Report on Rmg Sector in Bangladesh free essay sample

[pic] [pic] At first we desire to express our deepest sense of gratitude of almighty Allah. With profound regard we gratefully acknowledge our respected course teacher Mr. A. K. Nabil Ahmed for his generous help and day to day suggestion during preparation of the report. He is so much an inspiration and guidance to us that we are, short of words in expression our gratitude. We like to give thanks especially to our friends and many individuals, for their enthusiastic encouragements and helps during the preparation of this report us by sharing ideas regarding this ubject . And finally, thanks to my group members as he serious and prolific towards making this assignment. Once more time to Sir, we owe more than we can mention†¦Ã¢â‚¬ ¦mostly for teaching us to see the silver lining in every hard work [pic] [pic] [pic] 1. 1 Abstract The ready-made garment (RMG) industry of Bangladesh started in the late 1970s and became a prominent player in the economy within a short Period of time. The industry has contributed to export earnings, foreign exchange earnings, employment creation, poverty alleviation and the mpowerment of women. The export-quota system and the availability of cheap labor are the two main reasons behind the success of the industry. Shirts, T-shirts, trousers, sweaters and jackets are the main products manufactured and exported by the industry. Bangladesh exports its RMG products mainly to the United States of America and the European Union. The Ready Made Garments (RMG) sector plays a pivotal role in the economy of Bangladesh. This sector accounts for approximately 76% of the total export earnings and nearly 10% of GDP. . 2 Introduction Like other 3rd world countries Bangladesh is a developing country. Her economic development depends firstly on Agriculture and secondly on Industry. Although Bangladesh is not developed in industry, it has been enriched in Garment industries in the recent past years. For Bangladesh, the readymade garment export indu stry has been the proverbial goose that lays the golden eggs for over fifteen years now. Traditionally, the jute industry dominated the industrial sector of the country until the 1970s. Since the early 1980s, the RMG industry has emerged as an important player in the economy of the country. In the field of Industrialization garment industry is a promising step. It is making significant contribution in the field of our export income and in the economical development of our country. At present the government of our country earns billions of dollars by exporting ready-made garments products to other countries. We have not achieved this success over night; we have some elements that help us to achieve this success. At present we are competing with our neighboring country; India and China. Though we are earning a handsome amount of profit each year from this sector, the ready-made garment sector is suffering with a lot of problems. We should solve these negative situations by ensuring proper steps [pic]  ¦ Broad objective: To gather knowledge about the overall scenario of Ready-Made Garments (RMG) Sector in Bangladesh.  ¦ Specific objectives: To attain the broad objective following specific objectives were pursued .  ¤To know briefly about economic significant of RMG. To identify what factors are affecting an entrepreneur  ¤ To identify the performance of an entrepreneur. 1. 4 Scope This report is on a wide exporting sector of Bangladesh. So, mainly we have tried to focus on the following factors.  ¤Current scenario of ready-made garment industry.  ¤Reasons for a healthy growth  ¤ Reasons for having comparative advantages in the world market.  ¤ Economical and financial contribut ion of this industry in Bangladeshi economy.  ¤ Beside these, we also brought several foreign benchmarks and statistics for doing the research work in a better way. . 5 Mythology This report has been prepared on the basis of experience gathered through learning annual report. For preparing this report, I have also get information from website of BGMEA, BKMEA Export Promotion Bureau and many Government and non government organization. I have presented my experience and finding by using different tables, which are presented in the analysis part. The details of the work plan are furnished below:  ¦ Relevant data for this report has been collected primarily by direct investigations of different leasing company’s annual report and website. The information and data for this report have been collected from secondary sources. The secondary sources of information are annual reports, websites and different manuals.  ¦ Data collected from secondary sources have been processed manu ally and qualitative approach in general and quantitative approach in some cases has been used throughout the study.  ¦ Qualitative approach has been adopted for data analysis and interpretation taking the processed data as the base. So the report relies primarily on an analytical judgment and critical reasoning. 1. 6 Literature Review Several Organizations have analyzed aspects of the garment industry in Bangladesh. Of thevarious aspects of the industry, the problems and the working conditions of female workers have received the greatest attention. There are several studies including The Centre for Policy Dialogue (CPD), study by Debapriya Bhattacharya, Mustafizur Rahman and Ananya Raihan(2002) and International Finance Corporation (2007) study on this topic. Both of these studies use accepted survey and research methodology to analyze a wealth of data on the social and economic background, Contribution of the RMG sector. Professor Muzaffar Ahmad looks at the industrial organization of the sector and discusses robustness and long-term viability of apparel manufacturing in Bangladesh. Wiigton (2000) provides a good overview of this industry,especially the developments in the early years. Nidhi Khosla writes on the women worker in Journal of International Women’s Studies (Vol. 11 #1 November 2009). The Bangladesh Planning Commission under the Trade and Industrial Policy (TIP) project also commissioned several studies on the industry. Hossain and Brar (2004) consider some labor-related issues in the garment industry. Quddus (2006) presents a profile of the apparel sector in Bangladesh and discusses some other aspects of the industry. Quddus (2006) presents results from a survey of apparel entrepreneurs and evaluates the performance of entrepreneurs and their contribution to the success of this industry. Islam and Quddus (2006) present an overall analysis of the industry to evaluate its potential as a catalyst for the development of the rest of the Bangladesh economy. [pic] 2. 