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Improvement in Dyspnea

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					                       Improvement in Dyspnea
                   Suggested Clinical Visit Guide-5 Visits


GOALS:
  • The home care patient will demonstrate compliance with dyspnea. Dyspnea
    will be managed by utilizing prescribed medications, treatments, diet, and
    dyspnea assessment guides.
  • The home care patient will demonstrate acceptance of dyspnea management
    interventions by verbalizing the importance of dyspnea management, the
    purpose of dyspnea management, and the goals of dyspnea management.
  • The home care patient will demonstrate knowledge of disease processes
    associated with dyspnea and disease prevention interventions.
  • The home care patient will verbalize knowledge of treatment goals, and self
    care management.
  • The home care patient will verbalize knowledge of and agreement with the
    plan of care.
  • The nurse will utilize teaching sheets based on patient needs for education.

STANDARDS OF CARE:
(Every Visit)
1. Complete physical assessment.
2. Vital sign assessment.
3. Teach each medication within 5 visits including dose, route, side effects, possible
    complications and any possible concomitant interactions.
4. Visit to physician since last visit?
5. New onset of symptoms or new complaints?
6. Dyspnea improvement or deterioration? (Use measurement tools)
7. Dietary compliance. (Diet quality, frequency, encourage protein, vegetables,
    fruits, and appropriate water intake or restriction as prescribed)
8. Exercise effort and tolerance.
9. Home safety survey.
10. Homebound status.
11. Provide teaching and education. (Enforcement of previous teaching, disease
    education, medication teaching, dietary teaching, equipment teaching, etc.)
12. Adherence to plan of care.




                                                                                     1
Visit 1:
  1. Secure consent & home health documents signed by patient or patient care
       provider and present with a copy.
          • Insurance documents.
          • Advanced directive materials.
          • Home safety surveys.
          • Patient rights.
          • Agency 24 hour contact number, responsibilities, and visit schedule.
  2. Provide complete patient assessment.
          • Complete physical assessment.
          • Medication assessment.
          • Psycho/social assessment.
          • Complete dyspnea survey.
          • Provide an overview of prescribed medications.
  3. Explain the Improvement in Dyspnea Assessment Guide and Tool.
          • Role of patient.
          • Role of caregiver.
          • Role of home care staff.
          • Relationship to discharge.
          • Provide overview on process to obtain/ record weights.
  4. Determine plan of care and objectives with patient and caregiver.
  5. Instruct on emergency/ non-emergency contact procedures.
          • Signs and symptoms to report and seek medical attention.
          • 24 hour on-call nurse/ agency number.
          • Emergency contact numbers and facility.
  6. Instruct on use of med-planner and instruct on proper set up if necessary.
  7. Provide a written visit schedule.
  8. Report abnormal findings to physician.

  Expected Patient Outcomes for Visit 1:
          • Verbalize emergency procedure to call 911.
          • Verbalize signs / symptoms to report to home health nurse or
            physician.
          • Verbalize medication route, times, and purpose.
          • Patient agrees to plan of care.
  Visit 2:
  1. Provide complete patient assessment.
          • Complete physical assessment.
          • Medication assessment.
          • Psycho/social assessment.
  2. Provide teaching/ instruction as needed regarding:
          • Medications (changes, purpose, side effects, route, frequency).
          • Appropriate disease processes.
          • Fluid intake or restriction as prescribed.
          • Equipment as needed.
          • Prescribed exercise.
          • Dyspnea, contributing factors, relaxation techniques, interventions &
            treatments.
                                                                                    2
   3. Evaluate understanding of the plan of care, reinforce as needed.
   4. Evaluate knowledge retention of disease processes, signs and symptoms to report.
   5. Evaluate knowledge retention of medications, diet, and equipment.
   6. Report abnormal findings to physician.
   Expected Patient Outcomes for Visit 2:
         • No worsening of symptoms or new onset of symptoms.
         • Demonstrates knowledge of nursing interventions that may reduce
             dyspnea.
         • Demonstrates and verbalizes compliance with me dications, diet, and
             equipment.
         • Verbalizes basic knowledge of treatments for dyspnea.
         • Identifies medications prescribed for dyspnea improvement including
             route, time, and adverse reactions.
         • Demonstrates ability to manage symptoms/ disease processes without
             physician or hospital visits.

Visit 3:
    1. Provide complete patient assessment.
           • Complete physical assessment.
           • Medication assessment.
           • Psycho/social assessment.
    2. Provide teaching/ instruction as needed regarding:
           • Medications (changes, purpose, side effects, route, frequency).
           • Disease processes.
           • Diet and healthy eating guidelines.
           • Fluid intake or restriction as prescribed.
           • Equipment.
           • Prescribed exercise.
           • Treatments.
           • Edema assessment and interventions.
    3. Evaluate knowledge retention of previously developed plan of care, reinforce as
        needed.
    4. Evaluate knowledge retention of disease processes, signs and symptoms to report.
    5. Assess:
           • Ability to cope at home with disease process/ anxiety related to condition.
           • Ability to manage medication regimen / medication compliance.
           • Changes in medication / physician intervention since last visit.
           • Diet compliance / nutrit ional quality.
           • Activity and exercise tolerance / Is patient doing prescribed exercises?
    6. Report abnormal findings to physician. Seek additional intervention as needed.
    Expected Patient Outcomes for Visit 3
           • No worsening of symptoms or new onset of symptoms.
           • Demonstrates knowledge of nursing interventions that may reduce
               dyspnea.
           • Demonstrates and verbalizes compliance with medications, diet, and
               equipment.
           • Verbalizes basic knowledge of treatments for dyspnea.
           • Identifies medications prescribed for dyspnea improvement.
                                                                                       3
        •    Demonstrates ability to manage symptoms/ disease processes without
            physician or hospital visits.
       •    Verbalizes specific disease process information.
       •    Demonstrates ability to cope with disease process and treatment.

