A 61-year-old female patient presented with increased shortness of breath, productive cough, and fatigue. She had a smoking history of 35 pack-years. Spirometry showed an FEV1 of 55%, consistent with moderate COPD. The patient was referred to pulmonary rehabilitation and smoking cessation programs. She successfully quit smoking after 12 weeks. Medications of tiotropium and salbutamol were prescribed according to guidelines. The patient benefited from non-pharmacological approaches and medication management of her COPD.

1. Introduction
I am a Practice nurse in Thurrock, Essex where we have 7000 patients from a deprived area.
I will be writing this assignemetn around the care and amanegemnt of a patient with Chornic
Obstructive Pulmanory Disease (COPD). I will be discussing the initial contact and concerns and
how as a clinician we met the diagnose of COPD and what symptoms the patient presented
herself with and her concerns. What history was taking alongside with tests and symptoms to
come to the intial diagnose of COPD. From there on what support was put in place for the
patient and how she felt and managed with her condition and intial diagnosis.
I will be exploring risk factors which could of led this patient to developing COPD and lifestyle
factors. Other services this patient was refered to for support and there management and
support. The patients understanding of her condition and education that was given to the
patient regarding her disease.
The patient I will refer to in this assignment is a 61 year old lady with a smoking pack year of 25
years. Presented with increased shortness of breathe, increased sputum production. Patient
suffering more frequently with chest infections and feeling generally fatigued. Feels she can not
walk as far without getting out of breathe and works as a painter and decorator in the evening. I
will refer to this patinet as Mrs A. She still smokes but has cut down to 10 roll ups a day and is
concerned about her health.
I will be focosing on all aspects of COPD management and also two main holistic approahces
which were offered to this patient which will be smoking cessation and Pulmonary Rehab and
the benefits this patient found undetaken these additional services with her management.
These two holistic approaches were used as she felt she needed support with understanding of
the disease and excercise tolerance and also to help stop smoking
Background of COPD
"COPD is predominantly caused ny smoking and is characterised by airflow obstruction that is
not fully reversible. The airflow obstruction does not change markedly over several month sbut
is usually progressive in the long term. Exacerbations often occur, when there is a rapid and
sustained worsening of the patients symptoms beyond normal day to day variations". (Nice
guidlines 2010)
Some risk factors that influence if people devlop COPD are inherited prediispostion, smoking,
occupation and also infections. There are 25,00 deaths a year in the uk from COPD and milluions
are left undiagnosed of the condition. There are also social factors that are linked to COPD such
as living ind eprived areas

2. http://www.hse.gov.uk/statistics/causdis/copd/index.htm
Problems that occur in my local area are on the increase according to the local CCG findings
"Thurrock has a greater proportion of its population in the age groups of 0‐14 and 30‐44 .comp
ared to England, and a greater proportion of females than males aged over 70 years. Life expect
ancy for both males and females has shown a slight increase over the past five years, although li
fe expectancy for both sexes is less than regional but similar to national levels. The majority of G
P practices in Thurrock have Index of Multiple Deprivation (2010) IMD scores within the mid to u
pper range of those for SW Essex. This indicates there are high levels of deprivation within Thurr
ock".
https://www.thurrock.gov.uk/sites/default/files/assets/documents/JSNA‐product‐clinical‐
commissioning‐groups.pdf
This also tranpires in findings from Public Health England who found Thurrock had one of the
highest rates of smoking deaths for every 100,000 peoples deaths in Thurrock 236 were smoking
realted. Thurrock also came very high with smoking related hospital admissions. Which in turn
made reducing smoking prevlance for Thurrock residents a key target in 2013 for the NHS
Thurrock CCG.
"Reducing smoking prevalence is a key health target for NHS Thurrock CCG, which is made up of
GPs and plans health services for Thurrock residents".
http://www.yourthurrock.com/2013/07/08/thurrock‐smokers‐urged‐to‐quit‐by‐health‐bosses/
This disease is becoming a increrasing concern and we as primary care clinicians are seeing more
patinets with COPD symptoms each year.
Anatomy and Pathophisology of COPD
Normal lung antamoy are as follows we have two lungs which Main functions of the lungs are
gases exchnage which in turn regulate the Ph of the blood with COPD these functions are
impaired for a number of reasons.
The nose filters unwanted irrittants which can go down to our mucus in our airways the cillia will
push these up to the throat and we will swallow these particles without knowledge.
Also whilst in the nose air is warmed and humidified it then travels down the trachea. The
treache adivides and air heads towards the bronchoiles which alveoli sacks at the end where
gases exchange take place.
A number of normal functions are damaged with COPD
The cillia are damaged which are tiny hairs along the respiartory tract wghich help keep

