Chronic Obstructive Pulmonary Disease (COPD): Post-Acute and Long-Term Healthcare Setting Presentation to Executive Leadership 1 Introduction: Major of Study Master’s of Science in Nursing Generalist (MSN) Analyze, Design, Implement, and Evaluate Nursing Care Simplify the Complexity of Transitions in Care Post-Acute /Long-Term Care Rehabilitation Community Services/Dwelling Clinic – Preventive and Palliative Care Acute – Reducing Readmission Rates for Exacerbation of Chronic Illness MSN competencies allow for a full analysis of design, implementation, and evaluation of nursing care to diverse populations and cohorts of patients, in clinical and community-based systems, (American Association of Colleges of Nursing [AACN], 2011). As a Director of Nursing within the long-term care continuum, having a MSN degree will allow for the integration of findings from across the sciences and humanities, and will facilitate continuous improvement of nursing care at the unit, clinic, home, and program level (AACN, 2011). The DON who acquires their MSN provides for a strong background in healthcare leadership, assessment, pharmacology, and pathophysiology in preparation to understand how the systems and organizational sciences can blend to meet the healthcare needs of a diverse population (AACN, 2011). This blending of core components will provide the knowledge necessary for transitioning patients with Chronic Obstructive Pulmonary Disease (COPD) safely through their continuum of healthcare needs, within the micro-, meso-, and macrosystems of healthcare. 2 Introduction: Chronic Disease COPD Characteristics Dyspnea Exercise Intolerance Shortness of Breath Chronic Cough Expiratory Exertional Effort – Force or Time Sputum Production Wheezing Exposure to Risk Factors for the Disease COPD is characterized by exertional effort, force or time, needed during the expiratory phase of the respiratory cycle, with the central symptoms being dyspnea, exercise intolerance, shortness of breath, chronic cough or sputum production, and/or exposure to risk factors for the disease, with the central sign being wheezing (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2018; McCance, & Huether, 2014). 3 Introduction: COPD Pathophysiology of COPD Insult to Respiratory System Airway Inflammation WBC Enter Bronchial Wall Pulmonary Edema Enlarged Mucous Glands & Goblet Cells Ciliary Impairment Inability to Clear Airway The pathophysiology of COPD involves the inspired agent resulting in airway inflammation, white blood cells enter the bronchial wall, leading to edema and enlarged mucous glands and goblet cells, which in turn impairs ciliary function, which results in the body being unable to clear the lungs of debris (McCance, & Huether, 2014). 4 Introduction: COPD Risk Factors Primary: Tobacco Use Air Pollution Genetic Factors Abnormal Lung Development Respiratory Infections The primary risk factor for COPD is tobacco use, with other risk ...

1. Chronic Obstructive Pulmonary Disease (COPD):
Post-Acute and Long-Term
Healthcare Setting
Presentation to Executive Leadership
1
Introduction: Major of Study
Master’s of Science in Nursing Generalist (MSN)
Analyze, Design, Implement, and Evaluate Nursing Care
Simplify the Complexity of Transitions in Care
Post-Acute /Long-Term Care Rehabilitation
Community Services/Dwelling
Clinic – Preventive and Palliative Care
Acute – Reducing Readmission Rates for Exacerbation of
Chronic Illness
MSN competencies allow for a full analysis of design,
implementation, and evaluation of nursing care to diverse
populations and cohorts of patients, in clinical and community-
based systems, (American Association of Colleges of Nursing
[AACN], 2011).
As a Director of Nursing within the long-term care continuum,
having a MSN degree will allow for the integration of findings
from across the sciences and humanities, and will facilitate
continuous improvement of nursing care at the unit, clinic,
home, and program level (AACN, 2011).

2. The DON who acquires their MSN provides for a strong
background in healthcare leadership, assessment, pharmacology,
and pathophysiology in preparation to understand how the
systems and organizational sciences can blend to meet the
healthcare needs of a diverse population (AACN, 2011). This
blending of core components will provide the knowledge
necessary for transitioning patients with Chronic Obstructive
Pulmonary Disease (COPD) safely through their continuum of
healthcare needs, within the micro-, meso-, and macrosystems
of healthcare.
2
Introduction: Chronic Disease
COPD
Characteristics
Dyspnea
Exercise Intolerance
Shortness of Breath
Chronic Cough
Expiratory Exertional Effort – Force or Time
Sputum Production
Wheezing
Exposure to Risk Factors for the Disease
COPD is characterized by exertional effort, force or time,
needed during the expiratory phase of the respiratory cycle,
with the central symptoms being dyspnea, exercise intolerance,
shortness of breath, chronic cough or sputum production, and/or

