Improvement in Dyspnea

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Improvement in Dyspnea

• Improvement in MO490
• Ann McCaughan BSN, RN, PhD(c)
• June 20, 2006

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States vs the Nation OASIS
MO MA ME NH NY VT USA
490- Pts SOB less often 59 59 59 62 59 59
Pts stay home after home health care ends 65 69 64 66 63 68
Pts who had to be admitted to hospital 32 28 31 31 32 28
Pts who need urgent, unplanned medical care 23 22 25 24 26 21
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Medicares view of Dyspnea monitoring value

• Why is this information important?
• Shortness of breath, or difficulty breathing, is
  uncomfortable. Many patients with heart or lung
  problems have shortness of breath because they
  cant get enough oxygen to their lungs. Shortness
  of breath is a big problem for many home care
  patients.
• If you have shortness of breath you breathe
  faster than normal and feel like you cant get
  enough air. This makes you uncomfortable and
  anxious. Shortness of breath can make you tire
  easily and unable to do normal activities. It is
  important that your doctor and home health staff
  check your breathing. They should teach you ways
  to improve your breathing and to be as
  comfortable as possible.
• http//www.medicare.gov/HHCompare/Home.asp

82 of pulmonary related hospital admissions were
due to anxiety.
Murata, 1996
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Expectations for your home health care experience

• Your doctor and home health care nurse or
  therapist should teach you ways to help you
  become more comfortable, including
• quitting smoking and avoid smoke
• breathing exercises
• positioning yourself to breath easier and
  encourage you to relax
• using several pillows to sleep
• planning for rest periods between your activities
  
• limiting talking, if talking causes shortness of
  breath
• opening a window or use a fan to get air moving
• using a humidifier in the winter
• when and how to use oxygen or medicine, as your
  doctor ordered
• Some patients who have a chronic breathing
  problem like emphysema may not get better even
  though the home health care agency provides good
  care. In these cases the doctor and home health
  agencys job is to make the patient as
  comfortable as possible.
• http//www.medicare.gov/HHCompare/Home.asp

Each home care visit should be initiated with the
shared expectation that home care is a finite
service. Set care goals as objective and
measureable as possible during that opening
visit.
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MO 490

• RESPIRATORY STATUS
• (M0490) When is the patient dyspneic or
  noticeably Short of Breath?
• 0 - Never, patient is not short of breath
• 1 - When walking more than 20 feet, climbing
  stairs
• 2 - With moderate exertion (e.g., while
  dressing, using commode or bedpan, walking
  distances less than 20 feet)
• 3 - With minimal exertion (e.g., while eating,
  talking, or performing other ADLs) or with
  agitation
• 4 - At rest (during day or night)
• (M0500) Respiratory Treatments utilized at home
• 1 - Oxygen (intermittent or continuous)
• 2 - Ventilator (continually or at night)
• 3 - Continuous positive airway pressure
• 4 - None of the above

What are the best assessment tools to effective
measure MO490?
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Morbidity

• DISEASE MILLIONS OF PATIENTS
• Hypertension 50.0
• Arthritis 32.6
• Heart Disease 27.6
• COPD 16.0 American Lung Association
• Asthma 13.1
• Diabetes 7.8
• Congestive Heart Failure 5.0
• Back Problems 4.3
• Alzheimers 4.0
• Lung Cancer
• 
  1997

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Home Health can help reduce the cost of COPD

• 50 of patients readmitted within 6 months.
• 53 of patients stayed at least one day in the
  ICU of these, 35 required mechanical
  ventilation.
• Average LOS 9 days.
• Average cost 16,100.
• Connors,1996

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Defining a Complex Disease Chronic Obstructive
Pulmonary Disease COPD

• CCOPD encompasses three separate disease state
  subsets that may or may not progress to COPD.
• TTreatment influenced by underlying disease
  state(s).

Chronic Bronchitis
Emphysema
COPD
Asthma
ATS
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COPD a insidious chronic disease

• Condition characterized by increased resistance
  to expiratory airflow.
• Encompasses 3 disease entities or combinations of
  them.
• Chronic Bronchitis
• Emphysema
• Unremitting/Irreversible Asthma
• Not readily distinguishable clinically and may
• overlap with other disease entities.

