a large part of the total medical admission to the hospital, wherein the most common is asthma and Chronic Obstructive Pulmonary Disease (COPD) (Roussos & Koutsoukou, 2003). It is estimated that there are about 600,000 patients in the UK with diagnosed COPD and there may be as many again who remain undiagnosed. Nearly one in three (29%) episodes of finished consultant episodes for patients over 60 years and one- fifth (21%) of bed days used for respiratory disease treatment are for chronic obstructive lung disease (British Thoracic Society, 2006b). These figures give us a clear picture as to how devastating COPD can be not only to the physical aspect of a patient, but as well as in the economic and psychosocial aspects. This essay attempts to describe respiratory assessment with a sound health history taking and also objective assessment particular to the respiratory system. A good medical history is pertinent to proper and effective medical care. During history-taking, significant personal information to ask are age and sex. It should also “begin with the “chief complaint”, the patient’s perception of why medical attention is being sought” (Sullivan & Schmitz, 2004a, p. 285). Among the common complaints of patients with COPD are difficulty in breathing or shortness of breath (dyspnoea), cough and chest pain. Dyspnoea which are of acute onset (minutes to days) can be indicative of “laryngeal oedema or acute asthma, acute cardiogenic or non-cardiogenic oedema, bacterial pneumonia, pneumothorax, pulmonary embolus” (Fauci, et.al, 2008a). A subacute (days to weeks) may suggest “an exacerbation of preexisting airways diseases such as asthma or chronic bronchitis or neuromuscular disease” and a chronic duration “often indicates COPD, chronic interstitial lung disease or chronic cardiac disease” (Fauci, et.al, 2008b). Precipitating factors, position, duration and quality should also be asked. The severity of orthopnoea (dyspnoea in the supine position) could be described by asking a question such as “‘how many pillows do you use?” (Wolters et al, 2008). Dyspnoea can be assessed by using several scales such as Medical Research Council Dyspnoea Scale, which lets the patient grade his/her symptom on a five-point scale with 0 being “Not troubled by breathlessness except on strenuous exercise” and 4 being “Too breathless to leave the house, or breathless when dressing or undressing” (American Thoracic Society & European Respiratory Society, 2004). Severe dyspnoea of rapid onset accompanied by hypoxemia with diffuse pulmonary infiltrates leading to respiratory failure” (Fauci, et.al, 2008c) is indicative of respiratory distress and should be given medical intervention quickly. “Cough, which is a common symptom, is normally a reflex response to stimuli that irritate receptors in the larynx, trachea or large bronchi. When given as the chief complaint, it should be assessed as to its onset & duration (acute, subacute or chronic), whether it is productive (with sputum) or non-productive, and exacerbating factors (position, activity, etc). If the patient has productive cough, color and quantity as well as blood in the sputum (hemoptysis) should also be noted, if present. Chest pain should be assessed as to its cause, whether of cardiac, respiratory or of other origin. Cardiac pain, otherwise known as angina, is “typically located in the substernal region or sometimes in the epigastrium that radiates to the neck, left shoulder and arm” (Fauci, et.al, 2008d) and is usually a severe discomfort described as a painful tightening on the chest area. Meanwhile, respiratory or pleuritic pain is usually diffuse and non-radiating. Other symptoms to ask the patient are “constitutional symptoms: fever, night sweats, unintentional weight loss, sinus congestion, facial tenderness, postnasal discharge and sore throat” (AETC, 2008a). After the chief complaint, it is important that a nurse should also ask the past medical history of the patient. Questions should pertain as to the any childhood illnesses (such as recurrent lung infection or primary complex), accidents and disabling injuries which might have affected the patient’s respiratory organs, past hospitalisations, immunizations (for flu, PTB), medications, transfusions and allergies. Family health history is also vital as it offers information about patient’s blood relatives and to identify genetic, familial or environmental illnesses that have implications for the patient’s present or future health problems. An important risk factor to ask the patients with COPD is their history of smoking, in pack years, if present. Cigarette smoke is the most commonly encountered risk factor for COPD (GOLD, 2007). “Smoking accounts for over 80% of people with COPD and it accounts for 90% of COPD caused death” (COPDFoundation.org, 2008). It is important to check also for passive smoking by asking for household members who are smokers. Nurses have an important role to play in helping smokers to stop as even brief cessation advice has been shown to be effective (Meighan-Davies & Parnell, 