Study of Older Adults' Use of Self-Regulation for COPD Self-Management Informs An Evidence-Based Patient Teaching Plan

Abstract

Purpose

People with chronic obstructive pulmonary disease (COPD) have frequent hospitalizations and emergency department visits, often due to COPD exacerbations which worsen disease status. Recognizing exacerbations is challenging; patients must distinguish between day-to-day COPD symptom variations and exacerbation symptoms. Self-regulation theory (Bandura, 1999) is useful for understanding symptom recognition, interpretation, and response. In this article a qualitative study of self-regulation use by 28 older adults with COPD (Brandt, 2005) is summarized.

Methods

Twenty-eight community-dwelling older adults were interviewed. Data were analyzed using the interpretive description method.

Results and Discussion

Informants used self-regulation behaviors in varying degrees. Most attended primarily to their breathing, comparing their usual degree of breathlessness and intensifying their everyday self-management practices if breathlessness worsened.

Clinical Relevance

A theory- and evidence-based COPD teaching plan for use by rehabilitation nurses is presented that includes attention to exacerbation recognition.

In chronic obstructive pulmonary disease (COPD), parenchymal destruction (emphysema) and small airway disease (obstructive bronchiolitis) limit airflow (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2010). COPD exacerbations increase healthcare utilization, accelerate declines in lung function, decrease functional status, and reduce quality of life (Bourbeau et al., 2007; Hurst, Vestbo, et al., 2010b). Healthy People 2020 objectives (U.S. Department of Health and Human Services [USDHHS], 2010 aim to reduce hospitalizations and emergency department (ED) visits in people with COPD. To reduce these admissions, rehabilitation nurses must help individuals recognize exacerbation symptoms and respond appropriately. This article includes a (a) review of literature on self-regulation and symptom recognition in COPD; (b) summary of a qualitative study of self-regulation use by 28 older adults with COPD (Brandt, 2005); and (c) theory- and evidence-based teaching plan for people with COPD.

Review of Literature

Self-Management and Symptom Recognition

Chronic disease self-management is the performance of day-to-day tasks necessary to control or minimize the disease impact on one's health status (Clark et al., 1991). COPD self-management includes understanding the disease, taking medications correctly, preventing infections, recognizing and responding to worsening symptoms, and working with healthcare providers. Self-management education may reduce hospital admissions (Effing et al., 2007). Current pulmonary rehabilitation (PR) program guidelines recommend education on COPD self-management and prevention and treatment of exacerbations (Ries et al., 2007).

Recognizing and interpreting symptoms has been investigated for decades (Prohaska, Keller, Leventhal, & Leventhal, 1987; Teel, Meek, McNamara, & Watson, 1997; Warwick, Gallagher, Chenoweth, & Stein-Parbury, 2010). Previous symptom experience and age affect symptom recognition. Remembering previous breathlessness altered current perceptions of breathlessness by people with COPD (Meek, 2000). Riegel et al. (2010) studied 29 adults with heart failure (HF), finding that older patients exhibited more errors in symptom recognition and were more likely to attribute HF symptoms to other conditions. They suggested elders' poor interoception is due to decreased function of cerebral cortical regions responsible for monitoring internal body states.

Unfortunately, not all older adults with COPD consistently monitor their symptoms. Warwick et al. (2010) found that older adults with COPD inconsistently monitored symptoms. Only 60% of 78 study participants reported monitoring dyspnea; more than 20% did not monitor any primary symptom of COPD. Married participants and those with more severe COPD reported better symptom monitoring. Langsetmo, Platt, Ernst, and Bourbeau (2008) found patients reported just 32% of COPD exacerbations documented in their symptom diaries. In summary, although symptom recognition is essential for identifying COPD exacerbations, many people neither monitor, recognize, nor report their symptoms.

Self-Regulation and Symptom Recognition

Nurses must find better ways to help people with COPD recognize exacerbations. Self-regulation, a Social Cognitive Theory (SCT) construct, may answer the need. Self-regulation is the process of monitoring the effects of one's actions and choosing subsequent behavior. According to Bandura (1999), self-regulation includes three subprocesses: (a) in self-observation, people attend to selected aspects of their functioning while ignoring aspects deemed less important; (b) in self-judgment, people compare self-observations against personally derived or externally generated performance standards; and (c) in self-reaction, people choose behaviors needed to achieve performance standards. In summary, they identify goals, select actions to reach those goals, employ the actions, judge their effectiveness, and revise actions as necessary (Cameron & Leventhal, 2003).