3. unwanted particles out of the lungs. You will notice with COPD patient they have a productive
cough this is one of the factors that contribute towards this as this function is a effective way of
riding particles when cillia are damaged.
This also causes inflammation in the lungs which causes a number of responses such as
neutrophils production, microphages and protease enzeymes which damage the alveoli which
are responsible for importnat gases exhnage with releasing Carbon Dioxide from the lungs and
letting Oxygen in to flow around important organs. Perfusion of the blood is vital so PH levels
are maintained. You may see with this patient confusion due to acidoic blood, Shortness of
breath due to low oxygen levels.
Narrowing of the airways occurs due to lung irriatitants which will make the tissue produce
more smooth muscle and thicken this is another imflammotiry response which will lead to
shortness of breath. Elacisty of the airways and imflammation to the lungs walls and more
mucus production decrease surface area for gases exchnage which in turn makes it more
difficult for a COPD patient to exhale due to the pressure in the chest.
All the above changes to the antaomy over time cause Shortness of breath, wheezing,
productoion of sputum which are commin symptoms a COPD patient will present in clinic with.
Assessment
Mrs A 6 1 year old lady presented to clinic with increased Shortness of breath, finding her
energy levels were decreased. Productiove cough in the morning with whitish sputum and states
she has had multiple chest infections over the previous winter. Mrs A had been smoking for 35
years on and off and was concerned her breathing felt worse.
Due to (Nice guidlines 2010) a diagnosis of COPD should be considered for patients over the age
of 35 who have a risk factor generally smoking and present with breathlessness and a chronic
cough and regular sputum production and bronchititis or frequent wheeze.
Listening to Mrs A general concerns were firstly she was expperiencing over the last few years
difficulty in going about her dialy job as a painter and decortor and felt her chest infections were
more frequent.
I started by taking a history
• Smoker 35 years
Due to this history I used pack years which calculates the frequency of cigerrtes over the years if
any smoking gaps and gives a more accurate picture of the actual smoking history. The smoking
pack years calculates the value of lifetime tobacco use. A pack year equates to 20 cigarettes
smoked everyday for one year. People who smoke generally change there trends in smoking so

4. the claculator helps you simplfie this and I find patients also find this useful when explaiend to
them during an assessment. http://smokingpackyears.com/
• Sputum production of which Mrs A states hse has been bringing up sputum frequently
for 5 years which is suggestive of chronic bronchitis. (COPD, omin min kon)
• Family History Mother died of COPD at the age of 74 and patient states she is the only
family memener known to her of which she also was a smoker and MRs A a passive
smoker as a child. (add passive smoking ref)
• Shortness of breath used the MRC questionaire patient scored a 3 stating she walks
slower than most people her age and has to stop for breath and it is impairing her wotk
life. (simply COPD, education for health)
• Occupational history Mrs A works a an industrial painter and decortaor over night and is
exposed to fumes and chemicals. Previous worked at a Motor Compnay near chemicals.
Finds using masks at work very difficult due to Shortness of breathe.
• Oxygen Saturation levels were 96% on room air. No concerns raised at that present
time.
• Mrs A had been experiencing wheezing on chest examination no wheeze heard just a
audial wheeze.
• No ankle swelling to rule out Cor Pulmonale
• She has been experiencing weight loss of 4kg but she had been stressed and felt
fatigued. She stated she ate a full diet and three meals a day.
• No finger clubbing on examination
• Mrs A was not using her accesory Muscles
• Respirations were 19 resps per minute.
• No cynasis on examination
• She has been experiencing no chest pain
• No haemoptysis
Due to Nice guidlines 2010 I invited Mrs A for a post bronchodilator and explained what the
procedure entiled and what was involved using BTS guidlines. I explained Spirometry is

