Holistic Assessment of COPD Patient: A Nursing Case Study

In this case study we will discuss about nursing and below are the summaries point:- Introduction to COPD and the importance of holistic assessment for patients with co-morbidities. Case history of an elderly patient with COPD and congestive heart failure. Utilizing the ABCDE approach and Roper-Logan-Tierney framework for comprehensive assessment of the patient's condition.

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HOLISTIC ASSESSMENT OF COPD PATIENT
[DATE]
HP
[Company address]

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Contents
INTRODUCTION:................................................................................................................................2
CASE HISTORY-.................................................................................................................................2
ROPER-LOGAN-TIERNET FRAMEWORK.......................................................................................3
ASSESSMENT OF BB USING ABCDE APPROACH:.......................................................................3
HOLISTIC ASSESSMENT...................................................................................................................4
REFERENCES......................................................................................................................................7

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INTRODUCTION:
COPD is known to be one of the leading causes of mortality and morbidity and
the person with COPD is often prone to have co morbidities that should be considered as
per the severity of COPD diagnosis (Wouter & Augustine, 2016). Several approaches
have been taken into consideration to assess and treat COPD pateints, out of which
multidisciplinary and holistic therapy are highly considered. In this essay, the case study
of an elderly patient (age-76) will be discussed. She was recently admitted to respiratory
ward due to certain respiratory discomfort after fall. The initial assessment suggests that
she is suffering from COPD and co morbid with several other health issues. Holistic
approach will be taken to assess the patient from the social, physiological, psychological
and spiritual aspects. Presently two tools will be employed namely the ABCDE method
to assess the initial symptoms. This approach has been accepted widely by the healthcare
experts and likely supports healthcare professional to achieve most significant clinical
outcomes (Slok, et, al. 2016). Second is the RLT or Roper-Logan-Tierney framework for
holistic assessment and evaluation of the patient’s condition (Williams, 2017). The scope
of this article is to thoroughly assess the patient’s health condition and identify her needs
using a systematic and holistic assessment. To maintain the confidentiality of the patient,
the name of the patient has been changed.
CASE HISTORY-
Patient BB is an elderly woman aged 76, has been recently diagnosed with
congestive heart failure. She was admitted to the respiratory ward due to infective
exacerbation of COPD. Her case was immediately looked into by the registered nurse and
as a part of initial assessment, transthorasic echocardiography was performed and further
investigation was done to understand the functionality of heart. BB lives alone in the flat
and reportedly lost her balance and fell in the lift. Her neighbours called the ambulance
and rescued her to the hospital. In her social life, she lives alone and mostly likes her
space and privacy. She is teacher and currently retired from the job. She also visits
church for her prayers every Sunday. Her only daughter Jane is a resident of Scotland and
visits her twice in a year. BB was recently diagnosed with CCF and has a medical history
of congestive heart failure and COPD.

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The patient is recently admitted to the hospital and the nurse has taken holistic
assessment approach for the initial few hours by using Roper framework. The holistic
approach is performed to get cues regarding the physical, spiritual, psychological and
social need of the patient.
The assessment will also involve the observational data that happened in the past
few days as it will help in designing the person centred care for the patient. As a part of
the follow up, desired planning will be done for her further care, discharge plan and care
plan within the community.
ROPER-LOGAN-TIERNEY FRAMEWORK
The Roper Logan Tierney (RLT) Framework provides skeleton of patient
assessment using holistic approach. It is quite appropriate in BB’s case because of her
current health condition. She is currently co morbid with multiple health ailments that
puts her under extreme risk of getting severe health complication in the future (Williams,
2017). The holistic assessment is highly essential in her case as the outcome of this
assessment will allow the nurses to facilitate a patient centred healthcare approach. The
parameter score achieved for BB ranges from 3 to 5, where 5 stands for an extreme case
of concern. It signifies that the patients is severely ill and have significant health
deterioration (Tedd et al., 2017).
ASSESSMENT OF BB USING ABCDE APPROACH:
The primary goal of the COPD assessment is to determine the severity of the
airflow limitation, its impact upon the health of the patient and potential risk in future due
to the present condition, therefore the immediate assessment of BB upon admission was
carried out in the presence of mentor (a senior nurse) by applying ABCDE approach to
identify critical symptoms and ascertain effective treatment.
Airway: At first signs of airway obstruction were analysed that included the
abdomen and chest movements, whether the patient is breathing through mouth or nose
and whether the entry or air is noisy. In the present case patient BB was having severe
difficulty in breathing therefore with the help of magnetometer the movement of chest
and abdomen was monitored and the result showed that the movement of chest and
abdomen was not unison. Secondly it was observed that patient BB was taking deep

