Health Professional Manual

Transcription

1 Health Professional Manual Session 3 Overview of the Action Plan and Management of an Exacerbation Action Plan: Objectives and Structure Signs and Symptoms of an Exacerbation Strategies to Prevent an Exacerbation Strategies to Manage an Exacerbation Adapted from the Living Well with COPD program (2nd edition), Montreal Chest Institute, Canada

2 SESSION SUMMARY Education Plan and Methods Session Length: minutes Introduction Working Phase 1. Feedback from Learning Contract. Group discussion. 2. Action Plan. 2.1 Presentation of the objectives and structure of the Action Plan. Interactive lecturing. 2.2 Presentation of the section Important Contacts of the Action Plan. Interactive lecturing. 2.3 Presentation of Part 1 of the written action plan. Interactive lecturing. 3. Signs and symptoms of an exacerbation. Interactive lecturing. 4. Strategies to prevent an exacerbation. Interactive lecturing. 5. Strategies to prevent an exacerbation. Interactive lecturing. 5.1 Presentation of Part 2 of the written action plan. Interactive lecturing. 5.2 Presentation of Part 3 of the written action plan. Interactive lecturing. 6. Reinforcement of participants understanding and self-efficacy. 6.1 Optional: Integration of strategies to manage an exacerbation. Case scenario. 6.2 Summary of the session and assessment of participants understanding and self-efficacy. Group discussion. Closing of the session Appendices section Appendix 1: Additional information 1. Factors that increase the risk to develop a respiratory infection. 2. Strategies to manage an aggravation of symptoms (exacerbation) due to environmental factors. 3. Strategies to manage an aggravation of symptoms (exacerbation) due to stress/emotions 4. Expert patient testimony on the use of the action plan. Human Resources 1. One health professional (recommended facilitator: nurse or physiotherapist).) Living Well with COPD for Pulmonary Rehabilitation Resources 1. Information Booklet (Pages 8 to 9) 2. Key messages: Energy Conservation 3. Cue cards: Pacing yourself, Blow-as-you-go, Action plan 4. Written action plan Prior to the session, ask participants to bring their own written action plan, if they have one. Additional Resources 1. Board / Flipchart Environment 1. Use a quiet and comfortable room for 10 to 15 people. Ensure proper ventilation. 2. Place the chairs in a semi-circle around the board. 2

3 GROUP INTERVENTIONS FOR EACH PHASE OF THE SESSION Introduction Presentation of the Facilitator. Outline the goals of this session. Review the key messages from the last session and link them to this session. Working Phase Educational Interventions 1. Feedback from learning contract 1.1 FEEDBACK FROM LEARNING CONTRACT Present this section using Group Discussion Use Attachment 1 (Key messages: Energy conservation), Attachment 2 (Cue card: Pacing yourself) and Attachment 3 (Cue card: Blow-as-you-go ) to support your teaching. Evaluate how participants managed to use the strategies for Energy conservation. Suggested script for the Facilitator: During the last session we looked at the daily activities that can cause fatigue and shortness of breath. We also explored strategies that you can use to conserve energy. Suggested questions: Did you practice each one of the different energy conservation strategies at home? Did you complete the Week-schedule? Were you able to plan and perform your activities in a more balanced way? Provide the participants constructive feedback and reinforcement on their understanding of the strategies for Energy conservation. Identify any participants having difficulty integrating the strategies, or any other participant that may require a one-to-one session with an Occupational Therapist 3

