Nursing Care for Chronic Obstructive Pulmonary Disease

Introduction

In nursing care, it is important nurses remain committed to treating any patients with physical alignment and are responsible to resolve their mental or emotional needs apart from physical health needs. The nurses are responsible to be empathetic and calm as it helps them in developing effective relationship with the patients which is important for delivering care with collaboration and competence from the patients (Østergaard et al., 2020). For those engaged in writing on nursing topics, seeking healthcare dissertation help can provide valuable insights into the complexities of patient care. In this essay, the nursing care of Mr W who is suffering from chronic obstructive pulmonary disease (COPD) and is 62-years-old is to be discussed with key focus on the role played by the nurses. The way assessment and planning of care for Mr W is developed is to be explained from the nursing perspective. Thereafter, the nursing intervention made and the outcome of the intervention for Mr. j is to be discussed and analysed.

Case Study

The part 5 of the NMC Code of Conduct mentions that the privacy and confidentiality of the patient are to be ensured under all conditions by avoiding sharing their personal identity beyond the need in their care (NMC, 2018). Thus, the pseudonym Mr W is used to mention the patient so that his confidentiality and privacy is perfectly established. Mr W is 62-years-old who is admitted to the hospital due to increased breathlessness, wheezing, intensive coughing that has increased in the last 12 hours with sputum and feeling of fatigue. His deteriorated condition led his wife to immediately admit him to the hospital. The initial health history reported by Mr W’s wife during his admission is that he was diagnosed with mild chronic obstructive pulmonary disease (COPD) 1 year ago and have been provided medication. However, in the last six months, he has deliberately avoided taking medication on daily basis as he mentioned himself to be cured of the condition due to lack of any symptoms previously being experienced.

Mr W’s wife reported he has started smoking 30 cigarettes a day for the last 6 months which he was trying to quit for the past 1 year. His health history mentioned he smoked nearly 50 cigarettes a day in before being diagnosed with COPD which was reduced to one cigarette after following initial care. However, with the improvement of his condition, Mr W initiated to smoke heavily again. It was reported that Mr W’s wife is an active smoker at home and they live in Chatham, UK where the air pollution is high. Mr W is mentioned never to use face mask to protect him while going out even after knowing the air pollution in the area is high. The initial assessment of vitals of Mr W led to determine that he has heart rate of 74 bpm, body temperature of 37.5℃ and breathing rate of 27 breath/min.

Pathophysiology of COPD

The chronic obstructive pulmonary disease (COPD) is referred to as chronic inflammatory disease of the lungs that creates obstruction in the airflow from the lungs leading individuals to face shortness of breath and coughing as major impacts of the disease (Dunican et al., 2021). The pathophysiology of COPD indicates that inhalation of harmful gases such as cigarette smoke, polluted air and others leads to create inflammatory response in the inner lining of the airways. This is evident as harmful particles present in cigarette smoke leads to cause increased protease activity and reduce antiprotease action. The proteases in the lungs mainly work to breakdown elastin and connective tissues to normalise the process of tissue repair (Higham et al., 2019). However, in COPD patients, it is seen that the exceeding of protease activity compared to the anti-protease activity leads to support increased destruction of the inner lining of the tissues in the airways and alveoli causing hypersecretion of mucus (Kim, 2017). Mr W is seen to be actively smoking and this may have led to worsening his condition along with resulted in exacerbation of the symptoms of COPD.

In the study by Bodas and Vij (2017), it is mentioned that destruction of the alveoli in the lungs due to harmful exposure to gases in COPD patients leads to the formation of large air pockets known as bullae. The air pockets hinder the exchange of oxygen and carbon dioxide from the lungs as less air is allowed to enter and released from the alveoli. It is argued by Dunican et al., (2021), in COPD patients, increased mucus is found to build up in the airways that create collapsing impact while breathing. This reduces the airflow to the bronchial tubes in the lungs making individuals develop tightness of the chest and hindered breathing. The overabundance of goblet cells and increased sized mucus gland in lungs of COPD patients due to destruction of the inner lining of airway and alveoli leads to hyperproduction of mucus in the patient that results them to face chronic cough to breathe effectively (Leap et al., 2021). Thus, the destruction of the inner lining of the tissues that led to inflammation of airways in Mr W led him to face shortness of breath and increased coughing.

