Teach best practices for care of COPD patients

Patients who have chronic obstructive pulmonary disease (COPD) might be on a fast or slow downward cycle, depending on how much help they receive from their physicians, nurses, therapists, and home health aides.

COPD patients often become depressed and frustrated with their inability to breathe freely and live an active life. But national pulmonary experts say they can have a better quality of life if they follow certain guidelines. And home care nurses and aides can help them achieve their goals.

Cozby-Germany Home Health in Grand Saline, TX, has an inservice on COPD that seeks to teach aides how best to care for patients who have this debilitating disorder.

"I wanted to help them understand how to work with these patients to help them have a greater level of productivity in their lives," says Shonna DeFoy, RN, assistant director of nurses and education director.

Aides often raised concerns about COPD patients, commenting that they weren't eating, were unable to bathe because they were too tired, or didn't want to wear hose because their legs were swollen, DeFoy recalls. She began to read every book the agency had on COPD and review teaching manuals. With that information, she created a training program to educate both staff and patients with the chief goal of improving care. (See COPD goals, inserted in this issue.) The inservice includes a post-test on COPD. (See COPD quiz, p. 92.)

"Teaching is everything," she says. "If you don't educate patients and staff, you won't have a continuity of care, and that's what home care is about today: education."

Teaching staff about COPD can make a huge difference in patients' lives, she adds. "We can teach aides how to make their lives more productive, with dignity and self esteem."

Here's how she structured the COPD inservice:

1. Define COPD and list COPD diseases. COPD consists of a group of diseases causing airway obstructions that result in patients hav ing trouble breathing, which is called dyspnea. (See story on teaching staff about dyspnea, p. 94.) Those diseases include chronic bronchitis, asthma, and emphysema. (See handout on how the lungs work, inserted in this issue.)

2. Who is at risk for COPD? Men 65 or older who smoke are at the greatest risk for COPD, according to statistics compiled by the American Thoracic Society and American Lung Association (ALA) in New York City. However, the ALA's statistics show a steady upward trend of women contracting COPD between 1979 and 1995, probably due to increases in smoking. The rate of women diagnosed with chronic bronchitis and emphysema rose from 7 per 100,000 population in 1979 to 17.1 per 100,000 population in 1995. During that period, the rate of men with the diseases increased slightly from 23.8 per 100,000 to 26.3 per 100,000.

3. Describe the basic anatomy of the lung and provide an oxygen therapy demonstration. DeFoy gave aides drawings of the lungs and respiratory systems and described the various parts. She also drew pictures of respiratory system structures and complications that may occur. (See anatomy of respiratory system and structure of chest area, inserted in this issue.) The inservice also included information on using oxygen machines and other devices.

4. Bathe patients in a way that increases circu lation. "People need to be taught how to increase the flow to remove the mucus from the lungs," DeFoy says. "That is to bathe them from the lower part of their spine in long, smooth strokes to help them excrete or remove mucus from their lungs. This forces the mucus up, and with water it helps to get the mucus out of their lungs so they don't have plugs in them." This little-taught technique is one of the best ways aides and caregivers can help COPD patients, she says.

5. Help lower patients' anxiety and depression. COPD patients may become anxious, depressed, and frustrated by their inability to do their daily activities as well or as fast as before. Aides, nurses, and family members can help ease those emotion al difficulties by creating a relaxing atmosphere, DeFoy suggests. "Slow down, show patience, and do not rush these patients because if you rush these patients at any time, they'll get anxious and have a shorter breath and energy level." If patients are rushed, they may not be able to complete a task and may become depressed, feeling as if they have failed, she says.

Aides also can make sure the patient has comforting items nearby, such as a table in the area the patient likes most or a glass of water and television remote control next to the chair. "This is so they don't have to get up and continuously search for these things, which can make them frustrated and tired," she says.

Home care staff also should help alleviate patients' fears because when COPD patients become afraid, their oxygen levels decrease and they begin to pant or have shallow respiration, which is difficult on the respiratory system. "Give them reassurance, and use guided imagery. When they get short of breath, teach them to close their eyes and imagine something that is a positive experience for them, like maybe a visit to a stream with water rolling over rocks."

Aides also are advised that if they notice depression in their patients, they should ask for a case conference. A social worker may need to visit the family, or the patient may need to become involved in the hospital's geriatric depression program.

6. Describe proper nutritional and hydration requirements. COPD patients, unlike heart patients, need more fat in their diet, DeFoy says. "When someone is panting heavily and is short of breath, they need something to insulate them, and most patients with emphysema are very thin, without enough insulation." The diet should have fewer carbohydrates because they turn quickly into sugar and waste energy. "It doesn't hurt them necessarily, but it takes them so much time and energy to eat." They'll need a mixture of proteins, but meats should be easier to chew. Meatloaf or chicken salad, for example, are excellent sources of protein.

Because COPD patients breathe through their mouths, their tongues become dry and crusted and they may lose some of their sense of taste. Lemon drops or lozenges will help. Also, fluids should be increased most of the time because patients lose so much fluid through their mouths, and most of them are taking diuretics because of the mucus in their lungs. "They're going to need small amounts of fluid at one time. They can't stop to drink a whole glass of water because it wears them out, so break an 8 oz. glass down into two 4 oz. glasses, or have them suck on ice chips."

7. Show how patients can conserve energy and improve breathing technique. It's possible to find less strenuous activities COPD patients might enjoy. For example, if patients like gardening but can no longer do so, perhaps they could plant a potted flower inside the house, DeFoy suggests. Also, if patients are too tired to sit and read for long, perhaps they could listen to books on tape.

Aides can ensure patients rest often. If they rest and breathe oxygen for at least 30 minutes, they may have enough energy to take a walk. Also, aides can help with breathing techniques. "Make sure the patient takes a nice, slow breath and sits in an erect position. Make sure their shoulders are as straight as can be because the lungs then can expand more and release carbon dioxide."

8. Discuss the weather's effect on patients. COPD patients must be careful to avoid weather that will make their condition worse. For example, cold weather might cause their lungs to constrict, trapping mucus inside. Summer weather might not be any better. In cities, heat can trap pollution near the ground and make breathing labored. Even in rural areas, COPD patients should be cautious before venturing outside, DeFoy says. "Maybe you look outside and think it's a great summer day, but your neighbor might be mowing a pasture or lawn, and dust is blowing. If you go outside, and mucus builds up in your lungs, it causes blocks and you don't have the strength to cough it out."

9. Teach aides what to report to the case manager. People unfamiliar with the disease may think patients are improving if they don't have the characteristic rattling or wheezing sound on a particular day. But the sound disappears only when patients' lungs are plugged and they're not getting enough oxygen. If a lack of oxygen continues, the patient could end up with pneumonia. The aide should tell the case manager or nurse if a patient's breathing suddenly becomes quiet.

10. Stress the importance of oral hygiene. This is a key factor to making sure the patient eats enough food. If patients have an unpleasant taste in their mouths, they won't want to eat. "They often have tooth decay because of their cigarette smoking," DeFoy says. The tendency to have a dry mouth also causes poor oral hygiene. Patients should take extra care to keep their teeth brushed and stay away from sugar.