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breathing through mouth and during both inhalation and exhalation there was noisy
sound.
Breathing: In this the general signs of respiratory distress were monitored such
as excessive sweating, abdominal breathing and central cyanosis. In the present case the
breathing rate of patient BB was more than 25 breaths per minute. The SpO2 reading was
also below 95 which indicated that due to shortage of breath there was not enough
oxygen concentration in the blood. There was also rattling airway noise during breathing
indicating that presence of airways secretion.
Circulation: The breathing problem also impacts the circulatory state of the
patient therefore analysing the symptoms of cardiac issue should also be assessed in the
initial stage. For this at first colour of the hands is determined, the limb temperature of
the patient is monitored, blood pressure is monitored, CRT or the capillary refill time is
determined and the pulse rate of the patient is recorded. In the present case patient BB’s
hands were found to be pale in colour, the limb temperature was slightly cold. The CRT
time was monitored and it was found to be prolonged compared to normal people. The
resting heart rate of patient BB was found to be 85-90 bmp. The blood pressure of was
also noted to be 140/90 mm Hg which is due to lack of oxygen in the blood which in turn
is due to difficulty in breathing.
Disability: Unconsciousness, inability to talk properly, inability to open eyes is
some of the disabilities associated with severe COPD therefore these symptoms were also
analysed. Here patient BB was not unconscious and was able to respond to the vocal and
touch stimuli. However, she was having difficulty in talking and opening her eyes
properly. Due to deep breathing through mouth she was unable to talk properly.
Exposure: With the permission of the patient and respecting her dignity full
exposure of the body was examined to find out any other signs and symptoms such as
entire body skin colour, pain in any other parts of the body (Thim, Krarup, Grove, Rohde
& Løfgren, 2012).
HOLISTIC ASSESSMENT
In contemporary nursing evidence based literatures, COPD is no more defined as
a simple physiological impairment rather the potential ability of the patient to manage

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their wellbeing and adapt to current situations (Steurer et al., 2018). In the present case,
BB’s health condition has detoriated over the time period due to concurrent CCF along
with exacerbation of COPD. The current literatures suggest that treatment approaches
towards COPD patient with co-morbidity or cardio-vascular disorders must be addressed
with holistic assessment strategy (Wouters & Augustin, 2016). The rationale is to
empower the patient for identification of diversity of factors, contexts and determinants
of health that affects their day to day lifestyle.
The current case study of BB will be assessed based on RLT model in order to
cover different aspects of her life and find out the main problem that warrants preventive
and management interventions.
Breathing – Breathing is an important factor that affects every aspect of health.
Abnormal breathing rate can make individuals fatigue or shortness of breath initiating
chain of metabolic pathways that interferes with day to day activities (Gerbrag & Brown,
2016). From the current assessment via ABCDE framework and investigations by
spirometry the FEV 1 was recorded 31%. Scoring of FEV 1 in between 30-50% is
considered as severe COPD. Due to breathing issues especially dyspnea, the energy level
reduces with palpitation and forced breathing on mobility. As a result oxygen
compensation occurs through rapid breathing rate evident in case of BB having a higher
breathing rate of 22 (Slater, Abshire & Davidson, 2018).
Maintenance of Safe environment- In the present scenario, the client was brought
to hospital after a fall and notified by the neighbor to ambulance service. The prevalence
of fall in older population and eventual disability is highly reported. It has direct
connection with mental health of an individual (Hakamy et al., 2018). Since, BB was an
avid sprinter as well as hiker some years before, the current fall might induce depressive
symptoms. She was living alone at 13th floor with a healthcare assistant. She has glasses
for clear vision and uses support while transferring from bed to chair. Her gate balance is
low that makes her prone to fall. There can be multiple factors contributing towards her
fall such as obstacles in her path, poor nutrition, and medication side effects (Lahousse et
al., 2015) Safe environment seems to be a determining factor for BB in order to have a
good health. Safe environment is another factor that must be considered while designing
care plan.

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Communication- Communication implies bi-directional convey of message and
understanding each messages towards productive action. Communication forms an
imperative part of good health. It is only through communication one can convey the
health status to another individual (Naylor et al., 2016). The sense of hearing, seeing and
touch plays an important role for communication. On assessment, BB was found to have
hearing issue that has been addressed by using a hearing aid. However, her response time
to verbal communication is slow implicating either poor analysis by brain or improper
placement of hearing aid. This needs to be assessed by other strategies that will evaluate
the mental capacity of the client. Communication enhances the mental capacity of an
individual as they feel empowered (Rainke et al., 2017).
Eating and Drinking – Nutrition has both physical and mental impacts on an
individual. A healthy nutrition can improve the health status of an individual
(Chambaneau et al., 2016). In the present case, the client’s subjective data implicates low
fluid intake and extremely low weight of 48 kg. The BMI is very low i.e. 18 implicating
mal-nutrition. In such cases, it is expected the client to feel more weak due to reduced
food supply and breathing in COPD patients demands higher energy. With reduced
energy, BB’s recovery might take longer and can impact on her mental health. The
chances of fall further increase implicating good diet to be initiated. However, shortness
of breath can be a hindrance to healthy eating due to discomfort and mouth breathing
(Ter beek et al., 2018).
Elimination – A healthy system must have a good excretory system. BB’s
assessment indicates she doesn’t have any issue with elimination whether it is bowel
movement or urination. But due to mobilization issue she need to have sanitary pads.
This reduced functionality can be depressive for patients and further impact on her
recovery cycle (Shay, Fulton & O’malley, 2019). This indicate, the breathing issue that
seems to the root cause for most physical and mental health issues found in BB’s case
must be addressed with top priority.
Washing and Dressing – She needs assistance to carry out her day to day
activities due to mobility issues. People with severe COPD has issues with washing and
dressing as it demands mobilization and in turn exerts more pressure on COPD
candidates (Lindenmey et al.,2017).

