Question

Powerpoint slides for COPD with the given case study by using CRC.

Ms Aaliyah Abimbola

Background information for the assignment.

You are the RN on a morning shift on the respiratory ward of a large inner-city hospital. At 10:30 AM you receive a patient from the Emergency Department.

This is the hand-over you receive.

I	My name is Catriona and I am the A&E RN who has been caring for Ms Aaliyah Abimbola. Thank you so much for taking this patient so quickly. We’re so busy we haven’t time to do much for her apart from get her ready to bring up here.
S	Ms Abimbola is a 56-year-old woman with a past history of COPD who was admitted to A&E via ambulance at 8am today in acute respiratory distress. She became acutely short of breath this morning while making breakfast and called an ambulance.
B	I only got the chance to ask her a few admission questions before I was told to bring her up here. She was able to tell me: She saw her GP two weeks ago due to increasing shortness of breath and fatigue and he gave her ‘some breathing medication’ (inhalers). She has had to use these with increasing frequency since then. Ms Abimbola has been working at the flour mill 50 hours per week recently. This has made it tough to look after her three daughters because she’s a single parent. She has a medical past history of moderate sleep apnoea for which she uses CPAP to sleep overnight, Type 2 Diabetes and hypertension diagnosed 3 years ago. She has never smoked but has a long history of severe exposure to industrial dust. Her children are at school but the oldest one knows she’s in hospital.
A	On arrival in A&E she was acutely short of breath with an expiratory and inspiratory wheeze. Her Sat’s were 93% on room air & her GCS was 15. We haven’t had time to do much for her apart from give her a couple of nebulisers. She has an interim medical diagnosis of acute exacerbation of COPD
R	Medical orders: 5mg salbutamol nebuliser as necessary, repeat every 20 minutes for 1 hour. O2 therapy to maintain SpO2 > 92%. Needs to have an ABG and a sputum sample collected for MC&S. Monitor vital ob’s half hourly and the respiratory medical team will be here soon to review her. Notify RMO if her condition gets worse.

Your initial assessment findings on the ward for Ms Abimbola are as follows:

Medications

Metoprolol 100mg daily, Aspirin 100mg daily, Atorvastatin 20mg mane, Glibenclamide (Daonil) 5mg orally daily before breakfast, Salbutamol sulphate (Ventolin) 100mcg inhaler as required for symptom relief (1-2 puffs as required), Fluticasone propionate/salmeterol xinafoate (Seretide) 50/25 inhaler (2 puffs BD)

Current vital observations:

BP 142/96mmHg

HR 96bpm

RR 24 bpm

SpO2 93% on RA

T 36.7C

Health assessment findings:

Height 158cm, Weight 93kg,

Total cholesterol level - 5.2mmol/L

Fasting BGL - 9.6mmol/L

Inspiratory and expiratory wheeze. speaking in short phrases taking 2-3 breaths between each phrase before continuing to speak.

Alert and orientated to time, place, and person.

Further information you gather from her medical history and as part of her admission questions:

Ms Aaliyah Abimbola is a 56 year old female who emigrated from Africa 20 years ago. Ms Abimbola is a single parent with three female children (ages 14, 17 and 18) living in the inner-west of Melbourne.

Ms Abimbola went to her local health care clinic 2 weeks ago complaining of increasing shortness of breath and lack of energy. She says she was given some breathing medication (inhalers) by the doctor and told to take it easy for a few days. She has been struggling to get from the ground floor living area to the upstairs bedrooms without resting half-way to catch her breath. She says sometimes the medication helps her catch her breath but she still has to rest half way even with the medication.

Ms Abimbola has been working at the local flour mill since she arrived in Melbourne from Africa 20 years ago. She has never smoked but says the dust at the flour mill often makes her cough. Her job for the first 3 years was filling bags with flour until that process became fully automated. She then got promoted to running one of the flour grinding machines. 2 years later she got another promotion to shift supervisor in the milling and packaging section. She says her clothes were always covered in white dust at the end of every shift. "I used to look like a ghost at the end on my shift. We all did!" The flour mill made it mandatory to wear a mask and other protective equipment when you're working in the factory about eight years ago. However, Ms Abimbola has been working in the office for the last 6 years and no-one wears protective equipment in the office as it's not necessary. She says there's always a fine layer of dust on the paperwork in the office because the 'flour just gets everywhere no matter how often you clean or how careful you are."

