PATIENT PATHWAYS OF CARE IN ADULT NURSING: COPD PATIENT CASE 

In this case study, a Right care pathway for a patient that was admitted to a medical and surgical assessment unit with Chronic Obstructive Pulmonary Disease (COPD) will be evaluated and discussed. Due to the regulations of NMC, the patient’s real name and other details will be kept confidential (Chambers et al., 2017). In this assessment, a nursing assessment tool is used by the time the patient is admitted and in it, an element of carefully picked and discussed critically. From the recommendations given, adequate reference is made from the national and local strategies and policies that guided care delivery structure and framework for the patient’s stay. Also, in this case, study, identification of the other members of the multidisciplinary team where the patient was referred to is stated. Finally, discharge considerations when the patient returns home will be given based on their safety and performance.

            Mr. James is turning fifty-nine years old in July this year. He retired early from his managerial job in a local warehouse where he earned a good salary and bought a family house in the locality. He is married to Mrs. James whom they have lived with for twenty-five years. They have two sons and the older one has already finished college and works in the same warehouse in an assistant managerial position. Mr. James has been smoking for thirty years now although he was not a heavy smoker. However, he has maintained good health all along with his career life. Recently, he had developed a heavy cough that saw him struggle to breathe sometimes. From this challenge, he visited the hospital and was scheduled to undergo several tests to determine the condition. Most of the diagnostic processes involved understanding the signs and symptoms, the family medical history, and knowing his smoking duration.

            From these observations, he was scheduled for several tests that included a CT scan for the lungs, arterial blood gas analysis, and lung function tests. When interpreted, these tests revealed COPD. Chronic obstructive pulmonary disease is lung disease emanating from chronic inflammation, causing obstructed airflow from and to the lungs. At the end of the tests, Mr. James had developed mucus production and the cough had become more intense. According to other nurses, this condition could put the patient at risk of heart disease, lung cancer, and other conditions. After this was determined, the staff could not let the patient proceed home due to the danger it may develop into. In that regard, several interventions had to be initiated. He was brought to the hospital by Mr. James who booked him in and provided all the necessary documents required including medical history forms and narrations. This was according to the NMC recommended principles to obtain consent from the patient or their family members.

            In this scenario, although the professionals understood that the cause of the COPD is smoking, it was not identified whether the airway obstruction was because of emphysema or chronic bronchitis. The difference between the two is that in emphysema, the elastic fibers of the alveoli are destroyed and small airways collapse when exhaling while in chronic bronchitis, the tubes become inflamed and narrowed and produce more mucus, which again blocks the narrowed tubes. In this regard, the spread of the disease had to be stopped using prevention measures (Dhand et al., 2018). From NHS recommendations, quitting smoking is the best option despite that most people may not do that immediately. Quitting is the best because it prevents further development of lung cancer and heart disease. Considering that this can become a very stressful situation, the doctor may help in alleviating chances of developing depression. Also, a regular vaccination for flu and pneumococcal pneumonia is crucial to reduce the risk of infection.

            The NHS (2015) recommended the Right care pathway for COPD, which aimed at reducing chances for mortality and optimizing long-term management to reduce hospital admissions. The right care pathway optimizes the use of a multidisciplinary supportive care approach to ensure that all the areas that need priority are addressed immediately. One of the cross-cutting themes in the optimization process is signposting and care navigation, community activation, psychological support, and recommendation on self-management plan, which should be supported by valid and good information to train the patient. In this multidisciplinary care process, all parties and stakeholders are involved in the process, including family members, health professionals, and other contributory parties such as the general community. According to different studies conducted on COPD patients that have undergone this care process, a major difference in patient’s health can be recorded within a year of following the procedures (Leap et al., 2021). From the NHS data findings, this procedure provided a hassle-free process for the patient to quit smoking and adopt healthier options of living.