4 GROUP INTERVENTIONS FOR EACH PHASE OF THE SESSION 2. Action Plan 2.1 PRESENTATION OF THE OBJECTIVES AND STRUCTURE OF THE ACTION PLAN Present this section in an Interactive Way Provide a copy of the Written Action Plan to the participants or ask them to use their own action plan. Describe the objectives of the Action Plan. Briefly describe the content of the different sections of an action plan. Note to the facilitator: The Action Plan is a personalised tool to help participants in their decision making process (Attachments 4 and 5). The goal of this session is to present an overview of the Action Plan to foster participants understanding and promote its use in helping them to manage an exacerbation. If participants have previously been given a written action plan by their community respiratory team, practice nurse or doctor they can use it within this education session. Suggested script for the Facilitator: Action Plan: Your Action Plan plays an important part in your life, as it will help you make key decisions in treating COPD when your symptoms get worse. If you use your Action Plan properly, you will become more independent and feel more in control when your symptoms get worse. Your Action Plan may make the difference between a trip to the hospital and treatment at home! Your Action Plan will help you to: Better recognise your usual everyday symptoms. List what you are doing every day to remain well, including taking your medication as prescribed. Recognise an exacerbation (a significant worsening) of your symptoms. Know what to do to prevent an exacerbation (a significant worsening) of your symptoms and start an early treatment if that happens. Know when and whom to call if your symptoms get worse or do not improve. 4

5 GROUP INTERVENTIONS FOR EACH PHASE OF THE SESSION An Action Plan includes the following sections: Contact list. Usual symptoms, medications and actions. What to do when symptoms are worse, or you are developing an exacerbation (significant worsening of symptoms). When to seek help. 5

6 GROUP INTERVENTIONS FOR EACH PHASE OF THE SESSION 2.2 PRESENTATION OF THE SECTION IMPORTANT CONTACTS OF THE ACTION PLAN Present this section in an Interactive Way Review the section Important Contacts of the written action plan to guide the participants to identify their key resources. Encourage the participants to fill it in. Suggested script for the Facilitator: An essential part of your action plan is to have the phone numbers of your contacts close at hand. These are the key people you should call when you have a problem with your symptoms or treatment. Important Contact GP Community Respiratory Team Pharmacy Out of Hours Service Name Telephone Number 6

7 GROUP INTERVENTIONS FOR EACH PHASE OF THE SESSION 2.3 PRESENTATION OF PART 1 OF THE WRITTEN ACTION PLAN Present this section in an Interactive Way Introduce Part 1 of the written action plan and encourage the participants to fill it in. Suggested script for the Facilitator: To remain well use your action plan to monitor your everyday symptoms, to take your regular medication as prescribed and to maintain healthy life habits. Now let us see how to complete part 1 of your action plan Present the sub-section My usual symptoms to the participants. Review with the participants the elements that should be covered in this section and that will help them to identify their everyday symptoms (baseline). Suggested question: What symptoms do you experience everyday due to your COPD? Guide participants to identify the following symptoms. Inform them to select only the symptoms that apply to them: SOB: Encourage the participant to use their own language to describe their shortness of breath. In response to I can usually walk before I become short of breath and need to stop and rest insert either the distance e.g. 20 metres, or use the participant s own words e.g. usually down to the newsagents and back. Sputum: Whether they cough up sputum (phlegm) daily and the characteristics of their sputum: colour, amount (volume), consistency. Other symptoms: Whether other usual symptoms are present daily, such as cough, wheezing, fatigue, limited sleep, loss of appetite, low mood, anxiety or panic Present the sub-section My usual medication to the participants. Review with the participants the elements that should be covered in this section and that will help them to identify: The medications included as part of the everyday treatment for COPD. Note to the facilitator: Identify participants who have been prescribed long-term oxygen therapy and/or have been given an oxygen alert card and Venturi Mask as per the BTS guidelines. Record this in the usual medication section. 7

8 GROUP INTERVENTIONS FOR EACH PHASE OF THE SESSION Present the sub-section Other actions to the participants. Discuss each symptom previously identified by the participants and discuss other actions they can take to control their daily symptoms, for example: SOB: positions of ease, breathing control, pursed lip breathing technique, pacing. Encourage participants to record on their Action Plan the actions that are appropriate to them. Note to the facilitator: Remember to emphasise the importance of healthy lifestyle habits, including taking part in regular physical activity, getting a good night sleep and eating a healthy diet. Encourage participants to acknowledge and record them as important other actions. Inform participants of the importance of getting a flu vaccination annually, as well as getting the pneumococcal vaccination. If participant is linked with COPD MET office, make sure they are receiving consistent information. 8