Visit 4:
1. Provide complete patient assessment.
        • Complete physical assessment. (Perform dyspnea assessments in packet)
        • Medication assessment.
        • Psycho/social assessment.
2. Reinforce teaching and instruction.
        • Medications (changes, purpose, side effects, route, frequency).
        • Disease processes.
        • Diet.
        • Fluid intake or restriction as prescribed.
        • Equipment.
        • Prescribed exercise.
        • Impact of non-compliance.
        • Symptom identification and management.
3. Evaluate patient and caregiver for knowledge and application of dyspnea
    interventions and treatments, rationales for interventions and treatments, and
    responses to interventions and treatments including, but not limited to, diet,
    exercise, medications, nursing interventions, and daily dyspnea comfort and
    assessment charting.
4. Reinforce areas of teaching related to knowledge deficits identified during
    evaluation.
5. Provide encouragement and support for daily use of dyspnea assessments,
    interventions, and treatments in a manner that fosters independent and self-
    motivating use. Relate dyspnea awareness to dyspnea intervention.
6. Assess:
        • Ability to cope at home with disease process/ anxiety related to condition.
        • Ability to manage medication regimen / medication compliance.
        • Changes in medication / physician intervention since last visit.
        • Diet compliance / nutritional quality.
        • Activity and exercise tolerance / Is patient doing daily exercise?
        • Frequency of rest periods.
        • Non-compliance with treatment plan / plan or care.
        • Patient concerns regarding discharge preparation and plan.
7. Discuss and prepare patient for discharge.
Expected Patient Outcomes for Visit 4
        • No worsening of symptoms or new onset of symptoms.
        • Demonstrates knowledge of nursing interventions that may reduce
            dyspnea.
        • Demonstrates and verbalizes compliance with medications, diet, and
            equipment.
        • Verbalizes basic knowledge of treatments for dyspnea.
        • Identifies medications prescribed for dyspnea improvement including
            route, time, and adverse re actions.
                                                                                    4
        • Verbalizes specific disease process information.
       • Demonstrates ability to manage symptoms/ disease processes without
          physician or hospital visits.
       • Demonstrates ability to cope with disease process and treatments.
       • Balances daily exercise with adequate periods of rest.
       • Verbalizes and demonstrates an appropriate level of comfort with
          discharge planning.
Additional Considerations
       • By the fourth visit, the patient or caregiver is expected to verbalize
          understanding of his/her dyspnea including what makes it worse and
          what interventions relieve dyspnea.
       • It is expected that the patient is in agreement with the plan of care
          and is actively interested and participating in care interventions
          independently.
       • During the fourth visit, the nurse is available to mostly enhance
          knowledge base but also to reinforce previous teaching.
       • The patient is expected to demonstrate greater confidence with overall
          knowledge base related to dyspnea and overall plan of care.
       • This visit is important in determining patient confidence with
          independent care including reportable changes in condition and when
          to seek intervention so that discharging the patient is done with
          confidence on the next visit schedule.

Visit 5
1. Perform a complete physical assessment.
2. Evaluate patient for knowledge retention related to previous teaching. Reinforce
    teaching as needed.
3. Assess:
        • Ability to maintain self care in home.
        • Ability to cope at home with dyspnea.
        • Ability to manage medication regimen.
        • Changes in medication.
        • Ability to afford medication refills.
        • Diet compliance and daily nutritional quality.
        • Activity and exercise tolerance.
        • Non-compliance issues.
        • Transportation issues for follow up physician visits (tests, labs, etc.).
        • Effectiveness of interventions.
        • Knowledge of when and how to call for help.
        • Knowledge, agreement, and comfort with discharge.
        • Importance of continuing plan of care post discharge.
Visit 5 Expected Patient Outcomes
        • Patient performs ADL’s adequately including periods of rest as
        § needed.
        • Patient experiences no worsening or new symptoms.
        • Demonstrates and verbalizes compliance with medications, diet, and
        § equipment.
        • Demonstrates knowledge of treatments for dyspnea.
                                                                                      5
•    Demonstrates and verbalizes medication compliance including route,
    time, and adverse reactions.
•   Verbalizes specific disease process information.
•   Demonstrates ability to manage symptoms/ disease processes
    independently and without physician or hospital visits.
•   Demonstrates ability to cope with disease process and treatments.
•   Verbalizes signs and symptoms to report to physician and plan for
    physician follow up.
•   Verbalizes prevention interventions




                                                                      6
                          DYSPNEA SURVEY
                          (Shortness of Breath)

1. The time of day that you are short of breath the most is:


2. What improves your shortness of breath:


3. What makes your shortness of breath worse:


4. Circle the measures that are currently in use to decrease your shortness of
   breath

Inhalers                Oxygen                       Spirometer

Fan                     Elevated Bed                 Pursed Lip Exercises
                                                     When Exhaling

Humidifier              Daily Exercise               Medications

High Protein            Low Fat/ Low                 3-5 Fruits &
Diet                    Cholesterol Diet             Vegetables a day

Sit Up in Chair          Rest

Influenza Vaccine Date: ____________Pneumococcal Vaccine Date:___________


How Does Shortness of Breath Effect Your DAILY Activities

                            No               Moderate                Big
                           Effect             Effect                Effect
 Using Telephone
 Doing Housework
 Doing Laundry
 Taking Meds
 Preparing Meals
 Sleeping
 Walking to
 Mailbox
 Bathing
 Toileting




                                                                                 7
             SHORTNESS OF BREATH ASSESSMENT TOOL
Score / Descriptive criteria for measuring shortness of bre ath
0      = Never short of breath
1      = Every now and then I am aware that it is difficult to breathe
2      = I get short of breath and I have to stop and rest occasionally
3      = Short of breath with minimal exertion (ex: talking, eating, and brushing teeth) /
       I get short of breath and it is bothersome frequently. I rest often.
4      = Short of breath at complete rest / I am short of breath most of my day and can’t
       seem to get anywhere or get things done. I sit around often thinking about how
       tired I feel. I get frustrated easily.
5      = Completely unable to focus on anyone or anything due to severe shortness of
       breath / I worry constantly that I might not catch my breath. (Seek emergency
       assistance)

Morning Assessment Scale:
   Score            0            1             2            3            4             5
 Sunday
 Monday
 Tuesday
 Wednesday
 Thursday
 Friday
 Saturday

Evening Assessment Scale:
    Score           0            1             2            3            4             5
 Sunday
 Monday
 Tuesday
 Wednesday
 Thursday
 Friday
 Saturday

Instructions: This chart is for you to use twice a day to indicate your level of shortness
of breath. Each morning use the top chart and place a check mark under the appropriate
number next to the day of the week to indicate the shortness of breath you are
experiencing.