            Although some of the procedures recommended in this care process may not bear equal results for all people, Mr. James demonstrated responsiveness since the process started. According to the evidence provided in the testing process, the hospital was aware of the best procedures to follow to ascertain the real cause and to advise on the best treatment process. After the tests, both of them were informed about the underlying problem and the steps that the multidisciplinary team will undertake to enhance quick recovery. Also, they have explained the risks involved such as pain management preparation, rehabilitation, and the needed participation of the patient. In that regard, the overall health of the patient was important, which include mental, psychological, and physical health. These as the needs of the patient were well recorded in a leaflet, which is a standard pathway recommended by NHS for COPD recovery.

            After some consultation with the multidisciplinary team, it was agreed that the patient should be admitted because he had chronic bronchitis as the cause of his COPD. Also, due to the prolonged period of smoking, his blood veins were weak and extra coughing and mucus production would create stress for the veins (Kurashima et al., 2017). However, this was done to ensure that the patient is in good hands and does not develop more complex issues that the family would not handle. In the process, the date of discharge was also set and was based on the condition that the patient will be better and safe from the threat of losing their breath. Initially, he was given five days in the hospital, where the family was expected to visit him more often, especially to reduce the stressful situations and conditions in which he was. Additionally, when discharged, a stoma nurse will be scheduled to visit him regularly for the update of the records and ensuring that the patient follows the guidelines provided. Therefore, the admission assessment, which involved five steps including the collection of data, sorting, analyzing, and organizing the data were completed.

            After admission to the ward, a preliminary assessment was carried out by the nurse practitioners. In this assessment, the Barthel Index was used with an aim to interventions that supported the independence of the patient. Barthel Index is a reliable tool that measures performance in activities of daily living. In this assessment tool, different activities are involved. The time is taken and the required physical assistance determines the assigned value of an item in the list. This tool measures the assistance degree that a patient requires for the items of mobility and self-management (Khalaf et al., 2017). Among the items in the list include feeding, dressing, transfer, toilet use, bathing, walking, bladder, and bowel. In these activities, one is the most important as it determines the ability to cope, which is feeding. This is one activity that can regulate the challenges that the patient is dealing with, especially when he can take good and healthy food. In Mr. James’ case, he was experiencing breathing problems, and thus it was necessary for nursing assistance, especially when eating, and to ensure the patient develops appetite for food.

            After the assessment using this tool, it was determined that Mr. James’ lungs were destroyed due to the high concentration of carbon in the air tubes and sacks. In that regard, a lung transplant was inevitable. In this light, the family had to find either a living donor or a deceased donor. Due to complications that existed, the family resolved for the deceased donor option to avoid further risks with already healthy people. From the deceased donor, a consent agreement had to be signed by the family of the deceased based on the procedures and practices as recommended by NHS. Also, on this requirement, the size of the lung was expected to match the air capacity of the patient. Additionally, in the tool activities, it was resolved that he had to eat a lot of health to be through the surgery procedure.

            As common with most patients, eating and drinking make the most crucial activity despite that others may develop a lack of appetite in the process of surgery. However, the eating and drinking needed to be adjusted for this patient before surgery to ensure that he had the strength to go through it (Jumbe, Hamlet, and Meyrick, 2017). To address this dietary need, the team brought in a dietician to guide him in eating and drinking. The dietician assessed Mr. James’s dietary condition and he termed it as not appropriate. He would advise that Mr. James was supposed to be taking a lot of protein and energy-rich food in small volumes three times a day. Taking such food would help him burn more unwanted fats and keep the body strong and active, especially during the surgery. Therefore, protein drinks and energy-rich meals were scheduled for every day for him.

            The patient had reported some signs of society withdrawal symptoms and was not willing to delve into them much. Withdrawal from society has a significant downturn in the psychological health of such patients. In this regard, the family and the loved ones had to be kept close to ensure that social bonds with his people are maintained and intact. This will ensure that his psychological health is good before surgery, which will enhance body performance. Due to the psychological needs of the patient, the hospital was required to provide a psychologist to provide the required information. From this information, the patient can be ready for the surgery ahead and conduct themselves well. This can also be done with the assistance of a nurse practitioner.