Assessment and Planning of Care

In determining the holistic needs and demands of Mr W, the health assessment by nurse is to be made by following Roper-Logan-Tierney Nursing Model (Roper, 1996). The specific model is to be used because it is effective in analysing and determining in the hindered activities of living faced by the patient and in which they are to be supported to ensure them better well-being in a continuous and consistent manner (Williams, 2015). The 12 key activities of daily living to be identified for patients are elimination, dressing and washing, safe environment, breathing, eating and drinking, mobilisation, body temperature, sexual expression, sleeping, working, communicating, dying and death (Holland and Jenkins, 2019).

In regard to elimination, body temperature, sexual expression, working, communicating, dying and death, Mr W reported no issues. However, he reported issues with dressing and washing, eating and drinking, mobilisation, sleeping, working and communicating due to shortness of breath and increased coughing. The individuals who actively involved in smoking develop COPD and face exacerbation of the symptoms related to the disease such as shortness of breath. This is because the harmful particles such as nicotine present in the smoke cause the defence mechanism of the lungs to be reduced, narrows the air passage by swelling the air tubes and destroy the alveoli or air sacs (Xiong et al., 2021). Mr W is actively involved in smoking increased number of cigarettes which is considered to have contributed towards his increased hindrance with breathing. In order to assess the level of shortness of breathing experienced by M, his breathing rate per minute is assessed by the nurse. The normal breathing rate of adults in resting stage is 12-25 breaths/min (Anzueto and Miravitlles, 2017). However, in case of Mr W, the breathing rate is recorded to be 27 breaths/min at rest which is considered to be abnormal.

The shortness of breathing in COPD patients is seen to cause lower oxygen saturation in the body which leads them to face hypoxemia that can result the patient facing adverse impact such as failure of organ system like heart, kidney and others (Baig et al., 2018). Thus, in relation to breathing assessment, the level of oxygen saturation in Mr W’s blood is assessed by using pulse oximeter. The normal oxygen saturation in healthy adults is 94-99% (Buekers et al., 2018). The oxygen saturation of Mr W indicates 88% which indicates that his blood has only 88% oxygen that is considered to be serious condition. In COPD patients, the spirometry test is performed to monitor and detect the efficiency of the lungs in supporting the exchange of air needed for enhanced respiration (Hoesterey et al., 2019). The normal value of FEV1/FVC ratio in the spirometry test is above 75 % (Kawachi and Fujimoto, 2019). However, the FEV1/FVC ratio in the case of W is mentioned to 70% indicating the individual is facing increased lung inefficiency in supporting exchange of gases contributing to the increased shortness of breath and coughing.

The health assessment factor further reported by the Roper-Logan-Tierney model mention presence of safe care environment is important. This is because safe living environment supports protection of the patient from harmful condition that instigates worsening of the disease and enhance their well-being (Roper, 1996). In the case of Mr W, it is seen that his wife is an active smoker indicating he is living in an unsafe environment where he is been exposed to secondary cigarette smoke which also worsens the COPD condition (Riesco et al., 2017). Mr W is found to living in an unsafe environment where the air pollution levels are high. This is evident as air quality level in Chatham where Mr W lives is found to have an average of 15.2 µg/m3 of P2.5 concentration (normal P2.5 concentration= 0-12 µg/m3) (kentonline.co.uk, 2020). The increased pollutants in the air lead to cause irritation of the airways resulting in individuals to face worsened condition with shortness of breath due to COPD (Doiron et al., 2019). Thus, Mr W needs the presence of a safe living environment to ensure the stability of his health with COPD. Therefore, the two key needs of Mr W to be immediately responded is breathing and the presence of safe living environment to control his COPD condition.

In order to meet the two key health needs of Mr W, the patient-centred care (PCC) approach is to be implemented by the nurse in framing the care plan for the individual. The importance of using PCC approach is that it helps the nurses to frame effective communication between them and the patients to develop collaborative decisions regarding the care to be delivered to the patients (Ali et al., 2021). As criticised by Gyllensten et al., (2020), lack of effective patient-centred approach leads them to feel lack of value in accepting care and lower satisfaction in care. This is because avoiding PCC approach leads the nurses to take own decision regarding care to be delivered to the patients and neglect effective communication to be established with the patients to form collaborative care decision which supports them to feel valued and satisfied. Thus, the PCC approach is to be used in planning care of Mr W where his opinion and needs regarding support are to be valued and understood based on which the final care plan is to be framed that meets his specific demands as well as promotes his well-being.

