Analysis of COPD Management: A Nursing Case Study Report

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NURSING ASSIGNMENT
Contents
INTRODUCTION...........................................................................................................................................1
PART I..........................................................................................................................................................1
PART II.........................................................................................................................................................3
I. BREATHING........................................................................................................................................5
II. MAINTAINING A SAFE ENVIRONMENT..............................................................................................7
EVALUATION:...............................................................................................................................................8
SELF-REFLECTION:.......................................................................................................................................9
REFERENCES..............................................................................................................................................10
1

INTRODUCTION
The following essay focuses on the healthcare plan of Jane Smith (pseudo-name), who is a 73-
year-old woman from Essex who was admitted to the hospital during my clinical placements.
She has been admitted to the medical clinic with ceaseless obstructive pneumonic sickness
(COPD) because of chest contamination. At the age of 62 years, she was diagnosed with breast
cancer and had to go for left mastectomy. Around then, she was under constant stress and began
to smoke vigorously. In 2014, Jane was determined to have COPD post which she surrendered
smoking. Recently, she has been admitted to the nursing care multiple times due to the
intensifications of COPD.
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PART I
The first part of this essay discusses about the communication needs for the patient and critically
analyzes the type of communication strategies that were helpful for Jane while the second part of
the assignment will discuss in detail the nursing care plan using the Roger, Lopan and Tierney’s
Living Model and with the identification of SMART patient goals. Finally, the essay will
conclude with self-reflection showcasing my professional development as a nurse with this case
study.
Webster, 2014, inferred that 'communication is comprised of a sender, a beneficiary and a
message for a specific purpose.' However, Sprangers, et al., 2015, trusts that 'communication is
the utilization of words to form, send and translate conversations.' Schuster's definition connects
together the verbal and nonverbal communication while the definition by Webster, 2014, centers
around verbal communication. Communication has two sections a verbal and a nonverbal
message (Struik, et al., 2014). Verbal communication is communication which is spoken and has
specific implication in nursing care with the proper utilization of pitch, tone, and volume. Jensen,
et al., 2015 distinguishes that the point of talking to a patient is to recognize their issues. The
nurse utilizes her relational abilities to interface with the patient while picking up the required
details about the patient. Verbal communication gives the medical attendant the chance to
console her patient and talk about their worries with them.
Jane complained of pain during breathing and a pain assessment was recorded which decoded the
observation that she had a sharp pain of score 9 due to tracheal infection. Other observed issues
were changes in respiratory pattern, abnormal sputum causing anxiety and stress that can
potentially lead to respiratory arrest.
Vital Signs:
COPD is a slowly progressing and chronic respiratory disease, described by irreversible airway
obstruction, which may impede the normal breathing, with occasional exacerbations that may
worsen the disease situation (Wedzicha, et al., 2017). On examination, Jane was alert, stressed
and was breathless during the exertion or when lying down. She was analyzed and her essential
signs were recorded so as to build up the baseline findings. This disease is a long-lasting sickness
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and can influence all parts of life, including feelings, work-related exercises, sexual connections,
speech and dimensions of freedom (Berry, et al., 2015). Besides, the chronic disease outbursts
are regular, bringing a surge in the admissions to the emergency clinics and putting more
pressure on the patient, healthcare staff and medical insurance companies.
In order to deeply identify the problems she was facing and minute recording of all essential
details, the nursing investigation requires appropriate questioning skills that can help Jane to put
up all her concerns and fears without any hesitations. For this, I have made use of certain
communication strategy that helped me in freely discussing the problems with Jane.
I have utilized the Peplau’s Interpersonal Relations Theory in order to communicate with Jane
which involves four distinct phases:
Orientation phase: Utilizing the skills from this phase, I ensured to make it comfortable for Jane
so that she can ask me her questions and I can clear all her doubts in relation to the health
condition as well as per personal worries. Also, with the help of this stage, I was able to develop
effective trust by which our nurse-patient relationship began to evolve (Breyer, et al., 2014).
