Stories of older adults with COPD in this study illustrate the need for education about effective disease self-management. The education must be practical because adults learn to solve problems (Knowles, Holton, & Swanson, 2005). Instruction must address (a) day-to-day self-management problems, and (b) recognition of and response to exacerbations.
A COPD teaching plan has been drawn from this research and other literature (see Table 4). This plan, reflecting the self-regulation process, self-management strategies, and the nursing care in the Collaborative Model, is designed to build practical self-regulation skills. The content is drawn from current clinical practice guidelines GOLD, 2010; Institute for Clinical Systems Improvement [ICSI], 2009; National Institute for Health and Clinical Excellence [NICE], 2010).
Table 4. Self-Regulation-Based Teaching Plan for People with COPD
|I need to understand my disease|| |
COPD and its impact on lung function, breathing, and other body systems
Participate in a pulmonary rehabilitation program
|Brandt (2005), Gelberg and McIvor, (2010), Ries et al. (2007)|
|What does everyday COPD management entail and how do I do it?|| |
Importance of smoking cessation
Effects of prescribed medications and when to take them
Proper technique for use of inhalers and nebulizers
Use oxygen therapy as prescribed
Engage in regular exercise, including strength and endurance training, especially of upper extremities
Use breathing and coughing techniques (e.g., pursed-lip breathing, diaphragmatic breathing, huff coughing)
Use dyspnea management techniques (e.g., pace activities, use adaptive devices, arrange home environment for efficiency)
Follow the Food Guide Pyramid (USDA) to plan a balanced diet; if BMI < 20 consider adding nutritional supplements
|Gelberg and McIvor (2010), GOLD(2010), ICSI (2009), NICE (2010), USDA and USDHHS (2010)|
What are COPD symptoms and how should I monitor them?
Signs and symptoms of an exacerbation, including increased dyspnea, increase in sputum amount, change in sputum quality
Maintain a daily symptom diary
If feasible, use a pulse oximeter and peak expiratory flow meter
|Hurst, Donaldson, et al. (2010a), Hickey (2010), Robinson et al. (2008)|
|What are exacerbation triggers and how can I avoid them?|| |
Cold weather, poor air quality, and respiratory infections are known exacerbation triggers
Maintain good indoor air quality (e.g., adequate ventilation, especially if burning solid fuels)
Monitor outdoor air quality using available means (e.g., local weather forecasts, air pollution reports)
Obtain vaccinations (i.e., influenza annually, pneumococcal vaccine per current guidelines)
Avoid people with known respiratory infections
|Gelberg and McIvor (2010), GOLD (2010), Hickey (2010), Kessler et al. (2006), Marno et al. (2010)|
How do I know I'm experiencing an exacerbation?
Signs and symptoms of COPD exacerbations including but not limited to (a) increased breathlessness, cough, sputum, fever, and fatigue, (b) orthopnea, (c) decreased activity tolerance, (d) poor sleep, and (e) change in mental status
Perform daily symptom comparisons against dyspnea log
|GOLD (2010), Hurst, Donaldson, et al. (2010a), ICSI (2009)|
How do I respond to a COPD exacerbation?
Use a COPD action plan developed in collaboration with provider; typical recommended actions when an exacerbation is expected are to
Continue prescribed medications and oxygen
Increase use of short-acting beta agonists via metered-dose inhaler or nebulizer
Self-initiate corticosteroids and antibiotics, if prescriptions have been issued by the physician
Use pursed-lip and other breathing techniques
Call provider if, for example, (a) symptoms persist despite taking the above actions, (b) drowsiness increases, and (c) severe dyspnea is experienced even at rest
|American Lung Association (ALA), http://www.lungusa.org/lung-disease/copd/living-with-copd/action-management-plan.pdf, Hickey (2010), ICSI (2009), NICE (2010), Seemungel and Wedzicha (2009), Turnock et al. (2005), Walters et al. (2010)|
One task faced by people with COPD is to understand their disease; information about COPD is included in the teaching plan (Gelberg & McIvor, 2010). Pulmonary rehabilitation programs, recommended for all COPD patients, include patient education (Ries et al., 2007). Outpatient PR for people with moderate to very severe COPD is a Medicare Part B-covered benefit (USDHHS, 2011).
