University of Malta
Faculty of Health Sciences
Department of Nursing
NUR1229 – Adult Nursing 1
Mr. Borg, a 75 year old now, was admitted to the medical ward suffering from
exacerbation of chronic obstructive pulmonary disease (a condition which started 5
years ago). He has been complaining of breathlessness, so he was keeping the head
of the bed up during the night and day. This has resolved the lower back pain. Mr.
Borg was assessed by the medical doctor who prescribed Acetaminophen without
any effect at all. Treatment was reviewed and he was started on Oxycodone two
tables orally 4-6 hours as needed (PRN). Mr. Borg is also on 2 liters of oxygen by
nasal cannula (specs). He is also making use of Albuterol (Ventolin) inhaler every
six hours as needed (PRN). When he ambulates, due to the hours spent in bed and
lack of oxygen, Mr. Borg has an unsteady gait and often needs to stop to catch his
breath. For this he needs someone (carer) with him every time he ambulates.
1. Briefly define chronic obstructive pulmonary disease (COPD). What
pathophysiology is occurring in the lungs of the client with emphysema? 10%
COPD is a common, preventable and treatable disease which is often caused by
respiratory symptoms and airflow limitations that is due to airway or alveolar
abnormalities. Some common symptoms of COPD are difficulty in breathing (dyspnea)
and sputum production when coughing. Unfortunately, these symptoms are not always
reported by the patients. This disease may develop either from external or internal
factors.
One of the main risks of developing COPD is smoking tobacco. Another external factor
is the burning of biomass fuels which is often used for heating or cooking. These gasses
are dangerous when inhaled as may lead to Chronic Obstructive Pulmonary Disease.
Other external factors leading to the disease is exposure to dusts, chemicals, fumes and
air pollution.
One of the main internal factors is related to genetics with deficiencies of alpha-1
antitrypsin (AATD) increasing the chances of developing COPD. Along with ageing,
studies reveal that gender is also a factor with females being more at risk. Problems
related to growth starting from gestation to childhood may also lead to the individual’s
risk of developing the disease. Other internal factors that increase the risk of COPD
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include asthma, chronic bronchitis and respiratory infections which reduce the function of
the lungs and lead to severe exacerbations.
Mr. Borg has COPD which is clearly affecting the way he breathes. The symptoms of the
disease are likely to have stared five years before when he was already having problems
with breathing. The physical changes associated to COPD are likely to have started in his
airways and air sacks in his lungs. Emphysema is the result of damage in the fibers that
make up the wall of the alveoli. These fibers become less elastic which make them unable
to work properly when inhaling and exhaling. Bronchioles may become irritated and
produce mucus which leads to bronchitis. As COPD progressed Mr. Borg is likely to
experience more respiratory problems like coughing, wheezing and chest tightness. With
such difficulties, less oxygen will be circulating throughout the body and Mr. Borg is
likely to feel more fatigued as more energy is required to breathe. Moreover, Mr. Borg
might also experience weight loss as he is using more energy to breathe.
2. What are the five signs and symptoms of respiratory distress the nurse may
observe in a client with COPD? 10%
a. By doing a chest X-Ray, the nurse can observe whether the patient has
COPD. One of the first signs of Emphysema is that the lungs in the X-Ray
result look hyper-inflated.
b. A nurse may also do a forced expiratory test to look for the forced vital
capacity and the forced expiratory volume. In a normal lung the result
should be 80% but in emphysema, the forced expiratory volume is
severely decreased because the inelasticity of the alveoli.
c. If Mr Borg is a non-smoker and was not exposed to air pollution and other
dangerous gasses/chemicals, the nurse might opt to do a blood test on
order to measure his Alpha-1 Antitrypsin level. If Mr Borg has an Alpha-1
Antitrypsin deficiency, elastase is not controlled. The compound Alpha-1
Antitrypsin is made in the liver stops elastase which in turn allows to be
more elastin. Elastin is what makes the alveoli elastic and hence
functional.
d. If all the above tests result in no obvious deficiencies the nurse usually
does a complete blood count test. This is done by taking blood from the
veins to test for the Bicarbonate compound. If the body is having too much
CO2 Bicarbonate levels increase to balance acidity.
3. Describe the physical appearance characteristics of a client with emphysema.
10%
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4. Discuss five nonpharmacological interventions that the nurse could
implement to help decrease Mr. Borg’s difficulty in breathing.
10%
The nurse might recommend Mr. Borg non-pharmacological interventions which
provides symptomatic improvement and a better quality of life. The most common
nonpharmacological option for Mr. Borg is to stop smoking. Other interventions are
pulmonary rehabilitation, immunizations, non-invasive ventilations and long-term
oxygen.
i) Stop smoking
It is widely known that COPD is the largest contributor to the development of COPD. To
this effect, smoking cessation is vital to stop the decline of the lungs. Sopping smoking is
one of the first advises given by nurses particularly if the disease is at an early stage.