Each afternoon on the bottom chart place a check mark under the number that indicates
your shortness of breath next to the day of the week.



                                                                                             8
                                      Daily Weight Log
       (Weigh at the same time each day before dressing or eating and after urinating)


Date           Time       Weight       Increase   Decrease               Nurse or        Other
                                      Since Last  Since Last              MD             Notes
                                     Measurement Measurement             Notified




                        COMMONLY PRESCRIBED MEDICATIONS

                                                                                         9
                               TO TREAT DYSPNEA

Anti-anxiety drugs – Prescribed to reduce anxiety and aid in relaxation

Antibiotics – Prescribed to treat infection

Antitussives – Prescribed to relieve cough
   • Dextromethorphan – Used to relieve mild to moderate cough
   • Codeine-Based Antitussives – Used to relieve severe cough

Bronchodilators – Prescribed to open airways
   • Albuterol – An inhaled or orally administered bronchodilator
   • Ipratroprium (Atrovent) – An inhaled bronchodilator
   • Theophylline – A bronchodilator that is taken orally

Corticosterioids – Prescribed to reduce lung swelling, fluid build-up in the lungs, and
bronchospasm (tightening of the airways)

Diuretics – Prescribed to eliminate excess fluid in the body thereby reducing fluid build-
up in the lungs

Morphine – Opioid (narcotic) pain reliever that is also prescribed to treat dyspnea in
terminally ill patients


   Your doctor currently has prescribed the following medications that
   may help relieve dyspnea:

              MEDICATION            /        CLASS
   ___________________________________________________________
   ___________________________________________________________
   ___________________________________________________________
   ___________________________________________________________
   ___________________________________________________________
   ___________________________________________________________
   ___________________________________________________________
   ___________________________________________________________
   ___________________________________________________________
   ___________________________________________________________




                                    Corticosteroids


                                                                                          10
 Uses:
Corticosteroids are used to decrease inflammation. They are used in respiratory illnesses
to reduce inflammation of the airways (reduce swelling and mucous production).

Common Side Effects:
                                  Short-term use
           •   Weight gain, fluid retention
           •   Mood changes
           •   Increased blood sugar level, which may lead to a type of diabetes caused
               by the medication (secondary diabetes) or, if the person already has
               diabetes, make diabetes harder to control
           •   High blood pressure
                                 Long-term use*
           •   Osteoporosis (bone weakening) is common. Destruction of bone from loss
               of blood supply is rare.
           •   Recurrent infections
           •   Cataracts
           •   Thin, fragile skin that bruises easily
           •   Increased risk for stomach ulcer

*Stopping corticosteroids after long-term use should never be attempted. Your
doctor will need to gradually taper your dose over an extended period to avoid
serious complications.

Contraindications:
Persons who are hypersensitive to corticosteroids and those with bacterial or viral
infections, or systemic fungal infections should not use corticosteroids. Breast- feeding
mothers should avoid chronic use.

Precautions:
Precaution should be taken in the following situations: recent heart attack, active
peptic-ulcer disease, high blood pressure, osteoporosis, diabetes, low thyroid levels,
seizures, following surgery, during infection, emotional instability, and during long term
use.

Patient Teaching:
* Weight should be monitored during therapy and sudden weight gain or swelling
   reported to the physician.
* Corticosteroids should be taken with food or milk to reduce upset stomach.
* Advise patient to watch for signs of adrenal insufficiency: lethargy, weakness,
   hypotension, nausea, weight loss, confusion, and restlessness.
* Monitor children periodically for growth during prolonged therapy.
* Avoid taking vaccinations during therapy if possible.




                                                                                            11
                             OXYGEN THERAPY

Uses:
Oxygen is commonly prescribed to combat oxygen deficiency. Conditions such as pneumonia,
congestive heart failure, chronic obstructive pulmonary disease, pulmonary edema, or airway obstruction
contribute to oxygen deficiency. Oxygen is used during and following surgery and medical procedures
that require sedation.

Common Side Effects:
Oxygen administration may cause dryness of the nose and mouth. The discomfort due to dryness may be
reduced by bubbling the oxygen through a sterilized water bottle. Vaseline or chap-stick used in small
amounts may reduce discomfort and dry cracked skin on the nose and lips.

Contraindications:
Supplemental oxygen should never be used while smoking, in the same house with a lit cigarette or cigar,
near open flames, oil lamps, gas heaters, or any electrical device that is being plugged or unplugged due
to the risk of electrical sparks. Oxygen will cause a fire to grow and spread. Supplemental oxygen is
highly concentrated and is combustible which means it could cause an explosion, fire, and death with
misuse.

Precautions:
Patients diagnosed with chronic obstructive pulmonary disease, COPD should not increase supplemental
oxygen rates without physician permission.

Patient Teaching:
* Avoid smoking when using oxygen.
* Place warning signs on all entrances to the house that smoking is not permitted due to the use of
   oxygen and the risk of explosion.
* If a pulse oximeter is in use, keep a daily log of readings twice a day.
* Report oximeter readings less than 92 to the physician.
* Keep a portable oxygen tank full in case of emergency power outages or the need to travel.
* Notify local emergency personnel of the use of oxygen in the home.
* Notify the power company that oxygen is being used in the home.
* Do not let oxygen tanks become empty before refilling or replacing.