9 GROUP INTERVENTIONS FOR EACH PHASE OF THE SESSION 3. Signs and symptoms of an exacerbation 3.1 PRESENTATION OF THE SIGNS AND SYMPTOMS OF AN EXACERBATION Present this section in an Interactive Way Invite each participant to describe the symptoms of an exacerbation (a significant worsening of symptoms). Write on the board all the symptoms described. Differentiate the symptoms specific to an exacerbation from the other symptoms related. Suggested questions: What is an exacerbation? Answers expected from the participants: An exacerbation is a significant worsening or a flare up of your usual COPD symptoms. An exacerbation can be caused by a chest infection, but sometimes it is not known why people have a worsening of symptoms. Suggested questions: What are the symptoms of an exacerbation? Answers expected from the participants: Specific Symptoms 1. More breathlessness than usual. You find it harder to perform your usual activities. 2. Changes in the colour, volume, and/or consistency of your sputum. Your sputum may become yellow or green, or sometimes just darker. You may produce more sputum. Your sputum can become thicker. Other Symptoms You may have a cold or flu-like illness and/or sore throat preceding the changes in your sputum and shortness of breath. Fever Fatigue Note to the facilitator: Make sure that participants are able to recognise the difference between their baseline usual symptoms and an aggravation of symptoms (exacerbation). 9

10 GROUP INTERVENTIONS FOR EACH PHASE OF THE SESSION 4. Strategies to prevent exacerbations 4.1 PRESENTATION OF THE STRATEGIES TO PREVENT AN EXACERBATION Present this section in an Interactive Way Invite participants to describe the strategies that they use to prevent an exacerbation. Write the mentioned strategies on the board, complete and correct as needed. Note to the facilitator: Emphasise the importance of prevention by avoiding as much as possible or reducing the exposure to the risk factors for an exacerbation. Exacerbations should be prevented in order to avoid related complications (e.g. hospitalisations), consequent deterioration of symptoms (e.g. not coming back to baseline after exacerbation is treated) and disease progression. Suggested question: What are the strategies that you use to prevent an exacerbation? Answers expected from the participants: Avoid people suffering from a chest infection (flu, bronchitis, cold). Wash your hands regularly. Vaccine against influenza (flu) every autumn and against pneumonia (pneumococcal vaccine) at least once in your life. Take good care of yourself, adopt a healthy lifestyle: sleep, eat healthy food, and exercise regularly. Avoid smoking and cigarette smoke (it paralyses the actions of the cilia, the tiny hairs in your airways). Avoid built up areas with a lot of pollution. Get help to solve problems (stress can increase your risk of developing an exacerbation). Do not use a humidifier (unless you provide your equipment with the proper maintenance). Ensure proper ventilation at home. Note to the facilitator: Sometimes participants have wrong or different beliefs with regards to exacerbations and risk factors. The objective is not to destroy those beliefs but to offer another explanation, another meaning. e.g.: humidifier, vaccines. 10

11 GROUP INTERVENTIONS FOR EACH PHASE OF THE SESSION 5. Strategies to manage an exacerbation 5.1 PRESENTATION OF PART 2 OF THE WRITTEN ACTION PLAN Present this section in an Interactive Way Introduce Part 2 of the action plan and encourage the participants to fill it in. Suggested script for the Facilitator: Your action plan helps you identify when your symptoms are worse and the appropriate actions to take. Now let us see how to use Part 2 of your action plan Present the section There may be times when your symptoms are worse to participants. Review with the participants the specific respiratory symptoms that can be aggravated by an exacerbation. Suggested script for the facilitator: We have seen before how to identify an aggravation of respiratory symptoms. Here at the section There may be times when your symptoms are worse you will find the symptoms you need to look for and that will indicate the presence of an exacerbation (a significant worsening) of your symptoms. My Symptoms My shortness of breath is worse. My sputum is worse (colour, volume, and/or consistency). Note that these changes may happen after a cold or flu-like illness and/or sore throat Identify with participants the strategies that they already use to manage an exacerbation. Suggested questions: What are the actions that you usually take to manage an exacerbation (a significant worsening) of your symptoms? Do you take additional medication to manage an exacerbation (a significant worsening) of your symptoms? 11

