Evidenced – based practice is considered the best available evidence derived from systematic research, clinical experience, and tested expertise to achieve expected and/or improved patient outcomes (Institute for Healthcare Improvement, 2008 ). The new protocols for surveyors have moved the focus to data – driven and outcome – oriented (CMS, 2011) and the need to establish a well defined plan of care foreshadows the need to follow evidence – based practices for specific diseases to achieve the expected outcomes (even though, at this time, CMS has not yet mandated their use). The following is an evidenced based process for COPD using SmartCues as reminders for clinicians.
A Focus on Chronic Obstructive Pulmonary Disease (COPD)
COPD is a progressive airway disorder associated with abnormal inflammatory response of the lungs to noxious gas and/or particles. It is primarily manifested as two related diseases: chronic bronchitis with the presence of cough and sputum production for at least three months and emphysema.
COPD and exacerbation is the fourth leading cause of death in US and causes about 500,000 hospitalizations annually. It is expected to move up to the third leading cause of death in the US by 2020 (Crawford & Harris, 2008). Anthonisen defines COPD exacerbation as requiring the presence of at least one or more of the following: increased sputum purulence, increased sputum volume, and worsening of dyspnea. COPD decompensation is seen 1-3 times per year when care is not managed. Exacerbation etiology is usually infection driven. Other triggers include heart failure, pulmonary emboli, and non pulmonary infections.
Though COPD is progressive, literature states, COPD can be managed better to produce improved outcomes. The Home Health Nurse should follow agency protocol, physician orders, and professional nurse evidence-based practice when assessing and planning care with the patient diagnoses with COPD. Consider the following when establishing care:
- Symptom: Assess for signs and symptoms of infection (especially pneumonia)
Instruct patient to note change in sputum quantity, volume, and consistency. Patients should also note temperature with any other sign of infection and not increased temperature > than 100 degrees lasting longer than 72 hours (unless different physician guidelines)
Clinician should reassess each visit.
- Symptom: Assess for hypoxia and dyspnea
Instruct patient to utilize airway tolerance techniques (cough and deep breathing exercises that may include incentive spirometry. Instruct patient when to call home health agency, physician, or to seek emergency care (severe SOB, severe wheezing, or uncontrollable coughing). If Oxygen is used, instruct in importance, in safety and appropriate use of flow rates.
Clinician should assess VS (TPR and B/P), pulse oximetry, and evidence of accessory muscle use.
Clinician should assess for jugular vein distension, peripheral edema, and peripheral edema.
Clinician should assess for anxiety and restlessness
- Symptom: Smoking
Instruct patient and family in need to cease smoking. First hand and second hand smoke is contraindicated with the patient with COPD.
Clinician must assess each visit.
- Symptom: Assess for signs of orthopnea
Instruct patient to identify any change in number of propped pillows needed to breathe comfortably when lying down.
Clinician should note baseline and changes each visit.
- Symptom: Increased wheezing (prolonged expiration)
Instruct patient to identify and eliminate triggers.
Instruct patient on stress reduction and stress management techniques such as guided imagery with simple exercises that can be utilized quickly.
Instruct patient in use of music therapy and choose a piece of music that is associated with calm and piece.
Instruct on airway clearance techniques that may include coughing and deep breathing exercises. Coughing is a general manifestation of COPD and may be worse in the morning. Patient should pace activities.
Instruct patient when to contact home health agency, contact physician, or to seek emergency care especially if there is severe SOB that is uncontrollable.
Clinician should assess incidences upon each visit and effect of instruction.
Clinician should inquire if “tripod” position has been necessary (patient leans forward with head tilted and arms resting on legs or table). Note visible use of accessory muscles in neck, abdomen, and chest. Teach patient to take slow deep breaths through pursed lips. (“This will help him relax and inhale oxygen and exhale carbon dioxide at a slower pace, decreasing the respiratory rate and preventing alveolar collapse” Crawford & Harris, 2008).
Clinician should assess lung sounds and listen for not only wheezes but crackles and may also note diminished breath sounds.
- Symptom: Assess activity tolerance
Instruct patient to identify activity daily and/or number of feet walked before dyspnea occurs. Wheezing can worsen with activity so a strong assessment and measured activity schedule is necessary.
Consider Physical Therapy referral for muscle strengthening exercises for legs and upper arms. Teach exercise safety. Teach energy conservation when appropriate. Conditioning exercises aid to strengthen the muscles used in breathing.
Clinician should note baseline and assess activity levels and evidence of dyspnea changes each visit.
- Symptom: Assess for increased weakness and fatigue
- Instruct patient in energy conservation to achieve ADLs life quality. Patient should note when the symptoms occur.
- Clinician should note baseline and progress each visit.
- Symptom: Assess nutrition and hydration status (may have low levels of serum protein)
Instruct in high protein foods that do not require significant energy for preparation. Maintenance of adequate caloric intake should be taught. Nutritional supplements should be considered.
Clinician should assess nutritional status at each visit.
- Symptom: Medication compliance
Instruct patient as to medication actions, side effects, contraindications, when and how to take, and how to store meds. Likely medications may include bronchodilators, steroids, antibiotics, mucolytics, antivirals, and antipyretics.
Clinician to assess medication changes as well as patient use of meds such as metered-dose inhaler; exhale completely, take a slow deep breath when inhaling, and holding breath for 5-10 seconds. Verify directions re use on each med.
Patients should have pneumonia and flu vaccine if agreed to by physician.
- Symptom: Assess for depression or lack of interest in surroundings and difficulty with focus.
Instruct patient as to psychosocial coping skills to maintain optimum self care-management.
Clinician should assess for symptoms of depression on each visit as well as assess family and support systems.
Caring for COPD can present a challenge for home health nurses, but proper patient education, using a variety of techniques, while gaining family and friends’ support can assist to motivate patients to strive for optimal outcomes.
Sources:
CMS Appendix B Guidelines for Surveyors
Crawford, A & Harris, H (2008) COPD Help your patients breathe easier. AHC Media. www.modernmedicine.com/modernmedicine/CE+Library/COPD-Help-your-patients
www.homehealthquality.org
HHQI Best Practice Intervention Practice, 8SOW-PA-HHQ07 467 App, 1/2008
http://mhcc.maryland.gov/consumerinfo/hospitalguide/hospital_leaders/best_practices/hf..h
www.chronicconditions.org/ClearingHouse/cat/Heart%20Failure,61.aspx
Heart and Ling Sounds by 3M
http://solutions.3M.com/wps/portal/3M/en_US/Littmann/stethoscope/education/heart-lung-sounds
Decision Support Tool: Heart Failure Publication # 8SOW-PA-HH05.187