1999). It is also important to ask any concomitant “cardiovascular diseases, including congestive heart failure, coronary heart disease, arrhythmia, pulmonary hypertension” (AETC, 2008b) as these are life-threatening conditions. Left-sided congestive heart failure (CHF) can manifest as pulmonary oedema, since this is the side of the heart that receives the oxygenated blood from the lungs. Patients with cor pulmonale, which is “right heart failure secondary to lung disease” (NCCCC, 2004) will also exhibit respiratory symptoms. Pulmonary oedema will cause dyspnoea and cough but CHF patients will present with other symptoms also such as murmurs, distended jugular veins, hepatomegaly and peripheral oedema. These life-threatening diseases should be determined or ruled out as the treatment of such are different from COPD. Assessment is “the first part of the nursing process” (Archibald, 2000). It is thereby important to do a thorough objective assessment after subjective assessment has been done to rule out the other possible diagnoses and narrow it down to just one working diagnosis. Physical examination should be performed “with attention to gen. condition, pulmonary, cardiovascular and neurological systems” (Chojnowski, 2003). Vital signs, especially the respiratory rate, depth and pattern should be taken. COPD patients are usually tachypnoeic and shallow. Observations should include the “neck and shoulder muscle which are used as accessory muscles for breathing for COPD patients, ratio of anteroposterior (A-P) to lateral diameter, presence of pursed-lip breathing, cyanosis around the lips, eyes and nail beds and digital clubbing” (Sullivan, S., Schmitz, T., 2004b, p. 285). Cyanosis is associated with excessive deoxygenation of haemoglobin and hypoxia so it is therefore characterized by a dusky bluish colour of the mucous membranes (Casey, 2001). Hypertrophied neck muscles, pursed lip breathing and a decrease in A-P to lateral diameter ratio (secondary to an increase in A-P diameter) are common signs for patients with emphysema. A thorough chest examination should include auscultation of breath sounds to check for the presence of abnormal or adventitious breath sounds, palpation to check for tactile fremitus & percussion. Upon auscultation, patients with asthma typically present with wheezes, which is high-pitched and more prominent in expiration, indicating that there is airway obstruction whereas patients with chronic bronchitis will present with crackles which is likened to the sound of hair being rubbed against each other, indicating that there is filling of the alveoli with liquid. Rhonchi, a sound created when the airway lumen is filled with liquid, may also be present. Tactile fremitus, which checks for the vibrations along the chest wall, is decreased for patients with emphysema. Ancillary procedures include a spirometry test performed in the initial diagnosing stage because this can detect any physiologic disturbances in the respiratory functions of the patient. For COPD,” the clinical hallmark is decrease in expiratory flow rates” (Fauci, et.al, 2008c), particularly FEV1 (forced expiratory volume in the 1st second) of [Accessed 15 October 2008] Second Piece of Evidence: Acute Care of Breathlessness Caused by Acute Exacerbation of COPD in an Admission Unit This essay will examine the care of a patient presenting with one particular acute care problem which is breathlessness. This will be explored using the nursing process of assessment, planning, implementation and evaluation and will discuss the care provided to the patient giving a rationale using current research and evidence. Furthermore it will consider how this knowledge of this acute problem can enhance future practice. In accordance with the Nursing and Midwifery Council, (NMC) Code of Professional Conduct (NMC, 2004) on safeguarding patient information, no names or places will be disclosed. The 62 years old patient presented to the department with a complaint of acute breathlessness (dyspnoea). He appeared distressed and reported he was finding it increasingly difficult to breath. He informed the staff that he had been producing excessive, abnormal sputum for a few days, however it was only the last few hours that his breathing had become unmanageable. The patient was diagnosed with chronic obstructive pulmonary disease (COPD), which the doctor stated was emphysema, the year previous, and although he occasionally becomes breathless but he felt this was different. The patient was diagnosed with an exacerbation of his COPD. An exacerbation is a “sustained worsening of the patient’s symptoms from their usual stable state which is beyond normal day-to-day variations, and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour” (NCCCC, 2004). Emphysema is a COPD which affects the alveoli, specifically their sensitive membranes through which the gas exchange process occurs. Emphysema produces alveolar membranes to lose normal elastic recoil, therefore trapping and stagnation of alveolar air, (National Emphysema Foundation, 2006) these then