1 History: Once upon a time the cloth of Bangladesh achieved worldwide fame. Maslin and Jamdani cloth of our country were used as the luxurious garments of the royal figures in Europe and other countries. The British rulers in India didn’t develop our cloth industries at all. Rather they destroyed them and imported cloths from England. After the emergence of Bangladesh radical change has come to our garment sector. Garment industries started working from the 10s of the late century. 2. 2 An Overview of the Bangladesh Ready-Made Garment Industry: The RMG industry is the only multi-billion-dollar manufacturing and export industry in Bangladesh. Whereas the industry contributed only 0. 001 per cent to the country’s total export earnings in 1976, its share increased to about approximate 80 percent of those earnings in 2010. Bangladesh exported garments worth the equivalent of $12348 Million in 2010, which was about 3. 00 percent of the global total value ($276 billion) of garment exports. The country’s RMG industry grew by more than 15 percent per annum on average during the last 15 years. The foreign exchange earnings and employment generation of the RMG sector have been increasing at double-digit rates from year to year. Some important issues related to the RMG industry of Bangladesh are noted in table 1 Table 1. Important issues related to the Bangladesh ready-made garment industry |Year(s) |Issue | |1977-1980 |Early period of growth. | |1982-1985 |Boom days. |1985 |Imposition of quota restrictions. | |1990s |Knitwear sector developed significantly. | |1993-1995 |Child labor issue and its solution | |2003 |Withdrawal of Canadian quota restriction. | | | |2005 |Phase-out of export-quota system. | Source: Compiled by the author from Quddus and Rashid (2000), Mainuddin (2000) and databases of the Bangladesh Garment Manufacturers and Exporters Association, and the Export Promotion Bureau, Bangladesh Currently, there are more than 4,000 RMG firms in Bangladesh. More than 95 percent of those firms are locally owned with the exception of a few foreign firms located in export processing zones (Gonzales, 2002). The RMG firms are located mainly in three main cities: the capital city Dhaka, the port city Chittagong and the industrial city Narayangonj. Bangladesh RMG firms vary in size. Based on Bangladesh Garment Manufacturers and Exporters Association (BGMEA) data, Mainuddin (2000) found that in1997 more than 75 per cent of the firms employed a maximum of 400 employees each. Garment companies in Bangladesh form formal or informal groups. The grouping helps to share manufacturing activities, to diversify risks; horizontal as well as vertical coordination can be easily found in such group activities. Ready-made garments manufactured in Bangladesh are divided mainly into two broad categories: woven and knit products. Shirts, T-shirts and trousers are the main woven products and undergarments, socks, stockings, T-shirts, sweaters and other casual and soft garments are the main knit products. Woven garment products still dominate the garment export earnings of the country. The share of knit garment products has been increasing since the early 1990s; such products currently account for more than 40 percent of the country’s total RMG export earnings (BGMEA website). Although various types of garments are manufactured in the country, only a few categories, such as shirts, T-shirts, trousers, jackets and sweaters, constitute the major production-share (BGMEA website; andante, 2001). Economies of scale for large-scale production and export-quota holdings in the corresponding categories are the principal reasons for such a narrow product concentration. 2. Reason behind the Growth of RMG in Bangladesh: The prime reason why garment industries have come out to be the champion in the field of export is obviously the cheap labor. Women contribute to the working force in these garment factories, as they are relatively cheaper than men. 2. 3. 1 Low cost labor: As Bangladesh is an overpopulated country it is very easy for the garment industries to hire labors at a lower rate. At present the government of our country has announced minimum wage to the garment workers but the industries can still earn a handsome amount of profit by exporting their product. Although it has increase but comparatively it is still low. Source: Ministry of Labor and Employment, Bangladesh. July 26, 2010 |Class |Existing Wage |Announce Wage |Increase in % | |Grade-1 |5,140. 00 |9,300. 00 |80. 93% | |Grade-2 |3,840. 00 |7,200. 00 |87. 0% | |Grade-3 |2,449. 00 |4,120. 00 |68. 23% | |Grade-4 |2,250. 10 |3,763. 00 |67. 24% | |Grade-5 |2,046. 00 |3,455. 00 |68. 87% | |Grade-6 |1,851. 0 |3,210. 00 | 73. 47% | |Grade-7 |1,662. 50 |3,000. 00 |80. 45% | |Apprentice | 1,200. 00 |2,500. 00 | 108. 33% | 2. 3. 2 Export-quota system: The â€Å"export-quota system† in trading garment products played a significant role in the success of the industry. However, that quota system came to an end in 2004. Therefore, the competitiveness issue needs to be addressed, with special attention given to the long-term sustainability of the industry. Unilateral restriction, short-term arrangement (STA), long term arrangement (LTA), Multi-fiber. Arrangement (MFA) and finally the WTO Agreement on Textiles and Clothing (ATC) are the chronological steps through which the â€Å"export-quota system† was administered until it was finally abolished on 31 December 2004, making worldwide textile and garment trade quota-free. . 3. 3 Easy Communication: It is very easy industries to collect raw materials from other countries and they can easily export their produced goods to the other countries. 2. 3. 4 Government Support: Government is supporting directly and indirectly the industries and monitors their activities so that they can perform properly. Government reduces tariff and supply production factors like electricity and water to them 2. 