3. exposure to risk factors for the disease, with the central sign
being wheezing (Global Initiative for Chronic Obstructive Lung
Disease [GOLD], 2018; McCance, & Huether, 2014).
3
Introduction: COPD
Pathophysiology of COPD
Insult to Respiratory System
Airway Inflammation
WBC Enter Bronchial Wall
Pulmonary Edema
Enlarged Mucous Glands & Goblet Cells
Ciliary Impairment
Inability to Clear Airway
The pathophysiology of COPD involves the inspired agent
resulting in airway inflammation, white blood cells enter the
bronchial wall, leading to edema and enlarged mucous glands
and goblet cells, which in turn impairs ciliary function, which
results in the body being unable to clear the lungs of debris
(McCance, & Huether, 2014).
4
Introduction: COPD
Risk Factors
Primary: Tobacco Use
Air Pollution
Genetic Factors
Abnormal Lung Development
Respiratory Infections
The primary risk factor for COPD is tobacco use, with other
risk factors including indoor air pollution, such as biomass fuel

4. used for indoor cooking and heating, air pollution, genetic
factors, abnormal lung development, and respiratory infections
(GOLD, 2018; McCance, & Huether, 2014).
5
Introduction: COPD
What happens with pulmonary insults?
COPD Exacerbations
Worsening Dyspnea
Productive Cough
Air Trapping
Reduced Tidal Volume
Hypoventilation
Hypercapnia
Insults to the respiratory system results in an increased risk for
respiratory infection, leading to further respiratory injury,
resulting in COPD exacerbations of worsening dyspnea,
productive cough, and air trapping; leading to reduced tidal
volume, hypoventilation, and hypercapnia (McCance, &
Huether, 2014, p. 1266-1267).
As lung function worsens, all other organs in the body are
impacted.
6
Introduction: COPD
Diagnosis
Symptoms
Physical Exam
Chest X-ray
Pulmonary Function Tests
Spirometry is most reproducible
Mild, Moderate, Severe, Very Severe

5. Blood Gas Analysis
(GOLD, 2018; McCance, & Huether, 2014)
Diagnosis is based on symptoms, physical examination, chest x-
ray, pulmonary function tests, and blood gas analyses (GOLD,
2018; McCance, & Huether, 2014). GOLD (2018) notes that
spirometry is the most reproducible and objective airflow
measurement when diagnosing COPD. Airflow limitation
severity is classified as mild, moderate, severe, and very severe
(GOLD, 2018).
7
Introduction: COPD
Prevention is key
Pathologic Changes are Irreversible
Smoking Cessation
Halts Disease Progression
Immunizations Reduce Risk
Influenza
Pneumococcal
(GOLD, 2018; McCance, & Huether, 2014)
Prevention of chronic bronchitis is the best treatment because
pathologic changes are not reversible. However, if a person
quits smoking tobacco, disease progression can be halted
(GOLD, 2018; McCance, & Huether, 2014). Immunizations,
such as influenza and pneumococcal, can reduce the risk of
serious infection (GOLD, 2018).
8
Introduction: COPD
Pharmacological Therapy

6. Symptom Relief
Improve Exercise Intolerance
Exacerbation Reduction
Individualized
Comorbidities
Side-Effects
Risk for Exacerbation
Symptom Severity
Preference
Ability
(GOLD, 2018)
Pharmacological therapy can improve COPD symptoms and
exercise intolerance, and reduce exacerbations; however,
treatment will be dependent on the individual’s symptom
severity, risk for exacerbation, medication side-effects,
comorbidities, pharmacological availability and cost, patient
response to the agent, their preference, and ability to use the
device (GOLD, 2018).
9
Introduction: COPD
Pharmacological Therapy
Bronchodilators
Beta2-Agonists
Short Acting
Long Acting
Antimuscarinic Agents
Short Acting
Long Acting

