Nursing in Breathlessness in Chronic Bronchitis - Essay Example

Applied Studies In Nursing: Breathlessness in Chronic Bronchitis Introduction The practice of nursing has advanced over years and is coping withcurrent trends and challenges of medical profession. For many years, reflection has been considered to be the key for successful learning process (Somerville and Keeling, 2004). In using reflection as a tool for the development of the professional nursing practice, a plan can be designed to meet the goals of the reflective activity by recording thoughts, observations, feelings, activities and questions. Through this, the effective practitioner can be challenged to think in new ways, raise new questions and explore new ways of problem-solving. In this essay, reflection on the nursing care of an adult patient will be done to meet the goals for the improvement of analytical thinking skills such as being able to identify problems that might arise, being aware to new or different ideas, and anticipating the consequences of one’s actions. Case Scenario 60 year old Mr.X was brought to the out patient department with cough and easy fatiguibility on and off since 6 months, breathlessness since 2 months and worsening of breathlessness since 2 days. He was accompanied by his wife and son. Mr. X, a retired teacher, was a chronic smoker. He was a known patient of hypertension and appeared obese. He used to exercise regularly until 6 months prior to coming to hospital, when he developed exercise induced cough and breathlessness which he thought was due to asthma. Initially, his symptoms responded to inhalers, but later the symptoms continued to persist. He was on amlodipine for hypertension. The problem which has been identified to discuss in this essay is breathlessness. Holistic Assessment A detailed history was taken in Mr. X to evaluate causes of breathlessness. The history included history of chest pain, edema, giddiness, exertional breathlessness, breathlessness in lying down position, vomiting and epigastric pain. Cough was present through out the day and was productive. Mr. X had only exertional breathlessness. The breathlessness was graded according to the Medical research Council Dyspnea Scale (table-1). Table.1: The Medical Research Council (MRC) Dyspnea Scale (NICE, 2004). On examination, the patient appeared mildly pale. He had no fever. Pulse rate was 100 per minute, respiratory rate 30 per minute, blood pressure 140/90mmHg and saturations were 89 percent in room air and 94 percent with 3 liters of oxygen through rebreatheble mask. Examination of other systems were unremarkable. Electrocardiogram was normal. The initial investigations which were sent were complete blood picture and arterial blood gas analysis. Complete blood picture was normal except for low hemoglobin (11g/dl). Total leucocyte counts were normal suggestive of absence of infection. Arterial blood gas analysis revealed mild respiratory acidosis. pH was 7.32, PaO2 was 80mmHg and PaCO2 was 30mmHg.Electrocardiography revealed left ventricular hypertrophy with normal pulmonary artery pressures. Chest X-ray was suggestive of increased bronchovascular markings with absence of consolidation findings. Based on these findings, a diagnosis of of chronic bronchitis was made. The diagnosis of chronic obstructive pulmonary disease is mainly on the basis of clinical presentation and exclusion of other causes of cough and breathlessness. According to NICE (2004), "diagnosis of chronic obstructive pulmonary disease should be considered in patients over the age of 35 who have a risk factor (generally smoking) and who present with exertional breathlessness, chronic cough, regular sputum production, frequent winter ‘bronchitis’ or wheeze." other than the above tests performed, pulmonary function tests are also important because they help in the assessment of the severity of lung pathology and also in monitoring response to treatment. The most common index of obstruction of air flow is FEV1 (Fromer and Cooper, 2008). NICE (2004) recommends confirmation of airflow obstruction by spirometry in all patients with COPD. Planning and Care Delivery The main goals of treatment in Mr.X were symptom relief, amelioration of disease progression, increase in exercise tolerance, improvements in health status, prevention of exacerbations and decrease in the risk of death due to COPD (Fromer and Cooper, 2008). There is no cure for chronic bronchitis, but the symptoms can be controlled effectively