COPD is a common pulmonary condition causing restricted airflow and respiratory problems. This chronic inflammatory condition involves lung parenchyma, airways, and pulmonary vasculature (Soriano et al., 2018). The pathophysiology process of COPD involves protease-antiprotease imbalances and oxidative stress. Emphysema is defined as a structural change seen in COPD where there is obstructive physiology due to the destruction of the gaseous exchange surface of the lungs (Rodrigues et al., 2019). In emphysema conditions, a nuisance like smoking initiates an inflammatory response. Macrophages and Neutrophils are activated and produce multiple inflammatory intermediaries. Excess proteases and oxidants destroy alveolar air sacs. Destruction of elastin by protease-mediated inflammation causes airway collapse during exhalation as elastic recoil of the surface is lost (Rodrigues et al., 2019).
Alpha-1 antitrypsin deficiency (AATD) involves imbalance and lack of antiproteases that leave respiratory parenchyma at risk of developing emphysema due to the development of protease-mediated damage. Deficiency of alpha-1 antitrypsin causes accumulation of mutated proteins in the liver. COPD patients with live conditions or damage are suspected of deficiency in alpha-1 antitrypsin protein (Rodrigues et al., 2019). AATD mainly involves the lower lobes as opposed to emphysema conditions relating to smoking. The pathophysiology of AATD in association with respiratory conditions can not be caused by external exposure; instead, this deficiency is inherited by genes from both parents. Generally, AATD is a genetic health condition that can cause live and lung damage (Leap et al., 2021).
The inflammatory response of the lungs and airways obstructions causes tissue destruction and lowers the forced expiratory volume, resulting in impaired gas exchange and limitation to airflow. Hyperinflation of the lungs is experienced during exhalation when the air trapped in the airways collapses; this can be seen in imaging studies (Santus et al., 2019). The inability for complete exhalation elevates carbon dioxide (CO2) levels in the lungs and bloodstream. With disease progression, the weakening of respiratory exchange is experienced. An increase in lung physiologic death region and reduction in ventilation leads to carbon dioxide retention. Pulmonary hypertension is encountered due to verbose vasoconstriction in hypoxemia (Soriano et al., 2018).
Ciliary dysfunction and mucous hypersecretion are other pathophysiologies of OCPD that cause productive cough. Mucous hypersecretion is not associated with airflow obstruction butt is a chronic bronchitis characteristic. Not all patient with COPD is characterized by hypersecretion of mucous. However, the excessive secretion of mucous results from squamous metaplasia, which elevates the number of goblet cells (Rodrigues et al., 2019). Therefore, the bronchial submucosal gland will increase in size due to chronic irritation by accumulated gases and noxious particles. Metaplasia of squamous epithelial cells causes ciliary dysfunction, and this causes difficulty in expectorating. In addition, acute exacerbations of COPD commonly occur due to triggers such as environmental irritants and viral bacterial pneumonia (Rodrigues et al., 2019).
Assessment of Nancy’s Findings using the A to G process
Assessment of Nancy’s clinical presentation using the A-G tool will help integrate procedures mandated for emergencies and resuscitation. A to G assessment will cover Nancy’s airway, breathing, circulation, disability, exposure information (family), and goals. Nancy’s airway assessment focuses on the nose, larynx, pharynx, trachea, and bronchus. During admission, the patient presents with airway obstruction symptoms, including productive cough, breathing sounds, wheezing, agitation, use of accessory muscles, and difficulty breathing. The second assessment is breathing, a process of moving respiratory air in and out of the lungs. For a healthier person, it should be balanced bilateral chest expansion, effortless in breathing, 12-20 breaths per minute, free of sputum, and noise-free. However, Nancy presents with clinical features including increased work of breathing (WOB), shortness of breath (SOB), oxygen saturation value 89%, respiratory rate 27, chest pain, and pain during cough.