Ms Abimbola is currently averaging 50 hours/week which means she needs to work on most weekends. Since the Covid 19 lockdown the factory has increased production to 24 hours a day 7 days a week. That means the office is also extremely busy. Ms Abimbola has always accepted any overtime on offer to help pay the rent for their house and cover the school fees for the Catholic school her children attend. She is adamant that she wants them to get a good education so they can make the most of the opportunities she never had in Africa. She has always been socially active within her Church community, but due to her increased working hours this has restricted her ability to attend mass and contribute to her community. She states that she needs to “prioritise any free time I have so I can spend it with the kids, especially my oldest who is doing VCE this year”. She has two close friends at church who help with looking after her children when she has to work late or on weekends.

Ms Abimbola states that she tries to exercise when she has time and walks to the train station every day to get to work. It used to take 8 minutes each way but lately it takes at least 20 minutes including rest stops to catch her breath. She also does a lot of walking at the flour mill taking paperwork to the production supervisors and picking up reports for processing. However, she has had to ask one of the younger staff to get the reports and deliver the orders more and more over the last year or so as she get's too short of breath when she walks too far too quickly.

Ms Abimbola has not spoken to her husband since she and the children left him 6 years ago. She says he used to work at the flour mill but was sacked for being drunk at work eight years ago. He had a hard time finding work so drank heavily and became violent. She took the children and left him after he hit the middle child for spilling his coffee. She doesn't know where he lives and has had no contact with him for over 4 years.

Family history

Her father died from a stroke in 2005.

Question

• Management of COPD in relation to Ms. Abimbola.

Answer 1

Question

• Management of COPD in relation to Ms. Abimbola.

ANSWER

INTRODUCTION

The expiratory airflow obstruction that characterises chronic obstructive pulmonary disease is usually progressive over time and caused by emphysema, obliterative bronchiolitis, and mucus hypersecretion. In chronic obstructive pulmonary disease (COPD), airflow is obstructed during expiration. This increases the work of breathing and causes dyspnoea.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, mucus (sputum) production and wheezing. It's typically caused by long-term exposure to irritating gases or particulate matter, most often from cigarette smoke. People with COPD are at increased risk of developing heart disease, lung cancer and a variety of other conditions.

COPD includes:

1. Emphysema

2. Chronic bronchitis

These two conditions usually occur together and can vary in severity among individuals with COPD.

Chronic bronchitis

It is inflammation of the lining of the bronchial tubes, which carry air to and from the air sacs (alveoli) of the lungs. It's characterized by daily cough and mucus (sputum) production.

Emphysema

It is a condition in which the alveoli at the end of the smallest air passages (bronchioles) of the lungs are destroyed as a result of damaging exposure to cigarette smoke and other irritating gases and particulate matter.

RISK FACTORS AND CAUSES

· Exposure to tobacco smoke. The most significant risk factor for COPD is long-term cigarette smoking.

· People with asthma. Asthma, a chronic inflammatory airway disease, may be a risk factor for developing COPD. The combination of asthma and smoking increases the risk of COPD even more.

· Occupational exposure to dusts and chemicals. Long-term exposure to chemical fumes, vapours and dusts in the workplace can irritate and inflame your lungs.

· Exposure to fumes from burning fuel. In the developing world, people exposed to fumes from burning fuel for cooking and heating in poorly ventilated homes are at higher risk of developing COPD.

· Genetics. The uncommon genetic disorder alpha-1-antitrypsin deficiency is the cause of some cases of COPD. Other genetic factors likely make certain smokers more susceptible to the disease.

