The introduction to caring for adults with long term health needs is to explore through a critical and evidenced review, a case study of a patient with a long-term health condition (LTHC).
Long term health conditions are conditions that cannot be cured, ongoing or recurring, they are managed by drugs or by specific therapies depending on what health condition a patient may have (Lloyd, 2012). This case study will be related and reflecting on the specific care on a patient whose name will be changed to ‘Chris’. This is due to the respect of autonomy (hiding identity) and respecting patient confidentiality under the Nursing and Midwifery Council (NMC) code of conduct (NMC, 2015). Chris is a 68-year-old Caucasian male and still works full time, he is a widowed man and has been hospitalised due to shortness of breath for the second time in a month and doctors are now querying he may have a medical condition called Chronic Obstructive Pulmonary Disease (COPD).
COPD is a long-term health condition and cannot be cured but is controlled by medication (Hansel et al, 2009). It is group term for other lung diseases such as emphysema, chronic bronchitis and non-reversible asthma. This is defined by breathing difficulties and difficulty emptying out the air from lungs because the airways have become so narrowed (Willbanks, 2015). COPD could become the third largest leader in death among patients by 2030 according to the World Health Organisation (WHO, 2015). The UK alone has 1.
2 million people diagnosed with this disease (British Lung Foundation, 2016). The assignment will go into depth and focus on specifically about Chris and his COPD, for example, the pathophysiology, pharmacology, the implications, impact responses, the social/psychological implications and an overview of the nursing support.The pathophysiology of COPD includes both emphysema and chronic bronchitis combined (Mitchell, 2015). They both have similar outcomes and both cause damage to be bronchioles, which narrows the airways making it extremely difficult to breath (Mitchell, 2015). The National Heart, Lung and Blood Institute (NIH) 2015 explain that to understand COPD, is to understand how the lungs work. In your lungs, you take in air called oxygen, this runs down your windpipes where you have your bronchial tubes. They then spread out into smaller tubes called the bronchioles and at the end of these tubes are tiny air sacs called the alveoli.
Little blood vessels run along the outside of the air sacs and then oxygen runs through the air sacs into the blood through the capillaries. A waste product gas called carbon dioxide (CO2) moves from the capillaries into the air sacs. The air which is called gas exchange, brings in the oxygen and removes the CO2. (National Heart, Lung and Blood Institute, 2015).
NIH, (2015) also explain that airways are stretchy or have elasticity, so when a breath is taken in, air sacs fill up and when you breathe out, these deflate. So, when COPD occurs, air cannot be released properly due to chronic obstruction, so the air we breathe out called CO2, is retained which becomes lethal; the airways have less elasticity and the bronchioles fill with mucus. The air sacs become destroyed, as well as inflammation build up along the tissues of the airways (NIH, 2015). COPD can be caused by a numerous of things such as environmental or occupational pollutions and smoking. Smoking being the main cause of COPD (Berry and Wise, 2010). Berry and Wise (2010) also mention that the typical symptoms of COPD are shortness of breath, a persistent cough, chest pain and sputum. Chris is a heavy smoker and became short of breath and had a persistent cough, so presented to the hospital because he had difficulty breathing which causes his respiratory rate to increase, additional effort to breathe. Chris underdone tests and a physical examination, to properly diagnose that he had COPD.
These tests include, pulmonary function test (PFT), chest x-ray and blood gases. PFT is a test that is used to measure the amount of oxygen that is getting delivered to your blood and done so by inhaling and exhaling, the most common one being the spirometry (Sharma, 2010). Chris had a spirometry test done and Sharma (2010) also explains that it is done by breathing into a tube that is connected to a machine called spirometer and this measures how quickly Chris can exhale out and how long much air the lungs can hold when he breathes in. Chris also had a chest x-ray done as this can show emphysema (Ackley, et al 2017). The blood gas is blood taken from the artery in the wrist and this measures how well lungs are bringing in oxygen and removing the CO2 (Ackley, et al, 2017). Once the tests were done, Chris was told that he had COPD and that he had to have several follow ups at his local clinic. Treatments are given to people with COPD, such as smoking cessation, vaccinations, inhaled therapies, corticosteroids and oxygen therapy (Hansel and Barnes, 2012).
On this occasion, Chris was offered smoking cessation, as he was advised to stop smoking as this would worsen his disease and could cause an inability to be able to breathe properly. He was also given to take home inhaled therapy such as a bronchodilator and a follow up at the COPD clinic to manage this.The pharmacology that Chris received was a bronchodilator. Albert et al, (2008) explains bronchodilators are an inhaled therapy, which is used by inhaling from the mouth to open the airways and bronchioles by relaxing the muscles, making it easier for Chris to breathe.
