Chronic Obstructive Pulmonary Disease (COPD)

Other names for COPD

•Emphysema•Chronic bronchitis

Lung function

•Normal lungs are like a sponge•The holes in the sponge are where the lungs are able to exchange carbon dioxide that the body produces, for oxygen•Air (oxygen) travels down the windpipe (trachea) through the bronchi (breathing tubes) to the bronchioles (smaller tubes) to the alveoli (sacs) where oxygen and carbon dioxide are exchanged

Lung function (continued)

•The body needs oxygen to function•The airways and air sacs are normally elastic and springy •The tubes are normally open and able to clear dirt/debris that enters the lungs

Anatomy of the lungs

•Photo of lungs

What is COPD?

•Lung disease in which the lungs are damaged•Typically occurs in smokers, but may happen with other environmental exposures and hereditary conditions

What is COPD?

•Breathing tubes that carry air in and out of the lungs are obstructed•In COPD air sacs lose their elasticity and so they collapse or don’t inflate properly•In COPD the breathing tubes are blocked with mucous and become swollen so air cannot move in and out

COPD facts

•14 million people in the United States have COPD•Develops slowly•Not contagious•Fourth leading cause of death in the United States•There is no cure

Causes

•Exposure to pipe, cigar, tobacco smoke•Exposure to second hand smoke•Exposure to heavy air pollution•Exposure to heavy dust•Exposure to chemical/toxic fumes•Genetic conditions

Signs and symptoms

•Wheezing•Coughing•Sputum production•Shortness of breath •Chest tightness

physical examination

•Taking your temperature, pulse, breaths per minute, pulse and blood pressure•Listening to your heart and lungs with a stethoscope•Examining your ears, nose, eyes and throat for signs of infection•Examining your fingers for signs of cyanosis and clubbing•Assessing for signs of swelling in your legs, ankles and feet or other parts of your body•Evaluating the veins in your neck to assess for complications of COPD such as cor pulmonale

Diagnosis

•Clinical symptoms•Chest x-ray•Lung function tests

Classification•At risk- breathing test normal, mild symptoms•Mild- breathing test shows mild limitation, increasing symptoms•Moderate- person will typically seek care for symptoms, shortness of breath with significant exertion, lung tests abnormal•Severe- shortness of breath with limited activity, lung tests abnormal

Treatment

•Eliminate exposure to things that cause COPD•Quit smoking•Exercise and pulmonary rehabilitation•Inhaled medications to open the breathing tubes or decrease the inflammation•Oxygen•Pneumococcal and flu vaccines

Medications

•Inhaler use•Spacer use•Discuss use

Meter dose inhaler

•Abbreviated MDI

•Aerosolized medicine in canister in plastic holder

Spacer

•Plastic tube that attaches to the inhaler

•Makes the use of the MDI easier

•Ensures delivery of the medication to the lungs

Meter dose inhaler/spacer use

•Remove the cap from the inhaler and from the spacer•Shake the inhaler well•Attach the inhaler to the spacer•Exhale deeply•Purse lips around the mouthpiece•Take a slow breath in•Hold breath for at least ten seconds

Meter dose inhaler/spacer use

•Wait two to three minutes•Repeat process•Rinse mouth after use if using a steroid inhaler

Warning symptoms

•Increasing shortness of breath•Increasing coughing and wheezing•History of fever

Warning signs*

•Increased wheezing•Decreased pulse ox •Fever ( greater than 101 degrees Fahrenheit)•Increased pulse (greater than 100)•Decreased pulse (less than 60)•Increased respiratory rate

*ALL vital parameters are determined by RN supervisor and are patient specific

Other warnings

•Not taking medications

References•Neal, LJ. & Guillett, SE .Care of the adult with a chronic illness or disability. Mosby, St. Louis, Missouri, 2004.

pp. 107-126.•Kennedy – Malone, L. et al. Management guidelines for gerontological nurse practitioners. F.A. Davis Company, Philadelphia, PA, 2000.

pp. 194-202. •Lippincott, Williams and Wilkins. Managing chronic disorders. Lippincott Williams and Wilkins, USA, 2006.

pp. 137-140.•www.nhlbi.nih.gov/health/dci/Diseases/Copd/Copd_WhatIs.html•http://www.cumc.columbia.edu/dept/pulmonary/4ClinicalPage/Clinical%20Centers/Website/understanding.htm

Case study

•70 year old female•Difficulty with breathing for the past six months•Wheezing•Coughing•Smokes one pack of cigarettes for forty five years

Case study

•No other medical problems•No problems with her heart•Does not drink alcohol or use drugs•Her husband smoked as well

Case study

•Which of her symptoms suggest COPD?- -

•What are her risk factors for COPD?--

•What might be appropriate treatments for her?

