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| Did you learn about your disease
when you had your PFT?
Can you describe your disease?
What do you want to know about your disease?
Do you understand how your symptoms (difficult breathing, fatigue, increased secretions, others) relate to your disease?
Can you describe how the components of your treatment plan affect your symptoms?
Do you understand how you slow your disease by adhering to all interventions?
Do your medicines relieve your symptoms? |
Asthma/COPD are diagnosed primarily
from spirometry, which shows: 1) how much and how fast air is exhaled 2)
the extent of obstruction (airway limitation) - mild, moderate or severe,
3) degree of reversibility after medicines such as controllers and relievers.
Use chart data, including spirometry, and/or peak flows to illustrate airway limitation.
Patients may want to understand terms associated with PFT. Explain in lay terms.
COPD - Chronic -always with you. Obstructive - secretions, inflammation, swelling (controllable factors), permanent narrowing and other damage. Pulmonary - the lung system and its blood flow. Alveoli-air sacs. Italian for bunch of grapes.
Bronchoconstriction - the narrowing of the airways by irritation, allergens. Permanent or intermittent.
Air trapping - after damage, small airways collapse on exhalation; air is trapped in alveoli.
Bullae - air trapping breaks small blood vessels and alveoli, making large ones unusable in exchanging O2 and CO2. This causes increase in ventilation to fill this "dead space"; work of breathing increases.
Work of breathing - the energy expended to maintain the body’s metabolic needs. The more weight, disease and activity, the harder lungs and heart have to work. Work decreases when muscles are conditioned.
O2 saturation - the amount of O2 in hemoglobin. O2 Sat depends on type/extent of disease.
Smoking inflames airways, and over time kills cilia (brushes), increases secretions - airway clearance less effective. |
The patient:
Describes basic lung changes underlying symptoms.
Describes relationships between symptoms and specific test results.
Describes reasons for treatment and action plans in terms of underlying disease processes.
Describes the expected course of the disease and its severity.
Reads or otherwise becomes familiar with available written materials and identifies additional resources for disease information. |
Physician; PFT technologists RCPs,
respiratory Nurse specialists.
Provide lists of additional resources if patient desires: written materials, organizations to contact (American Lung Association, asthma organizations and Lung Clubs) |
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| Do you understand why your are
prescribed these medicines?
What is the dose and frequency for each drug?
What does each drug do?
What are the undesirable side effects with each of these drugs?
Which drug is your controller and which is your reliever?
Why should you only take relievers when you have worsening of difficult breathing?
Why do you only take your Salmeterol BID? |
The written medication management
plan identifies:
Medication information sheets providing actions, potential side effects and adverse reactions are generally given to each patient by the Pharmacy Service. The provider should be familiar with these sheets.
Categories of Inhaled medicines:
1. Controller or Preventer medicines - anti-inflammatory agent and steroids. Effects not immediately apparent but are the most important in treating the underlying inflammation of the airway in Asthma/COPD.
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The patient:
identifies each medication of prescription.
states the action for each drug.
identifies dose and frequency for each drug.
describes possible side effects for each drug.
knows who to call or what to do when there is an adverse effect.
Differentiates controller from relievers.
Differentiates fast relievers from slow reliever and knows the importance of using each as directed.
States that Salmeterol does not take effect for a few hours but lasts a long time. |
Seek assistance of respiratory
care practitioners.
Respiratory Nurse specialists
Pharmacists
to supplement or provide teaching elements. |
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| Show me how you use your inhaler?
Do you have difficulty using your inhaler?
Why do you use your holding chamber with the inhaler?
When do you use your holding chamber with your inhaler?
Do you know that you can use tidal breathing with a holding chamber?
How do you clean your inhaler and holding chamber?
How do you know your inhaler is empty? |
Inhalers contain liquid under
pressure. When the canister is depressed it sprays a small particle mist,
which if used properly get to small airways and decrease bronchconstriction
or inflammation if there is a reversible response.
Demonstrate use of inhaler alone as described in expected skills. This technique is generally effective with the absence of difficult breathing and with excellent hand to mouth coordination.
Holding chambers differ from spacers. They have larger volumes to mix with medicine and a one way valve to allow tidal breathing when difficulty occurs.
Aerosol devices have high oral deposition. Up to 80%. With steroids, oral deposition is associated with opportunistic infections. Holding chambers reduce oral deposition.
Poor hand breath coordination, especially during difficult breathing can result in reduced drug delivery.