                                                                                                       12
                                                  FUROSEMIDE
Uses:
Furosemide (Lasix®) is a diuretic (water pill) that is used to decrease the amount of fluid in the body by increasing
the amount of salt and water lost in the urine. Fluid retention and build-up is common among patients with
congestive heart failure, liver or kidney disease, and high blood pressure.

Side Effects:
If you experience any of the following serious side effects, stop taking furosemide and seek emergency medical
attention or call your doctor immediately:
    • an allergic reaction (difficulty breathing; closing of your throat; swelling of your lips, tongue, or face; or
         hives)
    • an irregular heartbeat;
    • low blood pressure (weakness, dizziness, fatigue);
    • muscle cramps or weakness;
    • abdominal pain or diarrhea;
    • decreased hearing.

Other, less serious side effects may be more likely to occur. Continue to take furosemide and talk to your doctor if
you experience
             • dry mouth or increased thirst;                        • headache, dizziness, or lightheadedness;
             • constipation;                                         • increased sensitivity to sunlight;
             • a rash;                                               • jaundice (yellow skin or eyes);
             • ringing in the ears;                                  • nausea;
             • easy bleeding or bruising; or                         • numbness in the hands or feet.

Contraindications:
Furosemide should not be taken by individuals allergic to furosemide and should not be taken by individuals that
have an absence of urination. Furosemide should be avoided with uncorrected electrolyte imbalance or hepatic
coma.

Precautions:
Caution should be taken when administering furosemide to geriatric patients, individuals with liver and kidney
disease, pregnant and lactating women, children, individuals with diabetes, and combination diuretic therapy.
Persons with an allergy to sulfa drugs, such as sulfa-based antibiotics, should inform their doctor before taking
furosemide.

Patient Teaching:
* Take doses in the morning or early afternoon to reduce night time urination.
* Muscle weakness and cramps may be a sign of low potassium.
* Consider potassium rich foods during furosemide therapy such as bananas, citrus fruit, dates, and
    potatoes.
* Blood tests for electrolyte levels may be performed during treatment by your physician.
* Keep a record of daily weights and blood pressures.
* Monitor blood sugar levels.
* Store tablets in a dark container.
* Administer with food and milk to decrease stomach irritation.
* Use sunscreen during sun exposure.
* Change positions slowly to avoid postural hypotension.




                                                                                                                       13
                               INHALERS / NEBULIZERS

Uses:
Inhalers are commonly prescribed by physicians to relieve uncomfortable respiratory symptoms and make
breathing easier. Inhalers that contain a bronchodilator relax muscles in the airways and relieve
bronchospasm. Bronchospasm may cause a tight feeling in the upper airway and contribute to difficulty
breathing, shortness of breath, and coughing.

Common Side Effects:
The use of inhalers may cause:
   • headache, dizziness, lightheadedness                  •   sleeplessness
   • heart palpitations or rapid heart rate                •   elevated blood pressure
   • dry mouth                                             •   tremors or nervousness
   • nausea, vomiting, or diarrhea                         •   sweating

Contraindications:
The use of inhalers is contraindicated with hypersensitivity to the medication or any of the ingredients.
Some inhalers contain sulfites and should be avoided by individuals with allergies to sulfite. Inhalers
containing epinephrine (i.e. Primatene Mist) should be avoided by individuals with glaucoma, organic
brain syndrome, heart arrhythmias.

Precautions:
Caution should be used in women who are pregnant or breast feeding, the elderly, children, people with a
history of cardiac arrhythmias, or peptic ulcer.

Patient Teaching:
* Correct use of inhalation medication includes shaking the canister, exhale completely, lean head
   back slightly, place mouthpiece in mouth, press medication and breathe in slowly by mouth for
   at least 3 seconds, hold medication and breath for several seconds before exhaling.
* Avoid nose breathing during inhalation of medication.
* Be sure to slowly inhale medication and avoid sudden gasping.
* Wait at least one minute before inhaling a second puff of medication.
* Use bronchodilator inhalers before steroid inhalers if both are ordered.




                                                                                                            14
                             METERED DOSE INHALER (MDI)1

A metered dose inhaler delivers a specific amount of medicine in aerosol form. This makes it possible to
inhale the medication, instead of taking it in pill form.

MDIs are commonly used to treat asthma, COPD, and other respiratory conditions.

                                     How to Use a Metered Dose Inhaler
   1.   Before using any MDI, read the product's instructions carefully. Remember that MDIs are not all
        alike. If you have any questions, call your doctor, nurse or pharmacist for help.
   2.   Remove the cap and look inside to see that nothing is blocking the mouthpiece.
   3.   Hold the inhaler upright with the mouthpiece at the bottom and shake it.
   4.   Tilt your head back slightly and breathe out fully.
   5.   Position the inhaler in one of the following ways (A is best, but C is okay for those who have
        difficulty with A or B)




   6. Spacers are useful for all patients. They are recommended for young children and older adults and
       for use with inhaled steroids.
   7. Press down on the inhaler to release the medication as you start to breathe in slowly.
   8. Breathe in slowly and steadily. Take 3 to 5 seconds for each breath.
   9. Hold your breath for 10 seconds to allow the medication to reach deeply into lungs.
   10. Remove the inhaler from your mouth.
   11. Breathe out slowly.
   12. If your doctor has instructed you to take more than one puff of medication, repeat this procedure.
       Waiting 1 minute between puffs may allow the second puff to get into the lungs better.
   13. If a steroid inhaler is used, rinse the mouth after use.

                        How do I know when my metered dose inhaler is empty?

The number of puffs contained in your metered dose inhaler is printed on the side of the canister. After
you have used that number of puffs, you must throw away your MDI even if it continues to spray. Keep
track of how many puffs you have used.

