Case Study and Care Plan

Answer

According to the World health Organization recommendations, chronic conditions or diseases require a comprehensive care plan and an ongoing management system that may stretch over a long period of time (WHO, 2011). Effectively addressing chronic diseases such as those of the lung or pulmonary necessitates coordination among different care providers and interdisciplinary intervention for both medical prescription and periodical monitoring (WHO, 2011).  This papers aims at developing a comprehensive care plan for a case study patient with a pulmonary disease. The rate of chronic pulmonary diseases especially among the elderly in the society has increased, and as the population ages, so are the rates expected to rise further (Do & Chin, 2012)This essay presents a comprehensive care plan for an elderly patient with COPD based on the pulmonology case study.

Case Study Evaluation

Pathophysiology, signs/symptoms, progression trajectory, diagnostic testing, and treatment options

Pathophysiology of COPD

COPD has several physiological anomalies and signs such as the inflammation of the airways which causes the difficulty or shortness in breathing, hyperinflation, shortness in breath (dyspnea), impairment of the respiratory muscle, emphesema, and a reduced FEV1 (Vestbo, Hurd,  Agusti, Jones, Vogelmeier, Anzueto & Stockley, 2013). Other Pathophysiology of the disease includes mucus hypesecretion, pulmonary hypertension and other cardiac anomalies (Do & Chin, 2012).  The current patient in the case study  has hyperinflated lungs with increased AP diameter, a confirmation that he has emphysema.

Signs and Symptoms

According to the American Thoracic Society, the signs and symptoms of the disease include shortness of breath (chronic and progressive dyspnea), chronic cough, sputum or mucus production (though not necessarily), wheezing, chest discomforts, and limitation in capacity to exercise (Qaseem, Wilt, Weinberger, Hanania, Criner,  Molen & MacDonald, 2011). The current patients has most of these symptoms except that her cough is unproductive

Progression Trajectory

COPD progresses slowly and insidiously in a patient’s lifetime and exacerbated by exposure to some risk factors especially smoking (Qaseem et al, 2011). At the onset of the disease, patients complain of mild chest pains which may be misdiagnosed or ignored, making the disease to progress to acute exacerbation (Qaseem et al, 2011). The disease’s trajectory involves slow but steady decline in the functionality of a patient throughout many years, such as speedy decline in a patient’s FEV1 with exacerbations followed by sporadic improvements (Qaseem et al, 2011). The current patient’s condition has also progressed over time since she stated that she has had similar episodes of current symptoms in the past. Her condition Presently her situation has worsened necessitating hospitalization. With COPD, the health status progressively declines, and with time, symptoms increase in severity (Vestbo et al, 2013). Eventually, the disease leads to increased disability and later on death (Boyle, 2009).

Diagnostic Testing

A diagnosis for COPD should be undertaken for a patient who has previously been exposed to the risk factors such as prolonged smoking, and with symptoms such as coughing that is recurring, production of sputum, dyspnea or difficulty breathing (Vestbo et al, 2013). Spirometry may be necessary in the diagnosis and early detection of any physical abnormalities in the air flow passage, and in cases of severe COPD. Differential diagnosis and testing should, in some cases, include patients who have a history of chronic asthma, bronchitis, tuberculosis, and congestive heart failure (Vestbo et al, 2013). Distinguishing COPD from these associated diseases may be challenging hence the differential diagnosis. X rays for the chest, (as the cone conducted for the current patients), arterials blood gas study and sputum examinations are also necessary in diagnosis (McMurray, Adamopoulos, Anker, Auricchio,  Böhm, Dickstein & Jaarsma, 2012).