Identification phase: With the utilization of this phase in this case study, I was gradually able to
develop my interaction with Jane by showing my genuine concern for her health. I tried to
explicitly show the ways by which she can improve her health and the results helped her in
developing her trust on me. I also tried to take care of her interests (music and reading books) by
which she was able to relax amidst the stressful period of respiratory pain (Diez-Manglano, et al.,
2014).
Exploitation phase: With the utilization of this phase, Jane was able to understand and apply all
the interventions that were advised to her. With the help of this phase, Jane was able to obtain
maximum clinical benefits and her health showed significant improvement post all the
respiratory tests.
Resolution phase: This was the final phase during which an analysis was made where it was
observed that most of the clinical needs for Jane were met, however this disease is a chronic one
and requires continuous patient monitoring (Corhay, et al., 2014).
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Elain Bramhall identified the usual barriers to effective communication and some of them have
also been identified in the current case study such as noise, fear, anxiety, emotional status,
difficulty in explaining the feelings and trying to stay strong for someone else (Dal Negro, et al.,
2015). Here, Jane was emotionally weak because she had a daughter, Mary (27 years) who was
her only support. Jane was worried about Mary due to her persistently poor health conditions. I
have utilized non-verbal communication skills (facial expressions, friendly and good touch)
along with effective listening and reasoning ability to understand the difficulties for Jane and
made a distinct nursing care plan for resolving each of the problems.
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PART II
The following part of the assignment focuses on two identified major nursing problems that have
impeded the health of Jane in the current case study, utilizing the Roger, Lopan and Tierney’s
Living Model. The purpose of this model is to conduct an assessment that will be utilized during
the entire care plan on the patient. The aim would be to categorize its discovery into the
respective activities of living that can ensure independence for areas that are normally difficult
for the patient to address.
The different activities listed in the Roper-Logan-Tierney Model of Nursing are:
• Maintaining a safe environment – Jane was living in an unsafe environment and posed a high
risk of falls, poor oral hygiene due to dehydration, and skin isues.
• Communication: It was difficult for Jane to express her needs and concerns freely with the
doctor and me due to her depressed state of mind.
• Breathing - Jane's respiratory rate was 29 breaths for each moment; and there were signs of
wheezing with shallow and rapid breaths where she was utilizing extra-respiratory muscles to
relax.
• Eating and drinking: Jane lost her weight due to poor dietary habits and often due to skipping
meals. Her body hydration levels were poor due to lack of adequate liquid consumption.
• Elimination: Her urinary output was low
• Washing and dressing: She had problems in dressing and washing herself due to poor
mobility levels, age and compromised body mobility.
• Controlling temperature - Upon examination, the blood pressure was 160/90 mmHg in a
sitting position, heart rate was 83 beats per minute, and body temperature was 37.2°C.
• Mobilization: This was impacted and poor
• Working and playing: She lacked interest in any other work due to the fear of falling down
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• Sleeping: Although she attempted to sleep but this was compromised due to shallow
breathing while in supine position.
Jane was recommended long term oxygen treatment, Ventolin (salbutamol sulfate), Seretide
(steroid), Spiriva (tiotropium), Pyridostigmine bromide (Mestinon for disposal), Atrovent,
furosemide, prednisolone (steroid), and to treat the chest contamination anti-infection agents
including: clarithromycin, amoxicillin and co-amoxiclav intravenously (IV). All medications
might be utilized for the administration of intensifications of COPD and chest contamination
(Yohannes and Alexopoulos, 2014).
Jane's principle issues are identified with:
 Breathing, and
 Maintaining a safe environment
I. BREATHING
Assessment:
The oximetry (SpO2) estimations were made to identify the seriousness and the levels of
hypoxaemia, hypercarbia, and screen the level of hemoglobin in her blood. The findings were:
• pH: 7.1(↓)
• PaCO 2: 53 mmHg(↑)
• PaO 2: 70 mmHg(↓)
• SpO 2: 88%(↓)
The other investigations included measure of the lung capacity, MEWS (Modified Early
Warning System), and the cough examination (to identify and check the colour, quantity,
consistency, smell of the sputum) that can help to identify the extent of infection and the
appropriate interventions required (Du, et al., 2014).