-

Case study

•Which of her symptoms suggest COPD?-Wheezing-Shortness of breath

•What are her risk factors for COPD?- Smoking- Spouse smoking

•What might be appropriate treatments for her?

- Inhaled medications

Case study

•If she had quit smoking, can she still have COPD?

-•How would you counsel her?

----

Case study

•If she had quit smoking, can she still have COPD?

-yes•How would you counsel/coach her?

- Smoking cessation- Exercise- Medications as prescribed by her

doctors- Report new symptoms

Case study

•How would you explain to her what COPD is?

Motivational interviewing

•What could you do to help her stop smoking?

oNow that you’ve gained her trust, you can start asking questions that will begin the change talk.

Starting the change talk

•What questions can we ask that could start her thinking about cutting out smoking?

–Tell me about smoking?–What do you think about smoking?

WILLING, ABLE, READY

•In the next few slides, put yourself in this client’s shoes. Try to write down answers to the questions from her point of view.

Find out how WILLING she is to change

•Ask open ended questions so she can:oState her reasons for smokingoState the reasons she has for

stopping smoking•Have her write down her answers to

the following questions

What are her reasons for Not Quitting Smoking? – 2 good questions to ask

Reasons I have for Staying the Same (Continuing to Smoke)

Reasons I have to ChangingQuitting Smoking

What benefits are you getting by smoking?

What are your fears, concerns about quitting smoking?

What are the worst consequences you can imagine if you continued to smoke? Hint: these are your fears, concerns about not quitting)

What benefits could you get by quitting? Hint: Imagine what your life would be like if a miracle happened tomorrow and you could quit.

Explore her reasons fully

•Ask her how smoking could be good for any of these aspects of her life:

–Health–Lifestyle–Emotions–Relationships–Coping abilities (stress, for example)–Work–Social life–Spiritual life

Here are some sample reasons for smoking

Reasons I have for Smoking

What benefits are you getting by continuing to smoke?RelaxingSocializing with friendsCoping with stress

What are your fears about quitting smoking?Don’t want to disconnect from my peer’s cultureDon’t have another way to handle stressLose friendsTried once and failed; don’t want to fail again

Next, what reasons does she have for Not Smoking?

Reasons I have for Staying the Same (Continuing to Smoke)

Reasons I have to Quit Smoking

What benefits are you getting by smoking?

What are your fears, concerns about quitting smoking?

What are the worst consequences you can imagine if you continued to smoke? Hint: these are your fears and concerns about quitting

What benefits could you get by quitting? Hint: Imagine what your life would be like if a miracle happened tomorrow and you could stop smoking.

Explore her reasons fully

•Ask her how taking her meds could be good for any of these aspects of her life:

–Health–Lifestyle–Emotions–Relationships–Coping abilities (stress, for example)–Work–Social life–Spiritual life

Here are some sample reasons for quitting

Reasons I have for Quitting

What is the worst outcome you can imagine if you continued to smoke?Lung cancerStrokeHeart attackCan’t enjoy children

What would your life be like if a miracle happened and you stopped smoking tomorrow?Stop wheezing, coughingClothes stop smellingBreath smells good

Next, how important is it for her to change?

•Ask her to compare her reasons for not changing with her reasons for changing•Have her assign a number to the Ruler of Change in the next slide.•This will show how important it is for her to change

How important is it for you to change?

•On a scale of 0 to 10, how important is it to you to quit smoking?

The “Ruler of Change”

0 1 2 3 4 5 6 7 8 9 10

Not at all

Very Important

WILLING

•This number on the Ruler of Change will show how WILLING she is to change

•It will show how willing she is to quit smoking

Willing (continued)

•If her Ruler of Change number is below 3 or 4, she is not willing to consider change.

oShe has lots of resistance to change

oHer reasons for smoking are STONGER THAN her reasons for quitting.

Sample question to help decrease resistance

•What would have to change to decrease the importance you give to your reasons for smoking?

Questions to decrease resistance•A low number on the ruler of change says she does not think that quitting is important and she does not want to change

•But, look at her number on the Ruler of Change•If she’s not at zero, she must have at least a small interest in change.

Decreasing resistance

•If this is the case, Ask:

oWhy are you at ___ and not zero?

oWhat would it take for you to go from__ to__ ?