It is administered for breathing difficulties and on this occasion, Chris has found it hard to breathe due to his new diagnosis of COPD. There are two different types of bronchodilators and these are the long acting and short acting (Albert et al, 2008). They both do work similarly, except the short acting bronchodilator is used for the quick relief and rescue medication and then the long acting bronchodilator is used to longer control breathlessness and used every day (Bourke and Burns, 2011). The bronchodilator that Chris received was called ‘Incruse Ellipta’ and contains ‘Umeclidinium bromide’. The GlaxoSmithKline plc (2017) explain on their page that Umeclidinium is a long acting muscarinic antagonist and works by blocking the muscarinic receptors around the airways, this stops the chemical called ‘acetylcholine’ acting causing muscles in the airways to narrow and contract. Umeclidinium also contains anticholinergic. Anticholinergic is stopping the actions of the neurotransmitter acetylcholine which reduces spasms and relaxes the muscles in your airways and stops symptoms such as, coughing, wheezing and shortness of breath (Currie, 2010).
The National Institute for Health and Care Excellence (NICE) (2015) describe the inhaler as a plastic and light green which contain a foil strip with blisters, each of these blisters contain white powder (umeclidinium) and every time the inhaler is used by inhaling through the mouthpiece, the blister is exposed and disperses into the mouth straight into the airstream. NICE, (2015) also explain that Incruse Ellipta is delivered in either 55mcg or 62.5mcg in each blister and has 30 per inhaler. It should be administered by Chris himself, orally inhaled; once daily no more than one every 24 hours. The Drug Development Technology (2014) have mentioned that in April 2014, Incruse Ellipta was the first anticholinergic inhaler to be approved for COPD patients, as it shown in a clinical study with 4,000 people (done by the European Medical Agency), to be effective in lung function and relieve symptoms in the 79% of the patients that enrolled on the study. Precautions should be taken for Chris as the medication he is on may cause side effects, this being breathing problems, anaphylaxis reactions, urinary retention and acute narrow-angled glaucoma (Workman et al, 2013).
With all medications, they all come with possible side effects. Bronchodilators such as Incruse have side effects such as nausea, vomiting, upper respiratory infections, runny nose and constipation with them being the main ones (Tiziani, 2017) There are other complicated side effects such as paradoxical bronchospasm, narrow angle glaucoma and worsening urinary retention (Tiziani, 2017). There are other common medications that can be given for COPD and these are Beta-2-agonists and theophylline (Workman et al, 2013). It was reported that beta-2-agonists can be used for both COPD and asthma patients, they are given as an inhaler or tablets but for symptoms more severe they can either be nebulised or injected (Leader, 2018). Beta-2-agonists work by stimulation the beta-2-receptors that are lined in the airways, causing them to dilate and relax so this makes it easier to breathe (Kenakin, 2016). Kenakin (2016) also goes on to explain that theophylline is taken by capsule or tablet but can also being given intravenously, depending on the severity of the symptom; the effect is much weaker than bronchodilators and are likely to cause side effects and is used with other medications if they are not effective as they should be. There will be some psychological issues that will arise with Chris being diagnosed with COPD.
There is a health belief model (HBM) that is a systematic way that healthcare professionals can use to promote health behaviours and distinguish behavioural change; it is usually used to figure out the willingness of an individual to whether or not they’ll take recommended health action to their illnesses (Dalal, 2015). Chris expressed his worries about the responses he may have towards having COPD in the future as he had suffered depression before, so was worried this may trigger it off again. Comorbid depression and anxiety are common in patients with COPD, because of the life alterations, exacerbations, possible future hospital stays and a decreased value of life (Pumar et al, 2014). Fortunately for Chris, he was offered treatments available if this was to ever occur and support alongside his treatments. Treatments include pulmonary rehabilitation, psychological and pharmacological interventions, such as cognitive behavioural therapy (CBT) and anti-depressants (Cafarella, 2012). It has been concluded in a review in an article by Fritzsche et al, (2011) that CBT is more effective on patients with depression, showing significant improvements in their behaviour. The anti-depressants did show some good results but differentiated by person (Fritzsche et al, 2011). Yohannes and Alexopoulos (2014) have stated that under-recognised and untreated anxiety and depression has become noticeably increasing over the last decade and has destroying effects on patient’s physical well-being and mental state; it is often overlapped because of the symptoms with those of COPD and difficult to identify.
It becomes a burden to those have COPD and can cause frequent hospitalisation and premature death. Chris took up the treatment of pulmonary rehabilitation, this is usually given to patients who are severely breathless, but Chris wanted peace of mind so insisted he would like to attend. Pulmonary rehabilitation includes an exercise programme tailored to suit Chris and his needs.
The programme could be at his local hospital that is done over six to eight weeks and it’s all about strengthening the muscles around the airways and improving fitness. It also talks about how to look after the body such as the lungs and advice on how to manage the condition if Chris ever feels out of breath (NICE, 2016). Wise (2016) has said that NICE has recommend pulmonary rehabilitation to be a successful way of improving patients (with stable COPD and limited fitness) quality of life and reduce the risk of future hospital admissions. The impact this may have on Chris’ life, when being diagnosed with COPD, may have a massive effect on his future. Social implications with Chris and his diagnosis are closely related to his psychological issues. Chris likes to work and still is working full time and does not want to give up work.