The PCC approach leads care to be delivered to the patients in specified manner and ensure transparency along with access effective compliance from them. This is because the PPC approach leads to support enhanced flow of knowledge to the patient by the nurses to make them develop informed decisions regarding care where they have clarified ideas regarding the need and way the specific care chosen is to be provided (Ali et al., 2020). Thus, the PCC approach is to be used for Mr W by the nurse to make him effectively comply with them in accepting the care without creating hindrances. As mentioned by Fors et al. (2018), PCC approach is important as it promotes independence in patients. This is because in the approach the patients are allowed to decide their personal care in informed manner. Thus, the PCC approach is to be used for Mr W so that he can feel motivated to accept care out of independence to decide and plan own care.

Role of Nurses in care

According to part 3 and 7 of the NMC Code of Conduct, the nurses are to meet all the physical, phycological and social needs of the patients along with frame effective communication with them to determine their needs and develop collaborative decisions regarding care to be delivered (NMC, 2018). Thus, during PCC approach for Mr W, the role of the nurse is to frame enhanced communication in understanding his key needs to be fulfilled which is already been done. The part 10 of the NMC Code of Conduct mentions nurses have the role of effectively documenting and recoding each aspect of the care for monitoring and follow-up care process (NMC, 2018). This is because documentation of the care by the nurses would help the physicians to determine the impact of each of the intervention suggested by them and the progress or deterioration in the health condition of the patient (Kurniawandari et al., 2019). Therefore, the nurse caring for Mr W has the role to appropriately document and record the care delivered to him in each step for exacerbated COPD management in the hospital.

The part 8 and 9 of NMC Code of Conduct mentions that nurses have the role to work cooperatively with other professionals and required to share knowledge, skills and experiences with one another in delivering quality care (NMC, 2018). This is important as cooperative care with the involvement of professionals from different disciple helps in the inclusion of expert ideas and skills to develop well-planed care for the patient (Gifford et al., 2018). Thus, the role of the nurse in caring for Mr W is to framed cooperative care by collaborating with colleagues and multi-disciplinary team to deliver him quality care support for COPD management. As argued by Grover et al., (2017), the failure of the nurses to play their role of delivering care to the patient in a respectable and valued manner leads to unsatisfactory care delivery. This is because lack of respect makes the patients feel ignored and undervalued of their opinion. Thus, role of the nurse in delivering care to Mr W is that they are top respect the individual under all conditions.

Nursing Intervention

The nursing assessment led to identify the two care goals which are supporting increased breathing efficiency and promotion of safe living environment to be accomplished through nursing intervention for Mr W. The shortness of breathing in Mr W can be improved by enhancing his breathing efficiency and increasing oxygen saturation in the blood. In this regard, the nurse is to provide 24% or 28% oxygen through venturi facemask as per instruction by the pulmonologist to Mr W to improve his breathing rate and increase the oxygen saturation in the blood to more than 90%. On reaching oxygen saturation in the blood above 95%, the nurse is to support Mr W involve in normal breathing process (Pisani et al., 2017). The oxygen therapy is important because it helps to provide increased amount of oxygen in the blood at a time that is unable to reached through normal breathing process. The normal oxygen concentration in the body would lead individuals to breathe normally with gradual effect out presence of adequate oxygen in the blood (Spadaro et al., 2018). The nurse would monitor the efficiency of breathing and oxygen saturation in the blood after the intervention for Mr W through use of pulse oximeter and detecting breaths/min.

The NICE guidelines mention that smoking cessation is to be supported for patients with COPD and in their surroundings to enhance their well-being and effective management of the condition (NICE, 2019). In this regard, the nurse with the help of professionals from smoking deaddiction centre is to intervene in including Mr W as well as his wife in smoking cessation program. This is because smoking cessation program helps to guide individual who are actively involved in smoking through information sharing, therapeutic intervention and medication regarding the way to quit smoking (Ianosi et al., 2018). The NICE guidelines mention that nicotine replacement therapy combined with use of bupropion or varenicline is used in supporting cessation of smoking (NICE, 2019). This is because they reduce the affinity of smokers towards nicotine use, in turn, making them gradually quit smoking (Van Eerd et al., 2017). The smoking cessation in case of Mr W as well as his wife is also to be reached so that safe living environment where Mr W is no more exposed to secondary smoke of cigarettes needed for COPD management can be established by the nurses.