7. Methylxanthines
Combination Agents
Inhaled & Oral Corticosteroids
Oxygen
(GOLD, 2018)
Pharmacological agents include bronchodilators, Beta2-agonists
– short and long acting, antimuscarinic agents – short and long
acting, Methylxanthines, combination bronchodilator agents –
short and long acting, anti-inflammatory agents, inhaled and
oral corticosteroids, and oxygen (GOLD, 2018).
10
Introduction: COPD
Nonpharmacological Interventions
Smoking Cessation
May incorporate pharmacological agents in some situations.
Pulmonary Rehabilitation
Surgical Procedures
Palliative Care
End of Life Care
Hospice Care
Ventilatory Support
(GOLD, 2018)
Individualized to the patient and their family.
11
COPD: Typical Visit
Post-Acute/Long-Term Care
Less than 20 Days
Discharge Goals are Individualized
Admission Intake

8. Social Services
Admission Nurse
The typical visit for someone entering the post-acute care
setting is less than twenty days in length. The discharge goal
and treatment options will be individualized to the patient. They
will complete the admission process with Social Services, and
the admission nurse, developing a baseline care plan.
12
COPD: Typical Visit
Baseline Care Plan
Language & Manner Understood by Patient & Family
Medication/Treatment Reconciliation
Advance Directives
Dietary Needs
Religious/Spiritual Needs
Cultural Needs
ADLs
The admission nurse will interview the patient and their
representative, if not completed ahead of time, to determine
their goals and preferences for care, such as code status,
advance directives, living will, bathing and dining rituals, sleep
patterns, spiritual needs, activities and hobbies, education level,
occupation(s), level of assistance desired for activities of daily
living, special equipment or treatments, desired discharge
location and the ADL ability level needed for successful
discharge. The patient and their representative will sign and
date the baseline care plan, to include medication

9. reconciliation, which will be produced in a language and
manner they are able to understand.
13
COPD: Typical Visit
Meet & Greet
Dietary Manager
Activity Department
Introduction to Primary Staff
Nursing Assistant(s)
Nurse
Physician Visits Every 30 Days, for first 90 days, every 60 days
thereafter, and as needed
ARNP may complete every-other Physician required visit in
SNF.
Housekeeper
Unit Aide
Activity Aide
Nursing Supervisor(s)
Therapist(s)
They will receive a visit from dietary services and the activity
department, to learn likes, dislikes, and interests.
They will be introduced to their primary staff, to include:
nursing assistant, housekeeper, unit aide, activity aide, nurse,
and nursing supervisor. If therapy is ordered, evaluation and
treatment will likely begin on day of admission. Their attending
Physician or ARNP will make rounds every 30 days for the first
90 days, and every 60 days thereafter.

10. 14
COPD: Typical Visit
Discharge Planning
Begins on Day One
Comprehensive Care Plan
Updated Summary from Baseline
Rehabilitation to Meet Goals
Medication/Treatment
Assessment
Teaching
Adherence
Internal & External Service Coordination
Transitions Between Levels of Care
Discharge planning also begins on day one. The comprehensive
care plan will be completed within the first few weeks, within
the time allowed as per state and federal regulations, and an
updated summary will be provided to the patient and their
representative if there are changes, also in a language and
manner they are able to understand. The patient will receive
restorative and/or rehabilitative services to meet their discharge
goals, as well as medication and treatment assessment and
teaching for adherence. Providers, social services, pharmacy,
resident accounts, billers, therapists, dietary, activities,
environmental service, special vendors (i.e., oxygen delivery,
private or managed insurance companies, home health services)
and nursing will coordinate internal and external services to
ensure smooth transitions between healthcare providers, as the
patient moves through the long-term care continuum and back to
their prior or new setting.
15
Key Leadership Positions

11. Formal
County Commissioners – Operational Rules
Delegation Members – Financial Resources
Administrator – Vision & Mission
Department Heads – Supports Vision & Mission
Resident Council President – Guides Delivery of Services
Informal
Front-line Managers – Organize workflow
Natural Leaders – Optimize workflow, Feedback
Lead Nursing Assistants
Lead Housekeepers
(Linkosky, 2014)
Leadership positions within the long-term care continuum
include those in formal and informal positions of authority.
Formal leadership positions include the county commissioners
and delegation members, the administrator, and the
organization’s department heads, and resident council president.
Informal positions of authority include front-line managers, and
the natural leaders within a peer work group may include a
nursing assistant who is passionate about a new or emerging
topic, or a housekeeper who had a personal goal for keeping
high-touch areas within the patient environment cleaned and
disinfected hourly and is recruiting people to help her.
The macrosystem of the long-term care facility includes the
county commissioners, the county delegation, and the nursing
home administrator; the mesosystem includes the department
heads and their interdepartmental staff (Linkosky, 2014). How
these systems relate are knowing their functions, so as to
leverage them to meet stakeholder expectations for improving
quality, safety, and cost of care. The county commissioners
determine the county rules for operational direction and setting