In the domain of health behavior, self-observation and self-judgment correspond to symptom recognition and interpretation, respectively; self-reaction corresponds to appropriate response. For example, if a man with chronic bronchitis recognizes his cough is heavier than usual and his sputum quantity has increased, he has engaged in self-observation and self-judgment. If he thinks, “If my cough gets worse I'll try some extra updrafts and maybe call the clinic nurse,” then he has engaged in self-reaction.

The model of chronic respiratory illness self-management by Clark and colleagues includes self-regulation and exacerbation recognition (Clark, 2003; Clark & Dodge, 1999; Clark & Gong, 2000). Clark and Nothwehr (1997) asserted that self-regulation is central to translating disease knowledge into specific self-management behaviors. On this view, self-management is the overarching endeavor; self-regulation is a core process of self-management. Clark (2003) reviewed research on chronic disease management, citing studies demonstrating significant relationships between use of self-regulation and positive health outcomes, especially for people with asthma. For COPD, however, such a relationship has not yet been clearly demonstrated. The sparse research on COPD and self-regulation (Kuo & Lin, 2009) needs to be augmented.

Study of Self-Regulation in Older Adults with COPD

Theoretical Framework

The Collaborative Model for Self-Management of Chronic Disease (Figure 1) was the theoretical basis for a study of self-regulation by older adults with COPD (Brandt, 2005). The Collaborative Model was influenced by two existing chronic disease self-management models. The first, the “Model of patient management of chronic lung disease” (Clark & Gong, 2000), depicts relationships among patient factors, external resources, self-regulation, management strategies, and identified goals. The second, the “Nursing practice model for chronic illness” (Burks, 1999), situates self-management actions within ongoing client–nurse collaboration. The Collaborative Model blends the self-regulation core from Clark and Gong's model with the patient–nurse collaboration explicit in Burks' model.

Figure 1. Collaborative Model for Self-Management of Chronic Disease

Method

The qualitative arm of this exploratory, descriptive study used the naturalistic method of interpretive description (Thorne, Kirkham, & MacDonald-Emes, 1997). After obtaining IRB approval, a nonprobability sample (N = 28) of English-speaking community-dwelling adults age 50 or older with COPD was recruited through the offices of four pulmonary medicine specialists in a medium-sized upper Midwest community. Informants' mean age was 69.1 years (SD 6.7); two-thirds were male (see Table 1). The majority were Caucasian, married, high school graduates, retired, with a household income between $15,000 and $34,999.

Table 1. Demographic Characteristics of the Sample

Demographic Variable	All Subjects (N = 28)	Males (n = 19)	Females (n = 9)
Age in years
M (SD)	69.1 (6.7)	70.3 (6.7)	66.6 (6.3)
Race, n (%)
Black/African-American	1 (4)	1 (5)	0 (0)
White, not Hispanic	27 (96)	18 (95)	9 (100)
Marital status, n (%)
Married	20 (71)	13 (68)	7 (78)
Divorced/widowed	8 (29)	6 (32)	2 (22)
Level of education, n (%)
Grade 12 or lower, no diploma	2 (7)	2 (11)	0 (0)
High school graduate	15 (54)	11 (58)	4 (44)
Some college/A.D.	8 (29)	4 (21)	4 (44)
Bachelor's degree or higher	3 (11)	2 (11)	1 (11)
Employment status, n (%)
Part-time	2 (7)	1 (5)	1 (11)
Full-time	0 (0)	0 (0)	0 (0)
Homemaker/retired	25 (89)	17 (89)	8 (89)
Other	1 (4)	1 (5)	0 (0)
Level of income, n (%)
<$14,999	2 (7)	1 (5)	1 (11)
$15,000–34,999	16 (57)	11 (58)	5 (56)
$35,000–49,999	5 (18)	4 (21)	1 (11)
$50,000 or more	5 (19)	3 (16)	2 (22)
Living arrangements, n (%)
Alone With spouse/	7 (25)	5 (26)	2 (22)
significant other	20 (71)	13 (68)	7 (78)
Other	1 (4)	1 (5)	0 (0)
Housing, n (%)
Single family residence	26 (93)	18 (95)	8 (89)
Apartment/high-rise	2 (7)	1 (5)	1 (11)

After obtaining informed consent, all but one of the semi-structured interviews were conducted in informants' homes. To increase credibility (Polit & Beck, 2011), the interviews were recorded and transcribed verbatim. The interview guide focused on the three subprocesses of self-regulation: (a) What kinds of things do you observe about yourself in order to monitor your lung condition? (b) When you notice something in particular about your lung condition, how do you decide whether it is significant? (c) When you decide that the thing you noticed is significant, how do you react? Prompts and open-ended questions encouraged informants' reflection and sharing. The 45–90-minute interviews afforded time for building trust and rapport and collecting in-depth data, further enhancing research credibility.