If you use an MDI every day to control your asthma symptoms, you can determine how long it will last by
dividing the total number of puffs in the MDI by the total puffs you use every day. For example, if your
MDI has 200 puffs and you use a total of 4 puffs per day, divide 200 by 4. In this case, your MDI will last
50 days. Then, using a calendar, count forward that many days to determine when to throw away your
MDI and begin us ing a new one. If you use an inhaler only when you need to, you must keep track of how
many times you spray the inhaler.




                                                                                                           15
                                               SPACERS 2

Spacers (also called holding chambers) work with your metered dose inhaler (MDI) to deliver inhaled
medication more easily and effectively, and can reduce side effects. They are useful for people of all
ages.

When you use an MDI by itself, more of the medicine is left in your mouth and throat, wasting your dose
and causing an unpleasant aftertaste. Spacers hold the “puff” of medicine between you and the MDI, so
that you can inhale it slowly and more completely. As a result, more of the medicine gets into your lungs.


                                          How to Use a Spacer
   1. Insert the mouthpiece of your inhaler into the opening at the flat end of the spacer.
   2. Hold your spacer and inhaler together and shake well, at least four times.
   3. Seal your lips tightly around the mouthpiece on the spacer or position the mask of the spacer over
      your mouth and nose.
   4. Keep your body straight and your eyes forward. Exhale.
   5. Spray one puff of medicine into the spacer, and immediately begin to inhale slowly, taking a full
      deep breath.
   6. Remover the spacer from your mouth or face. Hold your breath and count to 10. Slowly exhale.
   7. If your doctor has instructed you to take more than one puff of medication, wait one minute then
      repeat this procedure.




                                                                                                         16
                                  DRY POWDER INHALER3

A dry powder inhaler is similar to a metered dose inhaler (MDI), but the drug is in powder form. The
technique for using a powder dose inhaler is different than for an MDI.

Dry powder inhalers are commonly used to treat asthma, COPD, and other respiratory conditions.


                           How to Use a Dry Powder Inhaler
   1. Before using any dry powder inhaler, read the product's instructions carefully. Remember that dry
       powder inhalers are not all alike. If you have any questions, call your doctor, nurse or pharmacist
       for help.
   2. Remove the cap and look inside to see that nothing is blocking the mouthpiece.
   3. Hold the inhaler upright or according to the product’s instructions.
   4. Tilt your head back slightly and breathe out fully. Do not breath directly into the inhaler.
   5. Put the mouthpiece to your lips and close your mouth tightly around the mouthpiece.
   6. Breath in quickly and deeply.
   7. Remove the inhaler from your mouth.
   8. Hold your breath for 10 seconds to allow the medication to reach deeply into lungs.
   9. Breath out slowly. Do not breath directly into the inhaler.
   10. If your doctor has instructed you to take more than one puff of medication, repeat this procedure.
       Waiting 1 minute between puffs may allow the second puff to get into the lungs better.
   11. If a steroid inhaler is used, rinse the mouth after use.




                                                                                                        17
                                      NEBULIZERS 4

Nebulizers deliver a stream of medicated air to the lungs over a period of time.

Nebulizers are used to treat asthma, COPD, and other conditions where inhaled
medicines are indicated.


                                 How to Use a Nebulizer
   1.   Assemble the nebulizer according to its instructions. Connect the hose to an air
        compressor.
   2.   Fill the medicine cup with your prescription, according to the doctor’s
        instructions.
   3.   Attach the hose and mouthpiece to the medicine cup.
   4.   Place the mouthpiece in your mouth. Breathe through your mouth until all the
        medicine is used, about 10-15 minutes. Some people use a nose clip to help them
        breathe only through the mouth.
   5.   Some people prefer to use a mask.
   6.   Wash the medicine cup and mouthpiece with water, and air-dry until your next
        treatment.




                                                                                      18
        CONGESTIVE HEART FAILURE (CHF)
Congestive Heart Failure is a condition in which the heart does not pump blood as
effectively as it should. There are two ways in which the heart may fail to pump
effectively. Systolic dysfunction is associated with decreased squeezing of the heart
during pumping. Diastolic dysfunction occurs when the heart is too stiff to pump
effectively.

When the heart fails to work it does not fill up and empty out the normal blood volume,
the body attempts to compensate by secreting hormones to increase the work of the heart,
constrict blood vessels, and stimulate kidneys to retain water and salt in the body.
Although the body seems to compensate initially, the long-term effect is more harmful.
Eventually the heart will stretch, like a rubber band, and reach a point where it cannot
stretch anymore. If untreated, the body may show signs of fluid accumulation in lower
extremities, upper extremities, abdomen, and lungs. The body becomes congested with
fluid. The cycle must be interrupted to inhibit progression of fluid accumulation and
permanent cardiac damage. Early intervention is essential for optimal CHF management.

Potential Causes of CHF
Coronary Artery Disease                              Heart Attack
High Blood Pressure                                  Diabetes
Faulty Heart Valves                                  Kidney or Liver Failure
Alcohol                                              Irregular Heart Rhythm
Smoking                                              Viral Infection
Congenital Heart Defects                             Obesity
Hyperthyroidism

Symptoms of CHF
Fatigue                                              Weakness
Dyspnea with exertion or rest                        Enlarged Neck Veins
Persistent Wheeze or Cough                           White or pink tinged phlegm
Swelling in feet and legs                            Abdominal swelling
Rapid or fluctuating weight                          Nausea / Poor appetite
Faint or dizzy spells                                Decreased Mental Alertness
Lightheadedness

Treatment
*ACE inhibitors may be prescribed to lower blood pressure and strengthen the heart.
*Beta-Blockers may be prescribed to lower blood pressure and relax the heart.
*Digitalis may be prescribed to help the heart constrict and pump blood better.
*Diuretics may be prescribed to remove excess fluid from the body’s circulation.
*Dietary considerations include sodium restriction, possible fluid restriction, reduced
 cholesterol and fats, and potassium rich foods if diuretics are prescribed.
*Physical exercise, rest, breathing exercises, and smoking cessation.
*High blood sugar, high blood pressure, and high cholesterol management.
*Supplemental oxygen therapy may be prescribed.