            The exacerbation frequency may increase exponentially, which prolongs the recovery period. In appropriate terms, the polarization of the lungs will require transplanting. Assuming that the lung was ready by the time, several steps were involved. They include incision on the chest, detaching the airways and blood vessels, replace the lung, reattach the airways and blood vessels, and finally close up the incision (Alshabanat et al., 2017). Before this happens, the patient is prepared before the transplant. Some of the things he did as advised are not to eat or drink anything, he took an antimicrobial shower, and he packed and brought all the medications he was using before with him. For accuracy, the surgeon determined the size of the donor lung and that of the patient to compare the sizes and the match of the antibody panel.

            For this case, it was a single-lung transplant meaning it would take seven hours to complete. However, before that is done, the nurse conducts basic testing. The nurse also prepares a history and physical of the individual. He or she also facilitates the signing of the consent forms for the transplant surgery. General anesthesia is administered at this point to ensure that pain is blocked from the patient. At all this time, the patient remained on the ventilator because he could not breathe on his own. At this point, the nurses were responsible for administering anti-rejection drugs regularly until the body recognizes the new lung. Often, when the body recognizes a new organ, it perceives it as a threat and starts fighting it. Therefore, anti-rejection drugs suppress the immune system’s response process to the pathway for the new lung to be accepted in the body.

            After the lung transfer and acceptability in the body, which may take about three weeks, the patient entered the new face of care called lung transplant recovery and aftercare. At this stage, the patient had started feeling stronger and the end goal was for him to live freely without the use of ventilators. After the surgery, the first few months entailed the recovery process, which needed serious attention because of the high risk of infection (Soumagne et al., 2020). After discharge, it would take Mr. James 2 to 3 months to recover fully. During this time, he was expected to live not very far from the hospital to ensure that new issues are addressed conveniently. According to NMC, such a patient must have a caregiver that attends to them closely and conveniently (Graarup et al., 2017). Luckily, the patient had a loving family that supported him, especially his wife. These would ensure that he follows all the prescriptions after discharge. All this long, feeding (eating and drinking) had to be observed because it determined the strength and response the patient had towards the surgery.

            The activity of feeding is carried out throughout the surgery process and post-surgery. During the surgery process, the patient was expected to have eaten six hours before to ensure that there was no digestion taking place there (Gillis and Wischmeyer, 2019. At this stage, most patients may lose their lives due to a lack of body strength to sustain the procedures conducted. Most of the challenge is the body not accepting the new lung transplanted. Although the doctors conduct a thorough investigation of the new lung for compatibility issues, bodies are different and thus they may become incompatible. After the surgery, the patient was not allowed to feed through the mouth. It was argued that when fed through the mouth, it will increase the need for a very active digestion system, which would have created a high flow of blood, which would compromise the breathing process. Therefore, he was fed using pipes, content that seemed like porridge but it contained all the minerals that were essential for his body at that time. After the surgery, a holistic care plan was drafted based on Mr. James needs physical, psychological, and social states.

              Physically, the patient has numerous needs such as feeding, being helped in moving around, and to take care of their hygiene. Often, they may develop signs of infection that can become detrimental to their health. One such occurrence is having chills or fever that is over 100.4^o C. Also, the patient can develop redness, swelling, fluid draining due to the incisions done in that area. This means that care teams as advised by the NHS will be willing to help Mr. James for the rest of his life. At this point, the body is weak due to the low immunity suppressed by anti-rejection drugs. Due to the use of these drugs, the body becomes susceptible to infections (Graarup et al., 2017). At this stage, the patient also required care for the wound. Care for a recovering surgery wound is challenging considering that most of them may take a long time to heal. Therefore, the patient should not be exposed to areas where he is exposed to germs or in places that are prone to the spread of germs. At this point, the activity of feeding is relevant all along. This is because even with a suppressed immunity, healthy foods ensure that the body is still guarded. Often, a nutritionist will be involved to advise the best eating and drinking habit that Mr. James can adopt as a new lifestyle.

            On psychological needs, the patient is required to be reassured that a lung transplant is not the end of their lives. Although they had to prioritize their safety, they were capable of living for long enough until when it can allow. Combined with sociological needs, this is the time that the patient needed the love of his family members and close friends. Finally, in the third week, a discharge summary was sent to the nurse practitioner and the necessary referrals recommended were documented. The involvement of psychologist at this point was essential because the patient and the family learned how to take care of their mental health, clearing their mind, and having a good relationship with people. According to the NHS, most physical exercises lead to better mental health outcomes (Graarup et al., 2017). However, in this case, higher blood pressure or faster lung function should not be involved in the process of care considering it could interfere with adapting to the service of the new lung. Therefore, the patient must be kept still at all times though non-intense activities are good for him.