After an assistant transcribed the audiotapes, the researcher reviewed each transcript to ensure accuracy and increase credibility. Data were analyzed using inductive methods, incorporating measures to ensure trustworthiness (Lincoln & Guba, 1985). Units of analysis were individual words and phrases. The researcher repeatedly reviewed transcripts, highlighting words that reflected self-observation, self-judgment, and self-reaction. Common and unique themes were identified and tallied. Field notes about interviews' contexts and details provided background information to strengthen the credibility of the study.

To further enhance credibility, a reflective journal was kept during transcript analysis (Thorne et al., 1997). To strengthen the dependability and confirmability of findings, an inquiry audit was solicited. Informants' transcripts, along with the researcher's analysis and interpretations, were submitted to a nurse reviewer experienced in qualitative research. The expert researcher judged the analysis and interpretation to be accurate (S. D. Moch, personal communication, November 18, 2004).

Findings

Informants' responses reflected the use of self-regulation behaviors to varying degrees. Table 2 displays themes identified in informants' responses to interview questions.

Table 2. Self-Regulation Themes and Informants' Comments

Self-Regulation Subprocess	Themes	Comments Given by Informantsa
^a Comments that are phrases are paraphrases unless in quotation marks.
Self-observation	Breathing/dyspnea	Difficulty moving air in and out Tightness or stiffness in chest Sensation of heaviness or pressure Sensations of gasping, suffocating, drowning Dyspnea triggers Walking—“anything over 2 blocks is a chore” Climbing stairs Carrying groceries and laundry Carrying out activities of daily living Hurrying Anxiety Heat, cold, wind, humidity, smoke, pollen, and dust
	Decreased activity tolerance	Feeling weak, fatigued, exhausted Feeling the need to stop or risk “collapse”
	Signs and symptoms of acute illness	Change in amount, character, and color of sputum Increased feeling of agitation that accompanies increased shortness of breath Decline in sleep quality Decline in hemoglobin saturation
	Other symptoms	Increased cough Feeling as if one's heart was “jumping out” of one's chest Difficulty talking due to gasping for air “Fuzzy” brain Tingly fingers and feet, sore legs Holding one's breath during exertion
Self-judgment	Compare to ordinary symptom status	Used degree of shortness of breath as a gauge of symptom status Compared current level of activity tolerance and fatigue to “typical” levels
	Apply past experience	Judgments about current condition were informed by previous experiences with respiratory illnesses and COPD exacerbations Increased fatigue that had accompanied previous respiratory infections served as the comparison standard for subsequent experiences with fatigue accompanying respiratory infections Assessed all respiratory infections knowing that previous “colds” had become pneumonia
Self-reaction	Attempt to self-treat	Intensify everyday self-management regimen including use of rescue inhalers and nebulizer treatments Stop or slow activities; either sit down or sit up Use special breathing techniques (e.g., purse-lip and/or diaphragmatic breathing) Administer oxygen Get additional rest Take OTC medications to thin and raise sputum
	Seek out professional health care	When the illness was lasting too long with no improvement Call the doctor if increase in cough, change in sputum, inability to raise sputum, no air moving in lungs, when rest afforded no improvement, “when anything I did wouldn't help” Call the doctor on Friday rather than be seen in the ED over the weekend Try to get to the doctor soon enough to be seen in the clinic rather than have to go to the hospital
	Procrastinate	“I assume things will get better” “It has to be pretty bad before I'd call the doctor” “I don't like the Emergency Room” “I don't want to go to the hospital” Too much effort/time are required to seek out care No wish to “bother” the doctor
	Delay until someone else decides	Spouse or adult daughter urges or arranges for medical care

Self-Observation

Most informants described symptoms they observed, though one admitted, “I don't think that I really am good at self-observation.” Nearly all informants observed breathing difficulty. One monitored his breathing using his own pulse oximeter. Many activity- and environment-related dyspnea triggers (e.g., carrying groceries, hurrying, wind, humidity, and smoke) were described. Nearly half of the informants associated emotions, particularly anxiety, with dyspnea.

Informants also reported observing symptoms of (a) decreased activity tolerance, (b) acute illness, and (c) other phenomena (e.g., increased cough, tingly fingers and toes). A small number were not aware of observing any symptoms.

Self-Judgment

Most informants used usual degree of breathlessness as the chief standard to gauge status changes, though usual activity tolerance was also mentioned. In other words, many informants used anotion of their baseline status for comparisons. Four informants said past experience with signs and symptoms of acute respiratory illnesses and COPD exacerbations informed their current symptom judgments.

