Chronic obstructive pulmonary disease (COPD) is a leading health concern for the elderly. It affects approximately 1 out of 14 persons over the age of 45 and is surpassed only by heart disease in the number of people it affects in this age group.1 According to the 1985 National Health Survey, COPD affects 165.3 persons per 1000 in the 65 to 74-year age group, and 117 persons per 1000 in the 75 and older age group.2 The illness usually produces symptoms in the fifth and sixth decades of life and is predominate in the elderly who may already have decreased energy levels and coping abilities. Therefore, management of COPD can be difficult.3
Chronic obstructive pulmonary disease is an umbrella term encompassing the conditions of chronic bronchitis, emphysema, and adult asthma. These conditions commonly coexist, presenting similar signs and symptoms, and condition specific diagnosis is usually not possible. The most pronounced symptom of COPD is obstruction of airflow entering and exiting the lungs. This is due to increased mucus secretion, increased viscosity of secretions, narrowing of bronchial airways, impaired gas exchange, and loss of lung elasticity. The lungs are chronically infected.
Individuals with COPD experience a frequent productive cough, dyspnea, shortness of breath, and recurring acute lower respiratory tract infections. Since the condition is chronic, it gradually progresses with symptoms becoming more severe and acute respiratory tract infections occurring more frequently. The primary focus of treatment is to slow progression of the illness and assist the individual to maintain a quality lifestyle . The treatment program is usually multidisciplinary, consisting of respiratory therapy, medications, rehabilitation, and education. An effective education program can allow the individual to maintain a better quality lifestyle and help achieve the overall treatment goals.
Importance of Assessment
Many times, because an individual has a chronic illness that has existed for several or more years, nurses assume that the client has knowledge concerning the condition and how to care for it. In actuality, dus may not be the case. Client education is one part of the treatment plan that usually receives low priority. In the nurse's hurried, busy, and hectic schedule, education for clients is often minimal to nonexistent. Usually due to time constraints, a few quick instructions are given to the client and labeled education. Moreover, when teaching is performed by the nurse, it often lacks assessment or evaluation. Without careful assessment, planning, delivery, and evaluation, teaching is usually not effective. Learning does not occur.
With any chronic illness, clients need all the information they can obtain to assist them in maintaining a feeling of control, maximum independence, and active participation in the treatment plan. For the client with COPD, knowledge concerning self-care of the condition greatly affects the quality of life and level of wellness. Following are the components of an effective education program along with corresponding underlying physiologic and psychologic causative factors. The program is confined to major aspects of self-care for the client with COPD.
The first stage begins with assessment. Before any teaching program can be effective, the client must want to learn. Ask the client if mey would like to know more about COPD and how to control it. Inform the client that it is possible to gain greater independence, improve mobility, decrease dyspnea, and decrease the frequency of acute respiratory infections. The client needs to view the knowledge offered by the nurse as being helpful and useful.
Also assess the client's present level of knowledge concerning COPD and self-care. What and how much does the individual already know about the condition's affect on the body? What is the client's knowledge level concerning ways to slow down and/or counter the effects of COPD on the body? These questions will pinpoint the exact areas of knowledge deficit.
It is also important to assess the client's formal education level and communication skills. This facilitates planning and delivering a program the client can understand. The content should be delivered at the client's level of ability. The nurse must also assess for the presence of other factors or conditions that might affect the teaching-learning process. Examples include visual, verbal, and/or auditory impairment.
The assessment process allows the nurse to determine the specific, individual needs of the client. Presenting an individualized education program, based upon assessment data, helps to assure that the client will comprehend, learn, use, and ultimately benefit from the education. Following assessment, learning objectives should be established with the aid of the client. What exact knowledge do you want the client to obtain? What aspects concerning COPD would the client like to know more about? Again, this allows for individualization of the education program. Following are essential knowledge components of an effective education program.
Ineffective Breathing Patterns
The client with COPD typically displays a forced expiration and shortness of breath related to air trapping in the lungs. Also exhibited is a decreased tidal volume and vital lung capacity. Various diagnostic studies confirm the compromised state of the pulmonary system. Spirometry is utilized to evaluate lung volume, lung capacity, and pulmonary flow rates. Sputum analysis may be used to detect abnormal pulmonary secretions.
Arterial blood gases provide accurate information concerning the client's acid-base balance and the amount of oxygen and carbon dioxide in the blood. Normal values are p02 = 80 to 100 mm Hg, pC02 = 38 to 42 mm Hg, and pH = 7.38 to 7.42. A decrease in the p02 signifies a decrease in the amount of oxygen to the tissues. An increase in the pC02 signifies impairment of alveolar ventilation, and a decreased pC02 indicates alveolar hyperventilation. Moreover, an increase in the carbon dioxide level results in a decreased blood pH or acidosis and a decreased carbon dioxide level produces alkalosis or an increased pH.4
Breathing retraining functions to improve breathing patterns and maximize use of respiratory function. Breathing retraining focuses on the use of controlled breathing. One method is pursed-lip breathing. Pursed-lip breathing helps to maintain patency of the airways during expiration. As a result, expiration is slowed, the airways remain open, and a greater air volume is exhaled.5 Instruct the client to relax, inhale through the nose, pause, then exhale through pursed lips slowly and completely. Tell the client to imagine slowly blowing up a balloon during exhalation.