Goal:
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Based on Jane's recognized issues, the objective was to take care of her respiratory issues. The
point was to empower Jane to breathe with ease, keep up SpO2 above 90%, reestablish typical
breathing, reduce the levels of anxiety, ensure appropriate coughing and a respiratory tract free
of disease (Franssen and Rochester, 2014).
Care plan:
Jane was advised to keep up an upstanding position, which helped the lungs to extend with the
goal that more oxygen could be ingested. Amid the day time, Jane was urged to sit out in her seat
and when dozing to keep up an upstanding position to augment lung limit. Full and incessant
perceptions of her indispensable signs were recorded each 15 minutes. After giving oxygen for
30– a hour, the blood vessel blood gases were rechecked to permit recognition of any expansion
of carbon dioxide fixation or falling pH (Jensen, et al., 2015). On the off chance that Jane's
breathing or SpO2 crumbled further, the restorative group ought to be reached and she ought to
be surveyed inside 30 minutes (NICE, 2010). The NICE rules (2010) suggest that Jane ought to
be given oxygen by means of a venturi cover (high-stream gadget), which conveys precise
centralizations of oxygen as it isn't influenced by the patient's breathing. The oxygen likewise
ought to be conveyed at either 28% with a stream rate of 4 liters/minute or 24% with a stream
rate of 2 liters/minute (Jonkman, et al., 2016). A short-acting beta 2-agonist bronchodilator was
recommended as it stimulates β2 adrenoceptors to loosen up the smooth muscle and help
improve breathing (NICE, 2010). It is additionally also important that Jane can utilize
supplementary oxygen and inhalers accurately.
Additionally, COPD exacerbations frequently require nebulizers attributable to shortness of
breath, large amounts of nervousness, absence of focus, and shakey hands; all hindrances to hold
the hand-held gadgets. Jane liked to utilize the hand-held inhaler as it is less massive and simpler
to convey. Jane was alluded to the respiratory medical attendant for appraisal of her inhaler
systems, the requirement for a nebulizer, and further training of her condition, including the
signs and manifestations of contamination, and how to manage crises while encountering
exacerbations (Lee, et al., 2014). The physiotherapist surveyed Jane's difficulties, and
encouraged her for different activities and control methods for when there is lack of adequate
Oxygen supply. The point of this referral was to lessen the length of Jane's medical clinic remain,
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decrease the probability of contracting different contaminations, and empower her to stay
responsible for her condition.
Most exacerbations of COPD are brought about by viral and bacterial contaminations; along
these lines, inoculations could decrease the quantity of exacerbations experienced. As indicated
by NICE rules (2010), patients with COPD ought to be offered pneumococcal and influenza
immunizations (López-Campos, et al., 2014).
Jane's breathing example has improved and no indications of trouble or torment amid breathing
have been watched. She had the capacity to expectorate emissions all the more viably.
Fundamental signs were back to ordinary and SpO2 is above 92%. Since Jane was determined to
have COPD she has shed pounds and her hunger has been poor. This has been an aftereffect of
her shortness of breath, nervousness, beneficial hack and her prescriptions, for example,
Salbutamol. Jane's weight was checked and her weight record (BMI) was determined to be 19.6
kg/m2.
II. MAINTAINING A SAFE ENVIRONMENT
Assessment:
Despite the fact that the diuretic furosemide assists with breathing, it can likewise cause lack of
hydration, a dry mouth and stomach upset. Jane's skin was unblemished, dry and flaky. In this
manner, a Waterlow hazard evaluation was performed to recognize the zones in danger and
decrease the related complexities (Miravitlles, et al., 2014). Evaluations demonstrated that Jane
was malnourished, underweight and dehydrated. Jane's weight was checked once consistently,
guaranteeing a similar scale was utilized unfailingly, in the meantime of the day, and that Jane
wore comparative garments.