12 GROUP INTERVENTIONS FOR EACH PHASE OF THE SESSION Explain to the participants the decision process to initiate their actions based on symptoms presentation. Suggested script for the facilitator: You have to look at the changes in your symptoms in order to decide what actions you need to take and if you need to start additional medication. 1. Look at your shortness of breath If your shortness of breath is worse than usual, you should first: o Use positions of ease, breathing techniques and pacing; o Increase your BLUE RELIEVER INHALER (SHORT ACTING BRONCHODILATOR) prescribed by your doctor; and o Seek advice from your resource person. If after increasing your blue reliever inhaler (short-acting bronchodilator) your shortness of breath does not improve and you have difficulty performing your usual activities, you need to start your CORTICOSTEROID treatment (if you keep these medications at home). If you do not keep these at home then contact your resource person to request a prescription for corticosteroids. Do not wait more than 48 hours to start your corticosteroid. Help participants identify how to increase (puffs, frequency) their blue reliever inhaler (short-acting bronchodilator), who their resource person is and how long they should wait before seeking help or starting corticosteroids. Encourage them to insert this time scale in the space provided (for example, within 48 hours). 2. Look for changes in your sputum colour, volume and consistency (not only in the morning). If the colour becomes yellow or green you probably have a bacterial infection. You need to start short sessions of breathing exercises and huffing, seek advice from your resource person and start your ANTIBIOTIC (if you keep these medications at home). If you do not keep these at home then contact your resource person to request a prescription for antibiotics. Do not wait more than 48 hours to start your antibiotic. For any other changes in your sputum (volume, consistency) discuss with your doctor the need for antibiotics. Help participants identify who their resource person is and how long they should they should wait before seeking help or starting antibiotics. Encourage them to insert this time scale in the space provided (for example, within 48 hours). 12

13 GROUP INTERVENTIONS FOR EACH PHASE OF THE SESSION 5.2 PRESENTATION OF PART 3 OF THE WRITTEN ACTION PLAN Present this section in an Interactive Way Identify with the participants the warning symptoms that indicate that they need to get help immediately. Suggested question: What are the symptoms that can indicate that you need to get help immediately? Complete the list of symptoms mentioned by the participants. Review the actions to be taken in an emergency situation. Discuss with the participants the expected effects of these actions. Suggested script for the facilitator: When you feel much worse your action plan helps you recognise the symptoms that tell you that you need to get help immediately, as well as the actions that you need to take. Actions In any situation if you are extremely short of breath, hot and shivery, confused and/ or drowsy, and/or you have chest pain, do not take any risk Contact your GP practice or out-of-hours service immediately or you may need to visit your Accident and Emergency department. If at any stage you feel you are in danger phone 999. Expected Effects Intervene to save your life Inform participants who have been given an Oxygen Alert Card what they should do when they phone 999. Suggested script for facilitator: If you have an Oxygen Alert Card, please show this to the ambulance staff and also take it with you to the hospital. Note to the facilitator: Stress that correct utilisation of the action plan will allow the participant to be more independent, to initiate a treatment at home and to avoid a visit to the emergency room or a hospitalisation. 13