•Her answers might get her to start thinking that change might be a good thing

Willing (continued)

•If the number the client gives for the importance of changing is around 5:

oShe is “on the fence.”oShe is split between wanting to

take action and not being able to take the first step.

oIn this condition, she can’t change.

Sample question to help increase motivation

•What would have to change to increase the importance of the reasons you have for quitting?

Willing (continued)

•If the number she gives for the importance of change is greater than 6 or 7:

oShe is not resistant to change

oShe is not “on the fence”oShe is ready to take some

action

Next, find out if she is ABLE

•Measure her Confidence and Ability to quit smoking

•Use the Confidence and Ability “Rulers of Change” in the next slide

Assessing Confidence and Ability to Make a Change

•Score your confidence to quit smoking.

•Score your ability to quit smoking.

Handout : How Can I Quit Smoking?

0 1 2 3 4 5 6 7 8 9 10

None Low Medium Very High

0 1 2 3 4 5 6 7 8 9 10

None Low Medium Very High

For Scores of About 6 and Below

•Ask, “What would it take to increase your confidence to quit smoking?”

–What encourages you to believe that you can achieve your goals for change?

•Ask, “What would it take to increase your ability to quit smoking?”

Increasing confidence and ability about change

•Other questions to ask”

–What else could help you stop smoking?

–Who else could help you stop smoking?

For low confidence and ability scores

•Maybe the goal is not realistic, it exceeds her confidence and ability. Ask:

oWhat would happen if you reduced the size of your goal?oWhat would you be willing to try?oMaybe if you reduced your goal

for changing, you would be more likely to try.

Role of the Nurse Aide

•Find out what is important to the client and use this to motivate him/her to change

•Help the client identify an activity that he/she has the ability and confidence to achieve

The next step: being READY

•If she’s WILLING (Importance Score 5 and above)

•If she’s ABLE (Confidence and Ability Scores are 5 and above)

•Then she’s READY

Being READY means:

•Being READY to set a goal and make a plan

•Keeping track of progress toward the goal

•Being prepared for setbacks with the right attitude and a Plan “B”

Class exercise – goal setting

•Put yourself in the shoes of the client who is smoking

•Using your current goal setting skills, write a goal for quitting smoking on the next slide

Write down your personal goal and plan below, using your own words

Setting and planning a goal – SMART Method

•A useful method for setting goals, SMART.

•To be effective, Goals need to be:

oSpecificoMeasurableoAction orientedoRealisticoTime

SMART method – some examples

•A goal that is not SMART will probably fail.

•“I want to stop smoking” is not specific, measurable and does not have a time frame for when the goal will be done.

•It also may be unrealistic – it might be more realistic to phase out slowly.

Set and plan a goal – SMART method – some examples (continued)

•A SMART goal would be, “I will reduce my smoking by 2 cigarettes per day. After one month, I will cut out 2 more per day. In another month, I will cut out 2 more per day. I will continue this slow reduction until I am not smoking.”

Set and plan a goal – SMART method

•Now try rewriting a goal for quitting smoking on the next slide according to the SMART method

•Pretend you are the COPD client

What is your smart goal?

• S

• M

• A

• R

• T

READY

•READY also includes tracking progress in a written log or on a calendar

•Seeing concrete progress helps build confidence

•Adding comments can also identify what helped, what was difficult, what you learned, how you can get better

Progress check (sample)

•My goal was_____________•I was______ successful in reaching my goal•What helped______________•______________was difficult•I learned that__________________

Adapted from HIP CHA training, 2005

READY

•READY also includes being prepared for setbacks and relapses to old habits•Plan for recovery from setbacks – have a “Plan B”•Remember,

–Setbacks are chances for learning how to do things better,

–Setbacks are not failures.

READY - staying ready and motivated

•When you make your goal, Don’t Forget to Reward Yourself

•A reward provides an incentive to stay motivated.

•“After I do this, I’ll buy some new perfume now that I can smell it”

Final pieces

•Why is it important for the team to work on the goal of reducing/stopping smoking together?

•How can the team communicate progress towards the goal and encourage the client through reinforcing the planned reward?

What did you learn?

•How do the lungs work and what is the impact of COPD on respiratory function?

•What are healthy lifestyle choices for the person who has COPD?

•How would you use motivational interviewing with the person who has COPD?

How will what you’ve learned change the way you do your job?How will what you’ve learned change your life?

References

•HIP CHA training, 2005•Miller, W.R. and Rollnick, S. Motivational Interviewing. New York: Guilford Press,2002•Botelho, R. 2002. Motivate Healthy Habits.