NRP/555 Adult And Geriatric Management


NRP/555 See attached and below. Wk 8 DQ Respones 1 & 2 Instructions NRP/555: Adult And Geriatric Management I Wk 8 Discussion – COPD • Post 1 reply to each of the following discussion responses from classmates or your faculty member. Be constructive and professional. • Each reply must be minimum of 175 words each. • Each response must have at least 1 scholarly peer reviewed reference or textbook listed below under references. • Must cite and list references in APA 7th edition format. Wk 8 DQ Response 1. Please reply as instructed above. Early diagnosis of COPD is essential for lifestyle changes including smoking cessation and symptom control (Dunphy et al., 2019). When a patient is diagnosed in the later stages smoking cessation is vital slow the rate of declining lung function and should be discussed in depth with the patient (Dunphy et al., 2019). This patient has been diagnosed with severe COPD which is a Grade C and the patient should be managed according to the most current guidelines. Dunphy et al. (2019) explain that the 2017 GOLD Guidelines suggest a long-acting muscarinic antagonist (LAMA, or if exacerbations continue, switch the patient to LAMA + LABA or LABA + ICS. Since this patient was diagnosed with severe COPD, he should be seen by his provider monthly and then annually once stable (Dunphy et al., 2019). If the patient meets the criteria, he may also need to be put on home oxygen (Dunphy et al., 2019). The patient qualifies for home oxygen if they (1) have a resting oxygen saturation less than 88%, or a PaO2 of 55 mm Hg or less or an oxygen saturation below 88% and (2) a PaO2 of 55 to 59 mm Hg with congestive heart failure, edema, erythrocytosis or cor pulmonale (Dunphy et al., 2019). The patient’s O2 goal is 90% or greater which usually can be done with 1 to 2 L of oxygen per minute. Education is vital as it is with any newly diagnosed condition and the patient should be reevaluated with an ABG or oximetry at 1, 3, and 6 months and then annually (Dunphy et al., 2019). Reference Dunphy, L., Winland-Brown, J.E., Porter, B.O., & Thomas, D.J. (2019). Primary Care: The art and science of advanced practice nursing (5th ed.) Philadelphia: F.A. Davis. Wk 8 DQ Response 2. Please reply as instructed above. The GOLD standard stands for the Global Initiative for Chronic Obstructive Lung Disease. This standard helps providers to diagnose COPD and serves as a guideline for treatment options. COPD is defined as “COPD is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases. ” (Morroq, 2018). More specifically, it is a combination or small airway disease and parenchymal destruction. Bronchodilators are still the treatment of choice for COPD patients. For episodic symptoms a LABA or LAMA are recommended. For persistent symptoms and LABA & LAMA are recommended.In patients which exacerbation’s, LABA & LAMA or LABA & ICS are recommended. For future exacerbation’s, roflumilast or macrolides are recommended, specifically in smokers. The revisions made to the GOLD standards in 2017 are intended to simplify the process so providers can individualize treatment for patients. Success would be measured by a decrease in exacerbations. Reference Morrow, R. (2018, February). New GOLD standard in COPD guidelines. World of Irish Nursing and Midwifery, Textbook Dunphy, L. (2019). Primary care: The art and science of advanced practice nursing (5th ed.). F.A. Davis. Original Discussion Questions to have the entire scenario or idea of DQ responses. Imagine you are examining a 65-year-old man who smokes 40 packs of cigarettes in a year. He complains of shortness of breath. Spirometry finds he has severe obstructive nonreversible lung disease. • Which treatments would you use after consulting the GOLD standards? Which would you do first? • How would you measure success? • How would you handle the situation if the patient does not have insurance?


NRP/555 Response 1

It is true that patients categorised in severe COPD groups C and D need to be prescribed with either a long-acting anticholinergic or with a combination of a long-acting beta2 agonist and an inhaled corticosteroid. Research has shown that fluticasone/salmeterol (Advair) has a higher capacity to decrease mortality and increase daily symptom scores compared to tiotropium alone. It was however seen to increase the incidences of pneumonia and does not alter the rate of exacerbations. Patients such as the one in question who have poorly controlled symptoms therefore need to first start with triple therapy with a long-acting anticholinergic bronchodilator, an inhaled corticosteroid, and a long-acting beta2 agonist. Research has found data for triple therapy to be consistent in showing improved lung function as well as improved symptom scores (Dunphy, 2019).

It is however also important to discuss the means by which treatment success can be measured. An important marker in determining the severity of COPD symptoms and treatment algorithms for the same is Post-bronchodilator forced expiratory volume (FEV1). This is used to indicate how COPD is progressing. The percentage predicted value of FEV1 and the fixed ratio of forced vital capacity (FEV1/FVC) are used in diagnosing COPD, staging it according to GOLD guidelines and in its treatment (Mirza et al. 2018).

In the event that the patient is not insured, their physician could also educate them on the role of Medicaid in treatment of COPD among the insured and the under-insured. Other suggestions that can be given include avoiding triggering exacerbation, and looking into government assistance programs.

Response 2

While the treatment course discussed is accurate, it is important to note that smoking cessation is the first step in treating COPD especially in cases where the patient is diagnosed with groups C or D. This will ensure that lung function deterioration does not proceed at the current rate which is a function of the risk factor in question. The individualization of treatments for patients could also cover the issue to do with lack of insurance. Individuals without insurance could receive treatment plans that involve the use of generic medication, patient assistance programs from drug manufacturers, government assistance programs and avoiding triggering exacerbations. Treatment success is another important aspect of not only COPD but of all other chronic illnesses. In the case of COPD, Post-bronchodilator forced expiratory volume (FEV1) can be used to determine the rate of deterioration at diagnosis and during and after treatment so as to compare (Dunphy, 2019).

COPD may also be treated through surgery. One such surgery is lung volume reduction surgery. The surgeon removes small wedges of lung tissue that are damaged from the upper part of the lungs. This will create additional space in the chest so that the healthier tissues that remain can expand and the diaphragm is able to work more efficiently. A long transplant may be an option for the patient if his lung function continues to deteriorate at the current rate. However, unless he ceases to smoke, he may not meet some of the criteria for a lung transplant. Finally, the patient could undergo a bullectomy. This is where the bullae or large air spaces form in the air sacs of the lungs are destroyed.  The choice of treatment is therefore dependent on several factors including the level of deterioration in lung function as well as whether or not the patient continues to be in contact with risk factors (Mirza et al. 2018).


Dunphy, L. (2019). Primary care: The art and science of advanced practice nursing (5th ed.). F.A. Davis.

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