Chronic Obstructive Disease: A Case Study

Weekly Journal

Clinical Week 11
Clinical Date: Monday, November 10 2014 Working with a patient living with and experiencing chronic obstructive disease (COPD) I feel it is necessary to better understand the dyspnea. COPD is a respiratory disorder mainly caused by smoking, characterized by progressive, partly reversible airflow obstruction, systemic manifestation, and increasing frequency and severity in exacerbations. Cardinal symptoms experienced by patients with COPD are dyspnea, difficulty breathing, or shortness of breath and activity intolerance (Lewis et al., 2010). The RNAO communicates dyspnea should be considered as the sixth vital sign for persons living with COPD, as it is considered the disabling symptom of COPD (2005). Dyspnea
is defined as “a clinical sign of hypoxia and manifests as breathlessness. It is the subjective sensation of difficult or uncomfortable breathing”(Potter & Perry, 2010, p.
892). Dyspnea is further described as a subjective symptom of challenging or uncomfortable breathing, which cannot be measured objectively. Dyspnea must not be confused with observable changes in the rate or depth of respiration, which may not harvest a subjective experience of breathlessness (RNAO, 2005). As nurses, it is important to be able to assess and treat the patient who is experiencing dyspnea. The assessments used by nurses to measure the presences of dyspnea are visual analogue or numerical rating scales. Both types of assessment tools are beneficial in assessing the effectiveness of an intervention like as medication, breathing exercises, position change, or relaxation exercises. Nevertheless, these assessment tools do not aid explanation of what functions the patient is capable of, or what activities are avoided to prevent dyspnea (RNAO, 2005). The visual analog scale (VAS) is an assessment tool often used. Using the VAS can aid patients in making an objective assessment
of their dyspnea. The VAS consists of a numerical scale on 100mm vertical line with end points of 0 and 10. Zero is associated with no dyspnea where 10 is associated with the worst breathlessness the patient has experienced. VAS abilities to evaluate a patient’s dyspnea have been validated by studies (Potter & Perry, 2010). Treatment of dyspnea is prescribed on an individual basis. Treatment of dyspnea for a patient could include medications, controlled oxygen therapy, secretion clearance strategies, non-invasive and invasive ventilation modalities, and energy conserving strategies, relaxation techniques, nutritional strategies, and breathing retraining strategies (RNAO, 2005).
The patient I care for currently uses medication, controlled oxygen therapy, and nutritional strategies to aid in alleviating his dyspnea. However, I believe this patient could benefit from breathing retraining strategies, positioning and relaxation techniques. Breathing techniques are discussed as techniques to improve ventilation and oxygenation. The three basic techniques are deep breathing and coughing exercises, pursed-lip breathing, and diaphragmatic breathing (Potter & Perry, 2010). Diaphragmatic breathing, however, is not a recommend breathing exercise for COPD patients as studies have yet supported its use (Lewis et al., 2010). Relaxation therapies are often forgotten about in nursing practice scenarios. According to The American Thoracic Society, relaxation guidance may improve dyspnea in the short term, but has not been shown to have long-term effects (as cited in RNAO, 2005). Relaxation techniques often taught are progressive muscular relaxation, positive thinking and visualization, use of music, yoga, and humour. However, in the hospital setting not all of these techniques are facilitated. The progressive muscular
relaxation technique is one I would like to implement with this patient. The Institute for Clinical Systems Improvement insinuates that progressive muscle relaxation has been shown to reduce psychological distress and dyspnea. Two randomized controlled trials analyzed progressive muscle relaxation to reduce the anxiety associated with dyspnea in patients with COPD. These studies both reported an improvement in dyspnea rates in the relaxation groups (RNAO, 2005). Positioning, a suggested strategy designated by patients to help them cope with dyspnea (RNAO, 2005). The American Thoracic Society, reports the leaning forward position has been conveyed to improve overall inspiratory muscle strength. Therefore, increasing diaphragm recruitment, reducing participation of neck and upper costal muscles in respiration, and decreasing abdominal paradoxical breathing, as well as reducing dyspnea in COPD (as cited in RNAO, 2005).

References
Lewis, S.L.; Heitkemper, M.M.; Dirksen, S.R.; Bucher, L.; O 'Brien, P.G. (2010). Medical-surgical nursing in Canada (2nd ed.). Toronto: Elsevier Canada.
Potter, P.A., Perry, A. G. (2010). Canadian fundamentals of nursing (Revised 4th ed.). Toronto, Canada: Elsevier Inc. Canada.
Registered Nurses’ Association of Ontario (2005). Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with Chronic Obstructive Pulmonary Disease (COPD). Toronto, Canada: Registered Nurses’Association of Ontario.