Stabilize patients with dyspnea education
A Texas home care agency has decided to target patients' difficulty in breathing or dyspnea as a quality improvement and education project. "What we were looking for is improvement or stabilization in the patient's condition," says Sue Honeycutt, RN, BSN, director of professional services for IHS South County Health Care in Port Arthur, TX. The private, full-service agency serves six counties in Southeast Texas.
Before the educational program began, the agency's dyspnea patients showed improvement in breathing 41.1% of the time, Honeycutt says. One year after the program was implemented, the improvement rate had climbed to 57.1%. "We did a lot with patient educational materials, standardized our patient teaching, and we had a better teaching plan that included all aspects of patients with respiratory problems," she explains.
Staff education focused primarily on congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The agency created its own teaching plan, which included diet, medication, caregiver support, and critical areas of activity. Inservices on dyspnea varied according to the audience: There were separate teaching levels for registered nurses, licensed vocational nurse (LVN), and aides. Each inservice was broken into one-hour segments. For all skilled nurses, for instance, one segment would cover assessment.
Honeycutt offers this guide to the dyspnea inservice:
1. Identify dyspnea. "There are so many different kinds of dyspnea," she says. "Why is a patient having difficulty breathing? Is it because they are weak or anemic?" She also covered the causes and standard definition that dyspnea is shortness of breath or difficulty in breathing that may be caused by a heart condition, strenuous exercise, lung disease, or anxiety. "Dyspnea is a symptom. It's not a disease in and of itself, but it might be a symptom of some underlying disease, such as lung disease or cardiac problems."
2. Cover the major causes of dyspnea. Honeycutt lists these three major causes:
· Physiological: Physical exertion is the most common cause. "If you went out and ran a mara thon, or if you normally live at sea level and you took a vacation in the mountains, that's physiological dyspnea," she says. "The obvious solution is to increase activity slowly and increase your strength and improve your diet."
· Pulmonary: This type involves patients who have COPD, pulmonary fibrosis, lung disease, and pneumonia. Interventions with those patients would involve determining what the problem is and what type of outcome might be achieved.
"You would want to increase their air flow, have them on oxygen," Honeycutt says. "Also, look for underlying infections and help them keep their air passages cleared out of any congestion and drainage."
· Cardiac: This includes CHF. "Your cardiac output can't keep pace with your need for oxygen during exertion and exercise. Encourage this person to rest." Such patients may need to sit up to breathe, which indicates they may have nocturnal dyspnea, breathing problems that occur only at night.
3. Divide treatment tasks among staff. At IHS South County Health Care, RNs write the treatment plans, and the LVNs and RNs are responsible for helping patients implement them. The RNs also evaluate how patients respond to the interventions. They note whether the plans are working and then report to case managers.
LVNs are taught to listen to the patient's breath sounds. They learn how to identify signs and symptoms of CHF and how to check for edema. Home health aides focus on the dyspnea patients' activities of daily living. Because aides often prepare meals for patients, the inservice includes a lecture on diet by a dietitian.
Aides also were cautioned not to rush patients through their daily activities. For example, they shouldn't eat, bathe, and then walk without being given some time to rest between each activity. "We tell them, 'What do you think you could do? Tell me about your patient, and tell me what you do to help them when they get short of breath, and let's problem-solve it together,'" Honeycutt says.
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