He no longer likes to be at home alone after losing his wife. He knows that being at work and doing things he used to do before are not going to be as easy as before, such as lifting heavy weights, walking up the stairs or fixing things. Chris is worried about the stigma revolving around COPD and worrying that his job may find him ‘less able’ or ‘undesirable’ to do the job he has worked for, for the last 25 years. COPD has become a stigma of social consequences for patients with COPD, they feel as if society are judging them as ‘handicapped’ or ‘tainted’; this then puts major pressure on those with COPD and could possibly disrupt all social interactions altogether and they become isolated (Johnson et al.
, 2007). The quality of daily life, their social life and work life may be altered in ways that may be distressing (Carlone et al, 2014). A loss of income is becoming a concern for Chris as he feels that losing his job will be major impact on his life. Fletcher et al, (2011) did an international study with 1,000 individuals with COPD and surveyed them on how their working life had changed when dealing with COPD; with 44% of people find working life more difficult but are coping, whereas the other 56% have had to reduce their hours, have time off work or end up retiring.
Chris likes to socialise with his friends most of the time and he feels that this may impact his social life due to COPD having a major effect on his health and wellbeing. Chris could become quite anxious about being breathless all the time and limit his routines to suit him. This could result in becoming lonely and having a decline in his physical health (Petitte et al, 2015). Chris’ physical health could possibly lead to a downhill spiral altogether as his breathlessness could cause him to fully isolate himself and not even return to work. The muscles start to weaken and the body starts to decondition, resulting in becoming increasingly unable to be active (Primary Care Respiratory Society, 2017). Chris has noticed he struggles to have any appetite when trying to eat and worries this may affect his body image and self-esteem altogether by losing too much weight.
Attraction to food decreases as COPD patients tend to lose their sensation to taste, using inhalers can cause mouth infections and the coughing can cause loss of concentration to eat and prove to be too hard (Odencrants et al, 2005) Chris has become more tired and his fatigue levels have risen, he hardly sleeps at night and has insomnia. Sleep deprivation and insomnia is common within COPD patients, this causes patients to be more tired through the day stopping them from their normal daily activities; this is due to the excess coughing and the desaturation of oxygen levels when they are asleep (McNicholas et al, 2013).Nursing support for Chris is important, when breaking bad news about COPD and having no cure, this can be emotionally draining and upsetting. Chris will receive moral support and guidance to be able to relieve and reduce the impact of the symptoms he may be getting. Chris had a lack of knowledge and understanding to his condition but is now receiving all the help nurses can do for him. Nurses improve their professional development and clinical expertise by a range of clinical studies, by implementing and reflecting on any decisions that are made when in practice and any given policies; this is known as the hierarchy of evidence (Daly, 2007). This is to improve their evidence-based practice so patients get the very best care and are given the outstanding treatment (Malloch and Porter-O’ Grady, 2010).
Nurses have a vital position in leading the role when managing a patient with COPD and must be aware of ethical and professional issues; always be doing what is best for the patient (Fletcher, 2013). They are first point of contact and will be involved in all the stages of their care, from the planning, implementing, prevention, provision and their end of life care (Fletcher, 2013). The Nerdy Nurse (2017) explain on their page that there are two types of assessments and these are the subjective and objective data. Subjective being, what the subject of the problem is and objective being the overall physical examination of the patient. Nurses have an important role to be able to build a rapport with the patient, this includes establishing the medical history of the patient, allergies, smoking habits and their social history (Cutcliffe, 2010). Nurse led interventions are to help patients cope with their condition and advance their quality of life, this can include such things as smoking cessation, pulmonary rehabilitation and self-management (Padilha, 2017).
Nurses are bound to give their educated advice and it is up to Chris whether he wants to take or reject the advice given to him (Foskett-tharby, 2017). When assessing Chris, nurses will follow a NICE pathway, especially for COPD patients; this is a flow chart that nurses will use to manage patients with COPD. This can also establish the severity of the condition and give additional treatments if needed (NICE, 2018). Chris is still smoking, so nursing interventions such as education on smoking when he has COPD and the benefits of quitting altogether. Monitoring oxygen saturations for COPD and encouraging a healthy weight, as proper nutrition for the body helps the body so it is at its peak performance (NRSING, 2017).
NRSNG (2017) also mention on their page that motivating a patient to stay active is important and to make sure nurses help with breathing techniques if breathing difficulties ever occur. There are challenges that come across to being able to guide patients with the consequences of their condition and patients are likely not to follow through with guidance and treatments due to the denial of their condition. It is a nurse’s duty of care to build trust and inform what is best for the patient and try to prevent the patient to come to any harm and promote independence (Rodrigues, 2014).
In conclusion, this reflected on my patient Chris and his LTHC of COPD. The assignment touched on the pathophysiology and pharmacology (what medication Chris received and detailed description). The psychological/social issues Chris was having or could possibly have, and the nursing responses/interactions that a nurse has within their duty of care. Overall, Chris received the best treatment possible.