When experiencing difficult breathing, always use a holding chamber with the inhaler. This is effective with rapid shallow breathing. The lips must be kept tight around the mouthpiece during this type of breathing. Use inhaler with holding chamber as described in expected skills.
Inhalers and holding chamber are cleaned by washing every 3 days with mild soapy water. Rinse thoroughly and dry.
Floating canister in water may work with Albuterol. Best method is keeping count of actuations. |
The patient:
demonstrates proper technique of inhalers alone:
Demonstrates proper technique with holding chamber:
Describes cleaning procedure.
Calculates puffs based number of actuations. |
Seek assistance of:
respiratory care practitioners
respiratory nurse specialists
pharmacists to supplement or provide teaching. |
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| How do you assemble your nebulizer?
How do you mix medications for use with the nebulizer?
How long does the nebulizer treatment take?
How often do you clean your nebulizer?
How do you clean your nebulizer?
How often do you replace your nebulizer? |
Nebulizers may be ordered for
home use when inhalers (MDI) formulations are not available.
Nebulizers are often ordered inappropriately for fast relievers as patients claim to get more relief than with an inhaler. Generally, it is not the nebulizer providing the relief but rather the dose of medicine (about 12 times greater with the nebulizer than 1 puff of an inhaler after factoring for loss on exhalation). More puffs, with proper use of the holding chamber, will achieve the same end in less time(up to 12 puffs).
Nebulizer/compressor device combinations should be matched for proper output and particle size, nebulizer type and brand should not be changed by patient or vendor unless combination has been shown to perform adequately.
Unit dose medications for nebulizer use are more convenient and more expensive. Bulk medications need to be mixed properly and handled aseptically to minimize infection risk.
Nebulizers need to be cleaned between each use.
Change according to the Home Medical Equipment (HME) Company’s requirements. |
The patient:
demonstrates proper assembly of nebulizer with compressor.
mixes medications and place in nebulizer.
uses aseptic technique with bulk medications and solutions.
rinses nebulizer with water and shake dry between treatments,
washes daily with mild dish soap, every 4 days, after washing, soak in dilute (1:4 ) vinegar solution. |
Seek assistance of respiratory
care practitioners.
Respiratory Nurse specialist.
Pharmacists
to supplement or provide teaching elements.
Equipment vendors and HMEs need to be instructed to provide matched compressor nebulizer devices, and to provide educational materials consistent with those provided by the VA to the patient. |
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| Do you know what to do when your
breathing gradually gets worse?
When it gets rapidly worse?
Do you know who and when to call for help? When to go to the ER?
How does your peak flow affect your assessment?
How do you change your dose of controller?
How do you change your dose of relievers?
What do you do if you do not get relief? |
Written action plans indicate
a course of action when breathing gets worse (gradually or rapidly).
The plan elements include:
When using peak flow, follow the green, yellow, red zones. Refer to the Action Plan, approved by your primary provider, for instructions on when to increase or decrease medicines.
The manufacturer’s instructions on use of the peak flow are very good.
Doses of fast relievers can be increased during times when breathing becomes rapidly worse. Monitoring is critical so no more than a total of 12 puffs is taken within 24 hours.
Frequent use of fast relievers indicates failure to control breathing with maintenance medicines. It is important to discuss this with the primary provider. |
The patient:
recognizes intensity and frequency of symptoms.
identifies dose of medicine which relieves symptoms and conforms to action plan for controller medications.
calls clinician or comes to ER if reliever does not work after 12 puffs with holding chamber.
uses peak flow meter correctly.
brings, medicines, holding chamber, peak flow meter, medicine and symptom log on return visits.
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Seek assistance of respiratory
care practitioners.
Respiratory Nurse specialist.
Pharmacists
to supplement or provide teaching elements.
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| ASSESSMENT QUESTIONS |
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| How do you determine changes in
your breathing, cough, secretion color and volume and wheezing?
Do you have a symptom diary?
Do you use it?
Do you have a peak flow meter?
Do you use it?
What is your best peak flow when you feel good?
What is your predicted peak flow? |
Develop a diary to use twice a
day (morning and evening) with scales, such as modified Borg scale to assess
breathing status.
The symptom diary tracks severity of difficult breathing, intensity and frequency of cough, color of amount of secretions, presence of wheezing, pattern of medication use and peak flow reading.
The diary follows changes in breathing and identifies when the medication type, dose and frequency need to be adjusted if there is a need for a fast reliever.
Follow the peak flow meter use and monitoring with the green, yellow and red zones taken from the manufacturer’s package.