by prompt treatment and diligent follow-up. Of all the symptoms, the worst symptom in chronic bronchitis is breathlessness because it cripples the functioning of the patient. Mr. X was advised to quit smoking completely. The first and foremost step in the management of COPD is smoking cessation (NICE, 2004). Cessation of smoking prevents further progression of the disease, decreases exacerbations and thus decreases symptoms including breathlessness. The next step in treatment was aimed at reducing the severity of breathlessness and also in decreasing cough. This was done by using a combination of pharmacotherapy and physiotherapy. Most experts use a combination of medicines and physical therapy to decrease breathlessness (Sharma, 2006). Research has shown that combination therapy is more effective than only drug-therapy in the management of breathlessness in COPD. This is evident from the study by Cambach et al (1997). Mr. X was started on oral theophylline and asthalin through nebulisations. Medical therapy involves usage of drugs like bronchodilators, steroids and other drugs. The bronchodilators which are useful in COPD are anticholinergics, methylxanthines and beta-2 adrenergic receptors (Fromer and Cooper, 2008). The initial empirical treatment for relief of breathlessness and limitation of exercise should be short-acting bronchodilators. The effectiveness of the medications should be evaluated based on improvement in exercise capacity, day-to-day activities and the rapidity of symptom relief. In case there is no proper response to these medicines, then either long-acting bronchodilators or a combination of short-acting anticholinergic should be switched over to. In patients who have 2 or more exacerbations in one year, long-acting bronchodilators must be the first line of treatment for breathlessness (NICE, 2004). Oral Corticosteroids have a role during exacerbations. Inhaled corticosteroids are prescribed in those with an FEV1 of 50% or less than 50% of predicted and also in those who are suffering from more than 1 exacerbation in a year which requires oral corticosteroids or antibiotics (NICE, 2004). Combination therapies should be started if patients continue to be breathless when on monotherapy. Some of the effective combinations are beta2-agonist and anticholinergic, beta2 agonist and theophylline, (NICE, 2004). Mucolytics like N-acetyl cysteine can decrease the number of exacerbations (Poole and Black, 2001) and thus decrease breathlessness. Cough syrups have no role in the management of breathlessness in COPD (ATS, 2005). Thus, Mr. X was given acetyl cysteine and no cough syrups were prescribed. Mr. X responded well to the medications and no steroids were instituted. he was admitted to the ward for four days after which he was discharged on long term advice pertaining to pulmonary rehabilitation. In most COPD patients with breathlessness, pulmonary rehabilitation programme is advocated. Pulmonary rehabilitation is defined as “a multidisciplinary programme of care for patients with chronic respiratory impairment that is individually tailored and designed to optimize physical and social performance and autonomy” (ATS, 1999). This program should be offered to all patients with breathlessness of grade 3 or above but are not suffering from unstable angina, recent attack of myocardial infarction or inability to walk (NICE, 2004). The program must incorporate disease education, physical training, nutritional intervention, psychological support and behavioural therapy. Pulmonary rehabilitation program improves the quality of life of the patient, increases exertional and exercise tolerance, decreases breathlessness, increases autonomy and coping skills, decreases exacerbations and prevents complications (Brooks et al, 2002). Pulmonary rehabilitation plays an important role in the management of COPD. Research has shown that comprehensive pulmonary management significantly improves exercise performance and decreases the amount of breathlessness. Ries et al (1995) evaluated the effects of comprehensive pulmonary rehabilitation programmes in COPD patients and opined that these interventions significantly decrease the symptoms and the benefits can be partially maintained for atleast a period of one year. The benefits of rehabilitation programme are further emphasized by a randomized case-control study by Toshima et al (1990). Education is important in the program because it enhances active participation in health care, increases