Self-Reaction

Informants' reactions to symptom changes included electing not to react. More commonly, they responded to worsening symptoms by intensifying everyday COPD management techniques. Even when it became apparent they were ill, four informants procrastinated in contacting their healthcare provider, stating, “I assume things will get better,” “I don't want to go to the hospital,” or “no wish to ‘bother’ the doctor.”

Once informants realized intensified self-management activities were ineffective, most sought professional health care. Eleven informants identified particular indicators that prompted them to call their physicians (e.g., increase in cough, inability to raise sputum, “when anything I did wouldn't help”). A few delayed acting until someone else, such as a spouse or adult daughter, decided that action was needed.

Everyday Self-Management Activities

Informants described using a range of everyday self-management practices. These may be classed as learning, planning, and doing (see Table 3).

Table 3. Everyday Self-Management Activities (Self-Reactions) Reported by Informants

Classification	Self-Management Activity	Examplesa
^a Examples are paraphrases unless in quotation marks.
Learning	Attending pulmonary rehabilitation programs	Valuable for learning how to manage COPD
	Seeking additional information on COPD management	Searching the Internet for additional information on COPD management Talking to other people with COPD for the sake of comparing own disease trajectory to that of others Obtaining information from physicians
Planning	Adjusting and modifying activities	Slowing down the pace of activities Taking rest periods; “I know when to quit” Using assistive devices (e.g., three wheeler to get to the mailbox, motorized shopping cart, cart to carry trash) Sitting down to perform activities previously done while standing
	Remaining flexible in scheduling events and activities	Delaying or modifying planned activities if not feeling well enough to carry them out as planned Strategizing the best way to carry out known dyspnea-causing activities Lowering housekeeping standards; “just because I can't do everything I used to it's not going to kill me”
	Modifying the environment	Constructing an entry ramp to bypass stairs Keeping needed objects close Planning household activities to minimize trips up and down the stairs Arranging oxygen supply lines to maximize mobility and minimize trip hazards Using computer battery pack to power a nebulizer in the car while traveling
Doing	Taking medications	Taking bronchodilators and inhaled steroids via MDIs Timing nebulizer treatments to permit work, household tasks Taking decongestants and nasal sprays as needed
	Using oxygen therapy	Using oxygen (“I call it my lifeline”) Avoiding oxygen therapy (“I'm trying to keep myself off oxygen”) Using CPAP or BPAP
	Managing symptoms other than dyspnea	“Working” to raise sputum Keeping well-hydrated to keep “phlegm” thinner
	Using breathing and positioning techniques	Using pursed-lip breathing Using extra pillows for sleeping Using positioning to breathe easier (e.g., forward leaning with arms supported)
	Managing air quality-related factors	Avoiding going outside when temperature is extremely hot or cold Covering face during cold weather Avoiding high-humidity environments (e.g., hotel swimming pools) Using dehumidifiers, air conditioners, and fans Maintaining furnace filters and ductwork (i.e., changing filters, cleaning ducts) Smoking cessation
	Managing emotions	Taking antianxiety medications Turning off the TV broadcast of a football game because excitement increases dyspnea Using a pulse oximeter for reassurance when feeling dyspneic
	Taking illness-prevention action	Obtaining immunizations against influenza and pneumonia Avoiding people during cold and flu season Limiting trips outside during the winter
	Managing other aspects of health for the sake of the COPD	Managing weight to avoid weight gain Avoiding constipation Managing other disease conditions (e.g., fibromyalgia)

Learning

Informants described obtaining information about COPD from various sources. They attended PR programs, searched the Internet, and discussed COPD with other patients and their physicians.

Planning

Most informants modified activities as part of self-management. They struck a balance between planning less exertive ways to carry out activities and canceling activities when not feeling well. One rural informant described riding a three-wheeler to collect his mail when he could no longer walk to the mailbox. About one-third of the informants described arranging their environments for maximum efficiency (e.g., constructing an entry ramp to the front door, keeping oft-needed items close).

Doing

Informants performed various management activities. Nearly all used metered-dose inhalers; many used nebulizers, chronic oxygen therapy, continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BPAP), breathing techniques, and positioning to manage dyspnea. Several described (a) taking action to improve their air quality, (b) managing their emotions, especially anxiety, and (c) preventing illness (e.g., influenza and pneumonia immunizations).

In summary, most informants engaged in self-observation, self-judgment, and self-reaction, some poorly and others consistently. Some, however, reported not observing their symptoms and/or delaying symptom response. Dyspnea and activity tolerance were the most common parameters observed by informants. Usual symptom status and past COPD exacerbation symptoms served as self-judgment standards. Finally, self-reactions included using everyday COPD management techniques, self-treating increased symptoms, and seeking treatment or letting others react.