            This case study has discussed the journey of Mr. James from admission to the hospital to discharge from the hospital. After understanding the risks that the patient was in, the hospital admitted him to the ward immediately. In the surgical ward, the nurses undertook a comprehensive assessment of the care plan and how it resonated with the patient’s needs. One of the activities that were identified in the assessment processes includes feeding, which was proven to be relevant as it was the source of strength for the patient. According to evidence, the care process was centered within the entire aspect of human life including physical needs, psychological, and social needs. It was discovered that the social circle which includes family and friends would aid him in the healing process. The guidelines of the Right care pathways holistically brought together members of the multidisciplinary team involving nutritionists, nurses, surgeons and doctors, psychologists, and physicians. This was done according to the national and local policies and guidelines whereby the goal was to maintain the patient’s safety, privacy, and hide confidential information. Also, literature informed most of the evidence-based nursing and the holistic approach to care adopted in this case study.

References

Chambers, D.C., Yusen, R.D., Cherikh, W.S., Goldfarb, S.B., Kucheryavaya, A.Y., Khusch, K., Levvey, B.J., Lund, L.H., Meiser, B., Rossano, J.W. and Stehlik, J., 2017. The registry of the International Society for Heart and Lung Transplantation: thirty-fourth adult lung and heart-lung transplantation report—2017; focus theme: allograft ischemic time. The Journal of Heart and Lung Transplantation, 36(10), pp.1047-1059.

Gillis, C. and Wischmeyer, P.E., 2019. Pre‐operative nutrition and the elective surgical patient: why, how and what?. Anaesthesia, 74, pp.27-35.

Jumbe, S., Hamlet, C. and Meyrick, J., 2017. Psychological aspects of bariatric surgery as a treatment for obesity. Current obesity reports, 6(1), pp.71-78.

Dhand, R., Mahler, D.A., Carlin, B.W., Hanania, N.A., Ohar, J.A., Pinto-Plata, V., Shah, T., Eubanks, D. and Braman, S.S., 2018. Results of a patient survey regarding COPD knowledge, treatment experiences, and practices with inhalation devices.

Soumagne, T., Guillien, A., Roche, N., Annesi-Maesano, I., Andujar, P., Laurent, L., Jouneau, S., Botebol, M., Laplante, J.J., Dalphin, J.C. and Degano, B., 2020. In patients with mild-to-moderate copd, tobacco smoking, and not copd, is associated with a higher risk of cardiovascular comorbidity. International Journal of Chronic Obstructive Pulmonary Disease, 15, p.1545.

Alshabanat, A., Otterstatter, M.C., Sin, D.D., Road, J., Rempel, C., Burns, J., van Eeden, S.F. and FitzGerald, J.M., 2017. Impact of a COPD comprehensive case management program on hospital length of stay and readmission rates. International Journal of Chronic Obstructive Pulmonary Disease, 12, p.961.

Khalaf, R.M., Lea, S.R., Metcalfe, H.J. and Singh, D., 2017. Mechanisms of corticosteroid insensitivity in COPD alveolar macrophages exposed to NTHi. Respiratory research, 18(1), p.61.

Kurashima, K., Takaku, Y., Ohta, C., Takayanagi, N., Yanagisawa, T., Kanauchi, T. and Takahashi, O., 2017. smoking history and emphysema in asthma–COPD overlap. International journal of chronic obstructive pulmonary disease, 12, p.3523.

Leap, J., Arshad, O., Cheema, T. and Balaan, M., 2021. Pathophysiology of COPD. Critical Care Nursing Quarterly, 44(1), pp.2-8.

Graarup, J., Mogensen, E.L., Missel, M. and Berg, S.K., 2017. Life after a lung transplant: a balance of joy and challenges. Journal of clinical nursing, 26(21-22), pp.3543-3552.