Watch a health care practitioner perform the technique
Record the best of three in the diary. Clean the peak flow meter by running warm water through it, drying it thoroughly every other day.
Identify predicted peak flow. Find "personal best" peak flow when feeling best and/or from the highest number ever reached. This may take a bit of time.
Describe use of peak flow and symptom diary in action plan management.
Use diary daily and bring in diary and peak flow meter, (as well as inhalers, holding chamber and medications) to each clinic, ER and hospital visit.
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The patient:
records inhaled medications morning and evenings.
assesses and records:
demonstrates proper technique of using a peak flow meter.
Measures and records peak flow.
states best peak flow for use in action plan.
brings diary and peak flow meter into clinic visits. |
Seek assistance of respiratory
care practitioners.
Respiratory Nurse specialist.
Pharmacists
to supplement or provide teaching elements.
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| Do you hurry to perform tasks
and then need rest thereafter?
Do you fatigue on most days?
Are you aware of relationship between fatigue and activity performance?
Because of your difficulty breathing and fatigue, do you eliminate usual activities?
Are you aware of the availablilty of devices that will help you to function?
Are you aware of ways to conserve your energy during daily activities?
Do you need assistive devices or home modications to conserve energy and prevent fatigue?
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Hurrying produces difficult breathing.
One way to diminish difficult breathing is to plan activities and allow
adequate time to prevent the need to hurry. Balance strenuous activities
and rest period throughout the day.
Conditioned muscles, through exercise, will help in this balance. The strenuous activities become less strenuous and recovery time decreases.
Second only to difficult breathing, fatigue is the most common symptom limiting function in COPD. Fatigue is often associated with failure to rest and increases difficult breathing.
Plan activities to coincide with periods of peak energy.
Organizing work can result in greater work efficiency and decrease daily fatigue.
Using diaphragmatic breathing and pursed lip breathing will help to conserve energy.
Assistive devices, small ladders, long handles with specific hooks, bathtub handles. are available to simplify daily activities in the home and at the workplace to reduce energy expenditure.
Home modifications can be fairly inexpensive with significant impact on improving level of functioning. |
The patient:
paces activities throughout day to minimize dyspnea and fatigue.
describes several ways to conserve energy
uses assistive devices appropriately as needed.
uses equipment and assistive devices appropriately.
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Seek assistance of respiratory
care practitioners.
Respiratory Nurse specialist.
Occupational or physical therapists
to supplement or provide teaching elements.
Home assessment from Prosthetics and Sensory Device Services, physical or occupational therapy. |
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| Do you understand what this prescription
means?
How often do you cough to raise secretions (sputum)?
Are your secretions difficult to clear… thick or thin…yellow or green?
What is the usual color of your urine?
Have you done these techniques before?
Which of these techniques works best for you?
What technique is most difficult to do?
How often are you to do this each day?
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For COPD patients, coughing can
cause airways to collapse, trapping air and secretions. Huff cough, pursed
lip breathing, and PEP(positive expiratory pressure) can help splint airways
open.
Thick secretions can be a problem with poor systemic hydration. Drink at least 8 glasses of water or liquids (not including caffeinated drinks or alcohol) each day. Changes in secretions may be an indication of infection. Consult your primary provider.
Assess urine color; the lighter the color (as long as there are no other disease processes to consider), the better the body is hydrated.
Resistive devices - PEP device (positive expiratory pressure) or flutter valve have been shown to help move secretions and may improve respiratory muscle strength.
Use postural drainage if all other techniques are ineffective. Follow chart positions, it takes time to learn postural drainage and time to perform. Few people are candidates for this process.
Multiple techniques may be tried to determine the most comfortable and the most effective. |
The patient:
uses "Huff coughing" slow maximal inspiration - followed by one or two coughs saying the word "huff" softly which prevents the glottis from closing.
drinks adequate fluids.
demonstrates airway clearance techniques.
identifies when sputum production or consistency has changed.
identifies the frequency and duration for each technique taught.
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If indicated provide written information
regarding "huff coughing" and adequate liquid intake.
Your patient will best be served if you are able to ask for a airway clearance techniques protocol when techniques are ordered. Possible referrals may be to Respiratory Care Services, Pulmonary Nurse specialists. Consult the Pulmonary Section for services provided.
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| Do you know how oxygen works?
What worries you about using oxygen?
Do you understanding of how oxygen may help you?
Do you understand this prescription?
How do you feel about wearing oxygen?
