Case Study of COPD: Pathophysiology and Management Plans

COPD refers to a group of health conditions that affect a persons lungs as well as his ability to breathe. As a result of the disease, a persons flow of oxygen from the lungs to blood is blocked. Also, oxygen is prevented from reaching the rest of the body. Even though there are some risk factors, the major cause is smoking that damages one's lungs with the adverse effects irreversible. The common symptoms are coughing, which is usually worse in the morning with the production of a small amount of colorless sputum, wheezing, which occurs mostly during exacerbations and exertion, and breathlessness, which mostly occurs in the 60s (Schweitzer, et al., 2011).

Pathophysiology of COPD

Pathophysiology of COPD shows that the condition comprises of airway inflammation, airway structural changes, and mucociliary dysfunction. All these are evidenced in the case of Bill since the main cause is smoking, and for the patient, he has smoked one packet of cigarette daily for 35 years. According to Tuder and Petrache (2012), airway inflammation results from exposure to inhaled irritants (in this case tobacco smoke). This leads to chronic inflammation of pulmonary blood vessels, airways, and lung tissue. After inhaling the tobacco smoke, the patient suffers from inflammatory cells including macrophages, neutrophils, B cells, CD8+, and T-lymphocytes.

With activation from the irritants (tobacco smoke), the cells induce an inflammatory reaction triggers the release of immune mediators such as interferon gamma, fibrinogen, necrosis factor alpha, interleukins, C-reactive protein, and matrix-metalloproteinases. The immune mediators lead to inflammation later causes tissue damage and other systemic effects. While chronic inflammation of the airways is at the initial stages of the disease, it later leads to structural changes and eventually airflow limitation (Rajendrasozhan, et al., 2010).

Structural changes are evidenced in the form of airway remodeling due to inflammatory response linked to the disease. This results to narrowing of airways. The three factors leading to structural changes are peribronchial fibrosis and excess multiplication of epithelial cells in the airways lining. The patient also experiences parenchymal destruction linked to loss of elasticity of lung tissue resulting from destruction of structures that feed and support the alveoli or emphysema. This way, the small airways fail when exhaling further impeding airflow. This traps air in the lungs and reduced the capacity of the lungs (Schweitzer, et al., 2011).

Lastly, for mucociliary dysfunction, Seimetz et al. (2011) argue that smoking and inflammatory reactions lead to enlargement of mucous glands that lines the airway walls of the lungs. This leads to goblet cell metaplasia as well as having healthy cells replaced by cells that secrete more mucus. Also, inflammation from the condition leads to damage of the mucociliary transport system. Since this system helps in the clearance of mucus in the airways, more problems are evidenced. McDonough et al. (2011) note that it leads to excess mucus in the air passages thus accumulating, blocking, and worsening airflow. At this point, the condition is worsened, and just as is the case of Bill, the patient would have a chronic productive cough, copious quantities of purulent sputum, shortness of breathing even when resting, wheezing, tiredness, and chest pain.

Management Plans

The nursing management plan for the patient would include diagnosis and treatment for impaired gas exchange. The expected outcome of nursing intervention, in this case, is to help the patient learn when to use the oxygen therapy, demonstrate improved oxygenation and ventilation, and exhibit arterial blood PaCO2, pH levels, and PaO2 at baseline. The nurse should, therefore, monitor ABGs to determine indications of respiratory alkalosis, hypoxemia, and respiratory acidosis. Based on the evidenced symptoms including a headache, tachycardia, irritability, cardiac dysrhythmias, confusion, increasing somnolence, and asterixis, the nurse would determine the need for oxygenation (Kuzma, et al., 2008). The nurse would also determine whether the patient meets the criteria for home oxygen therapy.

With oxygen therapy, the nurse should educate the patient and his family on how it is used. Some of the major points to note are that oxygen should be delivered at the prescribed rate of flow, oxygen leads to drying of nose membranes, and therefore water-soluble lubricant rather than Vaseline should be used, in case of using humidification, the quantity of water on the bottle should be checked within 6 hours and refilled with distilled or sterile water when need be, new oxygen supply should be ordered when oxygen is full, and safety precautions to observe. The patient should also be informed of when to conduct the physician such as in times breathing becomes difficult or is the patient experiences restlessness, cyanosis on lips or fingernails, anxiety, confusion, tiredness, slurred speech, drowsiness, persistent headache, and difficulty waking up (Fletcher & Dahl, 2013).

The nurse and the medical team should also assess for ineffective airway clearance. This aims at helping the patient have adequate airway clearance, use broncho active medication such as humidifiers, MDIs, nebulizers, and dry powder inhalers appropriately, and use effective coughing methods. The patient should learn to cough when sitting upright and huff coughing technique. In this case, the practitioner can prescribe expectorants or fluid intake of 3-4 L. The nurse should, therefore, teach the patient how to ensure adequate hydration while avoiding fluid overload. Since the patient produces a great quantity of sputum, Lewis et al. (2014) argue that mechanical or manual chest percussion or postural drainage is advisable.