Discussion

Not surprisingly, quality of breathing was important as a symptom to observe, and a standard by which status changes were judged. Dyspnea is the prevalent symptom of COPD. That some informants in this study did not use self-observation is consistent with others' findings that a significant percentage of participants with COPD did not monitor any primary symptom of the disease (Warwick et al., 2010).

Interestingly, none of the 28 informants described using a written COPD action plan to respond to symptom changes. Self-reaction behaviors included standard interventions for increasing dyspnea such as using oxygen, rescue inhalers, nebulizers, and breathing techniques. It is of concern that some informants procrastinated in seeking treatment for increased symptoms until someone else sought it for them.

Informants' stories illustrate the challenge people with COPD face in recognizing exacerbations. Day-to-day variation in symptoms (e.g., degree of dyspnea, cough) accompanying the disease makes it difficult to distinguish baseline symptoms from an exacerbation (Hurst, Donaldson, et al., 2010a). People with COPD must develop a sophisticated ability to recognize subtle changes in their ordinary symptoms. This is especially difficult for older adults who make up the largest number of people with COPD. They may have diminished symptom recognition ability, be more likely to attribute symptoms to other causes, and under-report symptoms (Riegel et al., 2010).

Once COPD patients recognize meaningful symptom changes, they must respond appropriately. Early treatment of exacerbations contributes to a more rapid recovery (Wilkinson, Donaldson, Hurst, Seemungal, & Wedzicha, 2004). The informants in this study who delayed seeking treatment illustrated the need for education on self-reaction.

This study adds to what is known about use of self-regulation by older adults with COPD. The naturalistic design is a strength; semi-structured interviews with informants familiar with the disease yielded rich information. A limitation of the study is that informants' experiences, while representative of community-dwelling adults in one geographic region, may differ from those of older adults living with COPD in other locations with different climates and population characteristics. Replication of the study with additional informants is recommended.

Implications for Nursing Practice

Patient Education

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

COPD Self-Management Issues	Teaching Plan	Source of Recommendations
I need to understand my disease	Knowledge COPD and its impact on lung function, breathing, and other body systems Action 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?	Knowledge Importance of smoking cessation Effects of prescribed medications and when to take them Bronchodilators Corticosteroids Mucolytics Proper technique for use of inhalers and nebulizers Actions 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? (Self-observation)	Knowledge Signs and symptoms of an exacerbation, including increased dyspnea, increase in sputum amount, change in sputum quality Actions 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?	Knowledge Cold weather, poor air quality, and respiratory infections are known exacerbation triggers Actions 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? (Self-judgment)	Knowledge 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 Action Perform daily symptom comparisons against dyspnea log	GOLD (2010), Hurst, Donaldson, et al. (2010a), ICSI (2009)
How do I respond to a COPD exacerbation? (Self-reaction)	Actions 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.

Conclusion

One of the informants in this study said of his COPD management, “I'm just trying to keep life the way that I have been living it, without too much difficulty.” Others shared that aim; however, unrecognized COPD exacerbations can interfere with the aim's achievement. Rehabilitation nurses, with their holistic, patient-centered, rehabilitation-focused practice, are perfectly positioned to teach older adults COPD self-regulation skills. Early symptom recognition and appropriate care can slow the progression and lighten the burden of their disease.

Key Practice Points

• Exacerbations of COPD are associated with worsened disease status and increased healthcare utilization.
• It is challenging for people with COPD to distinguish between their day-to-day symptom variation and the signs of an acute exacerbation; this makes early recognition of exacerbations more difficult.
• Self-regulation theory is useful to rehabilitation nurses as they use a patient-focused approach to help people with COPD self-manage their chronic disease.
• An evidence-based patient teaching plan for COPD self-management strategies includes instruction on exacerbation triggers, how to recognize exacerbations, and appropriate management.
• Structured COPD action plans can help patients better recognize and more appropriately respond to an exacerbation.

Acknowledgments

The author gratefully acknowledges Dr. CeCelia Zorn for her extensive and expert assistance in the preparation of the manuscript. Special thanks go to Dr. Joan Stehle Werner for her skillful review and invaluable insights, and to Mr. James D. Rapp for his editing suggestions.

Biography

• Cheryl L. Brandt, PhD, RN, ACNS-BC, is Associate Professor, Department of Nursing, University of Wisconsin – Eau Claire, Eau Claire, WI. Address correspondence to her at [e-mail].