Caring for the Patient With Chronic Obstructive Airway Disease (COPD)

Many persons in the world today are living with many medical conditions. One of the most common long-term conditions is Chronic Obstructive Pulmonary disease (COPD). This paper will address specific health needs -nutritional support- of patients suffering from COPD. Also, it will give an in-depth explanation of the various assessment tools to be used, the importance of a patient-nurse relationship as well as the importance of including parents and family in the assessment of the patient.

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COPD also called Chronic Obstructive Airway Disease (COAD) area group of clinical conditions in which there is partial, or complete obstruction of airflow at any level from the trachea to the bronchioles resulting in functional disability of the lungs (Mohan, 2005, pg. 477). COPD has four entities; chronic bronchitis, emphysema; asthma, and bronchiectasis (Mohan, 2005, pg. 476). COPD is one of the most common respiratory illnesses in the UK, and it affects people aged 35-45 years. It is estimated that about 3 million people have COPD in the UK (Lopez (2016; Department of Health (2010). About 900,000 know they have COPD and an estimated 2 million people are not aware (NHS, 2012). Qualitative studies carried out by Lopez (2016), Soriano and Roisin (2011), predict that by 2020, COPD could be the third most common cause of death worldwide (Lopez, 2016, Soriano and Roisin, 2011). However, there are concerns that the slow physical decline of those patients with COPD, which is punctuated by potentially serious but unpredictable disease exacerbations, may lead to avoidance rather than the provision of anticipatory care.

Clinical manifestations vary according to the entity. They all present with a cough, however, the cough of bronchiectasis is associated with the production of large amounts of copious sputum. Patients with asthma present with a dry cough that is worse at night (Soriano and Rodriguez-Roisin, 2011, pg. 365). Also, asthma presents clinically as difficulty in breathing and a wheeze (Kumar, Abbas, and Aster, 2017). COPD is a chronic disease as its name suggests. Chronic diseases are associated with unexplained weight loss. COPD causes profound cachexia which increases the chances of death significantly. Also, it weakens a patient to the state that they may be immobile because the body's metabolic function is just shut down hence no energy to go about daily activities. It is associated with anorexia and profound anemia. Also, response to pharmacotherapy declines. Cachexia can be a sign of other underlying disorders apart from the COPD. Therefore, it is very important to consider the nutritional support in COPD patients. Patients with COPD have poor nutritional status, and one of the most important health care needs of these patients during hospital admission is nutritional support (Dougherty, and Lister 2015). It is needed especially in patients that have (stage 4) COPD.

The trajectory of illness is the course of the disease. It tries to explain the disease from the time of its diagnosis to the time of death. The trajectory of illness tries to explain what will happen over the course of the illness. COPD follows a progressive course with remissions and exacerbations (Duenk et al., 2014, pg 24). Its course of illness is long and can last for several years. The COPD Foundation (2016) identified about half of the patients discharged after hospital admission for COPD will die within two years. COPD causes severe acute exacerbations associated with the decline of functions as illustrated in figure 1 below. As COPD advances focus on healthcare shifts from pharmacotherapy to palliative care. As illustrated in the figure below, the decline and exacerbations phase may continue for a long time before they deteriorate completely and ultimately succumb to the disease.

The nutritional support of patients with COPD is very important as mentioned above. For the body to maintain the normal physiological process, a person's must have good nutritional status. Other healthcare needs for COPD patients are pharmacotherapy, oxygen therapy, and psychology reviews. These patients also need to be educated about their disease and the importance of therapy instituted. Also, they need to be educated on how to cope with symptomatology related to their illness and when to raise the alarm or contact the healthcare provider. They need to be taught how to use their inhalers and proper medication taking. All these healthcare needs are related to nutritional support in one way or another.

Pharmacotherapy is one of the basic health care needs of these patients. Drug metabolism requires enzymes which need the energy to work. Therefore, if patients are wasted or rather malnourished due to the illnesses, even the drugs they are using will not help improve the course of COPD. These patients need energy and strength to move around. The energy comes from the food they eat. What does this mean? Patients who have poor nutrition, in addition to COPD are immobile due to low energy reserve. They are fatigued and always malaised. They will, therefore, end up with depressive illnesses. Lack of inactivity makes them have time to think of their conditions.

Patients with COPD always have to be educated a lot about their conditions. It is virtually impossible to educate cachexic patients. These patients are weak, and in such states, their brain is not functioning properly. It is highly unlikely that they will grasp anything. Cachexia causes an apathetic condition. All healthcare needs of persons with COPD are related to good nutritional support and guidance. Therefore the importance of proper nutrition cannot be underestimated in these people.