Do you always use your oxygen when you are active?
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Supplemental oxygen raises a low
oxygen level to a near normal level according to criteria established in
the supplemental home oxygen algorithm.
While supplemental O2 assures a near normal level of O2 in the blood, it is only when use. It keeps all the organs and muscles functioning adequately. It may or may not make breathing easier.
Reconditioning muscles will help the body use O2 more efficiently, thus decreasing the work of breathing and hence, difficult breathing over a period of time.
O2 must be used according to the prescription (appropriate liter flow setting for rest, activity and night).
Using more may be harmful. Using less may lead to the slow destruction of many cells in the body.
Portable O2 is provided to allow as much activity as needed to recondition muscles and increase activity.
If ears are sore from the nasal cannula, there are pillows which protect the ears from the cannula.
If nares are dry try a nasal gel (new product) or normal saline sprayed into nares.
Check the local electric company to see about a rebate for emergency care needs.
Nasal cannulas should be cleaned weekly with mild soap and water. Rinse well. |
The patient:
reads and signs an agreement to quit smoking and attend smoking cessation clinic.
describes the relationship of the oxygen saturation to the liter flow of oxygen at rest, sleep and when active.
adjusts liter flow on portable oxygen and concentrator to the prescription.
determines how much oxygen is left.
understands the hazards of oxygen use.
knows to contact physician when flying to check need for increased oxygen.
uses oxygen at prescribed liter flow and duration; does not use at other times.
demonstrates and or can state appropriate cleaning of equipment. |
If the facility has a home oxygen
program if may be just a matter of requesting a home oxygen evaluation.
Most programs are clinically coordinated by Respiratory Care and Diagnostic Services and Prosthetics and Sensory Device Services. There are variations on this model. Clinical nurse specialists also run home oxygen programs.
Where there are pulmonary physicians, they are responsible for all follow-up through the home oxygen coordinator.
There should always be one service responsible for the administrative and one for the clinical.
The patient should be seen for follow-ups relative to the stability of their oxygenation. |
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| Do you understand what this prescription
means?
Do you know who to call for help?
Do you understand that your weight is a large contributor to your problem? |
Consistent use of CPAP - single
or bilevel will improve sleep at night by decreasing the symptoms of sleep
apnea. The settings ordered have been determined by a sleep study to assure
the right amount of oxygen in the blood during sleep.
Home Medical Equipment companies (HME) are required to provide information and to have 24 hour emergency service. This is the first line defense if problems occur. The company will inform the health care practitioners when more help is needed.
If obesity is the cause, or has worsened sleep apnea, it is essential to work on losing weight.
This issue should not be under emphasized. While it is known that most patients do not follow weight reduction programs, part of the problem may be the apathy of the practitioner following the patient.
It is important to ground all sleep apnea electrical equipment. No one should attempt to make repairs or adjustments to the equipment without proper training.
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The Patient:
describes and identifies all components of the CPAP/Bilevel system.
demonstrates proper assembly of all components.
explains operating instructions, knows how to place mask and headstrap, and can adjust them so there are no leaks.
The patient knows:
how to entrain oxygen into the set-up if prescribed.
how to clean and/or replace filters and keep unit clean.
recognizes need for different mask or adjustments.
how to seek help from HME company and the VA contact. |
CPAP - bilevel should only be
ordered by a sleep specialist.
Refer all patients to a sleep specialist for use of CPAP or bilevel device.
Seek assistance of respiratory care practitioners.
Respiratory Nurse specialist.
to supplement or provide teaching elements. |
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| Do you currently smoke?
(information must be documented on the medical record) |
There are many benefits to quitting
smoking such as:
decrease risk particularly for lung disease stop irritation of airways and coughing stop raising secretions save money save your life stop being a bad influence on kids
anxiety, prolonged nicotine withdrawal lack of support fear of weight gain.
Use smoking cessation materials to assist efforts to quit, such as:
You can Quit Smoking AHCPR smoking cessation guide for all persons who smoke. |
The patient:
Understands the advantages to quitting
Understands the basis for the barriers to quitting.
Has been referred to a smoking cessation program
attends a smoking cessation program |
VA or community smoking cessation
programs.
The VA Preventive Medicine Program "Smoking Cessation- An Special Initiative for 1996-1997" is included in the materials.
