A Written Reflection on My Nursing Patient

Introduction

I am using Gibbs (1988) model of reflection as a template for my essay to enable me to analyse this situation. For the purpose of confidentiality I am renaming my patient Jim (Nursing and Midwifery Council (NMC) 2008). Jim is a 69 year old man, attending the pulmonary rehabilitation programme (PRP). He also has chronic obstructive pulmonary disease (COPD) and is prescribed short burst oxygen therapy (SBOT) to alleviate his symptoms. The World Health Organisation (WHO) (2013) defines COPD as a lung disease interfering with air flow to the lungs due to a chronic obstruction therefore; normal breathing pattern is not maintained and the adverse affects of COPD are not fully reversible.

Description

During my placement, I worked closely with the respiratory team when I was given the opportunity to attend the PRP as an insight into education and exercise for patients with COPD. The main focus of the education session was on breathing techniques, in particular pursed lip breathing (PLB). When assisting on the exercise programme I documented Jim’s score on the Modified Borg Scale (MBS) (Borg 1982). Shortly after starting the walking exercise Jim became very breathless, anxious and de-saturated. From the mornings education session I encouraged Jim to use the PLB techniques. After approximately ten minutes of reassurance, Jim had regained his breath and was much more calm and relaxed. However, Jim was unable to continue on the exercise programme that day.

Feelings

As I have worked on the respiratory clinic within my placement, I felt calm and confident in assisting Jim to help reduce his anxiety and breathlessness.

I had a feeling of helplessness as I could not physically do anything which would take away the debilitating symptoms Jim was experiencing. However, I felt by applying the techniques from the morning’s education session and my words of reassurance helped and were comforting to Jim.

Evaluation

The morning’s activities on breathing techniques were invaluable in this situation, as it was fresh in my mind and we had been through the education session together. I felt this helped in building a therapeutic nurse-patient relationship. Jim’s opinion of his experience of the PRP was very positive; he commended the programme and said it had benefitted him enormously. This is supported by Puhan et al. (2011) and Holland & Hill (2011) as they state that the PRP has improved outcomes for patients with stable and unstable COPD.

This can reduce hospital admissions, anxiety and depression; improve health related quality of life, as well as increasing exercise tolerance (National Institute for Health and Clinical Excellence (NICE) 2010; Puhan et al. 2011; GOLD 2011). From attending the programme that day it was obvious to me that dyspnoea is a common problem for Jim as well as others living with COPD. This is an area I aim to further explore for a deeper understanding of how it influences daily living and how it contributes to the anxiety associated with COPD. In addition to this I am going to explore the effectiveness of SBOT.

Analysis

Jim’s dyspnoea is a symptom that is commonly faced by people who have been diagnosed with COPD and is one of most concern (Nield et al. 2007; Lynes 2010; Bausewein et al. 2010). The difficulty with dyspnoea is that it is a subjective experience making it difficult to measure (Bellamy & Booker 2004; Williams’s et al. 2006; MacNee & Rennard 2009). Bellamy & Booker (2004) and MacNee & Rennard (2009) stipulate the particular importance of quantifying dyspnoea using specific tools for this goal. For example, the MBS (Borg 1982) scale which allows the patient and the health care professional to obtain an objective measurement. The PRP used the MBS (Borg 1982), which is an assessment tool to measure rate of perceived dyspnoea and an aid for patients to monitor their achievements. As Jim was unable to speak this was a useful tool, as he was able to point to his score without becoming more breathless. Kendrick et al. (2000) and MacNee & Rennard (2009) state that this is valid and reliable tool for measuring dyspnoea in COPD patients.

On commencing the exercise programme, Jim initially started well with moderate shortness of breath (SOB) until he commenced the walking exercise. It is extremely important to encourage participation in exercising, so Jim can minimise the risk of becoming socially isolated, loss of confidence and skeletal muscle deconditioning (Bellamy & Booker 2004). Jim de-saturated from 91% to 78%, as recorded by the pulse oximeter, he became very severely SOB and his anxiety levels had obviously increased. Jim was becoming panicky and at this point he could not continue. A patient with COPD should maintain oxygen saturation (Sp02) between 88% and 92%, unless advised otherwise (Currie & Douglas 2011). However too much oxygen can be fatal causing loss of hypoxic drive and the consequences of this can lead to retention of carbon dioxide, resulting in respiratory acidosis (Kennedy 2007). I assisted Jim to the chair; once he was seated Jim sat in an upright position to try to regain his breath.

