Review. Discuss the possibility of smoking and environmental exposure (“black lung”)
Ask participant to put one semi-closed fist up to their mouths and blow through it while their other hand is at the other end to feel the air. This is normal function. Ask them to close the fist completely and blow. Discuss the energy used in second effort and how they might feel if they had to breath this way all the time. Ask them to discuss how their clients with COPD might feel if they have to breath this way all the time.
Review. Ask them to describe someone they’ve worked with who had COPD and determine at what level that person might have been.
Review the importance of treatments to reduce restriction and the potential for additional damage/inflammation
Ask them to demonstrate then discuss why this is difficult…for them. Then discuss how much more difficult it might be for someone with COPD to do this process correctly.
Review and compare answers
Review and discuss
Compare to their responses
Ask for demonstration
Now that you have established a trusting relationship with your client you should be able to start the change dialogue by asking “leading” questions.
Emphasize that these are open ended questions that can be used to start the change dialogue.Don’t forget the importance of using good listening skills also.
To make a change, your client is going to have to be WILLING, ABLE, and READY.
There is still hope
Note on your record system what helped, what was difficult, and what you learned that can help you make changes in the goal that benefit from these lessons learned.
Chronic ObstructivePulmonary Disease (COPD)
Other names for COPD• Emphysema• Chronic bronchitis
Lung function• Normal lungs are like a sponge• The holes in the sponge are where thelungs are able to exchange carbon dioxidethat the body produces, for oxygen• Air (oxygen) travels down the windpipe(trachea) through the bronchi (breathingtubes) to the bronchioles (smaller tubes) tothe alveoli (sacs) where oxygen andcarbon dioxide are exchanged
Lung function (continued)• The body needs oxygen to function• The airways and air sacs are normallyelastic and springy• The tubes are normally open and able toclear dirt/debris that enters the lungs
What is COPD?• Lung disease in which the lungs aredamaged• Typically occurs in smokers, but mayhappen with other environmentalexposures and hereditary conditions
What is COPD?• Breathing tubes that carry air in and out ofthe lungs are obstructed• In COPD air sacs lose their elasticity andso they collapse or don’t inflate properly• In COPD the breathing tubes are blockedwith mucous and become swollen so aircannot move in and out
COPD facts• 14 million people in the United States haveCOPD• Develops slowly• Not contagious• Fourth leading cause of death in theUnited 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 ofinfection• Examining your fingers for signs of cyanosis andclubbing• Assessing for signs of swelling in your legs, ankles andfeet or other parts of your body• Evaluating the veins in your neck to assess forcomplications of COPD such as cor pulmonale
Diagnosis• Clinical symptoms• Chest x-ray• Lung function tests
Classification• At risk- breathing test normal, mildsymptoms• Mild- breathing test shows mild limitation,increasing symptoms• Moderate- person will typically seek carefor symptoms, shortness of breath withsignificant exertion, lung tests abnormal• Severe- shortness of breath with limitedactivity, lung tests abnormal
Treatment• Eliminate exposure to things that causeCOPD• Quit smoking• Exercise and pulmonary rehabilitation• Inhaled medications to open the breathingtubes 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 plasticholder
Spacer• Plastic tube that attaches to the inhaler• Makes the use of the MDI easier• Ensures delivery of the medication to thelungs
Meter dose inhaler/spacer use• Remove the cap from the inhaler and fromthe 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 steroidinhaler
Warning symptoms• Increasing shortness of breath• Increasing coughing and wheezing• History of fever
Warning signs*• Increased wheezing• Decreased pulse ox• Fever ( greater than 101 degreesFahrenheit)• Increased pulse (greater than 100)• Decreased pulse (less than 60)• Increased respiratory rate*ALL vital parameters are determined by RNsupervisor and are patient specific
References• Neal, LJ. & Guillett, SE .Care of the adult with a chronic illness ordisability. Mosby, St. Louis, Missouri, 2004.pp. 107-126.• Kennedy – Malone, L. et al. Management guidelines forgerontological 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 sixmonths• Wheezing• Coughing• Smokes one pack of cigarettes for fortyfive 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 forher?-
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 forher?- Inhaled medications
Case study• If she had quit smoking, can she still haveCOPD?-• How would you counsel her?----
Case study• If she had quit smoking, can she still haveCOPD?-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 COPDis?
Motivational interviewing• What could you do to help her stopsmoking?o Now that you’ve gained her trust,you can start asking questions thatwill begin the change talk.
Starting the change talk• What questions can we ask that couldstart her thinking about cutting outsmoking?– Tell me about smoking?– What do you think about smoking?
WILLING, ABLE, READY• In the next few slides, put yourself in thisclient’s shoes. Try to write downanswers to the questions from her pointof view.
Find out how WILLINGshe is to change• Ask open ended questions so she can:oState her reasons for smokingoState the reasons she has for stoppingsmoking• Have her write down her answers to thefollowing questions
What are her reasons for Not QuittingSmoking? – 2 good questions to askReasons I have for Staying the Same(Continuing to Smoke)Reasons I have to ChangingQuitting SmokingWhat benefits are you getting by smoking?What are your fears, concerns aboutquitting smoking?What are the worst consequences you canimagine if you continued to smoke?Hint: these are your fears, concerns aboutnot quitting)What benefits could you get by quitting?Hint: Imagine what your life would be likeif a miracle happened tomorrow and youcould quit.