PATHOPHYSIOLOGY

Emphysema

1. Abnormal inflammatory response of the lungs due to toxic gases.

2. Responseoccurs in the airways ,parenchyma & pulmonary vasculature.

3. Narrowing of the airway takes place

4. Destruction of parenchyma leads to emphysema.

5. Destruction of lung parenchyma leads to an imbalance of proteinases/antiproteinases.(this proteinases inhibitors prevents the destructive process)

6. Pulmonary vascularchanges

7. Thickening of vessels

8. Collagen deposit

9. Destruction of capillary beds.

10. Mucus hypersecretion(cilia dysfunction,airflow limitation,corpulmonale(RVF))

11. Chronic cough and sputum production

Chronic bronchitis

1. Infections or lung irritants cause acute bronchitis.

2. Chronic bronchitis is an ongoing, serious condition.

3. It occurs if the lining of the bronchial tubes is constantly irritated and inflamed, causing a long-term cough with mucus.

4. Irritants irrritate the airway

5. Excess mucus production

6. Inflammation

7. Cause the mucus secreting glands and goblet cells to increase in number.

8. Ciliary function is reduced.

9. More mucus production

10. Bronchial walls become thickened and lumen narrows and mucus plug the airway

11. Alveoli adjacent to the bronchioles may become damaged and fibrosed.

12. Alter function of alveolar macrophages.

13. infection

CLINICAL FEATURES OF COPD

· Shortness of breath, especially during physical activities

· Wheezing

· Chest tightness

· A chronic cough that may produce mucus (sputum) that may be clear, white, yellow or greenish

· Frequent respiratory infections

· Lack of energy

· Unintended weight loss (in later stages)

· Swelling in ankles, feet or legs

INVESTIGATIONS

a) History collection and physiclal examination

b) PFT

c) Spirometry-to find out airflow obstruction.

d) ABG analysis

e) CT scan of the lung.

f) Screening of alpha antitrypsin deficiency

g) X-ray radiography

COPD MANAGEMENT GUIDELINES AS PER WHO

An effective COPD management plan includes four components:

(1) assess and monitor disease;

(2) reduce risk factors;

(3) manage stable COPD;

(4) manage exacerbations.

The goals of effective COPD management are to:

1. Prevent disease progression

2. Relieve symptoms

3. Improve exercise tolerance

4. Improve health status

5. Prevent and treat complications

6. Prevent and treat exacerbations

7. Reduce mortality

Component 1: Assess and monitor disease

· Diagnosis of COPD is based on a history of exposure to risk factors and the presence of airflow limitation that is not fully reversible, with or without the presence of symptoms.

· Patients who have chronic cough and sputum production with a history of exposure to risk factors should be tested for airflow limitation, even if they do not have dyspnoea.

· For the diagnosis and assessment of COPD, spirometry is the gold standard as it is the most reproducible, standardized, and objective way of measuring airflow limitation.

· Health care workers involved in the diagnosis and management of patients with COPD should have access to spirometry.

· Measurement of arterial blood gas tensions should be considered in all patients

Component 2: Reduce risk factors

· Reduction of total personal exposure to tobacco smoke, occupational dusts and chemicals, and indoor and outdoor air pollutants are important goals to prevent the onset and progression of COPD.

· Smoking cessation is the single most effective and cost-effective way to reduce the risk of developing COPD and stop its progression. Brief tobacco dependence treatment is effective and every tobacco user should be offered at least this treatment at every visit to a health care provider.

· Three types of counseling are especially effective: practical counseling, social support as part of treatment, and social support arranged outside of treatment.

· Several effective pharmacotherapies for tobacco dependence are available, and at least one of these medications should be added to counseling if necessary and in the absence of contraindications.

· Progression of many occupationally induced respiratory disorders can be reduced or controlled through a variety of strategies aimed at reducing the burden of inhaled particles and gases.

Component 3: Manage stable COPD

· The overall approach to managing stable COPD should be characterized by a stepwise increase in treatment, depending on the severity of the disease.

· For patients with COPD, health education can play a role in improving skills, ability to cope with illness, and health status. It is effective in accomplishing certain goals, including smoking cessation.