12. of budgetary goals, the delegation oversee funding, and the
administrator enforces policy and leads the safety and quality
initiatives facility wide. The mesosystem supports the vision
and mission of the macrosystem in the delivery of care.
For example, the county commissioners may instruct the
administrator to seek additional revenue. The administrator
seeks a Nurse Practitioner (NP) to hire, and will be billing
Medicare for services rendered to patients within the long-term
care facility. The DON and front-line managers formulate a plan
to best organize the workflow to maximize the NP’s time, and to
best meet the needs of the patients, optimizing the care delivery
system.
16
Leadership Style Effectiveness
Resonant Leadership
Visionary
Anticipate Barriers to Goal Attainment
Coaching
Facilitate Independence
Affiliative
Coping & Positive Reinforcement
Democratic
Time Consuming
Gives All Team Members Voice in Workflow
Improved Communication
(Cummings, Midodzi, Wong, & Estabrooks, 2010)
Leadership styles considered effective in reducing 30-day
patient mortality in healthcare settings, in relationship to the
management of COPD, include resonant leadership styles, such
as visionary, coaching, affiliative, and democratic (Cummings,

13. Midodzi, Wong, & Estabrooks, 2010). Using visionary
leadership will help the patient to anticipate barriers in their
treatment course and help them to plan for what they will need
when returning to the community. With a coaching leadership
style, the natural leaders at the bedside can facilitate
independence in the patient, making their rehabilitation
timelier. Understanding how to approach a difficult situation
and avoiding negative coping through positive reinforcement
will improve relationships and foster teamwork. Use of a
democratic leadership style in the care environment can be time
consuming, however, it allows for all team members to have a
voice in the workflow, improving communication so that each
team member can vocalize concerns and ideas for meeting the
patients’ goals.
17
Common Barriers
Transportation
Technological Resources
Oxygen Reserves for ADLs
Primary Care Access
(GOLD, 2018)
In the post-acute/long-term care setting, barriers encountered by
patients when managing their chronic disease include lack of
transportation, lack of technological resources, lack of oxygen
reserves for meeting selfcare needs/goals, and lack of a primary
care provider in the community.
Patients with COPD will require the special skill sets of an
MSN to improve the quality of care received, and to reduce the
healthcare cost-burden of COPD management. Through
implementation of advanced clinical reasoning for challenging
clinical presentations, the MSN is able to incorporate the

14. concerns of the patient, their family, significant others, and
community into the strategy and dissemination of patient care
(AACN, 2011).
Creating interprofessional partnerships and working with
community resources, allows the MSN to transition the patient
safely back to their primary or desired environment.
18
Common Barriers
Comorbidities
Lung Cancer
Osteoporosis
Depression
Anxiety
Obstructive Sleep Apnea
Gastroesophageal Reflux Disease (GERD)
Comorbidities place a patient at higher risk of morbidity and
mortality (GOLD, 2018). Additionally, comorbidities reduce the
patient’s ability for self-management of their personal health.
Complications or symptoms may duplicate between diseases.
For example, a person having COPD and Heart Failure may be
short of breath, and less likely to realize they are in fluid
overload and not in a COPD exacerbation. Assimilating an
interdisciplinary team, within the setting of the patient having
COPD, will allow for collaboration, timely, and correct care
(GOLD, 2018).
19
Barrier

15. Solution
s
Telemedicine may address:
Transportation
Access to Primary Care
Note research is promising, however, level of evidence is poor
Further Research Needed
Telemedicine has the potential to impact both transportation and
access to care (limited providers) barriers (Barken, Thygeses, &
Soderhamn, 2017). However, this would depend on the state
(licensing and authority) and organizational boundaries
regarding the advanced nurses’ availability, as well as the
infrastructure in the patients’ location to support electronic
communication, as the ability to video conference was
demonstrated to facilitate improved care more efficiently and
confidently, when compared to teleconferencing (Barken et al.,
2017). However, the level of evidence to support
telemedicine’s effectiveness is poor, with further research
needed in this area (Roche, 2017).

16. 20
Barrier