Agency for Health Care Policy and Research. Smoking Cessation. Clinical Practice Guidelines, no 18, US Department of Health and Human Services. 1996. Pamphlet "Helping Smokers Quit" |
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| Have you been screened for:
Hypertension
Cholesterol
Colorectal CA
Prostate CA
Cervical CA
Breast CA
Immunizations
Pneumovax
Alcohol abuse
Basic nutrition
Seatbelt use |
Give attention to blood pressure and may need to determine if salt sensitive
< 60 males, every 5 years. There is considerable information regarding cholesterol, such as difference between animal and vegetable fats or that cholesterol is not the only contributor to heart disease.
>50 years every 1-3 years.
Annually. The rate of prostate cancer is a concern for all men over 40.
A pap smear is recommended from 18-65 every 3 years. Early diagnosis can usually prevent cancer.
Examination for those > 40 years - annually. Teach self exam. Mammogram from 50-75 every 1 to 2 years.
Influenza for those at risk or > 64 years, annually
Those at risk, at least once.
Be aware of signs and symptoms of alcohol abuse
Refer to NUTRITION page 25.
It is the law and can prevent injuries. Read materials.
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The patient:
Knows what B/P is and what is normal. Understands fluctuations (i.e, may be higher when seeing a provider).
Is able to repeat and provide evidence of understanding all preventive measures.
Understands the advantages and disadvantages of flu shots. |
Refer to the VA Preventative Medicine
guidelines for recommendations.
When a screening test is positive the appropriate.
If able refer to local program .
If the patient is willing a consult should be sent to the alcohol abuse program.
If BMI over 27, refer to established program. |
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| How much exercise do you do now?
Do you have good walking shoes?
What stops you from exercising?
Does difficulty breathing or fatigue stop you from performing activities?
Are there contraindication present that would preclude an exercise prescription?
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Are you doing at least 30 min.
of moderately intense physical activity on most days of the week?
If engaging in less than 30 minutes of regular exercise three days per week, determine what the limiting factors are.
Limiting factors, such as poor walking shoes, failure to use a cane or other assistive device, need to be corrected immediately.
Limiting factors such as apathy may need the assistance of anti-depressive medication, group sessions, reeducation in all the consequences of being overweight, assistance and insistence on exercise from family and care providers, especially the primary care provider.
Contraindications to exercise are few: severe pulmonary hypertension, uncontrollable hypoxemia even with supplemental oxygen, uncontrolled systemic hypertension, musculoskeletal problems, significant cognitive impairment, recent surgery, or severe risk of falling.
If possible, perform a six-minute walk to determine the degree to which physical limitation is present - by determining when difficult breathing or fatigue limits continuation. -< 600 ft- severe - 600-1200 ft- moderate - >1200 ft. mild to moderate
Any exercise program should include: Aerobic or cardiovascular - (walking, swimming, biking) Strength or resistance training - lifting weights, crunches, pulling Stretching (without bouncing) |
The patient:
describes symptoms that currently limit his/her physical function.
Purchases good walking shows or necessary assistive devices.
Undergoes recommended referrals and consultations to overcome barriers to starting an exercise program.
Understands why an exercise program is inappropriate.
can describe the 3 types of exercises and give examples of each.
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Get a partner to exercise with.
If possible join a group of exercises who are at the same level.
Exercise program for respiratory patients (may or does not have to be part of a pulmonary rehabilitation program).
Specific exercises can be provided to
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What the dangers are by trying to do too much too soon?
Do you know how well or badly your muscles are conditioned?
Do you know how long it will take before you feel the benefits from exercise?
Do you feel you need to go through a formal program to start exercising?
Do you know of any resources for exercise training?
Do you use your fast reliever prior to exercise? |
The exercises must be started
gradually from the existing level of activity. Each session of exercise
is to include safe use of warm-ups and cool-downs and self-monitoring (Borg
scale and heart rate).
Exercises should be done at least 3 times a week for 10-15 minutes when starting -going slightly beyond existing ability each time. Start with walking and add one new type of exercise each week. (i.e. strengthening or stretching) Work up to 30 minutes a day on most days of the week using warm-ups, cool-downs. Do not forget upper extremity exercise
It will take 6-8 weeks to feel the progress.
EXERCISE IS A LIFELONG COMMITMENT, IF STOPPED THE BENEFITS STOP.
An unsupervised "at home" exercise program with an emphasis on walking, stretching and simple arm exercises, will result in similar benefits to a formal supervised program if carried out systematically over time.
If available, a formal, supervised and tailored exercise program should be carried out at least three days per week which includes all the components mentioned above. The goal of this program is to understand the benefits of exercise and to continue at home.