· None of the existing medications for COPD has been shown to modify the long-term decline in lung function that is the hallmark of this disease. Therefore, pharmacotherapy for COPD is used to decrease symptoms and complications.

· Bronchodilator medications are central to the symptomatic management of COPD. They are given on an as-needed basis or on a regular basis to prevent or reduce symptoms.

· The principal bronchodilator treatments are 2-agonists, anticholinergics, theophylline, and a combination of one or more of these drugs.

· Regular treatment with inhaled glucocorticosteroids should only be prescribed for symptomatic patients with COPD with a documented spirometric response to glucocorticosteroids Chronic treatment with systemic glucocorticosteroids should be avoided because of an unfavourable benefit-to-risk ratio.

· All patients with COPD benefit from exercise training programs, improving with respect to both exercise tolerance and symptoms of dyspnoea and fatigue.

· The long-term administration of oxygen (> 15 h per day) to patients with chronic respiratory failure has been shown to increase survival.

Component 4: Manage exacerbations

· Exacerbations of respiratory symptoms requiring medical intervention are important clinical events in COPD.

· The most common causes of an exacerbation are infection of the tracheobronchial tree and air pollution, but the cause of approximately one-third of severe exacerbations cannot be identified.

· Inhaled bronchodilators (particularly inhaled 2-agonists or anticholinergics), theophylline, and systemic, preferably oral, glucocorticosteroids are effective for treatments for acute exacerbations of COPD.

· Patients experiencing COPD exacerbations with clinical signs of airway infection (e.g., increased volume and change of color of sputum, or fever) may benefit from antibiotic treatment.

· Noninvasive positive pressure ventilation (NIPPV) in acute exacerbations improves blood gases and pH, reduces in-hospital mortality, decreases the need for invasive mechanical ventilation and intubation, and decreases the length of hospital stay.

COPD MANAGEMENT

Medical management

1. Improve ventillation

o Broncho dilators like beta2 agonists(albuterol),anticholinergic s(ipratropium bromide-atrovent).

o Methylxanthines(theophylline,amin ophylline)

o Corticosteroids4. Oxygen administration

2. Remove bronchial secretion

3. Promote exercises

4. Control complications

5. Improve general health

Surgical management

1.Bullectomy

Bullae are enlarged airspaces that do not contribute to ventillation but occupy space in the thorax,these areas may be surgically excised

2.Lung volume reduction surgery

It involves the removal of a portion of the diseased lung parenchyma.this allows the functional tissue to expand.

3. Lung transplantation

REHABILITATION

Behavioural management of chronic dyspnoea and the resultant physical deconditioning are important aspects of management. Pulmonary rehabilitation programs address these issues and lead to increased exercise tolerance, increased exercise ability, reduced dyspnoea and improved quality of life.The key parts of pulmonary rehabilitation are:

• exercise training
• education
• psychosocial/behavioural intervention
• Outcome assessment.

Each part should be systematically addressed in all patients with moderate or severe COPD. This can be achieved by referral to an established program, or by a series of consultations between the patient, doctor and allied health staff. Although low body weight is associated with impaired pulmonary function, clinical trials have not shown that nutritional supplements are beneficial.

HEALTH EDUCATION

1. Give up smoking

• Giving up nicotine is one of the most important things for health. Talk with provider to determine which one may be most helpful:
• Medications
• Nicotine replacement therapy
• Self-help materials
• Counseling
• Group programs

2. Eat right and exercise

Shortness of breath that comes with copd can make it hard to heat a balanced diet. Eating a healthy diet and exercising are important to keeping and improving y fitness level.

• eat small, more frequent well-balanced meals.
• Use a smaller plate and portions.
• Keep a bottle of water and drink before you eat.
• Eat one fresh vegetable or fruit with every meal.
• Keep moving to keep muscle strength.
• Use a step counter to track how much walking every day, build muscle by lifting a can of vegetables or using a exercise band.
• If physical therapy is prescribed, do exercises and go to appointments.