coping skills, enhances the understanding of the disease, assists in self-management and increases adherence to treatment plan (Neish and Hopp, 1988). The type of exercises to be included are aerobic and resistance exercises (Bendsrup et al, 1997). Aerobic or endurance exercise training should be performed atleast 3-4 times a week for about 20-30 min per session. The intensity of exercise must be at least 50% of maximal oxygen consumption. The mainstay of endurance training is lower extremity training. Strength training or resistance exercises improve respiratory muscle strength (ATS, 2004). Many COPD patients suffer from anxiety and depression which decrease the coping ability of the patient. Psychological and behavioural interventions which include stress management, progressive muscle relaxation and panic control increase the coping skills of the patient (Renfroe, 1988). Nutritional advice is essential because both underweight and obesity can contribute to increased morbidity and mortality in COPD (Chailleux et al, 2005). Nutritional advice is based on the BMI. Nutritional intervention should be considered in all patients with BMI less than 21 kg-m2, involuntary weight loss of >10% in the previous 6 months or >5% in the past one month, and also in cases where there is depletion in FFM (ATS, 2004). Nutrition advice consisted of adaptation of patients dietary habits supplemented by energy-dense supplements. The nutrition advised should avoid loss of appetite and at the same time prevent adverse metabolic and ventilatory efforts. Some research has questioned the benefits of nutritional supplements in COPD (Ferreira et al, 2000). Mr. X was also advised physiotherapy. Physiotherapy helps control of breathlessness by means of certain breathing techniques, relaxation and airway clearance. According to the NICE guidelines (2004), physiotherapy must be instituted to reduce work of breathing associated with COPD, to restore the maximum function of the patient and to improve respiratory and peripheral muscle weakness. Mr. X was asked tp perform physiotherapy at home itself. Moore et al (2009) compared the benefits of home-based physiotherapy over clinic-based physiotherapy and reported that the benefits were similar in both when the proper protocol was followed. Positioning of body, control of breathing, chest clearance, exercise training and chest physiotherapy are some of the methods which are commonly employed to reduce breathlessness in COPD patients. Evaluation of care given Mr. X responded well to the treatment provided in the hospital. He got discharged after four days. He came to for follow-up after a week. He said he was finding it difficult to quit smoking. Hence he was refereed to a supportive program and psychological counseling. the treatment provided for Mr. X was evidence-based and in accordance with standard treatment guidelines by NICE. On his second follow-up after 2 months, Mr. X said that he significantly decreased the number of cigarettes he took in a day. His breathlessness improved and he was able to exercise, because of which he lost a few pounds. Ethical issues Mr. X was brought to the hospital by his wife and son. Once Mr. X was informed about the diagnosis of chronic bronchitis, he became upset because it is an incurable condition. he requested the treating clinicians not to mention this diagnosis to his wife. When political correctness demands that we embrace change with enthusiasm there is a strongly held view that nursing, along with many other professions, struggles with a theory gap practice (Rolfe et al, 2001). The nurse has a duty to promote what is best for the patient, ensure that the patients needs are met and protect the patients rights (Nettina, 2006). Since Mr. X was capable of taking care of himself, his wishes were upheld according to the law and his wife and son wee denied the diagnosis of chronic bronchitis. they were told that he had mild breathlessness which would resolve with medication. according to the NMC code of conduct, nurses must "respect peoples right to confidentiality" (NMC Code, 2008, p.1) Reflection on professional account Through reflection on the case management of Mr. X, it has dawned upon me strategies to manage patients with breathlessness. First of all, though the diagnosis of chronic bronchitis is obvious on history, further assessment is essential to rule out other causes of breathlessness like angina, consolidation, asthma, etc. Cessation of smoking is very crucial