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Problem Symptoms are Vague, and Subjective

• Instruct patients regarding the signs and
  symptoms of Early, Late and Acute Exacerbation of
  their disease.
• Tailor motivation for action with the patients
  own words i.e. I never want to feel that
  drowning feeling ever again.
• Plan for action becomes, Call the nurse when
  your PEFR is 6.8 L/Sec or less, which is 80 of
  your personal best, so as to avoid that drowning
  feeling. This statement is objective and
  individually tailored.

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Identify Early Decompensation

• The care objective for all the aforementioned
  disease states is
• Early Identification of Decompensation

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Early Identification of COPD Exacerbation
Prevents Emergent Care Access Acute
Hospitalization
Early SS Exacerbation Late SS Exacerbation Acute Exacerbation
Anxiety Respiratory rate with exertion Fatigue Appetite Difficulty sleeping PEFR less than 80 of best effort FEF25-75 Restlessness Cough Sputum production Respiratory rate at rest PEFR between 50-80 of best effort FVC Pale nail beds SaO2 less than 90 FEV1 Green thick sputum Tachypnea Unable to talk in complete sentences Cyanosis
Home Care Must intervene here to prevent adverse
outcomes!
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Early identification of heart failure
exacerbation prevents disruption
Early SS Exacerbation Late SS Exacerbation Acute Exacerbation
? Appetite Fatigue Bloated feeling Fullness in ears Difficulty Sleeping ? ZO from baseline ? Peripheral edema ? SOB with exertion Weight gain ? Abdominal girth ? Pillow use Develops a cough Pitting edema ? SOB _at_ rest Develops S3 Develops crackles SaO2 ? JVD Zo less than 15 ohms
This is when home care nursing intervention must
occur to prevent CHF and hospitalization.
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History of Dyspnea

• Oxygen Utilization
• Medical H/O- COPD, asthma, TB, pneumonia, sinus,
  allergies panic attacks
• Surgical H/O- cardiothoracic surgery
• Comorbidities heart failure, cancer,
• Environmental exposures occupation, farm,
  industrial mold mildew dust
• Smoking history
• Hemoptysis
• Sleep habits - of pillows recliner of
  hours
• Medications

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Observation of Dyspnea

• Subjective
• Ease of Breathing Respiratory rate, rhythm and
  depth
• Borg Dyspnea Scale
• ATS Grade of Breathlessness Scale
• Skin Color
• Color of Nail beds
• Nasal Flaring
• Pursed Lip Breathing
• Chest Symmetry
• Uses accessory muscles
• Tenor of Voice (especially on the telephone)
• Cough
• Sputum color quantity, quality, blood, food
• Pain
• Living conditions cleanliness
• Nutritional Status

• Objective
• Six Minute Walk Test
• Pulse Oximetry
• Zo-Thoracic fluid measurement
• After auscultation
• Peak Flow Meter
• Spirometry

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Borg Dyspnea ScaleVerbal Breathlessness Scale
SCORE INTENSITY
0 Nothing at all
1 Very slight
2 Slight
3 Moderate
4 Somewhat Severe
5 Severe
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7 Very Severe
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9 Very, Very Severe
10 Maximal

• When asking patients to rate their breathing,
  also note the following
• Is their voice breathy, or seem out of breath?
• Are their sentences short or choppy?
• Is there audible wheezing or coughing?

Ask patient to rate breathlessness on each
interaction telephone or personal
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American Thoracic Society Grade of
Breathlessness Scale
Grade Degree Description
0 None Not troubled with breathlessness except with strenuous exercise.
1 Slight Troubled by shortness of breath when hurrying on level ground or walking up a slight hill.
2 Moderate Walks slower than people of the same age on level ground because of breathlessness or has to stop for breath when walking at own pace on level ground.
3 Severe Stops for breath after walking approximately 100 yards or after a few minutes on level ground.
4 Very Severe Too breathless to leave the house or breathless when dressing and undressing.
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Compare cardiac pulmonary assessment
measures

• Cardiac
• Pulse rate
• Heart tones - stethescope
• Single lead ECG
• 12 lead ECG

• Pulmonary
• Respiratory rate
• Lung sounds - stethescope
• Peak flow meter
• Spirometer

Zo can indicate fluid in the lungs which can
impede breathing.
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Pulse Oximetry
Decreasing SaO2 is a late sign of exacerbation.

• Normal adult 95-98
• Pulmonary dysfunction less than 90
• Home O2 reimbursed for SaO2 less than 90
• Usually patients have symptoms prior to decrease
  in SaO2.