If very limited, consider learning at least relaxation and breathing exercises.
If fast relievers decrease rapid worsening of difficult breathing, use them about 30 minutes prior to exercise. |
The patient:
complies with the need to go slowly and be persistent in doing the exercises
carries out a six-minute walk test with supervision
Undertakes an unsupervised home program of exercise which includes all the essential components. carries out self-monitoring.
Undertakes a formal supervised program exercise program, symptoms, and other responses (exercise diary, heart rate, Borg scale, etc..)
continues regular exercise after completion of the program.
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In the absence of a formal exercise
program at your facility, patients may be referred to Cardiac Rehabilitation
(with modifications), PT, OT, Respiratory Care, Exercise physiologist,
and other consultations:, pacing, and breathing retraining.
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| Do you know the current general
nutritional recommen-
dation?
Do you think you eat nutritious foods?
If a special diet is prescribed, do you understand why use must follow it?
What did you eat yesterday for breakfast? lunch? dinner?
Do you need dental work?
How does eating affect your symptoms?
Do you think you may be too heavy or too thin? |
Follow basic pyramid where each
day one eats:
vegetables and fruits, 5 times (more-better) dairy products about 4 times meat/fish/poultry limited to total of 8 oz. Keep fat and empty calories minimum.
Extra weight makes breathing more difficult.
The lungs and heart have to do more work. Extra weight pushes the diaphragm into the lungs, alveoli are more difficult to open.
Eating out? - change bad habits gradually, stay away from fatty burgers places. Minimize dressing on salads.
Pay attention to the calories and fat content on food labels. If change is difficult, seek help and stick with it.
Being overweight can cause sleep apnea. Obesity (> 20 % of ideal weight) can be more dangerous to health than tobacco.
Take care of teeth. Bad teeth can affect the desire to eat and what is eaten.
If underweight - supplements may be needed to maintain weight.
Smaller but more frequent meals help reduce feelings of fullness and difficult breathing.
Foods that cause bloating should be avoided. |
The patient:
describes the relationship between eating habits and health status.
describes the relationship between eating habits and exercise to maintain or control weight.
follows any prescribed diet.
makes attempt to carry out a regimen for weight control and exercise program has changed bad eating habits.
maintains an adequate fluid intake.
avoids foods that increase secretion production.
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Refer to dietitian if:
-not following special diet information, if obese or if very underweight.
Dental consult
Consider community resources for exercise and weight loss classes. |
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| Do you have breathing difficulties
or other respiratory symptoms (nasal congestion, post-nasal drip) all year
round in your home?
Do you or those around you smoke?
Is there evidence of workplace exposure to environmental irritants?
Do you experience difficult breathing outside? Can you identify the specific causes?
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Dogs, cats and birds are well
known to cause respiratory problems. They may have to be removed from the
house.
Dust mites are found all over the house, greatest exposure is from bed lines and carpets.
Washing bed linens in the hot water (1300), using bleach as well as detergent, at least every 2 weeks, should keep the dust mites under control.
Non-carpet floors such as wood or tile prevent the harboring of dust mites.
Cockroach droppings contain many irritants and may be a primary problem to respiratory symptoms.
Smokers in the household should be strongly advised to stop smoking or to smoke outside the home.
If known sensitizers are present in the workplace (tobacco smoke, hazardous substances, etc.), and if coworkers have similar symptoms, encourage the management to check for "sick building syndrome."
Once specific causes have been identified, an allergist may be contacted for desensitization. Stay away from offending allergen.
The following may be a source of air pollution or irritation: wood-burning stoves and fireplaces (not pellet stoves), unvented stoves or heaters, contact with other smells or fumes (perfume, cleaning agents or sprays). Stay away from these if a problem. |
The patient:
determines whether respiratory symptoms are episode or continuous during the year.
adheres to plan to wash bed linens correctly and to minimize carpet and/ or vacuum often, and if necessary using a mask.
agrees to smoking cessation and/or encourages other smokers in the home to stop smoking or smoke outside the home.
identifies possible sources of workplace exposure to environmental irritants.
sees an allergist if indicated.
gets retested when indicated.
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Consider
Allergy consultation.
Registered Nurse or Respiratory Therapist with special preparation.
Seek literature from Allergy or Asthma associations.
There are many companies who specialize in non- allergic products such as bed linens, vacuum cleaners, etc.
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| Do you have evidence of breathing
difficulties related to food allergens (sulfites, other)?
