Background to Clinical Scenari…

Background to Clinical Scenario Robert is a 51 year old man who lives with his wife in regional Victoria. He has been admitted to your ward from the Intensive Care Unit (ICU), where he had a 3 day stay for an acute exacerbation of COPD, caused by community acquired pneumonia.

He required several days of non-invasive ventilation whilst in ICU. Robert tells you his wife (Jill) was very frightened when he was admitted to ICU, and he doesn’t want ‘to put her through that anymore’. He would like some help to understand and manage his COPD. Robert said he was diagnosed with COPD about 18 months ago by his GP, but admits he was sick for ‘a while’ before that. He is a current smoker, and has smoked for about 40 years. He has unsuccessfully attempted to quit on more than 5 occasions. Robert worked for many years on his chicken farm, but now finds he becomes breathless very easily and Robert and Jill have had to hire a farm helper.

Robert’s medications include: Salbutamol 2 – 4 puffs PRN Budesonide/Efomoterol fumarate dehydrate 2 puffs daily Metoprolol 25mg daily Aspirin SR 100 mg daily Pathophysiology 1.1 Describe the pathophysiology of COPD. Include in your answer the two disease processes contained in the umbrella term ‘COPD’ and how they develop. COPD pathophysiology needs a deep understanding of how the air we inhale ends up into our lungs and exhaling it. To understand this, we need to look in the process of a person without COPD first to understand the changes of a healthy lung and a lung of COPD patient. In a health individual, when we breath, the air will travel down the trachea through to the tubes which are called bronchi. The air reaches the bronchi and moves into bronchioles which have air sacs, and this is the alveoli.

The alveoli have capillaries attached to them which are tiny blood vessels. Theses blood vessels carry the oxygen into the bloodstream and then into the lungs and exhaled. When oxygen is exhaled, the elimination of carbon dioxide occurs and this causes a process called gas exchange. Gas exchange happens when red blood cells carry oxygen to the heart. During this process, the carbon dioxide molecules in the alveoli are eliminated out of the body with the next exhalation.Now we have to understand the process of how oxygen works in the lungs of people with COPD as the same process does not occur. In COPD people less air flows in and out of their airways due different reasons such as air sacs losing their stretchiness, damaged or destroyed air sacs, clogged airway due to mucus produced, or walls of air ways are inflamed and thickened.

Individual with such problems/reasons find it difficult to inhale enough oxygen and exhale it out as carbon dioxide and air tends to end up getting trapped in the lungs. This will cause symptoms present in COPD people.COPD stands for chronic obstruction pulmonary disease. COPD is a term used to describe many different diseases that are progressive lung diseases such as non-reversible asthma, emphysema, chronic bronchitis. The symptoms of COPD include chronic cough, wheezing, shortness of breath and chest tightness. The main two diseases contained in the umbrella term COPD are emphysema and chronic bronchitis. Emphysema is a disease of the alveoli walls that are stretched and have lost elastic.

This make it hard to exhale and oxygen is trapped in the lungs. Chronic bronchitis is a lung response to irritation such as smoking, air pollution or allergy. In lung response the body’s defense mechanism, mucus is produced. In chronic bronchitis a lot of mucus is produced causing inflammation, making it difficult for the air to move in and out the airways.Risk factors of COPD are smoking, air pollution, genetic, occupational dusts and chemicals. Reference: GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE. (2017).

URL: http://goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf1.2 Explain the term ‘acute exacerbation of COPD’. What factors put patients like Robert at high risk for exacerbations of COPD? What else may contribute to an exacerbation of COPD? The term acute exacerbation of COPD ‘means the worsening’ of respiratory symptoms which will end up resulting in additional therapy. The worsening can be triggered by infection with bacteria, virus or environmental pollutants. COPD is classified in three stages.