Another controlled breathing method is diaphragmatic breathing. Clients with COPD usually utilize accessory muscles of the chest and neck to breathe. Diaphragmatic breathing teaches the client to use the diaphragm instead of these accessory muscles. The result is a decreased respiratory rate and increased pulmonary ventilation.6
Have the client sit comfortably. Instruct the client to inhale through the nose while relaxing the abdominal muscles and distending or pushing the abdomen out. Pause briefly, then exhale through pursed lips while contracting and pulling the abdomen in. The length of exhalation should be 2 to 3 times longer than inspiration. These new breathing techniques should be practiced in all positions, activities, and during exercise until the client leams to adjust the breathing pattern to the activity. Provide feedback and encouragement to the client during practice sessions.
Ineffective Airway Clearance
With the excessive mucus production, narrowing of the bronchial airways, and loss of lung elasticity, coughing is not always easy for the client with COPD. The individual often lacks the strength and physical endurance to accomplish effective coughing. However, effective coughing is essential to help clear the mucus from the airways. This coughing technique mobilizes and allows the mucus to be expectorated. A staggered coughing technique can help the client to accomplish effective coughing.
Instruct the client to relax in a sitting position, inhale by sniffing air into the lungs until they are full, exhale slowly through pursed lips, and repeat the process several times. Then, stagger the final exhalation using the word, hufhuf-huf.7 Although the sputum of a client with COPD is usually not infective to others, normal sanitary measures and clean technique should be followed by the client and nurse. The nose and mouth should be covered during coughing and tissues should be placed promptly into a waste receptacle.
The client with COPD should drink 10 to 12 glasses of fluids every day to assist in mobilizing and thinning respiratory secretions. Water and fruit juices may be consumed. Milk should be avoided if it tends to thicken the mucus.8 Coffee, tea, and other caffeinated beverage use should be kept to a minimum. Caffeine interacts with some of the common medications used in the treatment of COPD, such as theophylline, resulting in the increased side effects of diuresis, central nervous system stimulation, and increased gastric secretion.
Alcohol consumption should be avoided. In clients with COPD, alcohol produces many potentially hazardous effects including cell dehydration, induced bronchial constriction, increased metabolic acidosis, and enhanced likelihood of sleep apnea.9 Lastly, excessively hot or cold fluids should be avoided since they may cause coughing spells.10
It is also helpful to maintain a high humidity environment. If the client smokes cigarettes, strongly encourage cessation. One of the primary benefits will be a reduction in mucus production.11 There are many effective stop smoking programs. Know what is available in your community and assist the client in selecting one best fitted to the needs of the individual.
Any time mucus secretions change in color from clear or white, to yellow, brown, or green, acute pulmonary infection is indicated. The client's physician needs to be contacted immediately. To help decrease the incidence of acute respiratory infection, instruct the client to: 1) avoid crowds during the flu season; 2) practice frequent oral hygiene, at least twice daily and 3) avoid close contact with persons having respiratory tract infections.
Moreover, most inhalation devices used by the client should be cleaned, and disinfected or sterilized at least every 24 hours. The procedure will vary according to me device used. For specific information, consult the manufacturer's product manual or consult a respiratory therapy department.
Perhaps one of the most devastating effects of COPD is to the client's level of mobility. Since physical activity results in an increased need for oxygen, which the lungs of the client are unable to produce, impaired mobility results. When the client attempts physical activity, the result is usually a worsening of symptoms. Therefore, the client tends to engage in less and less physical activity with social and recreational pursuits being the first to be relinquished. As more and more activities are given up, the client becomes more dependent on others, socially isolated, and lonely.
An exercise program can function to increase physical endurance, thereby allowing an increase in physical activity. The final result can be greater independence and a feeling of wellbeing for the client. 12 However, many clients with COPD fear that exercise will result in increased dyspnea and shortness of breath. According to the American Hospital Association's Staff Manual for Teaching Patients About Chronic Obstructive Pulmonary Disease, this fear must be overcome. This may be accomplished by emphasizing to the client that as the level of exercise tolerance is increased, the degree of dyspnea and shortness of breath may actually diminish.
Moreover, initial testing and careful monitoring before and during exercise will help determine client capability. Arterial blood gas analysis, heart rate, and respiratory rate during rest and exercise, will provide the needed monitoring information. The client should also be taught that dizziness and irregular heart rate are signs of overexertion.13
One inexpensive and easy to follow exercise regimen is walking. Walking should be performed daily with the client keeping record of the progress in a log. The distance walked should be gradually increased as the client's endurance increases. Offer the client lots of positive reinforcement and praise even the smallest increase in distance. One study performed on the effectiveness of a walking exercise program for individuals with COPD, found that participants reported they were able to perform activities of daily living with less dyspnea.14 Before starting any exercise program, remember to consult the client's physician.