Treatment Options

For those who smoke, as is the case with current patient who has been smoking one pack per day for the past forty years,  cessation is essential, coupled by nicotine replacement. The current patient has been under treatment using inhalers, and at some point she has been using antibiotics. Pharmacotherapy can also be useful in treating the symptoms and reducing their severity (McMurray et al, 2012). The medication and treatment method preferred should be patient specific for improved outcome. Some of the medications for treating COPD include Corticosteroids for acute COPD, anti-inflammatory medications,   beta agonistic which improves dyspnea, methylxanthines for enhanced respiratory strength, Mucolytics , antibiotics which lessen the severity of sputum production and antidepressant drugs (McMurray et al, 2012). The current patient does not use any prescription medicine at the moment except for Tylenol , a pain killer. Other treatment methods include oxygen therapy, which slows down the advancement of the disease, aerosol therapy and vaccination are all treatment options available for patients of COPD.

Differentiating the Disorder from Normal Development

COPD causes a distortion of the lungs and the airways making it remarkably different from the lungs of the normal or health individuals both in structure and functionality. The current patient’s chest AP, according to the HEENT examination results,  has been enlarged by the disease. The disease leads to a malfunction of the lungs where the bronchial tubes produce more mucus than s normal lungs should hence causing a thickening of the airways, obstructing the breathing process (Qaseem et al, 2011). The disorder causes the lung muscles to be less powerful, easily irritated, shapeless and floppy. Normally the air sacs in healthy individuals allows for easier gaseous exchange, are elastic and deflate and inflate during exhalation and inflation respectively, while in COPD patients, the disease makes the air sacks to be less elastic, thick and inflamed hence difficulty in gaseous exchange (Qaseem et al, 2011).

Physical and Psychological Demand of COPD

 Physically, patients with COPD find it difficult to exercise or do other daily chores due to dyspnea (888). It thus affects their physical functioning by limiting them only to light duties. Controlling the symptoms is single most troublesome and demanding experience for the patients. Physiologically, patients may have increased need for air due to breathlessness. Lack of sleep, fatigue, and reduced appetite may mean that the patient requires a lot of care and attention. Psychologically, the burden of the symptoms may cause increased stress, loneliness, anxiety and later on depression (Qaseem et al, 2011).  Breathlessness may also cause fear and panic as patients expect a repeated period of breathlessness anytime (Qaseem et al, 2011). There may also be cognitive impairment or malfunctioning which adds on to the psychological distress. To the family with a COPD patient, physical demands include increased need to provide support to the nearly helpless patient, and have to spare more of their time for this.  Families may be forced to increase their help to the patients with their daily tasks such as household tasks, cooking and assistance with medication. Sometimes the patients may become entirely dependent on family members even on personal care (Boyle, 2009). The need and expectations of the society for family to take care of the patients may also cause psychological distress among family members. The prolonged nature of illness may also be a source of psychological distress to family members.

Optimal Disorder Management and Outcome

One of the most important and key concept that should be shared by patients and family is smoking cessation. The current patient needs to cease smoking since tobacco smoking exacerbates the disease,  and the patient’s family need to be informed of this so they support her in stopping the habit.  The family can provide the much needed support to achieve this, as a step towards managing the disease and increasing outcome of medication and other interventions (McMurray et al, 2012).  The patient and family should be well informed that while the disease is not reversible, prevention of progression of the symptoms is key in reducing the impacts of the symptoms (McMurray et al, 2012).

Multidisciplinary Personnel in COPD Management

COPD is a multisystem disease with multiple symptoms and causes and thus requires a team of different experts in its effective optimal management for enhanced outcome. The key team that the current patients may require includes respiratory therapists, pharmacists for pharmacological prescriptions, registered nurses, case managers and a physician (pulmonologist) (Bamiro, 2014). Dieticians, occupational therapists and pharmacists are important in providing secondary care. The first important member of the team is the patient herself  who should take the first step to seek help, follow instructions of the caregivers, be self-motivated and use all ways of improving his or her health status (Bamiro, 2014). A pulmonologist would be responsible for correct diagnosis, providing individualized goals and action plan for the patient, and general assessment and evaluation of the patient. A registered respiratory therapist would document the patent’s record of progress and monitor the rehabilitation program of the patient. For inpatients, a registered nurse would be more useful in providing immediate care in the hospital such as remedies for breathing difficulties (Bamiro, 2014)