become brittle, and then rips and tears (Sandford, Weir & Pare, 1997). These alveolar membranes cannot be regenerated by the body and each time alveolar membranes burst; further surface area within the lung necessary for gas transfer is permanently lost. Patients with emphysema have hyperinflated lungs due to the loss of elastic recoil. This disease decreases the efficiency of the gas exchange process (Shaw, 2005). Physical examinations in reference to respiratory symptoms were done. The patient was not showing any signs of cyanosis, however Considine (2005) reasons that cyanosis is an unreliable indicator of hypoxemia and a late sign of respiratory failure as it does not occur until hypoxemia is severe. The patient was also observed for signs of confusion and was found to be alert, responsive and orientated. Physical examinations and observations included the respiratory rate, rhythm and depth, blood pressure, pulse rate, pulse oximetry, temperature and sputum production (Jevon & Ewens, 2001). These according to Smeltzer and Bare (2004) provide a baseline for comparison, provide early recognition of deterioration and are useful to monitor changes in the patients’ condition. The patient was tachypneic - an attempt of the body to blow off accumulated CO2 (Workman, et.al, 2002). Patient’s temperature was 38.1°C which could be an indication of infection (Waught & Grant, 2004) with impact on respiratory rate since Dougherty and Lister (2004) state there is a seven breath per minute increase in respiratory rate for every 1 degree rise in temperature above normal. The patient was tachycardic and his blood pressure was 140/90mmHg - an attempt by the heart to compensate of decreased oxygen delivery (Lewis, Heitkemper & Dirksen, 2004). According to Celli and MacNee (2004), when the blood has too little oxygen, the heart starts to beat faster and harder to acquire more oxygen to the body’s tissues. This can lead to a pooling of blood in the veins of the lungs, and a reduced output of blood from the heart which can lead to breathlessness. The patient’s sputum was dark green and was indicative of an ongoing infection, the dark colour as a result of the neutrophils released by the immune system (British Thoracic Society, 2000). Pulse oximetry was obtained to measure the oxygen saturations as this is a useful guide to oxygen requirements. The oxygen saturation of 85% on room air, however because pulse oximetry does not measure partial pressure of carbon dioxide (PC02) or potential hydrogen (PH), arterial blood gasses were obtained since they are the only reliable way of assessing the patients oxygenation and carbon dioxide status (Holloway, 2004). The posture was observed and it was noticed that he exhibited increased use of accessory muscles as when sitting he placed both elbows on the arms of the chair and leant forward. This according to Bailey (2004) is an attempt to increase the vertical dimension of the thorax to achieve a mechanical advantage for the muscles of ventilation. Acute exacerbations should be treated appropriately and adequately, as failure to do such in a timely manner can possibly result to respiratory failure. Respiratory failure is defined as “a syndrome of inadequate gas exchange due to dysfunction of one or more essential components of the respiratory system” wherein the mortality in hospitalizations is as high as 36% (Katyal & Gajic, n.d). In exacerbations, bacterial numbers increase and this incites an inflammatory response causing further dyspnoea (Wilson 1998). Air trapping in emphysema, particularly carbon dioxide (CO2) retention, can lead to Type II or Hypercapnic respiratory failure. Arterial blood gas usually presents with PaCO2 >45 due to failure to exchange or remove carbon dioxide resulting in decreased alveolar minute ventilation (V-A). This ultimately causes a disturbance of the acid-base balance in which body fluids become excessively acidic (acidosis) which can lead to respiratory failure (Harrison & Daly, 2001). An altered respiration rate from rapid to a slower rate should be noted as it suggests extreme fatigue and the possibility of an impending respiratory arrest (Roussos & Koutsoukou, 2003). Medical goals and treatment included to address dyspnoea and promote ease of breathing as well as to clear his airways of sputum. The patient was placed in an upright position to ease diaphragmatic descent during inspiration; gravity also pushes downward on the abdominal contents, moving them out of the way of the descending diaphragm in this position (Thompson 2001). Oxygen therapy is indicated for exacerbations to address dyspnoea. Administration of oxygen is designed to correct hypoxemia when tissue oxygen availability is decreased (Charlebois, et.al, 2004). The patient was commenced on 24% prescribed oxygen as any higher may cause respiratory depression (NCCCC, 2004). He was subsequently reassessed when his blood gas results returned and his oxygen was increased until the goal of 92% SaO2 was accomplished (British Thoracic Society, 2000). National guidelines for the management