4 Produ ct Tree Bangladesh exports about 63 items to different apparel markets. Ready-made garments manufactured in Bangladesh are divided mainly into two broad categories: woven and knit products. Shirts, T-shirts and trousers are the main woven products and undergarments, socks, stockings, T-shirts, sweaters and other casual and soft garments are the main knit products. Woven garment products still dominate the garment export earnings of the country. The share of knit garment products has been increasing since the early 1990s; such products currently account for more than 40 per cent of the country’s total RMG export earnings (BGMEA website). Although various types of garments are manufactured in the country, only a few categories, such as shirts, T-shirts, trousers, jackets and sweaters, constitute the major production-share (BGMEA website; and Nath, 2001). It needs to be mentioned here that Bangladesh produces a very limited categories of expensive and fashion oriented garments. Economies of scale for large-scale production and export-quota holdings in the corresponding categories are the principal reasons for such a narrow product concentration. Main apparel items exported from Bangladesh is shown in the tree – diagram drawn below: YEAR |WOVEN |KNIT |TOTAL | | | |SWEATER | | |1995-96 |1948. 81 |598. 32 |2547. 13 | |1996-97 |2237. 5 |763. 3 |3001. 25 | |2004-2005 | 3598. 20 |2819. 47 |6417. 67 | |2005-2006 |4083. 82 |3816. 98 |7900. 8 | |2006-2007 |4657. 63 |4553. |9211. 23 | |2007-2008 |5167. 28 |5532. 52 |10699. 8 | |2008-2009 |5918. 51 |6429. 26 |12347. 77 | 2. 5 Exporting Condition of Garments Industry: The R eady-Made Garments (RMG) industry occupies a unique position in the Bangladesh economy. It is the largest exporting industry in Bangladesh, which experienced phenomenal growth during the last 20 years. By taking advantage of an insulated market under the provision of Multi Fiber Agreement (MFA) of GATT, it attained a high profile in terms of foreign exchange earnings, exports, industrialization and contribution to GDP within a short span of time. The industry plays a key role in employment generation and in the provision of income to the poor. Nearly two million workers are directly and more than ten million inhabitants are indirectly associated with the industry. Over the past twenty years, the number of manufacturing units has grown from 180 to over 3600. The sector has also played a significant role in the socio- economic development of the country. [pic] |YEAR |EXPORT OF RMG |TOTAL EXPORT |% OF RMGS TO | | |(IN MILLION US$) |OF BANGLADESH |TOTAL EXPORT | | |(IN MILLION US$) | | |1983-84 |31. 57 |811. 00 |3. 89 | |1984-85 |116. 2 | 934. 43 | 12. 4 | |2000-01 |4859. 83 |6467. 30 | 75. 14 | |2001-02 |4583. 75 |5986. 09 |76. 57 | |2002-03 |4912. 09 |6548. 44 | 75. 1 | |2003-04 |5686. 09 |7602. 99 |74. 79 | |2004-05 | 6417. 67 | 8654. 52 |74. 15 | |2005-06 |7900. 80 |10526. 16 |75. 6 | |2006-07 |9211. 23 |12177. 86 |75. 64 | |2007-08 |10699. 80 |14110. 80 |75. 83 | |2008-09 |12347. 77 |15565. 9 |79. 33 | 2. 6 Contribution in National Income: When the garment industries 1st started to export, the sector was not paid much attention but the situation has changed and at present it is earning the highest amount of foreign currencies in ou r country. [pic]  ¦ Major Product Export from Bangladesh: |Year |Product |Export |% | | 2 |RMG |12347. 77 |79. 3 | |0 | | | | |0 | | | | |8 | | | | || | | | | |2 | | | | |0 | | | | |0 | | | | |9 | | | | | |Frozen Food |454. 53 |2. 92 | | |Tea |12. 29 |0. 8 | | |Raw Jute |148. 17 |0. 95 | | |Jute Goods |373. 18 |2. 40 | | |Leather |177. 32 |1. 14 | | |Others |1508. 06 |9. 69 | | | | | [pic] [pic] 2. 7. 1 Backward Linkage: Backward linkage means the use by one firm or industry of produced inputs from another firm or industry (Alan V Deardorff 2001) That means the finished garment relies on three steps; first level for converting fibers/cotton toyarns, second step for converting yarns to grey fabrics and the final step for converting gray fabrics to dyed, printed of other finished fabrics. Out of three steps, Bangladesh is only capable of knitting, finishing in knitwear sectors but far behind in producing yarn, fabrics which is a major factor for woven section. Only success came to a ccessories where 80% demand of our country was fulfilled. The success of the government industry very much depends on how effectively RMG sector linkages may operate backward and forward. If the manufacturer has effective control over the supply of raw materials, Components and ancillary services needed to produce final product. Then the production is likely to be interrupted. If the company develops an effective marketing service strategies that provide right signal, and if marketing and distributing system as a whole are effective for having the products reach the target markets, then the sales revenue for the company is likely to be maximized. It means that to minimize cost of production and maximize sales revenues both backward and forward linkages need to be integrated. Here the issue of developing backward linkages is discussed with reference to the desirability of having control over the supply of inputs of RMG industry, mainly, fabric, yarn and processing status (Siddique, 2004). These three steps are integrated into each other as shown in table 1. It shows that these three steps are essential for backward linkage integration (BGMEA, January 2005) Some other problems that the industries face #Some other problems of RMG sector Dependency on different countries for raw materials †¢ Illiterate, unskilled and unsatisfied Workers †¢ Lacking of Resources †¢ Political Instability †¢ Low Working Salary: †¢ Lack in Marketing Tactics †¢ M/C advancement is necessary †¢ Absence of easily on-hand middle management. †¢ Small number of manufacturing methods †¢ Lack of training organizations for industrial workers, supervisors and managers †¢ Fewer process units for textiles and garments †¢ Incompetent ports, entry/exit complicated and loading/unloading takes much time †¢ Time-consuming custom clearance [pic] 3. 1 SWOT Analysis: 3. 1. 1 Strengths 1. The biggest foreign currency earning industry. 2. Ancillary services, fees, commission are more. 3. RMG credit experts are available. 4. Competitors like China doesn’t have vertical integration. 3. 1. 2 Weaknesses 1. Backward Linkage industry is absent. 2. Automation is not cost effective in our country. 3. External raw materials supply. 3. 1. 3 Opportunities 1. Investment in Backward Linkage Industry. 2. Liberalized Globalization will push to improve the quality of the RMG products. 