The medical dictionary defines holistic assessment as the assessment process where all domains or subdomains are addressed. It not only addresses the physical well-being of the patient but also the spiritual, psychological, sociological, developmental, spiritual and cultural well needs of a patient (Wallace, 2013, pg24). It has five stages; assessment, diagnosis, planning, implementation and evaluation (Wallace, 2013, pg 25). The assessment of nutrition in a patient with COPD is important (Bos-Touwen, 2015, pg 285). Using visual and other assessment tools gives the nurse a more conscious individualized nursing assessment (Doughtery and Lister, 2015; Arrowsmith, 1999; pg 1485).

One of the most important tools is the MUST tool (Bapen, 2015). Savage and Scott (2005) suggest that in order to care holistically for the health needs of a patient suffering from exacerbations of COPD, the use of a tool, such as MUST, needs to be the essential support from which to work; highlighting a patient`s need, not suggesting a solution. It is a five-step screening tool used to identify either undernutrition or obesity. The five steps also include the management plan for these patients. It is one of the easiest and quickest tools to use (Stratton et al., 2004, pg 799). MUST use five steps to assess a patient's risk of malnutrition: looking at height and weight which will give a Body Mass Index (BMI) score, weight loss which has been unplanned, acute disease effect, risk overall and guidelines in management (Gibson et al., 2012, pg.310). As a result of this, a care plan can be drawn up to address risks which have been identified, low, medium or high, using the frameworks that are provided by the tool. The tool, and local policy (Southern Health, 2009), states that within 24 hours of the patient being admitted an assessment using MUST should be carried out.

In patients with COPD, MUST tool has been shown to be very effective in detecting undernutrition. Research carried out by South Heath Hospital (2009) revealed that the MUST tool has helped establish that around 21% of individuals with COPD, that is, more than 600,000 people in Britain are at risk of suffering from malnutrition. Malnutrition may develop over a period. When a patient`s condition worsens, the result can be an escalation in malnutrition. However, there are certain concerns about it. The score in step 3 is too high. Inpatient COPD patients, those who have acute exacerbations are less likely to eat for the first few days. This is because the dyspnoea might be unbearable. They will probably eat when they go into remission, therefore, giving a score of 2 after five days seems a bit unreasonable. The MUST tool is effective in detecting undernutrition in these patients.

Another important tool used in COPD patients is Mini Nutritional Assessment Short-Form (MNA-SF). Body Mass Index (BMI) and Calf Circumference (CC) are used interchangeably in MNA-SF (Katsura, 2017, pg.244). Five parameters are looked into in MNA-SF and scored; appetite loss; points ranging from 0 to 2, weight loss; points ranging from 0-3, mobility; points ranging from 0-2, acute disease points ranging from 0-2, and depression or dementia (Katsura, 2017, pg.244). Depending on the points obtained the patient can be well nourished, at risk or malnourished. Figure 3 below is the MNA-SF. It is mostly used in geriatric patients. It is therefore not very beneficial in patients suffering from COPD as it is common in the 35-45 age bracket (Kaiser et al., 2009, pg.782). However, in very old patients with COPD MNA-SF is valid and very reliable.

Another assessment tool is the nutrition risk score (NRS). NRS is a tool that contains components of the MUST tool plus other additional features. It also tries to grade the severity of the disease (Schols et al., 2014). The more severe the disease, the greater the nutritional demand. If the patient is not feeding well, the nutritional status will be poor. It is a good tool. However, one of its biggest disadvantages is inter-observer variability (Mueller et al., 2011, pg.20). One nurse might consider a COPD patient very ill whereas the other might just consider them as ill making it not very good for assessment. NRS tool will only be useful if there is another criteria for grading the severity of COPD. Malnutrition Screen Tool (MST) is a nutrition screening tool used in hospitals to screen acutely ill adults mostly the aged (Cherill, 2005, pg.50). However, it is not reliable for assessing nutritional status in COPD patients because of the age factor.

The visual assessment of the patient is also critical. The nursing team should look for obvious signs of malnutrition such as loss of muscle bulk. These can be done by palpating muscle groups, for example, thigh muscles, biceps, and triceps (Schols et al., 2014). In a malnourished patient, the skin is loose and can be pressed against the bones due to lack of muscles. Normally these patients look apathetic and wasted. The prominence of bones- the ribs and maxillary bone- are signs of malnutrition.

Since we are making a holistic approach, it is also important to get an excellent nutritional history from these patients. The nursing team should do a thorough history and document the type of food the COPD patient eats, the quantity they eat and the frequency of eating. It is also important to know where they come from to know what types of food are available and whether they can sustain the increased nutritional requirements due to COPD (Ingadottir, 2017, S97). The history should be a corroborative one; in that, it can be taken from both the patient and the family. After that, during discharge, the family and patient should be offered nutritional guidance. Moreover, the patient can also be admitted to a nutritional clinic.

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