The assessment of a patient’s circulation is not limited to the heart; it also covers the vascular part and hemodynamics of the circulatory system. Nancy presents with symptoms, which include blood pressure ranging between 198/78 and 190/80, sluggish capillary refill, heart rate 109 to 95, and blood in sputum. Disability assessment focuses on the patient’s general unwellness. Many clinical manifestations include poor appetite, sleeplessness, recent episodes of fever, smoking 10/day, requiring assistance to eat, high level of ketone bodies in urine 5, pain score 4/10, and fast breathing. Assessment of patient’s exposures indicates requirements of special dietary. Nancy’s further information includes a history of COPD and hypertension, a body temperature of 38.8, and intravenous normal saline during admission of 80 ml/hour. The assessment findings indicate Nancy’s COPD condition, which affects her airway, breathing, and circulation mechanism. The goal will be to educate her on the effects of excessive smoking and provide her with appropriate medication to manage COPD manifestation.
ISBAR Format in Presenting Assessment Findings to Supervising RN
Introduction/Identification: I am handing over the patient’s assessment findings to my supervisor, RN. The patient’s name is Nancy Gray, her Date of Birth is 18/10/1998, and her address is 25 Long St Armidale. The patient was admitted to the hospital in the evening (1600 hours) due to some respiratory complication.
Situation: The patient is admitted to the medical ward directly with a known case of high blood pressure and COPD. The current working diagnosis for the patient includes a sputum culture to identify the possibility of pneumonia or fungi causing airway infections. Another underway is arterial blood gas collection for laboratory oxygen and carbon dioxide balance diagnosis. The clinical situation and recent observations for the patient include difficulty breathing, sound while breathing, wheezing, increased blood pressure 190/80, persistent pain during coughing, increased work of breath, and oxygen saturation of less than 90%. Also, the patient presents with an increased heartbeat of 109 and sluggish capillary fill; hence, it reflects the interference of the respiratory system.
Background: Nancy was admitted this evening for the treatment and management of a suspected respiratory condition. She has a medical history of COPD and hypertension. The patient is reported to have been smoking ten times a day.
Assessment: The clinical assessment findings reflect the patient’s risk of COPD and hypertension. She came in with complaints of difficulty in breathing, productive cough, slight fever, pain during cough, poor appetite, sleeplessness, oxygen saturation less than 90%, and she was conscious.
Recommendation: I would like the patient to be given appropriate medication, which will restore her normal breathing and reduce the pain. Also, Nancy can be given some medicine that will reduce her hypertension and retain average blood circulation in the body. I recommend making the medication faster due to the patient’s current presentation in the ward.
Nursing Management of COPD for Nancy
Normal Management of COPD
Most patients with COPD cannot enjoy their lives fully; however, nurses and clinicians are responsible for managing COPD conditions at various stages of health. A nurse should maintain patent airway clearance by assessing and monitoring breathing, sounds, and inspiratory and expiratory ratio. This airway assessment provides observable manifestation, and a patient can be given a drug of choice, such as corticosteroids. The second management intervention is promoting effective oxygen therapy and gas exchange. The therapy can be effective by frequently assessing the patient’s respiratory rate. The patient should be referred to pulmonary rehabilitation for better interventions if any complication is found. Another intervention is providing the patient with appropriate medication to retain normal breathing. For example, a patient can be given antibiotics to treat and manage respiratory-related infections. Also, a patient can be given supplemental oxygen to balance the body’s metabolic activities due to respiration problems. Lastly, health education, such as quitting smoking, having healthier nutrition, and engaging in physical exercise, is suitable for COPD patients.
Average and Pharmacological Management for Nancy
Nancy has a medical history of COPD and hypertension; hence, it requires nursing and clinicians’ management to help restore her health. Hypertension can complicate COPD in Nancy; it is associated with an increased risk of decreased survival and exacerbation (DeMeo et al., 2018). Therefore, the patient should be advised to eat healthy diets, reduce stress, limit excessive salt intake, and quit smoking. The patient is a chronic smoker 10/day; this is the main reason for the increase in COPD manifestations. Therefore, health education concerning smoking and a healthier diet is an essential management measure that can be undertaken in her current hypertension and COPD (Leech et al., 2019). Nany presents with low oxygen saturation; this can be managed by long-term oxygen therapy, which can help her breathe every day and live longer. Also, the patient should be given normal saline to manage breathlessness by nebulizing bronchodilators in COPD (Nici et al., 2020).