3. Composite plants will get advantage by reducing lead time. 3. 1. 4 Threats 1. WTO agreement 2. Pressure on Compliance issues from consumer groups. 3. Negative image of Bangladesh in the international market for less concern on human and social issues. [pic] 4. 1 Recommendation: Bangladesh economy at present is more globally integrated than at any time in the past. The MFA phase-out will lead to more efficient global realignments of the Garments and Clothing industry. The phase out was expected to have negative impact on the economy of Bangladesh. Recent data reveals that Bangladesh absorbed the shock successfully and indeed RMG exports grew significantly both in FY07 and (especially) in FY08. Due to a number of steps taken by the industry, Bangladesh still remains competitive in RMG exports even in this post phase-out period. Our Garments Industries can improve their position in the world map reducing the overall problems. Such as management labor conflict, proper management policy, efficiency of the manager, maintainable time schedule for the product, proper strategic plan etc. Government also have some responsibility to improve the situation by providing- proper policy to protect the garments industries, solve the license problem, quickly loading facility in the port, providing proper environment for the work, keep the industry free from all kind of political problem and the biasness. Credit must be provided when the industry fall in need. To be an upper position holder in the world Garments Sector there is no way except follow the above recommendations. We hope by maintaining proper management and policy strategies our country will take the top position in future.  ¦ Optimists see opportunities in challenges; pessimists see only challenges in opportunities.  ¦ With MFA phase-out US market for apparels is going expand dramatically as  ¦ uncompetitive US firms are compelled to make their exit. There will be enormous  ¦ opportunities for competitive players to make new breakthroughs in US market.  ¦ Bangladesh’s objective should be to retain the current share of 2. 5% in US market during the first 3 years of phase-out (2005-8). Then enhance the market share to 3% and above. Bangladesh should take the strategy of cautious Optimism [pic]  ¦ http://www. bgmea. com. bd/  ¦ http://www. bkmea. com/  ¦ http://www. epb. gov. bd/  ¦ http://www. bbs. gov. bd/  ¦ http://www. mincom. gov. bd/  ¦ http://w ww. btmadhaka. com/  ¦ http://www. epzbangladesh. org. bd  ¦ http://www. bangladesh-bank. org/  ¦ http://www. bangladeshknitwear. com/  ¦ http://www. nbr-bd. org/  ¦ http://www. fbcci-bd. org/  ¦ http://www. ideas. repec. org/p/pdb/opaper/50. html  ¦ https://www. cia. gov/library/publications/the-world-factbook/geos/bg. html  ¦ http://www. en. wikipedia. org/wiki/Bangladeshi_RMG_Sector Jacket Shirt Trouser Polo shirt Sweater ‘T’ Shirt KNITWEAR WOVEN RMG

Economic Development free essay sample

Nigeria as a developing economy cannot achieve full development without the contribution of the small and medium scale enterprises (SMEs). In most developed economies, the main stay of their economy has been attributed to the effectiveness of the small and medium scale enterprises (SMEs). Small and Medium Scale Enterprises (SMEs) is accepted globally as a tool for empowering the citizenry and economic growth. It has been associated with the rapid economic growth of countries in Asia and North America. In Nigeria efforts have been made by successive governments to reduce poverty and accelerate economic growth by increasing foreign direct investment, diversifying the economy, enacting policy frameworks which favor small business ownership and sometimes initiating employment and entrepreneurship programs. Nigeria as a developing economy needs the contribution of the small and medium scale enterprises (SMEs) to be able to become one of the twenty most industrialized economies by the year 2020. Therefore, the problem is to critically examine the role of the small and medium scale enterprises (SMEs) in the growth nd development of the Nigerian economy. We will write a custom essay sample on Economic Development or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page The role of Small and Medium Scale Enterprises in facilitating the economic development of any country cannot be underestimated. In Nigeria, for example, SMEs provide an average of 50 per cent of Jobs and same proportion of industrial output. Experts say that the SME sector, can thrive in Nigeria, if the government can address the challenges of poor infrastructure, lack of financing, multiple taxation and inconsistent government policy. The Africa Economic Analysis reported that, The proportion of Nigerian SMEs and heir impact on the economy is pretty much, similar to those in other countries of the world, especially in the advanced economies. There are approximately 23 million small businesses in the United States. These altogether employ more than 50 per cent of the private workforce, and generate more than half of the nations Gross Domestic Product. In the European Union, SMEs are seen as largely essential for European employment. Each year, one million new SMEs are set up in the European Union. SMEs account for 99. 8 per cent of all companies and 65 per cent of business turnover in the European Union. The Director-General of the Small and Medium Enterprises Development Agency of Nigeria, Alhaji Muhammad Umar, at a recent forum in Abuja said that the agency targets to develop a minimum of 10,000 small businesses which will in turn generate about one million Jobs annually. This study will attempt to denne what constitute small and medium scale enterprises (SMEs) from different authors, the challenges being faced by SMEs in Nigeria, the role of government in promoting the development and growth of SMEs, the role of financial institutions, and to also look at the role of the small and medium scale nterprises (SMEs) in the growth and development of the Nigerian economy. REFERENCES Central bank of Nigeria 2003, Seminar on small and medium industries equity investments scheme (smieis) publication of CBN Training Centre, Lagos. Edit Iukacs, 2003, The economic role of SMEs in world economy, especially in Europe, institute of business sciences, university of miskolic, Hungary. Normah M. A. 2005, SMEs: Building block for economic growth, Kuala Lumpur. Rotimi 0. , 2006, 6th African venture capital association conference, Dakar, Senegal.