                                                                                          19
        STAGES OF CONGESTIVE HEART FAILURE


Congestive Heart Failure, CHF, represents a disease state in which the heart fails to work
and pump blood around the body in an effective manner. CHF progressively worsens
over time meaning the heart functions in a declining manner and with less efficiency.
The progressive deterioration associated with CHF is broken down into four phases.

Phase I
Heart failure is considered mild. Left Ventricular function is abnormal. No symptoms
are obvious. Exercise does not produce symptoms of heart failure such as shortness of
breath, chest pain, heart arrhythmias, or excessive tiredness.

Phase II
Heart failure is considered moderate. Left Ventricular function is abnormal but the body
compensates for the abnormal function. Exercise produces tiredness, heart palpitations,
shortness of breath, and possible chest discomfort. Rest periods are comfortable. It is a
good idea to initiate treatment interventions at this stage.

Phase III
Heart failure is considered severe. Left Ventricular function is abnormal and the body is
unable to compensate without rest periods. Light exercise produces symptoms of
tiredness, heart palpitations, shortness of breath, chest discomfort, and general intolerance
to continued activity. Rest periods occur frequently to minimize activity intolerance and
treatments are helpful.

Phase IV
Heart failure is considered incapacitating. Left Ventricular function is abnormal and
refractory to any compensation with rest or other treatments. Rest periods may be
uncomfortable. Activity and exercise are not tolerated well. Palliative care is beneficial.




   Your physician associates you with phase_______as described
   above.




                                                                                          20
21
       CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Chronic Obstructive Pulmonary Disease is a condition in which the lungs are incapable
of performing normal ventilation. Tissues in the airway become inflamed and the airflow
is ultimately obstructed. Inflammation leads to thickening in the air passages and creates
an environment for mucus to accumulate. When mucus accumulates in the alveolar
spaces the oxygen exchange is reduced and alveoli lose elasticity.

COPD is a progressive disease that is not reversible. COPD may be thought of as the
following three diseases: (1) chronic bronchitis, (2) emphysema, and (3) asthmatic
bronchitis. Chronic bronchitis is determined by a cough lasting a minimum of 3 months
with reoccurrences over two years.

Possible Causes of COPD
Bronchitis
Asthma
Smoking
Emphysema



Symptoms of COPD
Persistent cough                                    Progressive shortness of breath
Wheezing                                            Multiple respiratory infections
Activity intolerance                                Muscle weakness
Extremity edema



Treatment
*Smoking cessation can prevent further pulmonary damage although it will not reverse
previous damage.
*Bronchodilators are prescribed to open narrowed airways. Albuterol and Theophylline
are commonly prescribed bronchodilators.
*Corticosteroids may be prescribed to reduce respiratory inflammation. Corticosteroids
are available as inhalers, oral tablets, and injections.
*Expectorants may be prescribed to loosen mucus.
*Supplemental oxygen therapy may be prescribed.
*Influenza and Pneumococcal vaccinations.
*Antibiotics may be prescribed to treat respiratory infections in early stages.




                                                                                        22
23
                                  DYSPNEA


Dyspnea is defined as being hungry for air. It is manifested as rapid inhalations and
expirations. Breathing is labored and difficult and may even be painful. It may feel
like a smothering sensation or the inability to catch a good normal breath.

Dyspnea is commonly associated with audible breath sounds without a medical
instrument, an anxious or distressed facial expression, mouth breathing or gasping,
dilated nostrils, and obvious bluish discoloration around the oral mucosa and lips.




                                                                                      24
             FACTORS THAT MAY CONTRIBUTE TO
               SHORTNESS OF BREATH (DYSPNEA)


Pain                             Anxiety

Fluid Accumulation               Increased Activity or Exercise

Anemia                           Fever

Depression                       Excess Sodium Intake

CHF / Congestive Heart Failure   Asthma

Bronchitis                       Pneumonia

COPD / Chronic Obstructive       Altitude Change

Pulmonary Disease                Exposure to Chemicals

Constipation                     Lack of Exercise

Smoking                          Obesity

Allergies                        Dust




                                                                  25
                     RELAXATION TECHNIQUES


Relaxation will reduce anxiety and improve mental and physical rest. Adequate
rest is important in maintaining good health. Relaxation may be enhanced by:


?Turning off TV’s, radio’s, and phones ?Taking a short walk

?Closing eyes and clearing your mind   ?Reading a good book or magazine

?Write in a daily journal              ?Getting a massage for feet or back

?Taking a nap                          ?Enjoying a pet

?Taking a bath or shower               ?Listen to soothing music

?Taking slow deep breaths              ?Enjoy a hobby

?Review photo albums                   ?Sing out loud




                                                                             26
                 AVOIDING SHORTNESS OF BREATH

Ensure that energy is maintained for proper breathing by eating proper calorie
amounts that are nutritionally sound such as fruits and vegetables.

Avoid large amounts of carbohydrate and sugar intake.

Exercise daily, as approved by your physician, to increase abdominal muscle strength
used with breathing.

Exercise regularly as approved by your physician to increase activity tolerance and
endurance. Walk daily.

Perform breathing exercise daily to increase endurance. Breathe in through the nose
while counting slowly to 3. Exhale through pursed lips making a slight whistle while
counting to 6 or 7. Concentrate on abdominal muscles while exhaling. This helps
trapped air to exit lung spaces.

Avoid smoking and avoid exposure to second hand smoke. Do not smoke when
oxygen is in use!

Ensure adequate ventilation with fresh outside air when household chemicals are in
use.