3. Get rest

Rest is important to over all health, but there are several things that can make sleep difficult if patient have copd.

• Try to avoid napping so tired at bedtime.
• Try to get 30 minutes of exercise three times a week.
• Don't do anything stimulating (exercising, working, arguing) 2 hours before bedtime.
• Have a small high-protein snack such as cheese and crackers, a glass of milk or handful of nuts before bed. Avoid large meals and a lot of carbohydrates.
• Keep bedroom cool, dark, and quiet.
• Wear socks to keep feet warm.
• No caffeine after 5 p.m.
• Keep regular bedtime and wake-up times

4. Take your medications correctly

Most people with copd take medicine to help with regular and occasional breathing problems.

• Use a daily routine for taking medicine.
• If patient take pills a different times during the day, use a medicine checklist to help to keep track of when patient needs to take which pill.
• Get a pillbox with sections for different days of the week and even times during the day to help not to miss a dose.
• Tell to doctor about unpleasant side effects they may be relieved by changing the dose or medication.
• Keep all medicines with patient while traveling, never check them in luggage.

5. Use oxygen appropriately

Some people with copd need oxygen therapy to help their body work properly. Oxygen therapy allows to be more active and does not cause any harm to lungs or body if it is used correctly. Patient may need it for sleep, rest and activity.

6. Retrain your breathing

Learning new breathing techniques will help to move more air in and out of lungs. This helps decrease shortness of breath.

• Diaphragmatic breathing: breathe in slowly and deeply through nose. While breathing in, push stomach out. This uses the diaphragm and the lower respiratory muscles.
• Pursed lip breathing: use the same diaphragmatic breathing technique, but when breathe out, purse lips slightly like going to whistle. Breathe out slowly through pursed lips. Do not force the air out.

7. Avoid infections

Copd patients are at increased risk of lung infections.

• Vaccines are often recommended. The influenza vaccine is recommended yearly. The pneumonia vaccine is recommended every 5 to 7 years.
• Wash hands frequently to prevent the spread of germs and infections.

8. Learn techniques to bring up mucus

When mucus collects in the airways, it can make breathing difficult and can lead to infection. Use the techniques after using bronchodilator medicine.

• Deep coughing: take a deep breath and hold it for 3 seconds. Use stomach muscles to expel the air. Avoid a hacking cough or just clearing throat.
• Huff coughing: take a breath that is slightly deeper than normal. Use stomach muscles to make a "ha, ha, ha" sound while you exhale. Follow this by diaphragmatic breathing and a deep cough if patient feel mucus moving.

NURSING DIAGNOSIS

• Impaired gad exchange related to decreased ventillation and mucous plugs ineffective airway clearence related to excessive secretion and ineffective coughing
• Anxiety related to acute breathing difficulties and fear of suffocation activity intolerence related to inadequate oxygenation and dyspnoea
• Imbalanced nutrition less than body requirement related to reduced appetite,decreased energy level and dyspnoea disturbed sleep pattern related to dyspnoea and external stimuli
• Risk for infection related to ineffective pulmonary clearence

COMPLICATIONS

COPD can cause many complications, including:

· Respiratory infections. People with COPD are more likely to catch colds, the flu and pneumonia. Any respiratory infection can make it much more difficult to breathe and could cause further damage to lung tissue.

· Heart problems. For reasons that aren't fully understood, COPD can increase your risk of heart disease, including heart attack

· Lung cancer. People with COPD have a higher risk of developing lung cancer.

· High blood pressure in lung arteries. COPD may cause high blood pressure in the arteries that bring blood to your lungs (pulmonary hypertension).

· Depression. Difficulty breathing can keep you from doing activities that you enjoy. And dealing with serious illness can contribute to the development of depression

CONCLUSION

COPD is a chronic and disabling condition caused by smoking and other causes. Disability can be minimised by a systematic approach to management that emphasises the use of safe, effective medications, withdraws unsafe or ineffective therapy, and attends to the effects of physical reconditioning and psychosocial distress through rehabilitation.