The current Nancy’s situation requires pharmacological intervention to manage her clinical manifestations and avoid exacerbation. Nancy should be given bronchodilators using an inhaler. The regimen treatment will ease airflow limitation and bronchial obstruction, improving respiratory exchange. Bronchodilators such as anticholinergics and beta-antagonists help patients control and alleviate long-term symptoms of COPD (Celli, 2018). The patient presents with hypertension; here, pharmacological medications such as dihydropyridine calcium blockers or thiazide-like diuretics should be administered to help restore average blood circulation. Another medication is the administration of mucolytics, which will reduce her persistent, painful, and dry cough (Hindelang et al., 2020). An example of mucolytic medicine is carbocisteine, which makes the throat phlegm easier and thinner to cough. Also, Nancy presents with blood in sputum; diagnosis is essential to determine the cause. If the findings are positive for respiratory infections, the patient should be administered antibiotics to kill the microorganisms. Generally, pharmacological intervention, behavioral modification, and lifestyle changes are effective in managing Nancy’s COPD (Padilha et al., 2018).
References
Celli, B. R. (2018). Pharmacological therapy of COPD: reasons for optimism. Chest, 154(6), 1404–1415. https://www.sciencedirect.com/science/article/abs/pii/S0012369218310614
DeMeo, D. L., Ramagopalan, S., Kavati, A., Vegesna, A., Han, M. K., Yadao, A., … & COPDGene Investigators. (2018). Women manifest more severe COPD symptoms across the life course. International journal of chronic obstructive pulmonary disease, 3021–3029. https://www.tandfonline.com/doi/full/10.2147/COPD.S160270
Hindelang, M., Kirsch, F., & Leidl, R. (2020). Effectiveness of non-pharmacological COPD management on health-related quality of life-a systematic review. Expert Review of Pharmacoeconomics & Outcomes Research, 20(1), 79-91. https://www.tandfonline.com/doi/abs/10.1080/14737167.2020.1734455
Leap, J., Arshad, O., Cheema, T., & Balaan, M. (2021). Pathophysiology of COPD. Critical Care Nursing Quarterly, 44(1), 2-8. https://journals.lww.com/ccnq/abstract/2021/01000/pathophysiology_of_copd.2.aspx?context=latestarticles
Leech, R. M., Timperio, A., Worsley, A., & McNaughton, S. A. (2019). Eating patterns of Australian adults: associations with blood pressure and hypertension prevalence. European Journal of Nutrition, p. 58, 1899-1909. https://link.springer.com/article/10.1007/s00394-018-1741-y
Nici, L., Mammen, M. J., Charbek, E., Alexander, P. E., Au, D. H., Boyd, C. M., … & Aaron, S. D. (2020). Pharmacologic management of chronic obstructive pulmonary disease. An official American Thoracic Society clinical practice guideline. American Journal of Respiratory and Critical Care Medicine, 201(9), e56-e69. https://www.atsjournals.org/doi/full/10.1164/rccm.202003-0625ST
Padilha, J. M., Sousa, P. A. F., & Pereira, F. M. S. (2018). Nursing clinical practice changes to improve self‐management in chronic obstructive pulmonary disease. International nursing review, 65(1), 122-130. https://onlinelibrary.wiley.com/doi/abs/10.1111/inr.12366
Rodrigues, S. D. O., Cunha, C. M. C. D., Soares, G. M. V., Silva, P. L., Silva, A. R., & Gonçalves-de-Albuquerque, C. F. (2021). Mechanisms, pathophysiology, and currently proposed treatments of chronic obstructive pulmonary disease. Pharmaceuticals, 14(10), 979. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8539950/
Santus, P., Pecchiari, M., Tursi, F., Valenti, V., Saad, M., & Radovanovic, D. (2019). The airways’ mechanical stress in lung disease: implications for COPD pathophysiology and treatment evaluation. Canadian Respiratory Journal, 2019. https://www.hindawi.com/journals/crj/2019/3546056/
Soriano, J. B., Polverino, F., & Cosio, B. G. (2018). What is early COPD, and why is it important? European Respiratory Journal, 52(6). https://erj.ersjournals.com/content/52/6/1801448.short
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