Clients with COPD often feel anxious, hopeless, worthless, and depressed. One helpful intervention is to assess the client's recreational interests and hobbies, and assist in exploring alternative activities as appropriate. Also, a support group composed of individuals with COPD and their families can be very beneficial. The group can function to provide coping strategies, increased feelings of self-esteem, and a social support network. If such a group is not available in your community, consider organizing one at your hospital, long-term care facility, or day care program. 15 Also encourage the client to participate in planning the day's activities. Moreover, allow the client as much freedom and independence as possible. If depression is prolonged, and/or of more than minor intensity, a psychiatric consult should be obtained.
COPD can be very taxing on the physical, social, emotional, and financial aspects of the client and family. Therefore, information is needed concerning community support services available. Helpful community resources include transportation services for the elderly, meals delivered to the home, meals served at community centers, public health departments, senior citizen centers, home health services, and the local Social Security office.
Moreover, often many other services can also be found including community mental health centers, social service agencies, welfare offices, offices on aging, and vocational rehabilitation services. Since continuous medication therapy is usually utilized in the treatment of COPD, it is important to review the medication(s) with the client. The client should understand the purpose of the medication, dosage, and side effects. It is also helpful to assist the client in comparing and obtaining the lowest prescription prices. Don't forget to consider generic medications when available. This is also true for any home support equipment needed, such as oxygen.
Irritants to the Respiratory Tract
Instruct the client to avoid activities and objects known to irritate the respiratory tract. Avoid dust-producing articles such as feather pillows, smokefilled rooms, inhaling paint fumes, inhaling extremely cold air, excessive heat, sudden temperature changes, pollen, and cat hair. The client should wear a scarf over the nose when outside during cold weather, to warm the air being inspired. Masks may be helpful when exposure to irritants such as dust, pollen, and cat hair is unavoidable. The home kitchen should be well ventilated, and it is wise to stay indoors with an air conditioner when the pollution level is high.
Anorexia is a common condition reported by clients with COPD. Your client will probably be underweight and possibly dehydrated. Consult height/ weight tables to determine desired weight range and assess skin turgor to determine hydration status. Try offering six small meals per day and provide rest periods before and after meals. Encourage a diet high in protein and make sure the environment is free of clutter and offensive odors.
Structure and Evaluation
Structure the education sessions so as not to overtax and/or overwhelm the client. This will vary according to the individual client, but each session should last no more than one hour in a group setting, or about 30 minutes if individual instruction is used. Use pictures, filmstrips, diagrams, etc., when available and appropriate to enhance the education session. There are numerous teaching materials available for use with clients with COPD. The American Lung Association publishes the booklet, Help Patients to Better Breathing. Another source is the American Hospital Association's Staff Manual for Teaching Patients about Chronic Obstructive Pulmonary Disease.
When teaching older adults, remember to speak slowly and clearly. Keep your voice pitch as low as possible, and don't drop your voice at the end of sentences. When writing instructions, print in large block letters, and use a wide point pen. It is also helpful to use non-glare paper and to keep a magnifying glass handy for small print.16
Whenever possible, include family members and significant others in educational sessions. Let them know when, where, and how long the session will last. Encourage family and friends to attend and let them know they can be of great assistance to the client. Family and friends of the client can also help you in assisting the client in carrying out the teaching instructions and reinforcing learning.
Periodic classes, workshops, and/or seminars should be offered for staff members by hospitals, long-term care facilities, and any other program providing care for clients with COPD, to review and update current care standards. When providing client education, write out the teaching plan and share it with other staff members. Encourage other staff members to assist in the teaching program by reinforcing what is taught and offering positive feedback and encouragement to the client. Also, solicit suggestions and input from other staff members.
Following each teaching session, write out on index cards a concise summary of the information given, for the client to keep. Not only will this serve to further reinforce what has been taught, but the client will have a ready resource to consult. The client can also share these written instructions with family members and friends unable to attend the educational session, visitors, group home staff, day care program staff, or any others needing knowledge of how to care for the client.
No education program is complete without evaluation. To ensure that knowledge has been gained by the client, and learning has occurred, evidence must be obtained. Evaluation is best accomplished by using a variety of methods. Have the client repeat back to you a summary of the topic covered, and/or demonstrate the behavior. You can also ask the client questions concerning the material covered and encourage the client to ask you questions concerning areas not understood.
Another method is to observe the behavior and actions of the client. Are the knowledge and techniques taught being used by the client? Are they being used properly and accurately? Are family members and friends helping or hindering the learning process? If the evaluation is positive, you will know you have been successful. If the evaluation is negative in one or more areas, revise and reimplement the education program.
Of all the health-care team members, the nurse usually has the most contact with the client. Therefore it is the nurse's responsibility to assist the client to achieve the highest possible level of wellness. It is the nurse's responsibility to provide the client with COPD, the knowledge concerning self-care. This is especially true if the institution and/or community has no formal education program for individuals with mis disease. If a formal education program exists, the nurse should function to ensure that the client attends. The nurse should also function in a collaborative role with the education program by reinforcing components of the program. The primary goal of education for the client with COPD is to allow a better quality lifestyle while staying within the limitations of the illness.
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