Goal:
The objective was to improve Jane's weight, empower a decent eating routine and liquid intake,
and ensure a healthy skin. Nursing intercessions concentrated on improving her physical
conditions and looking after strength, which would upgrade her execution with the exercises of
day by day living, and her feelings and emotions as a result.
Care plan:
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To keep up a protected situation, distinctive specialists from the multidisciplinary group were
included. Jane was urged to drink liquids and keep up an appropriate dietary regimen by thinking
about her preferences, and by helping her to pick a suitable meal from the available options. She
was encouraged to abstain from drinking before dinners to avoid any kind of swelling. Along
with this, mouth care was provided to her so as to assure healthy oral environment post difficult
respiratory situations (Miravitlles, et al., 2015).
Owing to the successive utilization of oxygen and inhalers, Jane had a dry and sore mouth, and
dental issues. Nursing intervention included assessment of her oral cavity to examine the
presence of any oral ulcers or anomalies. Jane felt constipated due to less liquid intake and her
inappropriate diet. Her sore mouth and difficulty in biting food items, persistent requirement for
oxygen, change in the environment, and dependence in accessing the washroom/toilets
additionally caused the difficulty (Price, et al., 2014). In this way, the nursing activities that are
expected includes helping her with all the included facilities and assisting her with toiletting,
monitoring the bowel movements, promoting intake of adequate liquid throughout the day, and
ensuring that she consumes proper medications as prescribed by the doctor (Pothirat, et al.,
2015).
Along with this, the moisturizing cream was utilized to reduce the risk of skin breaks. Jane was
trained successful breathing methods as breathing via the nose will decrease dryness of her
mouth. Jane's BMI levels were low. As per the NICE guidelines (2010), such patients should be
referred to the dietician for dietetic counsel and training. The dietician instructed Jane about the
significance of satisfactory sustenance and how to keep up a sound eating routine.
The occupational therapist was called to evaluate the difficulty associated with Jane's capacity to
perform the daily activities exercises and its impact like the extent of shortness of breath that
occurs while doing them. The therapist also explained her about the special types of useful
devices that can be utilized in order to help with every day exercises, for example, a flexible bed,
walking chair, and shower seat lift. Along with this, the therapist also assisted with her physical
rehabilitation, for example, how to prepare daily meals, clean up and look after her other
interests. Jane's physical condition turned out to be increasingly steady. Mentally, she gave off an
impression of being quiet, increasingly open and started developing conversations with others.
She and her daughter, in turn became increasingly aware about the effects of COPD, causes and
10

effects of its exacerbation, which eventually improved their ability to take the necessary
precautionary measures for its effective control.
Towards the day of discharge, Jane improved in terms of her body weight and her face looked
more splendid. Jane said she was feeling good and made the most of her morning meal in the
first part of the day. This shows a decrease in nervousness and improvement in her craving and
wellbeing. Jane's urinary output was more and was clear in terms of its colour. Jane seemed
better as she was supportive in choosing the list of preferable food items from the menu, and she
indicated more attention to her dietary needs.
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EVALUATION:
COPD has influenced Jane both physically and mentally. She gets short of breath upon exertion,
which caused her to become nervous and feel ashamed. She seemed to be emotionally upset and
was not confident enough about the betterment in her health upon admission. Her perception
may have also negatively affected her in the past due to which her health condition even
worsened and lead to severe dyspnea (Pumar, et al., 2014). From her mobility evaluation, it was
identified that Jane was under the risk of falls and her ability to move was poor. She was also
afraid about the shortness of breath and this made Jane avoid any sort of activity that may lead to
shortness of breath (Rossi, et al., 2014). This condition resulted in isolation and depression. At
this point when Jane was inquired how this has influenced her, she mentioned that she is
concerned more about her daughter and she was nervous and depressed.
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