Facilitators and Barriers to Optimal Management and Outcome

One important barrier to the optimal management and enhancement of outcome for the current patients is increasing severity of the disease’s symptoms which makes the patient weak and unable to perform physical activities or exercise, yet these are vital for integrated management of the disease (Thorpe, Kumar & Johnston, 2014). As a result of the limited nature of her insurance cover, she may be unable to access oxygen therapy and the continued aging of the patient also make management and outcome a challenges Oxygen therapy to address breathless is mostly available in hospital situations and not at home when it is needed (Thorpe et al, 2014). As a result of little disposable income, the patient may not be able to  afford certain services or medication for optimal management of the disease, hence a barrier. Her self-efficacy, which has of late been declining,  is yet other identifiable barriers in the optimal management and outcome of the patient’s disease. Some of the facilitators or enablers in the management of the disease include social support, family and friends (Thorpe et al, 2014). The patine has contacts in the church, has two daughter that she sees on a monthly basis and this kind of support can be effective in enabling her deal with her stress and depression symptoms, especially f she get support on a routine, possibly daily basis. Her primary care provider is also important facilitator in the management of her disease. Other facilitators include access to equipment such as wheel chair, and instruments for physical exercise, access to professional help such as therapists, and self-motivation are also good enablers and facilitators in improving her outcome (Gardiner, Gott, Payne, Small, Barnes, Halpin & Seamark, 2010).

Overcoming the Barriers

For the current patient to overcome the barriers, she should fist quit her smoking and seek as much information as she can to be knowledgeable about managing her condition. Additionally, she can find out about local  programs and support groups and any other community resources at her disposal that may assist her. This would help her access medication instead of using samples as is the case with the patient

Care plan synthesis

Recognition and Planning

 Correctly recognizing and diagnosing the disease is essential to be able to give the correct treatment based on the patient (McMurray et al, 2012). A holistic recognition requires also eliminating the possibility of confusing the disease with other respiratory diseases such as lung cancer, asthma, TB among others (MSRWG, 2010). A physician or pulmnologist would need to a diagnosis for COPD should a the key symptoms be present as is with the case with the patient in the case study. Key symptoms include chronic coughing, shortness of breath (dyspnoea), exposure to risk factors particularly smoking,  and tight chest, production of sputum (Garvey, 2011). For the patient in the case study, the presence of symptoms such as prolonged cough, shortness of breath and their chronic nature necessitates a COPD diagnosis. The hyperinflation and the evidence of emphysema also point to the disease since emphysema is a common occurrence in COPD patients (Garvey, 2011). However, accurate recognition for the current patient would also necessitate using the spirometry which helps in both diagnosis and detection of severity of the disease in the patient. COPD is more likely to be recognized in patients who have a long history of smoking, are old, have chronic coughs and dyspnoea and limited engagement in physical activities. The current patient well answers to these characteristics.

Planning

A holistic plan for the patient in question would include a thorough assessment of the patient’s history to check out for exposure to risk factors in the patient’s occupation or environment. Past medical history of the patient such as any respiratory diseases acquired in childhood and allergies should also be assessed. Family history, previous exacerbations, and comorbities would also be considered. Since the patient has respiratory symptoms, physical examination using a spirometry would be essential for diagnosis. Since the patient has multiple symptoms and the fact that he has suffered asthma in childhood implies that a collaborative test would be necessary in addition to pulmonary function test using the spirometer. Chest and Xray film would be required to examine the patient’s diaphragm so as to find out if there could be bronchitis. Additionally, arterial blood gas examination would be vital to find out the severity of hypoxemia. Finally, the patient’s sputum and blood would be examined. The sputum would be to necessary for testing gram stain and culture and also to identify presence of any other pathogens such H. influenza. Physical examination of the vital signs would also form part of the assessment and comprehensive, including checking for influenza as well as pneumonia and subsequent administration of vaccination for these two.