Explore her reasons fully• Ask her how smoking could be goodfor 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 smokingReasons I have for SmokingWhat benefits are you getting by continuing to smoke?RelaxingSocializing with friendsCoping with stressWhat 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 forNot Smoking?Reasons I have for Staying theSame (Continuing to Smoke)Reasons I have to Quit SmokingWhat benefits are you getting bysmoking?What are your fears, concerns aboutquitting smoking?What are the worst consequences you canimagine if you continued to smoke?Hint: these are your fears and concerns aboutquittingWhat benefits could you get by quitting?Hint: Imagine what your life would be like if amiracle happened tomorrow and you could stopsmoking.
Explore her reasons fully• Ask her how taking her meds could begood 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 quittingReasons I have for QuittingWhat is the worst outcome you can imagine if you continued tosmoke?Lung cancerStrokeHeart attackCan’t enjoy childrenWhat would your life be like if a miracle happened and youstopped smoking tomorrow?Stop wheezing, coughingClothes stop smellingBreath smells good
Next, how important is it for her tochange?• Ask her to compare her reasons fornot changing with her reasons forchanging• Have her assign a number to theRuler of Change in the next slide.• This will show how important it is forher to change
How important is it for you to change?• On a scale of 0 to 10, how importantis it to you to quit smoking?The “Ruler of Change”0 1 2 3 4 5 6 7 8 9 10Not at allVery Important
WILLING• This number on the Ruler ofChange will show how WILLINGshe is to change• It will show how willing she is to quitsmoking
Willing (continued)• If her Ruler of Change number isbelow 3 or 4, she is not willing toconsider change.o She has lots of resistance to changeo Her reasons for smoking areSTONGER THAN her reasons forquitting.
Sample question to helpdecrease resistance• What would have to change todecrease the importance you giveto your reasons for smoking?
Questions to decrease resistance• A low number on the ruler of change saysshe does not think that quitting isimportant and she does not want tochange• But, look at her number on the Ruler ofChange• If she’s not at zero, she must have at leasta 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 gofrom__ to__ ?• Her answers might get her to startthinking that change might be a goodthing
Willing (continued)• If the number the client gives for theimportance of changing is around 5:o She is “on the fence.”o She is split between wanting to takeaction and not being able to take thefirst step.o In this condition, she can’t change.
Sample question to helpincrease motivation• What would have to change toincrease the importance of thereasons you have for quitting?
Willing (continued)• If the number she gives for theimportance of change is greater than 6or 7:o She is not resistant to changeo She is not “on the fence”o She is ready to take some action
Next, find out if she is ABLE• Measure her Confidence and Abilityto quit smoking• Use the Confidence and Ability“Rulers of Change” in the next slide
Assessing Confidence and Ability toMake 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 10None Low Medium Very High0 1 2 3 4 5 6 7 8 9 10None Low Medium Very High
For Scores of About 6 and Below• Ask, “What would it take to increaseyour confidence to quit smoking?”– What encourages you to believe that youcan achieve your goals for change?• Ask, “What would it take to increaseyour ability to quit smoking?”
Increasing confidence and ability aboutchange• 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, itexceeds her confidence and ability. Ask:o What would happen if you reducedthe size of your goal?o What would you be willing to try?o Maybe if you reduced your goal forchanging, you would be more likely totry.
Role of the Nurse Aide• Find out what is important to the clientand use this to motivate him/her tochange• Help the client identify an activity thathe/she has the ability and confidence toachieve
The next step: being READY• If she’s WILLING (Importance Score 5 andabove)• If she’s ABLE (Confidence and AbilityScores are 5 and above)• Then she’s READY
Being READY means:• Being READY to set a goal andmake a plan• Keeping track of progresstoward the goal• Being prepared for setbackswith the right attitude and aPlan “B”
Class exercise – goal setting• Put yourself in the shoes of theclient who is smoking• Using your current goal settingskills, write a goal for quittingsmoking on the next slide
Write down your personal goal andplan 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 Specifico Measurableo Action orientedo Realistico Time
SMART method – some examples• A goal that is not SMART will probablyfail.• “I want to stop smoking” is not specific,measurable and does not have a timeframe for when the goal will be done.• It also may be unrealistic – it might bemore 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 cigarettesper day. After one month, I will cut out2 more per day. In another month, I willcut out 2 more per day. I will continuethis slow reduction until I am notsmoking.”
Set and plan a goal – SMART method• Now try rewriting a goal forquitting smoking on the next slideaccording to the SMART method• Pretend you are the COPD client
READY• READY also includes trackingprogress in a written log or on acalendar• Seeing concrete progress helpsbuild confidence• Adding comments can alsoidentify what helped, what wasdifficult, what you learned, howyou can get better
Progress check (sample)• My goal was_____________• I was______ successful in reaching mygoal• What helped______________• ______________was difficult• I learned that__________________Adapted from HIP CHA training, 2005
READY• READY also includes being preparedfor setbacks and relapses to old habits• Plan for recovery from setbacks –have a “Plan B”• Remember,– Setbacks are chances for learninghow to do things better,– Setbacks are not failures.
READY - staying ready andmotivated• When you make your goal, Don’tForget to Reward Yourself• A reward provides an incentive to staymotivated.• “After I do this, I’ll buy some newperfume now that I can smell it”
Final pieces• Why is it important for the team to work onthe goal of reducing/stopping smokingtogether?• How can the team communicate progresstowards the goal and encourage the clientthrough reinforcing the planned reward?
What did you learn?• How do the lungs work and what is theimpact of COPD on respiratory function?• What are healthy lifestyle choices for theperson who has COPD?• How would you use motivationalinterviewing with the person who hasCOPD?
How will what you’ve learnedchange the way you do your job?How will what you’ve learnedchange 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.