Kennedy (2007) agrees that this is beneficial for some patients. Alternatively, sitting down and leaning forward with elbows resting on a table is also said to reduce dyspnoea (Kennedy 2007; Currie & Douglas 2011). Positioning is said to have a varied effect on dyspnoea and certain postures can benefit some patients (MacNee & Rennard 2009). This can improve ventilation as well as conserving energy which makes breathing easier (Currie & Douglas 2011). Jim was so breathless he was unable to speak. From the mornings education session I encouraged Jim to use the PLB techniques, this appeared to slow down his breathing and reduce his anxiety. Dechman & Wilson (2004) state that it is well documented that PLB has the ability to slow down respiratory rate as well as increase exercise tolerance.

However, to be beneficial this should be carried out regularly for twelve weeks (Nield et al. 2007). Yet, it is unclear if the anxiety reduced before the dyspnoea or alternatively the other way around. Bailey (2004) suggests that dyspnoea provokes the anxiety, the anxiety increases the dyspnoea and then ultimately it becomes a vicious cycle. Furthermore, Bailey (2004) stipulates that anxiety is not the cause of breathlessness but a sign that the respiratory system is failing. Bailey’s (2004) qualitative research points out the vulnerability of a breathless patient living with this progressive condition. Subsequently, an episode of dyspnoea can evoke negative thoughts, thus losing control of emotions and the consequences of which can lead to the inability of dealing with a situation rationally (Bailey 2004). This makes completing daily activities difficult for Jim, due to the worry of knowing what will happen once he becomes SOB. This in itself becomes problematic as Jim knows that attending the PRP may increase his breathlessness, leading to intense levels of anxiety.

Currie & Douglas (2011) indicate that anxiety and depression are strongly linked to COPD by the severity of obstruction to the airway. Anxiety and depression are often underestimated therefore, recognition and more intervention in this area is needed (Currie & Douglas 2011). The Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith 1983) is a useful implement in assessing levels of anxiety (Currie & Douglas 2011) and could be beneficial to determine specific causes of anxiety. By using this tool this could address any reasons for anxiety prior to exercise or daily tasks and work on techniques in overcoming them. During Jim’s recovery from his walking exercise he used his SBOT. O’Neill et al. (2005) state that the most common reason for patients using SBOT was for the symptomatic relief of dyspnoea. The British Thoracic Society (BTS) (2006) state that one of SBOT’s uses is for dyspnoea after exertion.

There is controversy surrounding the evidence-based effects of this medication (O’Neill et al. 2006; MacNee & Rennard 2009; NICE 2010; Moore & Berlowitz 2011; Douglas & Currie 2011). This leads to the ethical debate as oxygen therapy is widely prescribed for the symptomatic relief of dyspnoea (O’Neill et al. 2005). However, O’Neill et al. (2006) claim that there is not any evidence to support the continued use of SBOT. NICE (2010) state that it is one of the most costly treatments in the National Health Service (NHS) and with no proven benefits it purely acts as a placebo.

Furthermore, Moore & Berlowitz’s (2011) literature review has shown that there is no evidence from randomised control trails that supports the continued use of SBOT. Also, the Improving and Integrating Respiratory Services (IMPRESS) (2011) stipulate that there are potentially 75% of patients who could be taken off SBOT after a clinical assessment. Theses patients should be offered support in withdrawing their SBOT and fan therapy or increasing medications should be tried (IMPRESS 2011).

Conclusion

On reflection, it is evident that COPD is a debilitating illness which causes patients emotional, social, psychological and physical distress due to the impact on daily living. Dyspnoea appears to be a major factor associated with all forms of distress. As this is a longstanding problem for Jim he will be an expert in managing his condition and know what techniques benefit him. However, programmes such as the PRP can be extremely important to Jim as education and physical activity may prevent social isolation and muscle deconditioning which are factors that are linked to the deterioration of his condition (Bellamy & Booker 2004). Assessing anxiety and depression in patients with COPD is important to gain an accurate understanding of the patients needs; this can lead to more appropriate individualised patient centred care in the future.

My assumption of SBOT prior to my research was that it was an evidence based form of medication which would alleviate Jim’s symptoms. On researching this subject I discovered that my initial presumptions of this were completely inaccurate. From the information I have researched the majority of people would discontinue the use of SBOT until there is proven evidence of its benefits for patient’s (MacNee & Rennard 2009; NICE 2010; Moore & Berlowitz 2011; Douglas & Currie 2011). To conclude, I did not find any concrete evidence to support the continued use of SBOT.

Action Plan

If a patient has been living with their condition for a number of years, they become an expert in managing their symptoms. Listening and communicating effectively will be essential to build a therapeutic relationship. As the patient will already be distressed it is important to stay calm and confident to be able to offer reassurance and manage the situation successfully. When possible I would try to use the HADS (Zigmond & Snaith 1983) assessment tool as being able to assess a patient holistically gives a better evaluation of their needs. I aim to apply the new information I have gathered to any situation that is relevant as I have a greater awareness of COPD and its contributing factors.

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