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Controlling temperature – Poor nutrition makes the body prone to different
infectious diseases and immobility further catalyse the factor. Although, her current body
temperature is 37 degree that is well within normal range, it demands frequent checkup.
Fluid balance maintenance is also related with temperature, as the client has already
mentioned she doesn’t take fluids outside her meals this could further worsen the case.
Mobilization – Need support and assistance for mobilization. Fear of falling. Fear
can further restricts her to one place and poor nutrition can escalate the case. If not
treated within time, it might lead to skin integrity issue due to poor fluid intake, pressure
ulcers and other bacterial infections as she is poor in reaching to toilet in time. Therefore
the underlying cause of immobilization must be addressed at first point (Pierik et al.,
2017).
Working and Playing – Previously she was more active and had a sprinter career
during her school days. Later post marriage she likes to hike with her husband. So, the
current impairment in functions and compounding factors might lead to depression and
anxiety. Anxiety can worsen the COPD condition.
Expressing Sexuality – She is currently not active sexually.
Sleeping – The patient assessment shows poor sleeping pattern as well as
difficulty in sleeping at night. The patient complains feeling sleepy at day time due to
altered sleeping pattern. Breathlessness is a risk factor that can affect the sleep pattern
negatively. Poor sleeping can affect the day to day life activities thus influencing the
social aspects of life too (Krachman et al., 2018).
Death and Dying – The spiritual aspects of patient and their belief on death and
dying can affect their adherence to medical regimen. However, in the present case BB’s
daughter takes decision on her part. BB’s lost her husband two years earlier. Losing your
partner or spouse can be traumatic and further add problems in pathway of recovery. This
might have affected her nutrition pattern as food has direct connection with life events.
Thus, from the above assessment it is evident that BB’s breathing issue need to be
addressed with top most priority in order to fasten her recovery and reduce the
comorbidities. The ABCDE assessment carried out reveals the same issue. Holistic
assessment through RLT model implicates, different aspects of life that need to be
addressed along with pharmacological and non-pharmacological interventions. Due to

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mobilization issue and breathlessness, her spiritual life must have taken a pause that need
to be reinstated through holistic interventions.
ACTIVITIES OF DAILY LIVING SCORING
A. TOILET
Care for self at toilet
completely; no
incontinence
Needs to be
reminded, or needs
help in cleaning self,
or has rare (weekly at
most) accidents
0
Soiling or wetting
while asleep more
than once a week
Soiling or wetting
while awake more
than once a week
No control of bowels
or bladder
B. FEEDING
Eats without
assistance
Eats with minor
assistance at meal

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times and/or with
special preparation of
food, or help in
cleaning up after
meals
Feeds self with
moderate assistance
and is untidy
Requires extensive
assistance for all
meals
0
Does not feed self at
all and resists efforts
of others to feed him
or her
C. DRESSING
Dresses, undresses,
and selects clothes
from own wardrobe
Dresses and
undresses self, with
minor assistance
Needs moderate
assistance in dressing
and selection of

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clothes.
Needs major
assistance in
dressing, but
cooperates with
efforts of others to
help
0
Completely unable to
dress self and resists
efforts of others to
help
D. Grooming (neatness, hair, nails, hands, face, clothing)
Always neatly
dressed, well-
groomed, without
assistance
Grooms self
adequately with
occasional minor
assistance, eg, with
shaving
Needs moderate and
regular assistance or
supervision with
grooming

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Needs total grooming
care, but can remain
well-groomed after
help from others
0
Actively negates all
efforts of others to
maintain grooming
E. Physical Ambulation
Goes about grounds
or city
Ambulates within
residence on or about
one block distant
Ambulates with
assistance of (check
one)
a ( ) another person, b
( ) railing, c ( ) cane,
d ( ) walker, e ( )
wheelchair
1.__Gets in and out
without help.
2.__Needs help
getting in and out
Sits unsupported in 0

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chair or wheelchair,
but cannot propel self
without help
Bedridden more than
half the time
F. BATHING
Bathes self (tub,
shower, sponge bath)
without help.
Bathes self with help
getting in and out of
tub
Washes face and
hands only, but
cannot bathe rest of
body
Does not wash self,
but is cooperative
with those who bathe
him or her.
0
Does not try to wash
self and resists efforts
to keep him or her
clean.

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Thus, based on the ADL scoring the patient is found to be highly dependent.
REFERENCES
Chambaneau, A., Filaire, M., Jubert, L., Bremond, M., & Filaire, E. (2016) Nutritional
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Hakamy, A., Bolton, C. E., Gibson, J. E., & McKeever, T. M. (2018). Risk of fall in patients
with COPD. Thorax [Online]. 73(11), Available from
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