Do you change the filters on air conditioners, humidifier or other conditioning machines?
Do you use your peak flow meter to see the effect of exposure to an irritant?
Do you use your symptom diary and peak flow diary? |
A diary may be kept to document
the occurrence of symptoms in association with specific foods.
A diet which systematically excludes possible food allergens should be started
Filters used with conditioning devices can harbor allergens and bacteria. These must be changed according to the manufacturer’s directions.
Evaluate peak flow readings during periods of exposure and compare to non-exposure readings.
Evaluate benefit obtained from relievers and controllers in such settings.
Document multiple readings of peak flows and treatment effects in the environment in question.
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The patient:
maintains a diary of symptoms and documents associations with specific foods.
does not eat food which triggers respiratory problems
adopts an exclusion diet to determine if refraining from certain foods eliminate symptoms.
undertakes allergy or other testing if suggested by the provider.
uses a peak flow meter to document breathing status and medicine benefits in settings where suspected bronchospastic or other symptom triggers exist.
Carries out a plan for elimination or distancing from potential sources of air pollution or irritation. |
as above |
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| Do you often feel discouraged
about how you have to live your life at this time?
What do you do when you feel discouraged?
How well are your wife/caregiver or other family members coping with your illness?
Are you having any increased family problems related to your illness?
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Depression is common problem in
chronic illness.
Taking a depression/anxiety test to screen for depression or other psychiatric problems may be useful.
Anti -depressive medications, relaxation techniques and exercise may be useful in reducing depression.
Discussing what is causing the depression with a loved one/care giver or health care provider is a useful technique and may lead to a referral for help with a trained counselor.
Use of the breathing and relaxation techniques described in Stress Response and relaxation and breathing techniques may help.
Many people becomes mildly to moderately depressed from time to time. It is usually associated with traumatic events. However, when difficult breathing is the issue, the degree and frequency of depression may increase and may not be related to traumatic events. Difficult breathing most of the time is a traumatic event. Getting help, taking medicines and talking about feelings may help in decreasing the depression.
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The patient:
provides evidence of compliance with techniques used to decrease depression..
carries out newly acquired skills for coping and demonstrate relaxation techniques.
communicates feelings to significant others.
knows who to call for help.
keeps scheduled clinic appointments
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Consider referral to mental health
providers.
Others who can assess and provide modification of patient’s coping mechanisms.
Family counseling
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| Do you have difficulty with ADL’s:
bathing, dressing, toileting, simple household chores?
Are you still able to work?
Do you want to work? |
Consider application for housebound/aid
and attendance benefits if significantly debilitated.
Family members often do not understand the extent of the disability the patient suffers.
Some people may benefit from job retraining to continue working. |
The patient:
performs daily activities to the extent possible.
Enlists understanding of family members. Refers them to providers for support.
performs work to the extent desired and within physical limitations. |
Social work evaluation to maximize
pension benefits
Consider referral to dietitian for nutritional assessment and counseling. Refer for job counseling
If significantly debilitated (ADL dependent), consider referrals to: community nutrition programs social work, supervised pulmonary rehabilitation program, hospital based primary care (HBPC), respite programs, or other assisted living programs. |
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| Are you currently sexually active?
If no, do you desire to engage in sexual activity?
Does your partner desire to engage in sexual activity?
Do you have questions related to sex you would like to discuss?
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How chronic lung disease affects
sexuality:
low oxygen saturation may interfere with erections or cause anxiety, irritability, tremor, headache
difficult breathing, frequent cough and sputum production, exercise induced wheezing may interrupt or disrupt lovemaking.
Measures to improve sexual functioning:
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If patient desires,
discusses sexual concerns with health care provider and significant other.
describes actions to promote sexual activity. |
Provide written information, books,
and videotapes dealing with sexuality and COPD.
Consider referral to: GU clinic, therapist specializing in sexual counseling. |
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| Do you experience episodes of
panic or severe stress associated with difficult breathing?
Do you feel your drugs aggrevate symptoms? Do you use them as prescribed?
Do you use oxygen as prescribed?
Do you understand that there may be a relationship between emotional situations and your breathing?
Do you use your fast reliever as soon as you feel a stressful situation is about to occur?
Do you find yourself making your lips narrow, like blowing out through a straw, when exhaling during difficult breathing? |
Difficult breathing can cause
anxiety, emotional disruption, physical fatigue and anger. Anxiety, emotional
disruption physical fatigue and anger can cause difficult breathing. There
are other factors which cause this stress response symptoms.