The Poetry of Physics Flashcard

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Busniess ethics Essay Example | Topics and Well Written Essays - 500 words

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Introduction Of Copd Health And Social Care Essay Chronic Obstructive Pulmonary Disease is a group of chronic and progressive respiratory disorders that are characterized by an airway obstruction with little or no reversibility. Damage to the lungs continues to make breathing gradually more difficult over time. Two clinical conditions often associated under the diagnosis of COPD are chronic bronchitis and emphysema, which obstruct or limit airflow into the lung fields. Chronic bronchitis is the presence of chronic productive cough for three months in each of two consecutive years in a patient in whom other causes of chronic cough have been excluded. Emphysema is an abnormal permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis (Lewis, S., Heitkemper, M., Dirksen, S., OBrien, P., Bucher, L., 2007, p. 629). Most patients diagnosed with COPD suffer from both pathological conditions, but manifestations can vary significantly from patient to patient. According to Medline Plus (n.d.), Your airways branch out inside your lungs like an upside-down tree. At the end of each branch are small, balloon-like air sacs. In healthy people, both the airways and air sacs are spring and elastic. When you breathe in, each air sac fills with air like a small balloon. The balloon deflates when you exhale. In COPD, your airways and air sacs lose their shape and become floppy, like a stretched-out rubber band (Medline Plus, n.d., para.2). These disease processes affect the bronchi, bronchioles and lung parenchyma with predominance on distal airway. COPD is a growing health problem not only in the United States, but also worldwide. In 2005, approximately one in 20 deaths in the United States had COPD as the underlying cause. Smoking is estimated to be responsible for at least 75% of COPD deaths (Centers for Disease Control and Prevention, 2008, para.1). The Centers for Disease Control and Prevention (CDC) also estimates that there are over 119,000 deaths, 726,000 hospitalizations, and 1.5 million hospital emergency department visits are caused by COPD annually(Centers for Disease Control and Prevention, 2009, para. 2). Even more alarming are the statistics world-wide. The World Health Organization (WHO) (2007), revealed that currently 210 million people have COPD and 3 million people died of COPD in 2005. WHO predicts that COPD will become the third leading cause of death worldwide by 2030 (World Health Organization, 2009, para.3). With statistics this rampant, what exactly are the manifestations that cause COPD? Etiology/Prognosis: There are several causes of COPD. Of all potential inhaled pollutants, cigarette smoking is the primary risk factor thought to contribute to COPD. Patients with a history of smoking a pack per day, over forty years, are especially predictive of COPD development. Exposure to passive cigarette smoking, air pollution, occupational hazards such as dust or fine particles (coal or silica dust, asbestos) and childhood respiratory disorders such as severe viral pneumonia can also contribute to the development of COPD. The elderly, patients with a low body weight and clients with a history of alcohol abuse are also susceptible. Prognosis of COPD is highly dependent upon the degree to which the patients breathing is affected and the ability to manage dyspnea, the ability of the heart to oxygenate other body systems. It is also dependent upon how damaged the lungs are upon diagnosis and if they are able to continue to oxygenate the blood without difficulty. Early diagnosis of COPD can help identify predisposing factors; such as smoking, and help provide a better prognosis through smoking cessation and deep breathing exercises to help ensure that the disease does not progress. A late diagnosis, that has affected the patients ability to perfuse vital organs, can result in organ failure on multiple levels and prognosis can be very grim. Further evaluation may be needed to determine the full extent of damage from lack of tissue perfusion. Pathophysiology: Chronic Obstructive Pulmonary Disease can be a result of chronic bronchitis and emphysema. An enlargement and multitude of mucous glands are produced with chronic bronchitis, resulting in an increased mucous production and a characteristic cough. Apart from the amount of mucous produced; the quality of the mucous also becomes more viscous in nature, making it harder for the patient to expel. Accumulation of excess mucus causes airway obstruction in the peripheral airway and therefore an increase in airway resistance. Lymphocytes, neutrophils and macrophages also accumulate which can lead to fibrosis or a formation of excess fibrous connective tissue in the lung fields as an attempt to repair the area. Emphysema results in large part from an enlargement of airspaces distal to terminal bronchioles. The loss of elasticity of the lung tissue and the closure of small airways is due to the destruction of the alveolar walls. When the connective tissue is destroyed in the alveolar walls, protease is released, further destroying elastin and inhibiting the ability of the alveoli to recoil. Protease affects structural integrity of the alveolar wall. In a healthy individual, the ability of the alveoli to recoil helps to maintain the patency of the airway lumen, especially during expiration. With COPD, there is airflow limitation due to loss of alveolar attachments, inflammatory obstruction of airways and obstruction of the terminal branches with mucus. Airways begin to narrow due to the inflammation, resulting in a loss of elastic recoil and loss of alveolar attachments. Ciliary function in COPD is also abnormally impeded. Cilia in the airway wall normally acts as a force to help thrust mucus or other foreign bodies toward the trachea for expulsion from the body. This function is often impeded by the thick and firm mucus often seen with chronic bronchitis. Lack of ciliary function increases the risk of recurrent infections in the lungs due to accumulation of these foreign particles within the lung fields. Destruction of the alveoli and profuse mucous accumulation destroys the ability of the body to deliver oxygen, resulting in hypoxia. The patient suffering from COPD often struggles to breathe and hypoxic-related dyspnea systemically affects other areas of the body ofte n leading to pulmonary hypertension and heart problems such as heart attacks and right-sided heart failure. Patients