Home Care Chronic Disease Prevention Program

Melanie S. Bunn RN,MS

A collaboration of Duke University, Division of Community Health and University of South Carolina, School of Medicine

Homework review
What did you do? What happened as you did that?

Why do you think that happened?

Heres what might have happened. How does this impact the next time you try this?

Chronic Disease Prevention Program

Module 1:Health/Illness, Vital Signs, Nutrition Module 2: Motivational Interviewing Module 3: End of Life Module 4: Heart Attack Module 5: COPD Module 6: Stroke Module 7: Hypertension Module 8: Diabetes Module 9: Congestive Heart Failure Exercise,

Chronic Obstructive Pulmonary Disease (COPD)

Objectives
Discuss how the lungs work and the impact of COPD on respiratory function Describe healthy lifestyle choices for the person who has COPD

Demonstrate use of motivational interviewing with the person who has 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 dont 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

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/Clinic al%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?

o Now that youve 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 clients 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:

o State her reasons for smoking

o State 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)
What benefits are you getting by smoking?

Reasons I have to Changing 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 are your fears, concerns about quitting smoking?

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? Relaxing Socializing with friends Coping with stress What are your fears about quitting smoking? Dont want to disconnect from my peers culture Dont have another way to handle stress Lose friends Tried once and failed; dont want to fail again

Next, what reasons does she have for Not Smoking?

Reasons I have for Staying the Same (Continuing to Smoke)
What benefits are you getting by smoking?

Reasons I have to Quit Smoking

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

What are your fears, concerns about quitting smoking?

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 cancer Stroke Heart attack Cant enjoy children

What would your life be like if a miracle happened and you stopped smoking tomorrow? Stop wheezing, coughing Clothes stop smelling Breath 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?
0 1 2 3 4 5 6 7 8 9 10
Very Important

Not at all

The Ruler of Change

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.
o

She has lots of resistance to change

Her 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 shes not at zero, she must have at least a small interest in change.

Decreasing resistance
If this is the case, Ask: o Why are you at ___ and not zero?

o What 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: She is on the fence.

She is split between wanting to take action and not being able to take the first step.
In this condition, she cant 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:
o

She is not resistant to change

She is not on the fence

She 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.
0
None

1
Low

5
Medium

10
Very High

Score your ability to quit smoking.

0
None

1
Low

5
Medium

10
Very High

Handout : How Can I Quit Smoking?

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:
o What would happen if you reduced the size of your goal? o What would you be willing to try?

o Maybe 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 shes WILLING (Importance Score 5 and above) If shes ABLE (Confidence and Ability Scores are 5 and above) Then shes 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:

o o o o o

Specific Measurable Action oriented Realistic Time

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

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, Dont Forget to Reward Yourself A reward provides an incentive to stay motivated. After I do this, Ill 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 youve learned change the way you do your job? How will what youve 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.

Homework Assignment
Think of another of your personal health improvement goals and fill out Handouts #1 to #5 and turn in next session:
o Handout #1: Reasons for staying the same and changing o Handout #2: How important is change to me? Answer the question: How could I increase the strength of my reasons for changing and decrease those for staying the same? o Handout #3: How confident and able am I? o Handout #4: Answer the question: What could increase my confidence and ability? o Handout #5: My health improvement goal using the SMART method

Handout #1
Reasons I have for Staying the Same
What benefits are you getting by staying the same?

Reasons I have to Change

What are the worst consequences you can imagine if you continued to stay the same? (these are your fears, concerns about not changing)

What are your fears, concerns about taking the actions needed to change?

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

Handout #2 Measuring Importance of Change

On a scale of 0 to 10, how important is it for you to make a change in this health behavior?

0
Not important at all

10
Very Important

Write down how you think you could increase the importance of reasons for changing and decrease the importance of those reasons for not changing

Handout #3

Confidence and Ability to Make a Behavior Change

Score your confidence to make the behavior change.

0
None

1
Low

5
Medium

10
Very High

Score your ability to make the behavior change.

0 1 2 3 4 5 6 7 8 9 10

None

Low

Medium

Very High

Handout #4

Write Down How You Think you Could Increase Your Confidence and Ability

Handout #5: Re-Write Your Goal Using SMART

S M

A
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This training aid was produced with the generous support of

The Fullerton Foundation, Inc.

For information on continuing programs that support CNA learning contact:
Duncan Howe, University of South Carolina, School of Medicine Duncan.Howe@uscmed.sc.edu or Claudia J. Graham, Duke University Medical Center, Department of Community and Family Medicine, Division of Community Health Claudia.Graham@duke.edu