First, is mild COPD which is treated with short acting bronchodilators. Second is moderate COPD which is treated with SABD’s and antibiotics or oral corticosteroid. Third is severe COPD is usually treated on emergency visits in the hospital. In this case Robert’s COPD is classified as severe due to the 3 days stay for an acute exacerbation of COPD caused by community acquired pneumonia. He also had non-invasive ventilation whilst on ICU.Factor that put patients like Robert at risk for exacerbations of COPD are the bad habits of 40 years of smoking and the exposure of air pollution due to working in a farm. Cigarettes smoke irritates lung tissue and cause inflammation.

Good education to COPD patients such as Robert will contribute to better management of his COPD, to avoid visit to the emergency. Other things that may contribute to an exacerbation of COPD include diabetes, infections, vehicle exhaust, pollution from factories, fumes at the gas pump.Reference: GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE. (2017). URL: http://goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdfKhan Academy.

URL https://www.khanacademy.org/1.3 Describe the pathophysiology of pneumonia. Include in your answer the differences between Community Acquired, Hospital Acquired and Health Care Associated Pneumonia. Pneumonia is inflammation of the lungs, which can be caused by inhaled irritants or infection. It affects one or both lungs and is cause by germs such as viruses, fungi, bacteria.

For Pneumonia to occur, a pathogen would have reached the alveoli, causing the lungs to be inflamed and filled with fluid. The community-acquired pneumonia caused by bacterial and viruses. It happens in people with limited or no contact with medical. The bacterial includes staphylococci infection, streptococci h, influenza. The viruses include chlamydia, Mycoplasma.The hospital acquired (nosocomial) pneumonia: refers to pneumonia contracted by patient in a hospital setting within 48 hours after being admitted. This is dangerous as most bacteria found in hospital are antibiotic resistant.

This includes gram-negative rods, penicillin resistant staphylococci.The health care associated pneumonia: occurs in non-hospitalized patients who reside in a nursing home or other long-term care facility. This includes bacteria other than streptococcus.Reference: McConnell, T.H. (c2014). The Nature of Disease Pathology For The Health Professions.

(2nd ed.). Dallas, Texas. pp294-95.2.1 For each of the three inhalers (Salbutamol, Budesonide/Efomoterol fumarate dehydrate and Tiotropium), describe the Mechanism of action in COPD. Contraindications and Adverse Reactions.

Nursing Considerations and Patient Education Points. Include in your answer why the respiratory physician might have changed Robert’s medication regime. 1. Mechanism of action in COPD Salbutamol is a bronchodilator which relaxes bronchial smooth muscle in COPD or asthma patients and it decreases airway resistance.Contraindications and Adverse Reactions Salbutamol is contraindicated in persons with a history of hypersensitivity reaction to salbutamol. Salbutamol is also contraindicated in patients with pre-existing cardiac tachyarrhythmias.Nursing Considerations and Patient Education Points Educate the patient the side effects are which are unusual in salbutamol, however depending on the route and dose of administration there may be a severity side effects.

There are still side effects present in some patients such as tremor of skeletal muscle in the hands and nervousness. It may also cause headache , palpitation, chest discomfort, muscle cramps, , tachycardia, difficulty in micturition and paradoxical bronchospasm. When these side effect occur, it is advised for patients to immediately inform their doctor.Include in your answer why the respiratory physician might have changed Robert’s medication regime. Robert’s salbutamol was not ceased as it’s a Short acting inhaled ?2 agonist. It starts to work within a few minutes. Rob will need it as it is a fast acting to relief his symptoms.

Reference:WebMD. URL https://www.webmd.com/drugs/2/index2. Mechanism of action in COPD Budesonide/Formoterol fumarate dehydrate are long acting inhaled ?2 agonist used in exacerbations of COPD.Contraindications and Adverse ReactionsThis medication is not a substitute for inhaled or oral corticosteroids. It should be used along with another controller-type COPD medication.