Consider eating small frequent meals instead of three large meals a day.




                                                                                      27
             OVERCOMING SHORTNESS OF BREATH

Elevate Head of Bed to 90 degrees

Sit on the side of the bed with outstretched arms resting on pillows or a bedside table
in a manner that does not crunch the stomach

Turn a blowing fan toward the face to reduce the air hungry feeling

Use a humidifier (*It is important to use bacteriostatic treatment in the water of the
humidifier and to change the water daily.)

Use supplemental oxygen if ordered by the physician during exercise and during
sleep.

Conserve energy / Take frequent rest periods throughout the day.

Use “Pursed Lip” breathing techniques. Your nurse will demonstrate this technique
for you.




                                                                                         28
  TREATMENTS COMMONLY PRESCRIBED FOR DYSPNEA

Supplemental Oxygen Therapy -Oxygen is often used during exercise or periods of
sleep. It is sometimes ordered for daily use.

Low Sodium Diet-Reduced sodium prevents unnecessary or excessive fluid retention

Smoking Cessation Programs / Medication- Avoiding smoking maintains
pulmonary function and quitting smoking prevents decline in pulmonary function.

Influenza Vaccine -Annually between October and December.

Pneumococcal Vaccine (PPV23)-At age 65 and repeated 5-10 years later as advised
by the physician. Also ages 2-64 with chronic illnesses.

Environment: No indoor pets, air purifier, dust free as possible, limit exposure to
aerosol sprays.

Limit or Avoid Alcohol Consumption

Management of Diabetes, Hypertension, and Cholesterol

Balanced Nutritional Meals-Meals containing high protein are important to
maintaining muscle mass. Vegetables, fruits, whole grains, nuts, and fish provide
quality nutrition and energy for the body. Foods such as red mead, whole dairy, fried
food, and foods containing saturated fat, and high cholesterol should be avoided.

Annual Spirometer Exam-This exam measures pulmonary function and is useful in
comparison from one year to the next. It may also be motivational in lifestyle
modification and is inexpensive.




                                                                                      29
                     Checking For Edema (Swelling)


Edema is a medical word for “fluid retention”. To check for fluid retention, push the skin
against your ankles and shins. If an impression of your finger remains, you are probably
retaining fluid. Larger amounts of fluid retention are indicated by a deeper finger
impression that takes a longer period of time (minutes instead of seconds) to go away.




                 Ways to Decrease Edema (Swelling)


   1. Take diuretic (fluid pill) as ordered by the doctor. A diuretic is a medicine that
      increases urine output to decrease edema (swelling) by removing excess fluid
      from the body.

   2. Take diuretic early in the morning. Taking it in the late afternoon or night often
      disturbs sleep.

   3. Keep a record of intake and output. You may loose large amounts of fluid even
      after a single dose of fluid medication.

   4. Weigh daily to be sure that the edema (fluid) is being controlled. Weight loss or
      weight gain should not be more than 1-2 pounds per day.

   5. Take potassium as prescribed by your doctor, or eat foods to supplement
      potassium loss. Your nurse will guide you in possible food selection for this.

   6. Report inability to urinate, weakness or muscle cramps.

   7. Check feet, legs, hands, face, stomach and tail bone areas for swelling each day.

   8. Avoid salt and foods high in sodium content and follow diet ordered by your
      doctor.

   9. Elevate feet above level of heart.

   10. Do not sit with your legs crossed.




                                                                                           30
                                  Skin Care


1. Inspect the skin daily. Observe for signs of breakdown.

2. Provide daily skin care:
      a. Wash with mild soap, rinse and pat dry
      b. Ensure that the skin is thoroughly dried
      c. Lubricate the skin with lanolin lotions

3. Report any signs of breakdown to the nurse or doctor immediately.
      a. Reddened areas that do not go away
      b. Breaks in the skin
      c. Blisters or any area of concern

4. Avoid applying adhesive tapes directly to the skin.

5. Avoid the use of tight, constricting socks or hose. Reposition the extremities (arm
   and legs) frequently. Do not cross the legs.

6. Use cotton or woolen socks that are the proper length and size.

7. Wear properly fitting shoes when out of the bed. Avoid going barefoot.




                                                                                   31
LOW SODIUM DIET GUIDE

 Foods Allowed:                                Foods to Avoid:
 Milk                                          Buttermilk
 Salt- free vegetable juice                    Tomato juice
 All fruit juices

 Enriched Breads                               Self-rising flour
 Cooked Hot Cereal                             Salted crackers
 Muffins                                       Instant Hot Cereal
 Puffed or Shredded Wheat Cereal

 Ice Cream                                     Chocolate
 Fruited Ice                                   Commercial Cakes, Cookies,
 Gelatin                                             Puddings, and Desserts
 Sherbet

 Vegetable Oil                                 Butter or Margarine
 Unsalted butter or Margarine                  Regular Salad Dressings
 Low Sodium Salad Dressings                    Bacon Bits
                                               Chips and Dips
                                               Processed Cheese

 Fresh Beef, Lamb, Poultry, and Fish           Canned Meats and Canned Fish
 Eggs                                          Ham
 Yogurt                                        Bacon
 Low Sodium Peanut Butter                      Hot Dogs
 Dried Peas                                    Salted Nuts

 Low-Sodium Soups                              Regular Canned Soups
                                               Bouillon Cubes

 White or Sweet Potatoes
 Pasta

 All Fresh Vegetables                          All Vegetables Frozen in Sauce
 Most Frozen Vegetables                        Regular Canned Vegetables
 Low-Sodium Canned Vegetables                  Pickled Vegetables

 *Salt Substitute                              Regular Salt / Garlic Salt
 Pepper and Herbs                              Meat Tenderizer
 Vinegar (Not Flavored)                        Barbecue Sauce
 Lemon / Lemon or Lime Juice                   Steak Sauce
 Low Sodium Ketchup, Mayo, and Mustard         Regular Ketchup, Mayo, & Mustard

 *All diet / food recommendations should be approved by your physician.