with COPD are more prone to respiratory infections, lung cancer and depression. Signs and symptoms of COPD usually do not occur until significant damage to the lungs and other body systems have occurred. Signs and Symptoms: Patients with COPD usually present with signs and symptoms of both emphysema and chronic bronchitis to include a continuous hacking-type cough that produces a thick mucus which is often hard to expectorate. Patient may also complain of significant shortness of breath that presents particularly with exercise or exertion. Clients may also complain of difficulty sleeping with constant fatigue and an abrupt, unplanned weight loss. Patients typically also present with rapid breathing, barrel-like distention to chest and will sit often in a tripod position, leaning forward with arms braced against their knees, chair, or bed. This gives them leverage so that their rectus abdominus, intercostals, and accessory neck muscles all can aid in expiration (Jarvis, C., 2008, p. 449). Due to lack of oxygen the patient might also present with cyanosis of the skin, wheezing and chest tightness, with possible signs and symptoms of respiratory infection. Patients with COPD can also experience exacerbatio ns, which are periods or episodes where the patients COPD symptoms can suddenly worsen. Exacerbations can be caused by influenza, infections or exertion. Other contributing factors include a rapid change in humidity or temperature, exposure to smoke or other pollutants, allergens and dust. According to report from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2009), COPD can be broken down into four various stages to include: Stage I: mild COPD: Characterized by mild airflow limitation predicted. Symptoms of chronic cough and sputum production may be present, but not always. At this stage, the individual is usually unaware that his or her lung function is abnormal. Stage II: moderate COPD: Characterized by worsening airflow limitation with shortness of breath typically developing on exertion, with a productive cough. This is the stage at which patients typically seek medical attention because of chronic respiratory symptoms or an exacerbation of their disease. Stage III: severe COPD: Characterized by further worsening of airflow limitation, patient experiences an even greater degree of shortness of breath, reduced exercise capacity, fatigue, and repeated exacerbations that almost always have an impact on patients quality of life. Stage IV: very severe COPD: Characterized by severe airflow limitation with the presence of chronic respiratory failure. Respiratory failure may also lead to effects on the heart such as cor pulmonale (right heart failure). At this stage, quality of life is very appreciably impaired and exacerbations may be life threatening (GOLD Report, 2009, p.4). With the varying manifestations in the progression of the disease, providers must take into account the assortment of challenges and medical interventions necessary in the treatment of COPD. COPD: Medical Interventions Diet Plan: Needs and Modifications: Individuals with COPD have overall muscular weakness, including the respiratory muscles, that relates to systemic inflammatory process in the lungs. Diet is an important factor to take into consideration, especially in the elderly because the risk for malnutrition increases. COPD and malnutrition go hand in hand, malnutrition and a low BMI of Individuals who are underweight have an underlying problem that relates to an increased metabolism and the breakdown of essential nutrients for energy requirements. In these individuals it is best to modify their eating habits, with frequent breaks to decrease fatigue. It takes a lot of energy to metabolize food, breathing and eating become harder, [the individual] may have to choose between taking a gasp of air or a bite of food (ONeill, 2004, para. 3). For those who are overweight, the problem as it relates to COPD is due to excess abdominal fat. Abdominal fat prevents the diaphragm from expanding completely, which causes a decrease in oxygen availability. This decrease in oxygen compromises the cardiovascular system due to the inadequate amount of oxygen being delivered to the heart and throughout the body. Both malnourished and obese individuals need to monitor weight, food and fluid intake daily. According to Peggy ONeil (2004), intake of fluids, calories, protein, calcium and potassium all play a role in protecting immunity and easing breathing (ONeil, 2004, para. 8). The American Lung Association states that the metabolism of each [nutrient] requires a different amount of oxygen and produces a different amount of carbon dioxide. Metabolism of carbohydrates produces the most carbon dioxide for the amount of oxygen used; metabolism of fat produces the least (American Lung Association, 2010, para. 3). Good sources of fat should come from unsaturated fats such as nuts, olive oil, soy and avocados. Protein is essential for muscle repair and assists in the healing process when an infection or injury occurs. ONeil recommends that generally two cups of milk plus six ounces of protein from other sources each day provide four servings of high-quality protein, good sources of protein, which is adequate for someone with COPD (ONeil, para. 12). Potassium is found in fruits, vegetables, dairy products and meats [and are] key to control blood pressure, muscle contraction, and nerve impulses transmission. Normal serum potassium levels help with optimal muscle contraction to aid breathing (ONeill, para. 15). Excessive need for increased nutritional intake is imperative for the adequate daily functioning and maintenance in the COPD client. In order to facilitate sufficient digestion and proper absorption of food the patient should remain upright after meals to prevent the stomach from pushing on his diaphragmà ¢Ã¢â€š ¬Ã‚ ¦limit intake of carbonated beveragesà ¢Ã¢â€š ¬Ã‚ ¦[and to consume] soft, easy-to-chew foods to prevent him from becoming short of breathe while eating (ONeil, 2004, para. 16). Consumption of clear fluids should be encouraged to prevent dehydration and also to help thin mucous secretions. Appropriate Medications and Diagnosis: Although there is controversy over the amount of oxygen to give a patient with COPD, it is generally understood that the long term use of oxygen therapy improves survival, exercise capacity, cognitive performance, and sleep (Lewis et al., p. 640). There are various ways that oxygen therapy can be administered to a patient with COPD. In hospitals the most precise delivery of oxygen therapy is through the use of the venturi