However, it should not be used with other long-acting beta-agonist inhalers because doing so may increase risk for side effects.Nursing Considerations and Patient Education Points Educate the patient the importance of infection control, patient must hand washing and drying hands before they touch the capsules. The patient must inhale rapidly and deeply through the mouthpiece. After use they should open the inhaler and check if the capsule is empty. If it is not empty, they should close the inhaler and repeat. Include in your answer why the respiratory physician might have changed Robert’s medication regime. Budesonide/Formoterol fumarate is only used when symptoms are not controlled and in this case, Rob’s symptoms were not controlled when he was first admitted to the hospital.

On discharge his symptoms are manageable. Using too much formoterol or using it too often may result in a decrease in drug effectiveness and an increase in serious side effectsReference: WebMD. URL https://www.webmd.com/drugs/2/index3. Mechanism of action in COPD Tiotropium is used to control and prevent symptoms in COPD patientsContraindications and Adverse ReactionsContraindication include patients past history of heart problems , diabetes ,high blood pressure, kidney disease, genetic history of glaucoma, seizures, overactive thyroid, difficulty urinating Nursing Considerations and Patient Education Points Educate patient on side effects such as nervousness, shaking or trouble sleeping may occur. Advice patient to inform their doctor if side effects persist.

Inform patient that this medication may raise their blood pressure.Include in your answer why the respiratory physician might have changed Robert’s medication regime. The reason to why Robert is not prescribed this medication is that one of the side effect is high blood pressure. Robert is already on s beta-blocker called Metoprolol which is used to treat angina and hypertension.Reference:WebMD. URL https://www.webmd.

com/drugs/2/index2.2 Identify three antibiotics that could be used to treat Streptococcus pneumoniae in Robert’s case. For each antibiotic, describe the three antibiotics that could be used to treat streptococcus pneumonia in Robert’s case are: augmented penicillins, fluoroquinolones, third-generation cephalosporins or aminoglycoside. These are used in patients with more severe exacerbations. 1. Mechanism of action Penicillin kills bacteria by connecting the beta-lactam ring to DD-transpeptidase, inhibiting its cross-linking activity and thereby stopping new cell wall formation. No cell wall, means the bacterial cell is weak to outside water and molecular pressures, and quickly dies.

Most efficient on gram positive bacteria’s. Contraindications and Adverse Reactions Food interferes with absorption of penicillin G should be given moments before or after a meal. All penicillins are excreted in urine and reach high levels in urine. Most adverse effects are hypersensitivity reactions. Rashes occur more. Seizures are likely to occur, if doses are high, especially in patients with renal insufficiency. Nursing Considerations and Patient Education Points Penicillins’ cause reach high levels in urine, doses given to Rob must be reduced because it will have severe boundaries.

This causes increase in blood levels. It is sometimes given concurrently to maintain high blood levels•multiple use of penicillin increases the risk of allergic reactions always check for hypersensitivity•take before or after meals•not to stop the anti-biotic without finishing them•follow the directionsReference:WebMD. URL https://www.webmd.com/drugs/2/index2. Mechanism of action Cephalosporins stops synthesis of the peptidoglycan layer of the bacterial cell walls. Peptidoglycan is an important structural molecule to the cells walls of bacteria.

With the cell wall structure ruined, the results are death of the cell. Body cells do not have cells walls or peptidoglycans. Cephalosporins can kill bacteria without causing harm to human cells.Contraindications and Adverse Reactions Contraindicates with patients who have had allergic reactions to drugs such as penicillins. Other reactions are: diarrhea, nausea, rash, electrolyte disturbances, and pain and inflammation at injection siteNursing Considerations and Patient Education Points People who have allergies to cephalosporins or ingredients found in it should not ingest it. Educate the Importance for Rob to finish the entire course you as prescribed, even if he feels better. This is to make sure the infection is gone there’s a risk the infection could return and difficult when it reoccurs.

Reference:WebMD. URL https://www.webmd.com/drugs/2/index3 Mechanism of action vancomycin prevents cell-wall biosynthesis of bacteria. It is more effective against gram-positive bacteria and resistant strains of MRSA Contraindications and Adverse Reactions Increased diarrhoea that is watery or bloody, kidney problems, little or no urinating, uneven heart rate, extreme thirst, increased urination, leg discomfort, muscle weakness or limp feeling. nausea; or stomach pain Nursing Considerations and Patient Education Points Educate rob that if dose is skipped take as soon as you remember. Skip the missed next scheduled dose.