SaO2 still requires a physician script for
integration into care plan.
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Auscultation

• Breath Sounds Begin at lower lobes and progress
  up throughout all lobes. Adventitious sounds
  identified, located (1/3 up right lower lobe,
  bases bilaterally) and described,
• Crackles - Rhonchi
• Wheezes - Pleural Rub
• Inspiration
• Expiration

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Peak Flow Meter

• Small easily-used, hand-held point of care device
  that measures the Peak Expiratory Flow Rate
  (PEFR).
• Usually covered by insurance for chronic
  respiratory problems asthma, cystic fibrosis.
• Adult PEFR normal range 300-700L/min
• Regular measurement provides trends for
  comparison to symptom related measurements.
• Less than 80 of Best Effort PEFR is considered
  time to take action.
• Patients must be able to demonstrate proper use
  of the Peak Flow Meter prior to attaining a
  reliable measurement.

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Spirometry

• Devices designed to objectively measure lung
  function and capacity.
• Two types used in home care
• Incentive point of care post surgical
  assessment of lung capacity and pulmonary
  exercise.
• Expiratory point of care ongoing management and
  tracking of lung function.

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Incentive Spirometry

• Indications Post surgery or recovery of an
  acute process to improve lung capacity and
  prevent atelectasis or pneumonia
• Frequency Every hour while awake or every TV
  commercial break!
• Log daily
• Set a Goal Increase by 200cc QOD

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Expiratory Spirometry

• Normal ranges based on age, height, weight,
  gender, and heritage. Provides peak expiratory
  flow measurement plus
• FEV1 Forced Expiratory Volume in one second
• FEF25-75 - Midexpiratory Flow
• FVC Forced Vital Capacity

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Improvement in DyspneaAs Measured by Goal
Attainment

• Long Term Goals
• Improved
• Breathlessness Rating
• Six Minute Walk Test
• Medication Regimen Compliance
• Nutritional Status

• Short Term Goals
• Improved
• SaO2
• Peak Flow
• Incentive Spirometry Measurement
• Sleep time
• Lung Sounds
• Skin Nailbed Color
• Minimize symptoms

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Improvement in Dyspnea Interventions

• Assess each home care interaction telephone
  interaction and visit
• Instruct patient regarding self assessment
• Instruct patient on symptom management and when
  to take action

End Goal is Self Care!
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Use of Inhalers

• Instruct the patient
• Remove inhaler cap and shake well
• Hold upright with index finger on the top and
  thumb on bottom of inhaler
• Blow all air completely out through your mouth
• Wrap lips around mouthpiece
• Begin a slow deep breath in and press the inhaler
  down with your index finger in order to give one
  puff of medication.
• Hold your breath in for at least 5-10 seconds
• Slowly breathe out, holding your lips tight
  together
• Wait one minute between puffs before taking the
  next dose of medication so as to allow lungs to
  open up as much as possible.

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Problem Nutritional Status Directly Affects
Pulmonary Status

• Instruct patient to eat small frequent meals high
  in protein if able to tolerate.
• Eat slowly and in a relaxed atmosphere.
• Sit in a chair that allows for good posture with
  arm rests.
• Do not engage in activity that requires increased
  energy for one hour after eating.

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Problem Energy conservation

• All patients must be instructed regarding the
  principles of energy conservation in order to
  avoid increased dyspnea.
• Sleep patterns must be thoroughly assessed in
  order to increase energy levels.

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Problem Patients are at risk for infection

• Instruct patient to
• Monitor temperature
• Assess sputum color, quality quantity
• COPD patients may find monitoring FEF25-75
  gives earlier indication of infection when
  decreasing

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Four attributes that affect self-monitoring
behaviors

• Identity of somatic sensations of illness
  representation
• Timeline features of disruption
• Environmental surroundings
• Actual/Perceived cause of sensations, symptoms,
  experiences
• Johnson, 1999

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Ambiguous symptoms can delay action

• Self-regulation theory research found
• When symptoms were ambiguous and unclear as
  indicators of illness, care seeking was delayed
  by 60 of the population.
• Leventhal, 1995
• Supportive-educative intervention is effective
  in enhancing heart failure-related self-care
  behaviour early after discharge, but new
  interventions are required for long term
  adherence of self-care behaviours
  Jaarsma, 2000

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Conclusion

• MO 490 currently adequate outcomes
• Can be greatly improved
• Increase objective assessment parameters
• Increase patient participation
• Set care expectations during first visit