of acute exacerbations of chronic obstructive pulmonary disease recommend an initial fractional inspired oxygen concentration (FiO2) of no more than 0.28. However, oxygen therapy with an FiO2 in excess of 0.28 is most often initiated during ambulance transportation but is perpetuated by hospital emergency staff and it may cause or aggravate acute hypercapnic respiratory failure (Denniston, O’Brien, Stableforth, 2002). Therefore, adequate information for health care practitioners, especially an emergency nurse, is needed to prevent this from happening. Vital signs and cognitive abilities were also evaluated for CO2 retention and narcosis associated with the delivery of too high a concentration of oxygen. Weaning was considered when the underlying disease was stabilized and when his BP, pulse rate, respiratory rate, skin colour, and oximetry were within normal range. Long-term oxygen therapy can be beneficial in some people with COPD who develop low blood oxygen levels (British Lung Foundation, 2004). The patient was prescribed an increased dose of short acting bronchodilators through a nebuliser as recommended by NICE (2004) since he was unable to use an inhale. This helped to improve the airflow and reduction of lung hyperinflation. The pulse increased when these medications were taken and he complained of a dry mouth – a side-effect of bronchodilators (National Health Service, 2005). Also stated in the NICE Guidelines, other medications indicated for patients with exacerbation of COPD are: oral corticosteroids (prednisolone) in the absence of significant contraindications, antibiotics to treat exacerbations of COPD associated with a history of more purulent sputum and theophylline for patients who are not responding well to bronchodilators” (NCCCC, 2004). The patient was producing excessive sputum and this can obstruct the airways and must be removed or the oxygenation of the blood will be affected (Roper, Logan & Tierney, 2000). The patient was encouraged to drink fluids to keep his secretions less viscous, aiding their expectoration (Lewis, Heitkemper & Dirksen, 2004), with caution if right or left sided heart failure is present (Smeltzer and Bare 2004). Medical intervention should be holistic and this should also address the psychosocial aspects of this disease. The functional status and quality of life of patients with COPD does not appear to be based exclusively on physical health status, but on a combination of both physical and psychological factors (DHSSPS Clinical Psychology Specialty Advisory Committee, 2004). COPD greatly limits daily activities and reduces health- related quality of life. Exacerbations of COPD do not merely affect the physical, but has emotional consequences as well. In the study by Kessler, et.al, 2004, “nearly 90% of patients reported that exacerbations had an influence on their ADL, with half of them needing additional help with certain tasks (particularly household chores, shopping, cooking, and “everything”) during an exacerbation. The majority of patients (65%) reported that these events also affected their mood and caused a variety of negative feelings, such as depression, irritability/bad temper, anxiety, isolation, anger, and guilt. These effects had adverse consequences for their personal and family relationships, leading to isolation and prevention of social activities”. Patient education is vital to ease the patient’s anxiety and fear. Explaining all activities and procedures, using non medical terms and in a calm and slow speech can help. Empowering the patient this way resulted in less anxiety and emotional distress for him (Lewis, Heitkemper & Dirksen, 2004). Helping the patient feel that he or she is still adequate to take care of themselves is a way for him to feel less depressed. An appropriate home care package, with the support of respiratory nurses, is of some benefit to housebound patients with COPD because it helps to relieve depression and improve their quality of life, especially among those with a high level of depressive symptoms (Yohannes, 2005). Coping through the difficult times can also be addressed by involving the family into the rehabilitation process to help the patient have a support system. The patient should be taught of the importance of lifestyle modification, most especially of smoking cessation (if applicable), alcohol cessation (if applicable), non-strenuous aerobic exercise and proper diet. Evaluation is ongoing and leads directly back to the assessment phase of the nursing process, culminating in further planning of care or discontinuation of the need, want or desire for intervention (Royal College of Nursing, 2006). This assignment has shown that the nursing process was holistic at all times, personalised. The nurses used this systematic, rational method of assessment, planning, implementation and evaluation to achieve a desirable outcome for patient. This required the nurses to have critical thinking skills to identify and treat the actual or potential health problems. 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