Do not take extra medicine. Shake the liquid well before taking it. Measure liquid medicine before taking them.If Rob does not have measuring device, offer one. Keep vancomycin capsules at room temperature. Follow doctor’s orders.Reference:WebMD.

URL https://www.webmd.com/drugs/2/indexPsychosocial issues 3.1Discuss three evidence-based interventions to help Robert manage his COPD. In the research based article: Care bundles in the management of a COPD exacerbation, the authors highlight that for effective COPD management, patient education including medication, inhaler technique, referral to see an outpatient pulmonologist is needed. Research studies show that over the past years, there have been poor education and no referral’s when patient’s get discharged home. This led to exacerbations of COPD.

reference:Lloyd, C., et al. (2018). Care bundles in the management of a COPD exacerbation. British Journal of Nursing (Mark Allen Publishing) 27(1), 47-50. URL: http://web.a.

ebscohost.com.ezproxy.federation.edu.au/ehost/pdfviewer/pdfviewer?vid=1&sid=42fcc62d-84d2-4cda-8286-6764e308981e%40sessionmgr4006In a research evidence based article: ‘Action plans for COPD: strategies to manage exacerbations and improve outcomes’ it illustrates strategies that will reduce and prevent COPD exacerbations. It is found that educating the patients of better understating of what COPD is and the process of the disease, medications for COPD, self-management strategies and collaborating with health care professionals is effective.

However, in most cases of exacerbation COPD, patients have been reported to have a poor understanding of the term ‘exacerbation’. This results to psychosocial well-being of the patient leading to negative emotions. Better education for exacerbations education will improve patient’s management of COPD and their mental state.Reference:Action plans for COPD: strategies to manage exacerbations and improve outcomes. (2 June 2016). URL: https://www.ncbi.

nlm.nih.gov/pmc/articles/PMC4898028/In the Lung foundation Australia website is strongly advices that health professionals should refer people diagnosed with COPD to pulmonary rehabilitation. Evidence based evidence shows that pulmonary rehabilitation will reduce symptoms, improves exercise capacity and strength, reduces anxiety and depression and reduces hospital admission. This advice is supported by Royal Prince Alfred Hospital respiratory Physiotherapist Dr Lissa Spence. The pulmonary rehabilitation is an 8 weeks programme that involves exercise, education sessions, nutrition counselling psychosocial support. A patient will have to be assessed before commencing the programme and after, to identify the effectiveness of the programme.

Due to their results, if the programme was not effective, the patient will have to be referred to a certain specialist or develop a new plan/strategy to help patients manage their COPD better.Reference:The Lung Foundation Australia. (November 25, 2016). URL: https://lungfoundation.com.au/pulmonary-rehabilitation-the-best-intervention-for-copd/ Reference: Action plans for COPD: strategies to manage exacerbations and improve outcomes. (2 June 2016).

URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4898028/GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE. (2017). URL: http://goldcopd.

org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdfKhan Academy. URL https://www.khanacademy.org/Lloyd, C., et al. (2018).

Care bundles in the management of a COPD exacerbation. British Journal of Nursing (Mark Allen Publishing) 27(1), 47-50. URL: http://web.a.ebscohost.com.ezproxy.

federation.edu.au/ehost/pdfviewer/pdfviewer?vid=1;sid=42fcc62d-84d2-4cda-8286-6764e308981e%40sessionmgr4006McConnell, T.H. (c2014). The Nature of Disease Pathology for the Health Professions. (2nd ed.

). Dallas, Texas. pp294-95.The Lung Foundation Australia. (November 25, 2016). URL: https://lungfoundation.com.

au/pulmonary-rehabilitation-the-best-intervention-for-copd/WebMD. URL https://www.webmd.com/drugs/2/index

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