Studies reveal that COPD patients who stopped smoking showed an improvement in
FEV1 which is 50% better than that of continued smokers after just one year. Halting
smoking is also known to improve mortality regardless of the stage of disease.
Unfortunately, the smoking addiction means that patients find it very hard to stop
smoking and more than 30% of patients continue to smoke despite being diagnosed with
COPD. The difficulty to stop smoking is derived from nicotine which is an addictive
drug. To improve the quitting rate, nurses ask the patients questions like the number of
cigarettes smoked daily and about their willingness to stop. The nurse also explains the
pharmalogical and non-pharmalogical options available to quit smoking like Nicotine
Replacement Therapy, Bupropion, Varenicline and Electronic cigarettes.
ii) Immunization:
Exacerbations in COPD patients lead to a faster decline in the function of the lung which
in turn increases illnesses and mortality. Treatment of exacerbations Are very limited;
therefore, prevention is vital. Influenza and Pneumococcal vaccines are often given to
COPD patients and are known to prevent morbidity.
iii) Pulmonary Rehabilitation
It is important for COPD patients to do physical activity and maintain a good muscle
strength. Pulmonary rehabilitation largely involves aerobic and resistance training and is
recommended to patients who do not have the expected reactions following
bronchodilator therapy. It is also generally given to patients within one month of an acute
exacerbation. Following exacerbations patients are less likely to be active and this leads
to a reduction in endurance and a decline in muscle mass. Studies reveal that patients
engaging in Pulmonary Rehabilitation following exacerbations are less likely to suffer
from hospital readmissions or death when compared to those who are just given usual
care. Moreover, patients who take PR show improvements in exercise tolerance, dyspnea
and tend to lead a better quality of life.
Despite being considered as a very good intervention, it is largely under-utilized simply
due to the lack of recognition of its value and of the ideal candidates to take this
intervention. Moreover, PR may not be available in hospitals due to time, mobility,
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commitment issues and other obstacles. If PR is not available in a structured program,
patients can go to gyms or do exercises at home. Although a structured program of
exercises is recommended, frequent exercising at home or at the gym are also known to
benefit patients in terms of aerobic and muscle strengthening.
iv) Non-Invasive Ventilation (NIV)
Non-Invasive positive pressure ventilation (NIPPV) is known to decrease morbidity and
the need for mechanical ventilation for acute respiratory failure. Thanks to NIV patients
are less likely to suffer from complications. Patients who are given NIV experienced less
re-intubations and less tracheostomies. Moreover, these patients experienced shorter stays
in intensive care.
Chronic NIV is used in cases where patients suffer from COPD and Obstructive Sleep
Apnea (OSA). Patients who are given continuous positive airway pressure are known to
experience fewer days in hospital when admitted with COPD exacerbations. Studies also
show that patients who are given CPAP when suffering from OSA and COPD tend to
experience a reduction of pulmonary hypertension and nocturnal hypoxia.
v) Long Term Oxygen Therapy (LTOT)
5. Explain why the nurse cannot increase Mr. Borg’s oxygen to help ease his
shortness of breath.
10%
6. Describe three nonpharmacological nursing interventions to help manage
Mr. Borg’s pain?
20%
7. Why should the nurse be concerned about the adverse effects of respiratory
depression and hypotension when giving Oxycodone to Mr. Borg?
10%
8. Mr. Borg will be returning home with oxygen. List and describe five safety
considerations the nurse should include in discharge teaching regarding the
use of oxygen in the home.
20%
NB – It is suggested that you write 300 words for every 10% of marks allocated.
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Instructions:
1. You must include a cover page which indicates:
a. The study unit code and title
b. The title of the assignment
c. Your name and identification number
2. The assignment should be typed using Times New Roman Font (12) with 1.5 spacing
between sentences.
3. Include page numbers at the bottom of each page in the format page x of x and a running
heading with the study unit code, your name and surname.
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the end of your assignment.
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and figures should only be used to substantiate the content of the text, not replace it.
When used these should be clearly labeled and referenced in the text.
7. Word length: 3000 words (+/- 10%). Ten marks will be deducted if you exceed the
word limit.
8. You may submit a 'Draft' assignment to TURNITIN once. This platform is named
‘Draft Assignment on the VLE and should not be confused with the actual platform
where you are to upload your final draft. TURNITIN will generate an originality report
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10. A hard copy of the assignment must be posted in Box no. 1 (The Box will be available
as from Monday 20th May 2018)
11. The deadline for submission of both the soft and hard copy of the assignment is Midday
of Friday 25th May 2018.
12. Late submissions will not be accepted and will be automatically awarded an F grade.
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Failure to submit a hard and/or soft copy of your assignment will automatically result in
the award of an F grade.
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avoid plagiarism: http://www.um.edu.mt/__data/assets/pdf_file/0009/95571/UniversityGuidelines-on-Plagiarism.pdf and
http://www.um.edu.mt/__data/assets/pdf_file/0006/95568/how-to-avoid-plagiarism.pdf
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