Research Paper: Chronic Lung Disease Care Planning

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Chronic Lung Disease Care Planning

Respiratory Care

A Case Study in Chronic Lung Disease Care Planning

A Case Study in Chronic Lung Disease Care Planning

A 65-year-old Caucasian woman is the subject of this case study. Symptoms include a dry nocturnal cough lasting two weeks, mild morning sore throat, and anorexia. The cough is worse when lying down and all symptoms have worsened over the past two days. Chest X-ray (CXR) revealed hyperinflation of lungs, increased AP diameter, and evidence of emphysema. Physical examination revealed prehypertension, body mass index (BMI) of 30.2 (obese), normal sinus rhythm, tachypnea, SpO2 at 98%, and leukocytosis with a left shift. Patient self-efficacy is low and she remains resistant to further diagnostic testing, possibly due to depression and/or cost concerns, despite reporting feeling better after a course of antibiotic therapy and inhaler use. The relevant patient history includes childhood asthma and life-long heavy smoking. One older sister developed osteoporosis and the other breast cancer as seniors. The signs and symptoms of primary concern are dyspnea, leukocytosis, fever, tachypnea, prehypertension, obesity, emphysema, asthma, depression/anxiety, and low patient self-efficacy.

Having been a widow for 20 years and living on a $40,000 annual pension the patient does not have the financial resources to cover expensive diagnostic testing. Prescription medications are often not covered by her insurance plan, which forces her to rely heavily on free samples. Two middle-aged healthy daughters visit once a month, but a desire to grow closer has not been acted upon. Her desire to spend more time with daughters may be related to a perception of declining self-efficacy, social isolation, and chronic depression. Regular church attendance has fostered connections with a few community residents, but the patient spends most of her time alone. Although she attends an occasional church function, she has remained ignorant of the many other services offered in her community. The primary socioeconomic concerns are social isolation, medical costs, and moderate estrangement from family members.

Despite personal awareness of the benefits of a healthy lifestyle, the patient fails to get any exercise due to shortness of breath. The patient has been smoking a pack of cigarettes a day for the past 40 years and reports eating a healthy diet. She is knowledgeable about the benefits of a healthy lifestyle; however, the main personal efficacy concerns are her resistance to diagnostic testing, continued smoking, sedentary lifestyle, obesity, and possible nutritional concerns.

Given the above assessment of the patient's medical issues, history, and socioeconomic concerns, an individualized patient care plan will be created. Special attention will be paid to pathophysiology, diagnostic testing, treatment recommendations, and the role and scope of integrated disease management.

Epidemiology of Common Pulmonary Diseases in Older Adults

Lung diseases, such as pneumonia, COPD, asthma, lung cancer, and fibrosis, are common ailments among aging adults (Akgun, Crothers, & Pisani, 2012). In smokers, the primary pulmonary concerns are emphysema, chronic bronchitis, and COPD. Most of these are relevant to the patient under consideration here. If the patient under consideration here has pneumonia it is probably community acquired, since the patient has not been hospitalized recently. In older U.S. adults an estimated 350,000 to 620,000 individuals are hospitalized each year due to community acquired pneumonia, with an incidence of 14 in 1,000. By comparison, over 10% of adults over the age of 65 have been diagnosed with COPD. The COPD incident rate for men over 55-years of age is equal to pneumonia, but it is half that for women. Asthma is also common, estimated to afflict between 4% and 8% of adults over the age of 65. Unfortunately, opportunities for effective treatment are missed because asthma is frequently misdiagnosed as COPD in older adults. The incidence of lung cancer peaks between the ages of 75 and 79, with most diagnoses occurring after the age of 60. Recent estimates suggest the incidence for men and women who are 65-years and older, between the years 2005 and 2009, was 4.2-5.5 and 2.9-3.2 per 1,000 residents, respectively (Henley et al., 2014). Other smoking related diseases, such as emphysema and chronic bronchitis, affect an estimated 5-6% and 6-7% of the U.S. population over the age of 65, respectively (Schiller, Lucas, & Peregoy, 2012, p. 152).