The initial case history of Mr W mentions that he avoided taking medication in continuously manner for COPD which leads to exacerbation of the condition leading him to suffer shortness of breath and other symptoms. Thus, to improve the breathing efficiency of Mr W with COPD in long-term conditions, as a nurse effective education regarding the need of continuing the specific medications such as bronchodilators, inhalers including short-acting beta2 agonists (SABA) and short-acting muscarinic antagonists (SAMA) is to be provided to Mr W and his wife who is also his carer. Moreover, way to remember taking medication through use of medication remembering applications is to be informed as nursing intervention for Mr W. The other nursing intervention for Mr W to promote his enhanced breathing is that he is to be educated regarding the way to perform pursed-lip breathing and other exercises. This is because pursed-lip breathing along with other exercise is seen to promote the lung functioning of COPD patients which helps them to breath effectively (Mohamed, 2019). In order to create safe environment for breathing within the home of Mr W, the nurses are to educate him regarding the way he can limit humidity and use indoor plants to purify the air. The nurse would also intervene to mention Mr W regarding the way and situation in which pollution prevention masks are to be used so that polluted air in his living surrounding and outside does not pose as risk for exacerbation of COPD symptoms in him.

Analysis of the outcome of nursing intervention

The analysis of the outcome of the nursing intervention of providing oxygen therapy to Mr W indicates that it helps in improving his breathing rate and oxygen saturation in blood. This is because the therapy allows increased amount of oxygen to be delivered to the lungs and within the bloodstream that gradually helps individuals to breathe in better way and overcome breathlessness (Pisani et al., 2017). The analysis of the outcome of nursing intervention for Mr W which is ensuring his enhanced medication adherence indicates that it would help in improving his breathing efficiency in long-term and ensure greater well-being while living with COPD. This is because medications such as short-acting beta2 agonists (SABA) and short-acting muscarinic antagonists (SAMA) take in adequate dose through inhaler helps in activating specific B2- adrenergic receptors on the smooth surface of the airways. This increases the level of cyclic adenosine monophosphate (cAMP) and ensures smooth muscle relaxation leading to widening of the airways and allowing enhanced exchange of air needed for normal respiration among COPD patients (Barstow and Forbes, 2019).

The involvement of patient Mr W and his wife together in smoking cessation program as nursing intervention led to analyse that as outcome enhanced health of Mr W and his wife is to be reached. This is because involvement of smoking cessation of couples at the same time helps to create support of partner for one another to effectively overcome the habit needed for their improved health (Gallus et al., 2018). The nursing intervention of mentioning Mr W to use face mask while going outside and promoting less polluted air in the room led to analyse that it would create less chances of exacerbation of COPD in future for Mr W. This is because it would lead Mr W to avoid exposure to polluted air that causes irritation of the airways in COPD to be inflamed and support breathlessness in COPD patients (Woldeamanuel et al., 2019).

Conclusion

The above discussion mentions that Mr W is suffering from COPD leading him to face increased shortness of breath. This is due to increased presence of mucus in the lungs, loss of elasticity of the lungs to support normal amount of air to be moved in or out, destruction of alveoli and inflammation of the inner lining of the airways that narrows the airways creating difficulty in air movement. The patient-centred care approach is taken in framing the nursing intervention for Mr W to support resolving his two key needs that are improved breathing efficiency and safe living environment free of pollution and exposure to secondary cigarette smoke. For this purpose, the nursing intervention such as supporting patient take adequate medication like SABA or SAMA, oxygen therapy, smoking cessation of patient and family members, use of face mask, use of indoor plant and others are made for Mr W.

Continue your journey with our comprehensive guide to Nurse Burnout in Dementia Care.

References

Ali, L., Wallström, S., Ekman, I., Swedberg, K. and Fors, A., 2021. Effects of person‐centred care via telephone on self‐efficacy in patients with chronic obstructive pulmonary disease: Subgroup analysis of a randomized controlled trial. Nursing Open, 8(2), pp.927-935.

Ali, L., Wallström, S., Barenfeld, E., Fors, A., Fredholm, E., Gyllensten, H., Swedberg, K. and Ekman, I., 2020. Person-centred care by a combined digital platform and structured telephone support for people with chronic obstructive pulmonary disease and/or chronic heart failure: Study protocol for the PROTECT randomised controlled trial. BMJ open, 10(7), p.e036356.

Anzueto, A. and Miravitlles, M., 2017. Pathophysiology of dyspnea in COPD. Postgraduate medicine, 129(3), pp.366-374.

Baig, M.M.A., Hashmat, N., Adnan, M. and Rahat, T., 2018. The relationship of dyspnea and disease severity with anthropometric indicators of malnutrition among patients with chronic obstructive pulmonary disease. Pakistan journal of medical sciences, 34(6), p.1408.