mask, however most patients prefer to use the nasal cannula. The structure of the nasal cannula allows the patient to perform daily activities such as eating and talking without interrupting oxygen delivery. When oxygen therapy is used in conjunction with smoking cessation it improves the patients quality of life by increasing the amount of available oxygen and increasing systemic perfusion. Depending on the severity of COPD, bronchodilators such as beta2-antagonist, anticholinergic, and methylxanthine (Lewis et al., 2007, p. 639) will be given to relax the smooth muscles of the airway, and to increase gas exchange. These medications can be administered as an inhalant or by the oral route. For those experiencing moderate-to-severe COPD, glucocorticoid therapy may be combined with a bronchodilator to decrease inflammation of the airways. Inhaled glucocorticoids are preferred over oral glucocorticoids for long term treatment, because oral treatments can lead to adrenal insufficiency and Cushings syndrome. (See Appendix A). Patient should expect to experience improved oxygen utilization. Diagnostic Tests and Lab Work: Pulmonary functions test measures the intake and output of air in the lungs and is used to confirm the diagnosis of COPD. There are four components to pulmonary function testing, [which consist of]: spirometry, postbronchodilator spirometry, lung volumes, and diffusion capacity (Chronic Obstructive Pulmonary Disease Diagnosis, 2010, para. 3). Also, there are many diagnostic studies that support the diagnosis of COPD, such as chest x-rays, arterial blood gases, echocardiogram and electrocardiogram (ECG) (Lewis et al., p. 638). X-rays are not the preferred method of diagnosing COPD since it cannot pick up abnormalities until COPD is in the later stages. Arterial blood gases are performed to monitor the amount of oxygen and carbon dioxide in the blood. In individuals with COPD typical findings are low PaCO2, elevated PaCO2, decreased or low-normal pH, and increased bicarbonate (HCO3) levels (Lewis et al., 2007, p. 638). COPD can cause right sided heart failure related to pulmonary hypertension so patient should be monitored regularly by ECG and echocardiogram. As discussed earlier, changes in the lungs are related to smoking, toxins in the environment or occupation. In order to identify the causative effects of these toxin, clinical trials are being conducted to development new diagnostic tests that are aimed at identify early neoplastic changes in the lung. For example, advanced imaging techniques such as the PET scan is able to reveal metabolically active nodule [that are] highly indicative of malignancy (Petty Miller, n.d. p. 7), that could not be found with prior diagnostic tests. Also, a tissue autofluorescence, which is an enhanced bronchoscopy technique, can indicate a high likelihood of malignancy (Petty Miller, p. 7) in the lung tissue, that cannot be seen in a CT scan or chest X-ray. Hopefully, these clinical studies as they become available to the general population, will not only identify acute changes in the lung structure in advance, but also could potentially assist in finding a cure for lung diseases. Treatment and Treatment Options: Medications can make COPD patients more comfortable, but there is no overall curative treatment. The disease itself extends beyond the airways and lungs to include other body systems, (Barnett, 2008, p. 30). The goal in treatment is aimed at the controlling the symptoms involved in these various areas of the body and to reduce the inflammatory response in the lungs. To do this, the patient will need to modify their diet and lifestyle habit to prolong the quality of their life. As discussed earlier, emphysema and bronchitis constitute the disease known as COPD. The management and treatment of these two diseases is necessary for the patient to live a quality life. The medical treatments used to treat COPD was reviewed earlier, there are also non-pharmacological treatment options available that slow the progression of the disease and the symptoms of chronic obstructive pulmonary disease. One non-pharmacological treatment option is pulmonary rehabilitation. The goal of this treatment is to: break the vicious cycle of increasing inactivity, breathlessness and physical de-condition, and improving exercise capacity and functional status as well as improving individual patients self-management skillsà ¢Ã¢â€š ¬Ã‚ ¦Pulmonary rehabilitation is conducted by physiotherapist and respiratory nurses. Each session is based on the patient exercise tolerance and consists of one to two sessions a week for about an hour, for 6-8 weeksà ¢Ã¢â€š ¬Ã‚ ¦ then followed by an educational component to enable to the patient to make lifestyle changes to help them cope better with living with COPD (Barnett, p. 31). There are various energy conservation techniques that a patient can use to improve the quality of available oxygen. Often COPD patients struggle to breathe. The overall goal of the following energy conservation techniques is to help the patient breath better and to improve activities of daily living by relieving the distressing symptoms that accompany COPD. According to Barnett (2008), these techniques are: Exhale during strenuous part of an activity and use pursed lips to reduce to work of breathing, alter strenuous activities with easier tasks, place items within easy reach, to reduce bending and stretching for items, If needed, use aids and equipment such as electronic wheel chairs and to sit down to perform many of the daily activities (Barnett, 2008, p. 32). With a healthy individual, there is a low residual of air that remains in the lung. With the COPD patient, the volume of trapped air is increased and therefore decreases oxygen exchange within the lungs. Stress reducing techniques can help relax the patient. Therefore the patient can exhale the excess retained carbon dioxide and inhale even greater amounts of saturated oxygen with each new breathe. Hence, the efficiency of oxygen and carbon dioxide exchange is improved. Individuals should be updated on immunizations, even more so if a patient has COPD. According to the CDC (2010) adult immunization schedule, patients with chronic lung disease are required to have one annual influenza and one or two pneumococcal inoculations within the patients lifetime (CDC, 2010, p. 2). If the patient becomes infected with influenza or pneumonia, damage to the lung fields can be exacerbated if not treated quickly and can possibly lead to death. COPD: Holistic Assessment of Patient Scenario: Mr. Johnson is a 73 year old male who has presented to the