Pathophysiology, Symptoms & Signs, and Diagnostic Criteria of Chronic Lung Diseases

Most patients with chronic pulmonary disease will present with cough and dyspnea, but the presenting symptoms for older adults can sometimes be atypical, especially patients with chronic comorbid conditions (Akgun, Crothers, & Pisani, 2012). In older adults, community acquired pneumonia (CAP) typically causes tachypnea, delirium, and failure to thrive, rather than the cardinal signs and symptoms of fever, cough, and purulent sputum. For this reason, a diagnosis of pneumonia in older adults is frequently delayed. Streptococcus pneumoniae is the most frequent pathogen found to be causing CAP (Garau & Calbo, 2008). Some of the other pathogens that can cause CAP in patients with lung disease include Haemophilis influenzae and Moraxella catarrhalis. Antibiotic therapy to rid the patient of the offending pathogen(s) is typically done empirically, most often with a ? lactam and macrolide combination (Drancourt, Gaydos, Summersgill, & Raoult, 2013). The reason for empiric antibiotic therapy is because the reliability and turnaround times of laboratory tests has been historically low and slow, respectively. Recent advancements in point-of-care testing have generated several rapid diagnostic tests that can provide some information is as little as 1 to 3 hours, but these tests are not universally available, nor comprehensive.

The main diagnostic indicators of a pulmonary infection are fever and leukocytosis (Mouton et al., 2001). In older adults (? 65-years) thermoregulatory responses can be poor; therefore, an increase in body temperature of 2° F. Or more should be cause for concern. If the temperature reaches 101° F. Or higher, a severe, life-threatening infection may be present and immediate hospitalization required. The patient considered here has a fever of 101° F, leukocytosis (> 11x10-9/L), and tachypnea, but does not have chest pains, hypoxemia, tachycardia, productive cough, or radiologic findings consistent with pneumonia (Albert, 2010); however, older adults often present with only a cough and a definitive diagnosis is obtained in only a minority of patients (Mouton et al., 2001). Given the serious condition of this patient, blood cultures should be performed, in addition to culturing sputum and conducting any rapid diagnostic tests that may be available. These tests must be performed to check for the presence of antibiotic-resistant strains. The patient under consideration here has most of the symptoms associated with CAP, including tachypnea, dyspnea, failure to thrive, malaise, fever, cough, and leukocytosis, which is enough to justify beginning empiric antibiotic therapy despite an unproductive cough and negative CXR. The risk of pneumonia-associated mortality is so great in adults over the age of 65, especially those with preexisting lung disease, that antibiotic therapy should be administered immediately for this patient.

Many of the same symptoms are found in patients with COPD, with chronic cough being the best predictor for smokers (Akgun, Crothers, & Pisani, 2012). The main presenting symptoms are cough, chronic sputum production, wheeze, and dyspnea. The experience of dyspnea can be so frightening in older adults with severe COPD that depression and anxiety are common. A definitive diagnosis of COPD is based on the presence of an airway obstruction, which can occur in a number of chronic airway diseases and conditions, including asthma, chronic bronchitis, and emphysema (Nakawah, Hawkins, & Barbandi, 2013). The obstruction can be caused by inflammation, bronchospasms, mucosal edema, mucus plugs, and smooth muscle hypertrophy and hyperplasia.

Differentiating asthma patients from those with COPD can be difficult, often leading to a misdiagnosis (Akgun, Crothers, & Pisani, 2012). A defining feature of COPD and asthma is a reduction in forced expiratory volume in the first second (FEV1) below normal limits (GICOPD, 2013, p. 7); however, total lung capacity (TLC) and carbon monoxide diffusing capacity (DLCO/VA) will be normal or above normal in asthma, whereas patients with COPD will have an elevated TLC and reduced DLCO/VA (Pelligrino et al., 2005). In addition, asthmatics will typically have a greater bronchodilator response compared to COPD patients, although COPD patients may experience some improvement due to the inflammatory component of their disease. A differential diagnosis is important because asthma is more responsive to treatment (Snider, 1985), while COPD is a progressive disease that develops later in life and the obstruction only partly relieved by bronchodilator use (Nakawah, Hawkins, & Barbandi, 2013). The severity of COPD is graded based on FEV1 scores and symptomology (Albertson, Louie, & Chan, 2010). FEV1 scores of > 80%, 50-80%, 30-50%, and < 30% are Stage I, II, III, and IV, respectively. When exacerbations occur they become clinically significant when acute worsening of dyspnea, cough, and sputum volume/purulence happens over a relatively short period of time.

COPD patients are typically heavy smokers presenting with hyperinflated lungs, hypoxemia, and diffusion impairment (Akgun, Crothers, & Pisani, 2012). The patient considered here has hyperinflated lungs and is a heavy smoker (Wender et al., 2013), but is not hypoxemic based on pulse oximetry (Pretto,… [END OF PREVIEW]

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