Bodas, M. and Vij, N., 2017. Augmenting autophagy for prognosis based intervention of COPD-pathophysiology. Respiratory research, 18(1), pp.1-8.

Buekers, J., De Boever, P., Vaes, A.W., Aerts, J.M., Wouters, E.F., Spruit, M.A. and Theunis, J., 2018. Oxygen saturation measurements in telemonitoring of patients with COPD: a systematic review. Expert review of respiratory medicine, 12(2), pp.113-123.

Doiron, D., de Hoogh, K., Probst-Hensch, N., Fortier, I., Cai, Y., De Matteis, S. and Hansell, A.L., 2019. Air pollution, lung function and COPD: results from the population-based UK Biobank study. European Respiratory Journal, 54(1).pp.78-90.

Dunican, E.M., Elicker, B.M., Henry, T., Gierada, D.S., Schiebler, M.L., Anderson, W., Barjaktarevic, I., Barr, R.G., Bleecker, E.R., Boucher, R.C. and Bowler, R., 2021. Mucus plugs and emphysema in the pathophysiology of airflow obstruction and hypoxemia in smokers. American Journal of Respiratory and Critical Care Medicine, 203(8), pp.957-968.

Dunican, E.M., Elicker, B.M., Henry, T., Gierada, D.S., Schiebler, M.L., Anderson, W., Barjaktarevic, I., Barr, R.G., Bleecker, E.R., Boucher, R.C. and Bowler, R., 2021. Mucus plugs and emphysema in the pathophysiology of airflow obstruction and hypoxemia in smokers. American Journal of Respiratory and Critical Care Medicine, 203(8), pp.957-968.

Fors, A., Blanck, E., Ali, L., Swedberg, K. and Ekman, I., 2018. Person-centred telephone-support is effective in patients with chronic obstructive pulmonary disease and/or chronic heart failure-six-month follow-up of a randomized controlled trial. European Journal of Heart Failure, 20(S1), p.194.

Gallus, S., Lugo, A., Suatoni, P., Taverna, F., Bertocchi, E., Boffi, R., Marchiano, A., Morelli, D. and Pastorino, U., 2018. Effect of tobacco smoking cessation on C-reactive protein levels in a cohort of low-dose computed tomography screening participants. Scientific reports, 8(1), pp.1-7.

Gifford, W.A., Squires, J.E., Angus, D.E., Ashley, L.A., Brosseau, L., Craik, J.M., Domecq, M.C., Egan, M., Holyoke, P., Juergensen, L. and Wallin, L., 2018. Managerial leadership for research use in nursing and allied health care professions: a systematic review. Implementation Science, 13(1), pp.1-23.

Grover, E., Porter, J.E. and Morphet, J., 2017. An exploration of emergency nurses’ perceptions, attitudes and experience of teamwork in the emergency department. Australasian emergency nursing journal, 20(2), pp.92-97.

Gyllensten, H., Björkman, I., Jakobsson Ung, E., Ekman, I. and Jakobsson, S., 2020. A national research centre for the evaluation and implementation of person‐centred care: Content from the first interventional studies. Health Expectations, 23(5), pp.1362-1375.

Higham, A., Quinn, A.M., Cançado, J.E.D. and Singh, D., 2019. The pathology of small airways disease in COPD: historical aspects and future directions. Respiratory research, 20(1), pp.1-11.

Hoesterey, D., Das, N., Janssens, W., Buhr, R.G., Martinez, F.J., Cooper, C.B., Tashkin, D.P. and Barjaktarevic, I., 2019. Spirometric indices of early airflow impairment in individuals at risk of developing COPD: spirometry beyond FEV1/FVC. Respiratory medicine, 156, pp.58-68.

Holland, K. and Jenkins, J. eds., 2019. Applying the Roper-Logan-Tierney Model in Practice-E-Book. Elsevier Health Sciences.

Ianosi, E.S., Postolache, P., Macovei, L.A., Szathmary, M., Szasz, S., Nemes, R.M. and Jimborean, G., 2018. Smoking cessation in COPD patients by a selective partial nicotinic agonist. Rev Chim, 69(7), pp.1766-1769.

Kawachi, S. and Fujimoto, K., 2019. Usefulness of a newly developed spirometer to measure dynamic lung hyperinflation following incremental hyperventilation in patients with chronic obstructive pulmonary disease. Internal Medicine, pp.1212-18.

kentonline.co.uk 2020, Centre for Cities report lists Chatham as one of worst towns in country for air quality, Available at: https://www.kentonline.co.uk/medway/news/deaths-in-town-blamed-on-air-pollution-223018/ [Accessed on: 06 July 2021]

Kim, E.K., 2017. Pathophysiology of COPD. In COPD (pp. 57-63). Springer, Berlin, Heidelberg.