Emergency Department for the third time this week with dyspnea. Patient has been smoking a minimum of one pack per day for the past 46 years. Patient is currently on two liters of supplemental oxygen at home via nasal cannula and states that he cannot seem to catch his breath. Mr. Johnson is leaning over the side of the bed in tripod position, gasping with supraclavicular retractions noted on inhalation. As a nurse, what do you think could be wrong with your patient? Physical Assessment Upon further evaluation, the nurse notices that Mr. Johnson also has a non-productive hacking-type cough that has persisted throughout the triage process. Mr. Johnson complains, I just cannot seem to get this thick mucus up out of my throat and I feel like I am suffocating, like I cannot catch my breath! Patient appears to be bracing himself over the side of the chair in a tripod position. The nurse is a waiting for the provider to place orders in the computer for the clients chest x-ray. A venturi mask is placed on the patient and oxygen delivery is set to be administered at three liters of oxygen per minutes. This intervention successfully alleviates the patients rapid and shallow respirations, as well as the circumoralcyanosis. Upon auscultation the nurse notices diminished lung sounds over the left and right lower lung fields with auditory wheezing upon exhalation. The nurse also notices a barrel-like distention to the patients chest. The nurse begins to take the patient to radio logy and abruptly stops as the patient begins to weep inconsolably. What could be the likely factor associated with the emotional reaction exhibited with the patient? Psychosocial Assessment: To make an accurate assessment of the patients psychological reaction, the nurse casually begins to inquire about the patients daily activities. The patient divulges to the nurse that he has lost his job, is no longer able to care for himself and feels a sense of guilt that he has become burdensome on his family members. Patient states, I have a loving family, but feel as though they would be better off without me. I know I shouldnt feel this way, but I have been depressed and feeling lonely for some time now. The nurse recognizes that the patient is displaying signs of depression, low self-esteem and lack of autonomy with loss of control over his personal life. The priority nursing interventions for this patient should include a referral to a mental health agency and community outreach programs that can assist the patient to meet the psychological strains produced by his current health situation. The patient then covers his face and whispers in a soft undertone, I cannot even afford to pay for my groceries, much less this visit! How can I afford this referral? With this statement in mind, what priority nursing assessment should the nurse consider? Socioeconomic Assessment: Mr. Johnson is one of many faces dealing with the strains and financial hardship associated with COPD. The overall costs of COPD are overwhelming. According to the Harvard University (2008), the annual cost to the nation for COPD (emphysema and bronchitis) is approximately $32.1 billion, including healthcare expenditures of $18.0 billion and indirect costs of $14.1 billion (Harvard University: Healthcare delivery- Deconstructing the costs, 2008, para 58). The global statistics are even more astounding. According to the American College of Chest Physicians (2003), the global direct yearly costs of chronic bronchitis and COPD patient was $1876. The cost generated by the patients with COPD was $1,760.00 [per patient/year/costs], but the cost of severe cases ($2,911 per year) [per patient/year/costs] was almost double that of mild cases ($1484 per year) [per patient/year/costs] (Miravitlles, Murio, Guerrero, Gisbert, 2003, p.786). With these statistics in mind, what are some of the teac hing points that a nurse can utilize to assist the COPD patient? Health Teaching and Community Resources: The nurse must take in various considerations when assisting the COPD patient. How well is the patient able to tolerate activity? Does the patient suffer from dyspnea related disturbance in their sleep pattern? What are the patients physical or financial resources? A patient that has a hard time meeting monthly utility bills is far less likely to be compliant with a medical regime. The nurse should focus on trying to coordinate social work service to help the patient to meet healthcare needs. If the patient has a family member, how does this affect his or her role if they are primary breed winner in the family? Interview should point out any psychological stressors that may be affecting the patient and should determine if therapy may be required. Primary education should focus on convincing the patient to quit smoking. Inform the patient to keep up to date on immunizations such as annual flu and pneumonia vaccines. Patient should compliantly take prescribed medications and avoid second-hand smoke or exposure to other irritants such as dust, smog, extreme heat or cold and high altitudes, pollutants that can exacerbate symptoms. COPD patients must increase fluid intake to decrease viscosity of mucous secretions in addition to maintaining an adequate nutritional status to facilitate extra nutritional requirements. Diets should be low in saturated fat and should include various fruits, vegetables and whole grains. Highly emphasize to the patient that use of oxygen therapy should be only used as directed and control of respirations with pursed lip technique. Direct the patient to take frequent breaks to minimize fatigue. Pacing of activities throughout the day will minimize undue stress on the lungs. It may be necessary to coordin ate follow-up appointments for the patient; however signs and symptoms such as shortness of breath, wheezing or the desire to lean forward to aid in breathing will warrant an earlier visit. A trip to the emergency room will be necessary if the patient starts to have sudden, severe shortness of breath, or if they become lightheaded, weak, faint or experience chest pain with a rapid, irregular heart rate. Conclusion Chronic Obstructive Pulmonary Disease is a progressive and debilitating disease process that wreaks havoc on the patients cardiovascular and respiratory systems. Management of COPD can be maintained and symptoms minimized through adequate diet interventions, medication regimens, completing diagnostic exams and lab tests. Though COPD is a preventable disease, the realistic nature of the disease process requires a nurse that is knowledgeable, caring and sympathetic to the patients overall needs.