                                                                                32
HEALTHY EATING GUIDE
 • Daily nutritional habits affect overall health. Daily dietary intake
   should include a variety of foods to ensure proper intake of calories,
   vegetables, fruits, carbohydrates, vitamins and minerals, fiber, protein,
   and fats in order to support proper body functioning and health.

 • Balancing food with exercise daily improves overall health and
   reduces risks of high blood pressure, diabetes, cardiovascular disease,
   and mental health.

 • Servings of 2-4 fruits adds fiber, vitamins, and minerals to the diet.

 • High fiber consumption daily is beneficial in reducing cardiovascular
   disease, colon cancer, and diabetes.

 • Low cholesterol and fat consumption is related to decreased risk for
   stroke and heart disease.

 • Reduced salt intake reduces the risk of cardiovascular disease and
   high blood pressure.

 • Reducing sugar intake prevents cavities, obesity, and filling up on
   empty calories.

 • Daily protein intake is important for maintaining muscle strength. Eat
   2-3 servings of meat, poultry, fish, dry beans, eggs, or nuts daily.

 • Eat 2-3 servings of milk or dairy products to ensure adequate calcium
   intake and strong bones.

 • Drink water daily for adequate hydration and good health. Water can
   help eliminate waste from the body. Observe physician advised
   fluid restrictions for health protection when prescribed.




                                                                            33
                                       References

1. Alabama Quality Assurance Foundation. (n.d.). Living with heart failure.
       Birmingham, AL: Author.

2. Briath, R.W. (2003, September). Exercise for those with chronic heart failure.
       [Electronic version]. Physician & sports medicine, 30(9), 29.

3. Congestive heart failure. (2002, March 22). Mayo Clinic.com. Retrieved April 14,
      2003, from http://www.mayoclinic.com/invoke.cfm?id=D5000618.

4. Damico, C.M., Neri, L.M., Zalewski, K.A., & Fulginit, T. (Eds.) (2001). Nursing drug
      handbook. (21st ed.). Springhouse, PA: Springhouse Corporation.

5. Delgin, H.J. & Vallerand, A.H. (Eds.) (1999). Dauss drug guide for nurses. (6th ed.).
       Philadelphia, PA: F.A. Davis Company.

6. Evolution of clinical stages. [Electronic version]. Retrieved May 29, 2003 from http://
       www.americanheart.org.

7. Gillespie, J.L. (2001). The value of disease management-Part 1: Balancing cost and
       quality in the treatment of congestive heart failure. A review of disease
       management services for the treatment of congestive heart failure. [Electronic
       version]. Disease management, 4(2), 41-51.

8. Harrar, Sari, Walsh, Teri. (2001, December). Smokers, coughers, throat clearers: Get
       this test. [Electronic version]. Prevention, 53(12). Retrieved April 15, 2003, from
       http://www.lib.ua.edu:2748/citation.asp?tb=1&_ug=dbs+2+1n+en%2Dus+sid+7
       AFOE1B8%2D8499%2D4C…

9. Held, J.L. (1994, July). Cancer care: Managing shortness of breath. [Electronic
       version]. Nursing 94.

10 How to cope with COPD. (2002, April). [Electronic version]. Harvard women’s health
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      sp?tb=1e_ug=dbs+2+1n+en%Dus+sid+7AFOE1B8%2D8499%2D4C…

11. Lawton, M.P. (n.d.). Patient assessment tool—Instrumental activities of daily living.
       Retrieved April 14, 2003, from http://www.acsu.buffalo.edu/~drstall/iadl.html.

12. M.G. (2003, January). New life for a tired heart. [Electronic version]. Prevention,
       55(1), 126. Retrieved April 16, 2003, from http://www.lib.ua.edu:2646/delivery.a
       sp?eb=1&_ug=dbs=2=1n=en- us+sid+B4134BE5-CCDB-45CE-A97C-…


13. Morphine relieves breathlessness in CHF. (2003, February 23). [Electronic version].
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                                                                                        34
14. Petty, T.L. (2000, December). Interventions for smoking cessation and improved
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        +1n=en=us=sid=7AFOE1B8-8499-4CFE-BCE8-E…

15. Recognizing influenza may be difficult in older patients with COPD. (2003, March,
        11). Retrieved April 15, 2003 from NewsRx.com.

16. Simon, H.B. (Ed). (2003, April). Treating congestive heart failure: The conclusion of
       a two-part series. [Electronic version]. Harvard man’s health watch, 7(9).

17. The American Dietetic Association. (1996). Manual of clinical dietetics. (5th ed.).

18. Thomas, C.L. (Ed.). (1997). Taber’s cyclopedic medical dictionary. (18th ed.).
       Philadelphia, PA: F.A. Davis Company.




This material (the "Dyspnea Protocol") is provided by the Alabama Quality
Assurance Foundation ("AQAF") to healthcare providers, including Home Health
Agencies, with the understanding that it is for informational purposes only. The
Dyspnea Protocol does not take the place of a healthcare provider's obligation to use
its own professional and clinical judgment, and to furnish patients and others with
medical care based on its own professional and clinical judgment. Healthcare
providers that use the Dyspnea Protocol agree to hold AQAF harmless from any
damages that it or any third party may incur, including but not limited to claims
and damages to patients caused by use of the Dyspnea Protocol. In the event that an
action is brought by a healthcare provider or any third party against AQAF because
of the Dyspnea Protocol or any consequences associated with use of the Dyspnea
Protocol, healthcare provider agrees to fully indemnify AQAF against all costs and
damages.




This material was prepared by Alabama Quality Assurance Foundation under a contract with the
Centers for Medicare & Medicaid Services (CMS). Contents do not necessarily represent CMS
policy.
7SOW-AL-HHQI-03-05


                                                                                               35

				
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