Impact of Patient’s Socio-Cultural Background on Optimal Management and Outcome

The cultural background of a patients affect the management of the disease right from the point of diagnosis  where in some cultures such diagnosis are considered unacceptable. The current patients is a Caucasian  woman, widowed, relying on pension and has a diploma education.  Socio cultural factors such as educational background, religion, diet, beliefs towards illness, race, income and one’s occupation all come into play in the effectiveness of management plan for a COPD patient (Shum, Poureslami  Cheng & Fitzgerald, 2014). Social habits such as smoking also impact on the optimal management of the disease. For example, the patient’s current smoking habit exacerbates the symptoms, and her limited income or reliance on pension may prevent her from accessing quality care for her condition.  Generally, high educational level, stable income, and a good job  are likely to impact positively on a patient’s optimal management and outcome of the disease. This is because such a patient is more likely to access and afford quality care services for the management of COPD compared to a patient with low level education, low income and working in an environment with the risk factors for COPD. Cultural background also affects the person’s diet, approach to exercise, and even general health beliefs about diseases. A culture that promotes high self-efficacy, that is supportive and whose diet consists mostly of natural foods as opposed to processed foods is likely to achieve higher quality outcome from the management of the disease and reduce its speedy advancement to serious stages. The patient culture seems to put her far away from her close ones since most of the times she’s away from her two daughters and sees them just once a month.

Evidence Base Practice in Addressing the Case

Adopting best practices based on latest information and evidence generated from research is important in ensuring that the treatment of COPD addresses a patient’s specific needs and is sensitive to a patient’s cultures, wishes, and has the patient’s best interest. The current patient’s COPD can be described as chronic since from her medical history she has had several hospitalization, and has multiple symptoms. One of the key issues in the case study is the diagnosis of the disease. One of the challenges is the correct diagnosis of what really the patient is suffering from. One of the evidenced based guidelines for the diagnosis of COPD is provided by the American Thoracic Society (ATS) which provides that the most accurate and recommended diagnosis of the disease should be assessment of the symptoms and the risks factors and the recommended tool for this is the spirometry (Battersby, Korff, Schaefer, Davis, Ludman, Greene & Wagner, 2010). Used with a skilled and a trained personnel, enhances the accuracy of the diagnosis and this would go a long way in eliminating misdiagnosis (McMurray et al, 2012). To further enhance the accuracy of the diagnosis and predict the current patients hospitalization and mortality since her condition is worsening is the application of the BODE index. This too is effective in predicting a patient’s need for hospitalization and the accuracy in pulmonary obstruction and the severity of the dyspnea which a patient is said to have.

Comprehensive Approach to Management of the Current Patients Condition

A comprehensive management of the current patient’s condition would require a multidisciplinary and best practice approach, based on recommended guidelines and the patient’s unique needs and characteristics (Battersby et al, 2010). Evidenced based and recommended pharmacotherapy would be used in addressing the patient’s symptoms. For the patient’s pharmacologic management, a combination of inhalers and medication would be used. The inhalers would rescue her breathing due to her dyspnea, while for medication, albuterol would be prescribed reducing the patient’s breathing difficulty. The patients would also be trained on self-management so as to effectively deal with the disease symptoms. Particularly, through pulmonary rehabilitation, she will be able to perform some exercises and engage in other physical activities and other routine activities. Existing evidence on pulmonary rehabilitation provides positive projection on the outcome of a patients symptoms, and so this will be emphasized for the current patient because the rehabilitations will significantly health improve the patient’s quality of life, reduce the rate of need for hospitalization, and reduce the dyspnea symptoms . Smoking cessation program would also be suitable for the current patient and this will prevent further damage to the patient’s lungs since she has been smoking for the better part of her life and still does and so the patient would be put under nicotine replacement therapy. Other care management  plans such as social support groups, counseling, involvement of family, and primary  care would be considered and effected as part of a comprehensive and multidisciplinary approach to assisting the current patient effectively manage the disease and realize enhanced outcome.