in the management of breathlessness in chronic bronchitis. A combination of pharmacotherapy and physiotherapy along with regular follow-up is effective in controlling the symptoms, though the disease is incurable. Conclusion COPD is a chronic incurable illness that causes intense suffering and affects quality of life. However, appropriate treatment and interventions can decrease the amount of suffering and help the patient lead a good health-related quality of life. The most progressive and frightening symptom of COPD is breathlessness which poses a challenge to the health professionals as far as management is concerned. The main forms of treatment for breathlessness are medical therapy and physical therapy. While medical therapy alone is useful in initial stages, introduction of physical therapy becomes essential as the disease progresses. Many experts prefer combination of pharmacological and physical interventions for effective management of breathlessness. Comprehensive pulmonary rehabilitation programme, along with bronchodilator therapy can decrease dyspnea, improve exercise tolerance, enhance quality of life and prevent complications and exacerbations. References American Thoracic Society/European Respiratory Society Task Force or ATS. (2004). Standards for the Diagnosis and Management of Patients with COPD. Retrieved on May 26th 2010 from http://www.thoracic.org/go/copd Bendstrup, K.E., Ingemann, J. J., Holm, S., Bengtsson, B. (1997). Out-patient rehabilitation improves activities of daily living, quality of life and exercise tolerance in chronic obstructive pulmonary disease. Eur Respir J, 10, 2801–2806. Brooks, D., Krip, B., Mangovski-Alzamora, S., Goldstein, R.S. (2002). The effect of postrehabilitation programmes among individuals with chronic obstructive pulmonary disease. Eur Respir J, 20, 20–29. Cambach, W., Chadwick-Straver, R.V., Wagenaar, R.C., van Keimpema, A.R., Kemper, H.C. (1997). The effects of a community-based pulmonary rehabilitation programme on exercise tolerance and quality of life: a randomized controlled trial. Eur Respir J.,10(1), 104-13. Chailleux, E., Laaban, J.P., Veale, D. (2003). Prognostic value of nutritional depletion in patients with COPD treated by long-term oxygen therapy: data from the ANTADIR observatory. Chest, 123, 1460–6. Fromer, L., and Cooper, C.B. (2008). A Review of the GOLD Guidelines for the Diagnosis and Treatment of Patients With COPD. Medscape CME. Retrieved on May 26th 2010 from http://cme.medscape.com/viewarticle/582762 Ferreira, I.M., Brooks, D., Lacasse, Y., Goldstein, R.S. (2000). Nutritional support for individuals with COPD: a meta-analysis. Chest, 117, 672–678. Moore, J., Fiddler, H., Seymour, J., Grant, A., Jolley, C., Johnson, L., Moxham, J. (2009). Effect of a home exercise video programme in patients with chronic obstructive pulmonary disease. J Rehabil Med., 41(3), 195-200. Neish, C.M., and Hopp, J.W. (1988). The role of education in pulmonary rehabilitation. J Cardiopulm Rehabil, 11, 439–441. NICE Guidelines. (2004). Chronic Obstructive Pulmonary Disease. Retrieved on May 26th 2010 from http://www.nice.org.uk/nicemedia/pdf/CG012_niceguideline.pdf NMC (2008). Code of Conduct. Retrieved on May 26th 2010 from http://www3.shu.ac.uk/HWB/placements/nursing/documents/NMCCode.pdf Renfroe, K.L. (1988). Effect of progressive relaxation on dyspnea and state anxiety in patients with chronic obstructive pulmonary disease. Heart Lung, 17, 408–413. Ries, A.L., Kaplan, R.M., Limberg, T.M., Prewitt, L.M. (1995). Effects of pulmonary rehabilitation on physiologic and psychosocial outcomes in patients with chronic obstructive pulmonary disease. Ann Intern Med., 122(11), 823-32 Rolfe, G., Freshwater, D., Jasper, M. (2002). Critical reflections for nursing. Basingstoke Palgrove. Sharma, S. (2006). Chronic Obstructive Pulmonary Disease. Emedicine from WebMD. Retrieved on May 26th 2010 from http://emedicine.medscape.com/article/297664-overview Somerville, D. and Keeling, J. (2004). A practical approach to promote reflective practice within nursing. Nursingtimes.net, 100(12), p.42. Retrieved on May 26th 2010 from http://www.nursingtimes.net/nursing-practice-clinical-research/a-practical-approach-to-promote-reflective-practice-within-nursing/204502.article Toshima, M.T., Kaplan, R.M., Ries, A.L. (1990). Experimental evaluation of rehabilitation in chronic obstructive pulmonary disease: short-term effects on exercise endurance and health status. Health Psychol., 9(3), 237-52. Read More