5. method of assessing lung function by measuring volume in the lung the patient can expel
after inspiration. I explained we use this alongside other examinations as a tool to measure
obtruction and restrictive diseases and the severity of COPD if it was to be present.
https://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/COPD/COPD
%20Consortium/spirometry_in_practice051.pdf
Mrs A attended for a psot bronchodilator spirometry at the clinic she was extremly nervous
and I explained the whole procedure again. She had not recently suffered with any chest
infections, or pnemothorax or recent surgery. She adhered to the no smoking and alchol and
there were no clinical indications for her to have the spirometry. She perfomred the
spirometry well and it met BTS guidlines. Her results were FEV1 below 70% . Her FEV1 was
55% post broncholidiot of which i explained is suggestive of moderate COPD.
(ELABORATE) discuss interaption of results
Mrs A was also sent for a rountinue x-ray as recommended in the NIce guidlines 2010, which
was clear. A full blood count was undertaken for any evidence of anemia and
polycytheamia. Her bloods were normal and no further action neccascery.
elaborate
BMI and blood pressure were undetaken
• BP 135/80
• BMI 19
ECG was perfomed to rule out any cardiac input which was also clear.(rationale)
Holistic Approaches
After discussions and as MRs A had a MRC of 3 and was struggling with her lifestyle we
decided pulmonary rehab would be a helpful option for helself as her BMI was on the
low side, she had disclosed she was struggling with her diet and keeping track of regualr
eating patterns due to fatigue and she was struggling with her daily activities of living
with her breathlessness.
Pulmaory rehab has been designed to improve quality of life there has been studies that
has shopwn it has no effects on mortality but less hospital admissions are noted, better
excercise tolerance and improved shorrtness of breath. There was also contrasting
studie sthat supported COPD patients lived longer who had attended Pulmanory rehab.

6. http://www.uptodate.com/contents/pulmonary-rehabilitation-in-copd
Pulmonary rehab focuses on main points helping patients with excercis etolerance and
coping with breathlessness. Each programme is tailor suited to the pascfic patients
needs and advice is giving and education around lung health and coping and also
nutrition. They can also educate patient smore on why theya re taking there medication.
(benefits of pulmoanry rehab)
http://www.blf.org.uk/Page/Pulmonary-rehab
Mrs A was happy to attend and liked the tought of a broader education into the disease
and also managing her conditiona s she was still working and her fatigue was impairing
her social life.
Mrs A attending for 12 weeks in a community based programme and she did seek advice
from a dietician about food she could eat to keep her energy levels up and fit into her
lifestyle.
She stated she felt better at work and was managing her breathlessness alot better and
her MRC had come down to a MRC of 2.
She also felt she had a better understanding of teh condition as she felt when intially
diagnosised in clinic with mysefl and a GP there was to much imformation to take in and
Pulmonary Rehab broke all that information down and it was eadier to digest over the
programme. It also helped her understand the importance of stopping smoking.
We also discussed smoking cessation Mrs A had already cut down her smoking hersefl
due to the breathlessness but after discussuions and councelling where she was ready
to quit.The importance of qutting smoking was discussed and how this will effect the
progression of the disease. As discussed the most important thing to do is to stop
smoking but this iwll not reverse the disease but will improve quality of life and slow
disease progression.
http://youandcopd.co.uk/living-with-copd.html
Mrs A was intersted if this would effect her medication if she was to carry on smoking. I
explained smoking can impair the effectiveness of COPD medication and studys have
shown this.
http://www.webmd.com/lung/copd/features/copd-quit-smoking
Mrs A came back to see myself for a stop smoking course and all aviable options were
discussed and we decided on double therapy as recommneded. The importance of
setting a quit date and making sure she fully understood the "NO PUFF RULE". We went
for NRT patches and lozenges as she felt sucking a lozenge would keep her mind off the

7. cigerrtets. I explained optium time to complete NRT is 12 weeks as we need to reduce
medication slowly and block receptors.
Intially Mrs A visited every week as she felt she needed more one to one sessions for
motivation. Week 3 MRs A had not adhered to the no puff rule but with a bit of support
and advice she got back on track. Mrs A did complete the course and we switched to
inlaetots at week 6 as she felt she needed to do somethign with her hands. She was a
succesfull quitter at week 12 and had struggled along the way but noted more energy,
she was sleeping better and could breath easier.
We did experience a few side effects such as increased appeitite which Mrs A did not
mind and constipation she was reassured this would return to normal and persisted
with her course.
Other than B12 injections and folic acid Mrs A took no regular medication.
Pharmacological intervention
After all asessments and investigations it was discussed with the GP and there was no
doubt of COPD due to symptoms and spirometry findings.
After discussions with Gp and referring to local precribing guidlines and the the nice
guidlines 2010. A Saba Short acting Beta Agonist was given and a Long Acting Muscarinic
agent. The two first line choices in Thurrock are Tiotropium 18mcg handihaler (LAMA)
and for the SABA Salbutamol PRN for breathlessness.
The above drugs work in different ways to relieve Mrs A symptoims. The Lama by
inhibiting the action of acetylcholine at muscarinic receptors using muscarinic
antagonists which in turn leads to better broncholidation.(BNF)
Salbutamol the SABA which was prescribed for MRs A to help relieve symtpoms of
breathlessnes and wheezing. This works by opening up the airways by dilating them.
http://www.patient.co.uk/medicine/salbutamol-inhaler
(inhaler technique)
As per local guidlines a rescue pack was issued to Mrs A in the event of a exacerbation
of her COPD and she hasd noted she was suffering with multiple chest infections which
was alsoe evdienced in her medical notes.
A pack with a full information leaflet of explaining when to use her rescue pack was
issued as supported in the nice guidlines