To help the patient with ineffective breathing pattern, the nurse should encourage him to use controlled breathing techniques such as abdominal breathing, pursed-lip breathing, and forward-leaning position to control anxiety and dyspnoea. The major aim is to enhance expiratory tidal volume and reduce the respiratory rate to decrease air trapping. The nurse should thus ask the patient to inhale via the nose with a closed mouth for a few seconds and exhale slowly via pursed lips that are held in a narrow opening (Sorknaes, et al., 2011).

According to Harrison, Daly, and Harrison (2011), the frequency of exacerbations is reduced using inappropriate inhaled bronchodilators and corticosteroids as well as vaccinations. In addition, the adverse effects of exacerbations are minimised through advice on how to respond promptly to exacerbation symptoms, start of appropriate treatment using oral antibiotics or steroids, use of NIV when with persistent failure of hypercapnic respiratory even after using medical treatment such as oxygen therapy, and use of assisted-, home- or hospital discharge schemes. Self-management is also very important with the medical practitioner encouraging the patient to respond fast to exacerbation symptoms through the start of oral corticosteroid therapy when with breathlessness problems, antibiotic therapy in times of purulent sputum, and adjusting bronchodilator therapy for controlling the symptoms of the condition (Yoost & Crawford, 2015).

Home Care Considerations before Discharging Bill

Bill has to be discharged with home oxygen at 2l/minute/nasal cannula. There is also need to have a supplier for the needed oxygen equipment. The main aim of planning for the discharge process is to ensure that the patient and his family members or carers are more secure before returning home. The medical team should, therefore, improve support to the patient and carers when discharged, improve the consistency of care, and improve the level of understanding of the patient and family members regarding the condition. Before the patient is sent home to be with his family, their level of confidence should be enhanced. It is after a patient feels confident that he understands everything regarding his condition and how to manage it that he feels ready to go home (Fan, et al., 2012).

Patients and their family members should, therefore, feel adequately prepared to manage the condition before going home. This is by ensuring that the patient can recuperate at home, is sure of when to take medications, can spot early signs that his condition needs medical treatment, and is sure of the support he would get from his family members. The patient should, therefore, be assured that the medication and oxygen therapy would help him to cope with his condition. This means that the oxygen supplier has arrangements with the family and the patient to have the required equipment and supplies delivered and set-up (Escarrabill, 2009). By the time the patient gets home, he should find the oxygen equipment already set up and ready for use.

Also, the oxygen supplier should communicate with the nurse or social worker who is coordinating home care. He needs to communicate when he plans to set up the equipment so that the nurse can be at home and ensures that the patient is not discharged before then. Further, since the physician has ordered for home nurse visits and follow-up check-ups, the arrangements have to be made before the patient is discharged. The physician has to be informed of the nurse responsible for the home visits, when and how they will be conducted, and the action the patient should take in case of an emergency (Ingadottir & Jonsdottir, 2010).

Perry, Potter, and Ostendorf (2016) also note that when the patient and his family get home after the discharge, the oxygen supplier should be home to educate him on how to administer it safely. It is the responsibility of the supplier of the oxygen equipment to not only deliver and set them up but also educate the patient and the carer on how they should be used. Before leaving the premise, the supplier should also assess the oxygenation status of the patient and ensure that the supplies and equipment are working properly based on his condition. The supplier can also answer some questions posed by the family members such as when to ask for more supply, what to do in case of complication, and any other burning issues. For further questioning and asking for supplies, the supplier should leave his contact information with the carer.

Support Resources in the Community and an Education Plan for Bill

Before Bill is discharged from the hospital, the physician should ensure that there is a nurse or social worker from the community for follow-up, a supplier is readily available for oxygen equipment and other supplies, there are support groups in the community for Bill to seek support from, and there is someone in the family who is prepared and available to take care of him. According to Walsh (2012), Bill would be able to cope up with his condition better if he interacts with people with similar conditions and this is possible at support centers. Also, Bill should be educated on the symptoms of worsening condition and where to seek help. He should be aware of how to use the oxygen equipment, how to switch it off when not in use, how to have it upright all through, and to avoid smoking near it. He should also be aware of ways of cleaning the equipment such as the filter and nasal cannula that can be cleaned with water and soap in the case of visible dirt and dried (Nettina, 2013).

Bill and his carer should also be aware of when to order for new oxygen supply, where it should be kept (such as far from open flame or devices producing heat) and when and how to switch off the tank. The patient should also be informed that he should only administer the prescribed amount of oxygen unless the physician makes changes. The patient should also know the importance of taking at least 2-3 liters of non-caffeinated fluids per...