Kurniawandari, E., Fatimah, F.S. and Listiyanawati, M.D., 2019. Implementation of Documentation of Nursing Care in Wates Hospital. Jurnal Ners dan Kebidanan Indonesia, 6(2), pp.68-75.

Leap, J., Arshad, O., Cheema, T. and Balaan, M., 2021. Pathophysiology of COPD. Critical Care Nursing Quarterly, 44(1), pp.2-8.

Mohamed, S.A., 2019. The effects of positioning and pursed-lip breathing exercise on dyspnea and anxiety status in patients with chronic obstructive pulmonary disease. Journal of Nursing Education and Practice, 9(6).pp.34-67.

NICE 2021, Chronic obstructive pulmonary disease in over 16s: diagnosis and management, Available at: https://www.nice.org.uk/guidance/ng115/chapter/Recommendations#managing-stable-copd [Accessed on: 06 July 2021]

NMC 2018, Nursing and Midwifery Council, Available at: https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf [Accessed on: 06 July 2021]

Østergaard, B., Clausen, A.M., Agerskov, H., Brødsgaard, A., Dieperink, K.B., Funderskov, K.F., Nielsen, D., Sorknæs, A.D., Voltelen, B. and Konradsen, H., 2020. Nurses' attitudes regarding the importance of families in nursing care: A cross‐sectional study. Journal of clinical nursing, 29(7-8), pp.1290-1301.

Pisani, L., Fasano, L., Corcione, N., Comellini, V., Musti, M.A., Brandao, M., Bottone, D., Calderini, E., Navalesi, P. and Nava, S., 2017. Change in pulmonary mechanics and the effect on breathing pattern of high flow oxygen therapy in stable hypercapnic COPD. Thorax, 72(4), pp.373-375.

Pisani, L., Fasano, L., Corcione, N., Comellini, V., Musti, M.A., Brandao, M., Bottone, D., Calderini, E., Navalesi, P. and Nava, S., 2017. Change in pulmonary mechanics and the effect on breathing pattern of high flow oxygen therapy in stable hypercapnic COPD. Thorax, 72(4), pp.373-375.

Riesco, J.A., Alcázar, B., Trigueros, J.A., Campuzano, A., Pérez, J. and Lorenzo, J.L., 2017. Active smoking and COPD phenotype: distribution and impact on prognostic factors. International journal of chronic obstructive pulmonary disease, 12, p.1989.

Roper, N., 1996. The Roper-Logan-Tierney. Blueprint for use of nursing models: education, research, practice, and administration, (14), p.289.

Spadaro, S., Stripoli, T., Volta, C.A., Trerotoli, P., Pierucci, P., Staffieri, F., Bruno, F., Camporota, L. and Grasso, S., 2018. High-flow nasal cannula oxygen therapy decreases postextubation neuroventilatory drive and work of breathing in patients with chronic obstructive pulmonary disease. Critical Care, 22(1), pp.1-11.

Van Eerd, E.A.M., Risør, M.B., Spigt, M., Godycki-Cwirko, M., Andreeva, E., Francis, N., Wollny, A., Melbye, H., Van Schayck, O. and Kotz, D., 2017. Why do physicians lack engagement with smoking cessation treatment in their COPD patients? A multinational qualitative study. NPJ primary care respiratory medicine, 27(1), pp.1-6.

Williams, B.C., 2015. The Roper-Logan-Tierney model of nursing: A framework to complement the nursing process. Nursing2020, 45(3), pp.24-26.

Woldeamanuel, G.G., Mingude, A.B. and Geta, T.G., 2019. Prevalence of chronic obstructive pulmonary disease (COPD) and its associated factors among adults in Abeshge District, Ethiopia: a cross sectional study. BMC pulmonary medicine, 19(1), pp.1-9.

Xiong, R., Wu, Y., Wu, Q., Muskhelishvili, L., Davis, K., Tripathi, P., Chen, Y., Chen, T., Bryant, M., Rosenfeldt, H. and Healy, S.M., 2021. Integration of transcriptome analysis with pathophysiological endpoints to evaluate cigarette smoke toxicity in an in vitro human airway tissue model. Archives of toxicology, 95(5), pp.1739-1761.