8. "Evidence of local arrangements to provide people who have had an exacerbation of
COPD with individualised written advice on early recognition of future exacerbations,
management strategies (including appropriate provision of antibiotics and
corticosteroids for self-treatment at home) and a named contact." (NICE 2010)
Standard rescue packs are 1st line Amoxicillin 500mg three times a day with
prednisolone tablets not enteric coated 30mg once dialy for seven days. If pencillian
allergic Doxycycline 200mg one day follwed by 100mg daily.
This was discussed with Mrs A when putting together a self management plan which is
supprted in effective managemt of patients with COPD. Nice 2010 A cochrane review
alos looked at studies of patients with COPD patients to manage excarebations and
understand the importance of when to recongize and respond appropriatelly to self
intitatyion of oral steroids and antobotics.
http://www.nursingtimes.net/nursing-practice/clinical-zones/respiratory/using-copd-
action-plans-to-manage-exacerbations/5043987.article
Self managemt plan discussed with MRS A were as follows so she understood what signs
to look for and so she could effectively manage thses at home
Green (When well)
• Normal colour of sputum
• Normal MRC score
• Any ankle swelling
• Normal cough
Also discussed drink plenty of fluids. Do not smoke, take regualr excercise, do not
run out of medication.
All medication wriiten down and to be adhered to and the importance of
compliance.
Annual flu vaccine
Amber (COPD MAy be getting worse)
• More breathless than usual

9. • a new cough or your usual cough has increased
• More frequent use of reliver inhaler
• Less energy and unable to dow hat you usually do
• Sputum has changed colour or increased sputum
Advised if she was experiencing more breathlessness than usual or had a
change in sputum production or colour she was to intiate her rescue pack or
contact us at the surgery
Advised to monitr symptoms closely and observe for two days
RED (Emergancy)
• High Feber
• Chest pain
• Extreme Shortness of breath with no relive
• Panic or confusion
Call Gp immdeiatelly o out of hours or 999
Mrs A was given all the above information on a card which was clear to
understand with contactd etails and doses she was required to take. The
patient relayed all this information back to myself and fully understood the
management plan.
I also ecplained she would be followed up once a yeat as she had moderate
COPD and would have repeat tests to make sure we were following her
disease progrssion and management but she could at any tiem contact me if
she had any questions. NICe 2010
Other areas of COPD management was discussed with MRS A such as

10. oxygen therapy. It was explained she did not fit that critrea as stated in the
Nice guidlines such as 92% air, no perpherial odema, cynasis amd fev1 less
than 30%. It was also explained the abstinece of smoking would help us noy
reach this point and maintain her quality of life. (More on 02 in copd)
Nutritoon was breifrly discussed but as she had full supoort at Pulmoanry
Rehab she was able to tell me more how she had managed to gain 2kg and
was eating a full and varied diet and understood the importance of this.
END OF LIFE discuss
Conclusion
Mrs A was succefsully picked up from her presnattion to the clinic from
her clinical history and symptoms. She came when concerned in changes
to her health and it was charactized due to her smoking history and
symptoms of COPD. She was not in denial that smoking had done damage
and taken its toll on her health and was engaging and actively wanted to
chnage her health.
Mrs A responded well to service she attended such as Pulmonary Rehab
and stop smoking services of which she completed succesfully adn felt she
had gained health benefits from.
I feel as a clinician we had followed all guidlines and local policies to
diagnosis Mrs A effectivelly and put in to place services she would most
benefit from.
She now is a non smoker who is still in meployment and has a further
understanding of her condition.