Knowledge and skills for everyday COPD self-management are the next component of the teaching plan. Patients must learn about their medications' effects and how to take them. Older adults often have difficulty using inhalers and nebulizers; teaching these skills is essential (Gelberg & McIvor, 2010). Upper extremity strength and endurance training helps people with COPD avoid deconditioning (ICSI, 2009). Patients are taught breathing and coughing techniques that aid in clearing sputum. Techniques are included for managing dyspnea, such as using adaptive devices and pacing physical activities. Finally, healthy eating is emphasized using the Dietary Guidelines for Americans, 2010 (U.S. Department of Agriculture [USDA] & USDHHS, 2010). People with a body mass index (BMI) of less than 20 are candidates for nutritional supplements (NICE, 2010).
Teaching self-observation/symptom monitoring is critical. Patients should be instructed to keep a daily symptom log, at least until they are familiar with their baseline dyspnea and other symptoms. Pulse oximeters and peak expiratory flow meters may enhance self-observation (Hurst, Donaldson, et al., 2010a). Patients also need to learn common signs and symptoms of an exacerbation.
The teaching plan addresses dyspnea triggers and how to avoid them. Respiratory infections are the proximate cause of many COPD exacerbations. Infections have been associated with delayed reporting and increased length of exacerbations (Seemungel & Wedzicha, 2009). Patients should also be taught to obtain influenza and pneumonia vaccinations at appropriate intervals (Gelberg & McIvor, 2010). Monitoring outdoor air quality is also included in the teaching plan, including temperature, humidity, pollen, and pollution levels. The United Kingdom Meteorological Office offers the “Healthy Outlook COPD Forecast Alert Service,” that issues helpful weather prompts (Hickey, 2010). In the United States, programs such as the program offer daily web postings of air quality information.
One of the greatest challenges in COPD self-management is recognizing an exacerbation. Current definitions of acute exacerbations of COPD (AECOPD) are symptom based (GOLD, 2010; ICSI, 2009; NICE, 2010). Recognition of an AECOPD requires symptom comparison (self-judgment). Thus, the teaching plan recommends daily symptom comparisons, contrasting new or different symptoms with baseline characteristics. A randomized clinical trial found that a self-regulation protocol aimed at improved monitoring of symptoms was effective in distinguishing and controlling self-identified exacerbation triggers and avoiding acute exacerbations (Kuo & Lin, 2009).
Finally, people need to know appropriate responses to COPD exacerbations (self-response). COPD action plans are guidelines for appropriate response. An action plan, developed collaboratively with the primary care provider or pulmonary specialist, identifies appropriate responses to worsening symptoms. U.K. guidelines recommend prescribing oral corticosteroid and antibiotic tablets for patients to self-administer if increased dyspnea interferes with activities of daily living (NICE, 2010). In contrast, U.S. clinical guidelines limit the decision to begin medications to providers (ICSI, 2009). The data are mixed as to the efficacy of action plans in achieving better disease outcomes, but their use has been associated with better recognition of and more appropriate response to an AECOPD (Ries et al., 2007; Turnock, Walters, Walters, & Wood-Baker, 2005; Walters, Turnock, Walters, & Wood-Baker, 2010).
In summary, the teaching plan for COPD patients reflects current research and practice guidelines, addresses patient experiences as identified in this study, and fits within the Collaborative Model (Brandt, 2005). The plan includes six essential components: (a) understanding COPD, (b) everyday management strategies, (c) symptom monitoring/self-observation, (d) exacerbation triggers and how to avoid them, (e) exacerbation recognition/self-judgment, and (f) management of exacerbations/self-reaction. Nurses in any setting may use the teaching plan to help patients reduce hospital and ED admissions. Nurse scholars might test the plan's effectiveness in reducing those admissions as part of a research program on COPD self-management.