Overuse of medications may also cause these symptoms.
If oxygen is not used as prescribed it can cause these symptoms.
The stress response is normal and controllable. Try decreasing symptoms by 1) avoiding or ignoring stress situations, 2) using prescribed medicines to reduce stress, and 3) use relaxation/ breathing control techniques. These actions will help control the "fright and flight" syndrome. It happens to everyone; in dangerous situations it is good. When anger or anxiety trigger it, and frequently, it can be dangerous to all body systems.
Identify situations that precipitate stress.
Use fast reliever before or soon after a stressful situation presents itself. Chronic stress can make improvement unattainable for the patient with COPD.
Pursed-lip breathing helps decrease difficult breathing by creating a "back pressure" which holds the small airways open longer while exhaling.
Inhale normally through the nose on the count of two.
Purse lips as if about to whistle |
The patient:
had an evaluation to rule out contributors to difficult breathing and reviews the treatment plan with provider(s)
describes the stress response including its relationship to specific dyspnea mechanisms related to the disease process
identifies situations which precipitate stress.
utilizes avoidance and appropriate use inhalers to prevent difficult breathing related panic.
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Seek the assistance of Respiratory
Care Services,
Respiratory Clinical Nurse Specialist.
Stress-Management Expert (if available)
OT or PT.
Some VA facilities may have inter - disciplinary classes already available to teach patients these techniques.
Many others may need to consider ongoing classes for their patient population.
Videos may provide some of the information.
Seek community resources. |
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Does your belly push out or pull it in when breathing is difficult? Are you able to use breathing techniques to control severe difficult breathing and panic?
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Exhale slowly and gently (not
forcefully) through the small opening and to the count 4 or 6. Do this
during periods when breathing is difficult i.e., exercising or any activity
which takes the energy of exercising. Continue even after you have to stop
until your breathing is easy.
Although the diaphragm may be too flat for diaphragmatic breathing to be effective, this technique can improve it’s use for those with some preservation of function. Practice the following:
Assume a comfortable position, lying down or in a recliner.
Place one hand over the center of the stomach and the other on the upper chest ( to detect movement).
Inhale so the abdomen moves out and down - the diaphragm creates this movement during inhalation. Use pursed-lip breathing when exhaling and feel the abdomen move in (help it if you can -this may improve exhalation and muscle strength) The chest should have little movement during either activity. If the chest does move, it is because the diaphragm is too flat and less efficient, muscles of breathing are being used.
Do this slowly and repeatedly about 10 times, three times a day. Start to practice with activity and exertion. Paced breathing during exertion is the coordination of pursed-lip breathing and diaphragmatic breathing - timing inhalation with the easier part of exertion and exhalation with the harder part of the exertion . For example, when lifting a box from the floor, first use good body mechanics by bending knees(squat if possible) instead of bending over (back injury possible) and inhaling while going down to pick up the box and exhaling while lifting it up. Do this with all exercises as well.
Relaxation techniques such as Yoga, systematic muscle tensing and relaxation throughout the body while reclining, visualization and other techniques may be used with the breathing techniques to promote relaxation and diminish the stress response. |
The patient:
demonstrates pursed lip breathing technique while walking.
carries out relaxation strategies to control difficult breathing-related panic. |
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| Do you understand the nature and
prognosis of your disease, including treatment options and potential outcomes?
Do you understand you have the right to express your desires about your care in the event you become incapacitated?
Have you completed advanced directive paperwork?
If not, are you interested in talking about advanced directive and end of life decision-making?
Have you discussed your wishes with your family or significant others?
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In advanced COPD the following
issues should be discussed. Each VA facility has a policy and procedure
for end-of -life decision making. These must be used to guide the conveyance
of sensitive questions and determinations.
Talk about the nature and prognosis of the lung condition
what happens when there is little to no hope of any quality of life:
Describe the resuscitation and life sustaining techniques which can be used to prolong life.
CPR Medicines Intubation Mechanical ventilation tube feeding
Discuss what the options would be for different situations.
Determine what might be withheld or withdrawn and what might be comfort care.
Explain a "living will" and "durable power of attorney for health care."
Include family members if desired.
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The patient:
expresses a desire to talk about making end-of-life decisions.
describes the "living will" and/or "durable power of attorney" for health care."
obtains documents if desired.
makes an informed decision in collaboration with his primary provider and significant family members regarding end-of-life treatment options.
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Primary health care provider;
social worker, religious counselor, family/ significant others. |