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A Case Study of COPD End StageResearch Paper

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¶ … Setting, or Special Group

A progressive medical condition, chronic obstructive pulmonary disease (COPD) is typically divided into four stages: mild, moderate, severe, and very severe or end-stage. Almost all cases of COPD are caused by smoking cigarettes (Nall, 2015). COPD is not a disease, but rather, a collection of more specifically diagnosed medical conditions such as bronchitis and emphysema. Patients diagnosed with COPD tend to be older because it takes time for symptoms to evolve; average age of first diagnosis is 40 (Cherney, 2014). The patient in question is 64 years old, a white male living at home in the end stages of COPD. His personal hygiene and ability to cope with daily life have both decreased significantly, and he is in need of almost continual care.

Patient needs including total smoking cessation, medical interventions, doctor-supervised exercise, and psychological treatments. The patient needs to take care to avoid loneliness and isolation, and social networks will be important. The nurse practitioner in charge of the patient's case can ensure the patient is aware of all the resources available in the community. Cultural issues in this case include the fragmentation of the family, poor communication between family members, and lack of support. Barriers to care include patient resistance to lifestyle change, patient resistance to smoking cessation, and lack of social support.

Clinical Evaluation

General considerations include providing effective palliative care for the patient. Being at home ensures that the patient is comfortable and has access to some social support including neighbors who can alleviate some of the isolation and loneliness that might occur if the patient were in a facility. The goals of care should be to maximize patient comfort and well-being, particularly paying attention to physical and psychological needs as well as any spiritual needs. The patient can be regularly encouraged to take fresh air and mild to moderate exercise like walking, and to take advantage of smoking cessation methods that might prolong life or enhance its quality. Quality of life is an ongoing concern among patients in the end stages of COPD (Spathis & Booth, 2008). The inability to breathe properly is the primary cause of concern, which is why all efforts must be made to provide the patient with medical tools and medications such as bronchial dilators. Assessment tools that can be used include pulse oximetry, diffusing capacity for carbon monoxide (DLCO), spirometry and other pulmonary function tests, and measuring arterial blood gas (Han, et al., 2016). Physical findings will depend on the outcome of these Assessment tests, and psychological findings will depend on the medical team that should include psychologists. The medical team may also need to determine whether there are other conditions or diseases present, which may impact the treatment plan.

Management

The plan of care for the patient will include ongoing assessments of patient lung functions, but also assessments of air quality inside the patient's house. Pharmacological interventions may eventually include the use of opioids to reduce dyspnea, and which in turn will impact patient sense of well-being. However, side effects may be a concern. Anxiolytics may also help with symptoms like dyspnea, although like opioids, anxiolytics do present side effects that need to be consistently monitored (Spathis & Booth, 2008). Oxygen therapies, including both short burst oxygen therapy and long-term oxygen therapy, may or may not benefit the patient. If these techniques are used, the patient should be monitored because of the severity of withdrawal symptoms (Spathis & Booth, 2008). If depression is an issue with the patient, then antidepressants might also be part of the pharmacological treatment plan (Ambrosino, Gherardi & Carpene, 2009).

Non-pharmacological interventions may be especially important for improving quality of life for the patient. In particular, carefully designed exercises will help the patient to regulate and monitor breathing and reduce the sensation of breathlessness (Spathis & Booth, 2008). Exercise programs should be designed by specialists, requiring the use of a referral to a physical therapist specializing in respiratory problems. The nurse practitioner may monitor patient responses. Furthermore, the exercises should not be strenuous and should be paced regularly throughout the day (Spathis & Booth, 2008). Breathing exercises are known to be helpful for some patients, as are humidifiers or air purifiers in the home (Nall, 2015). Depending on the climate where the patient lives, outdoor time may or may not need to be regulated. If the patient becomes open to quitting smoking, then a variety of psychological tools may be useful and the patient's quality of life may improve. Other referrals may include the use of psychologists for patients who are experiencing depression and family therapy to include end-of-life issues. The interdisciplinary team will include the primary care physician and related pulmonary specialists, nurse practitioners, psychologists, and physical therapists, as well as persons trained in the use of oxygen therapies.

APRN Role Functions

The Advanced Practitioner serves in several related roles to promote patient well being in end stage COPD. As leader, the APRN takes charge of the interdisciplinary team, coordinating meetings and ensuring timely interventions and responses to patient and family concerns. The APRN also acts as informer and educator for patient and family. Emerging literature may reveal new treatments, and the APRN can inform the patient of those new treatments. Likewise, the nurse practitioner is responsible for teaching the patient about his limitations as well as his potential to improve his quality of life through smoking cessation and/or recommended exercises. The APRN is also a clinician who performs direct activities like assessments, diagnoses, monitoring, and provision of treatments. As case manager, the APRN monitors patient progress and organizes future assessments and referrals.

Case Study/Specific Patient Example

Two case studies help to highlight the issues at stake with the chosen population: individuals with end-stage COPD. The first is a classic case study of a 51-year-old African-American female. The case study is significant not only because of her young age but because of her having received a lung transplant, something that has not yet been recommended for our patient but might if the medical team determined that his prognosis would improve and if he would quit smoking. The second case study is that of Andrew, who is more akin to the demographics of our patient. Andrew is a 75-year-old white male who was diagnosed with COPD at age 52. Like our patient, Andrew continues to smoke in spite of the diagnosis and a history of hospitalizations over the past twenty years.

Andrew's case study shows that situational variables and stress in particular can exacerbate COPD symptoms and also increase resistance to lifestyle changes. Andrew's wife died. Without any children, Andrew was left completely bereaved and lonely. His inability to make lifestyle changes reflects the same in our patient, who also suffers from social isolation and loneliness. Andrew has not yet lost the ability to perform some of his essential daily chores, and his personal hygiene has not fallen behind as it has with our patient whose condition makes it so that he needs continual care and support for daily life activities including grocery shopping and cleaning. Andrew's case manager introduced the patient to exercise therapies, and included a respiratory nurse specialist on the care team. This was an essential step in promoting Andrew's quality of life. Moreover, the nurse practitioner educated Andrew on the importance of specific types of exercises so that he could perform them on his own even after the therapy sessions were over. As a result, Andrew's activity level increased and although his symptoms persist, he has lost weight and reports feeling better.

Nutrition was an issue for Andrew. The nurse practitioners may have underestimated the importance of proper nutrition for well-being and also for weight management. After about a year of poor nutrition, Andrew's health deteriorated. As his health deteriorated, so too did his motivation and interest in exercise. The downward spiral required more acute interventions so that Andrew could once again take pleasure in movement and in eating well. Unfortunately, the improvements that Andrew eventually did make did not prevent the progression of COPD. Chest infections were a major and ongoing concern, and long-term oxygen therapy was recommended. He has trouble walking and physicians noted that he might not have long to live.

Summary

End stage COPD frequently requires palliative care. Palliative care given in the home was crucial in Andrew's case, as it is with our patient because in the home, the patient still does need almost continual support but receives it in the least intrusive way possible. "Meals on wheels" programs provided some alleviation of the burden placed on home health care assistants. Just as the nurse practitioners in Andrew's case did a good job of maximizing use of community resources and providing for effective palliative care of the patient, our patient will experience the best possible quality of life if the case is managed professionally and with a team of dedicated specialists. Providing for the psychological, social, and physical needs of the patients ensures holistic treatment.

References

Ambrosino, N. Gherardi, M.… [END OF PREVIEW]

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