14 GROUP INTERVENTIONS FOR EACH PHASE OF THE SESSION 6. Reinforcement of participants understanding and self-efficacy 6.1 OPTIONAL: INTEGRATION OF STRATEGIES TO MANAGE AN AGGRAVATION OF SYMPTOMS DUE TO AN EXACERBATION Case Scenario Note to the facilitator: The case study is an optional section. If time permits it should be presented to the participants Reinforce comprehension of the action plan use by presenting a case scenario based on an aggravation of symptoms (exacerbation) caused by a respiratory infection. Let participants share their experiences with respect to symptoms and actions to be taken. Suggested Case Scenario: You contracted a cold from your grandchild a week ago. You notice changes in your sputum and you are more short of breath. Suggested questions to foster discussion. Make sure each participant responds to at least one of the questions: What do you do to manage an exacerbation? Which symptom of an exacerbation tells you to start to take antibiotics? How soon should you start your antibiotic? How do you know that your shortness of breath has worsened? Give some examples. When should you increase your reliever (bronchodilator)? When your breathing becomes worse, how soon should you start your corticosteroid? How do you know that your additional treatment did not work? What should you do if you do not see any improvement or if your symptoms get worse? Note to the facilitator: Discuss each action proposed by the participants and question them about the expected effects of each one. Provide positive feedback to the answers given by the participants. Remark those suggestions supporting the compliance with the instructions given in the Action Plan. 14

15 GROUP INTERVENTIONS FOR EACH PHASE OF THE SESSION Evaluate participants understanding and self-efficacy to recognise and manage exacerbations by using the strategies included in the Action Plan. Use this opportunity to highlight the key messages from the session. Suggested questions: How confident are you that you can recognise an exacerbation (a significant worsening of your usual symptoms)? How confident are you that you know how to alter your therapy during an exacerbation (a significant worsening of your usual symptoms)? How confident are you that you know when to seek help during an exacerbation (a significant worsening of your usual symptoms)? Do you think your Action Plan will help you to prevent and manage an exacerbation (significant worsening of your usual symptoms)? Do you think your Action Plan will help you to prevent a visit to Accident and Emergency and an admission to hospital? Suggested script for the facilitator: 6.1 OPTIONAL: INTEGRATION OF STRATEGIES TO MANAGE AN AGGRAVATION OF SYMPTOMS DUE TO AN EXACERBATION Case Scenario Your Action Plan can help you to: Recognise an exacerbation. Know how to alter your therapy. Know when to seek help. Note to the facilitator: Inform participants that additional information is available in their information booklets (Pages 8 to 9). If participants feel capable to recognise and manage exacerbations using the strategies included in their Action Plan, ask them to continue applying these strategies. If some participants do not feel capable to recognise and manage exacerbations using their Action Plan, make sure to refer these participants to their community respiratory team, practice nurse or doctor to see them on an individual basis to investigate the reasons and reinforce the use of the action plan. 15

16 GROUP INTERVENTIONS FOR EACH PHASE OF THE SESSION Closing the session Answer the questions of the participants. Underline the importance of the use of the Written Action Plan (for the selfmanagement of COPD). Learning Contract: Ask the participants to ask a member of the pulmonary rehabilitation team (attachment 6: cue card: Action Plan), or their community respiratory team, practice nurse or doctor to review their Action Plan periodically. CONTRACT Ask participants to bring their action plan and inhaler devices to the next education session. Evaluate the satisfaction of the participants with regards to the present session 16

17 ATTACHMENTS Attachment 1: Energy Conservation Key Messages Learning how to manage your breathing when doing your day-to-day activities will help you save energy and manage fatigue. Some of the techniques you can use include: Pace yourself and avoid rushing. Alternate activities that you find more difficult with ones you find easier. Do the activities that you need more energy for at the time of day you have the most energy. Breathe out when effort is needed, for example when lifting heavy objects. Some people may need aids and appliances to help with their daily activities. If you would like information about these, please speak to a member of the pulmonary rehabilitation team. They will help you find out where or how you can get them. Including exercise or physical activity in your life is important. Even doing a small amount of exercise or physical activity, as long as it is done on a regular basis, can help manage breathlessness and fatigue. 17

18 ATTACHMENTS Attachment 2: Pacing yourself In order to conserve your energy and manage shortness of breath alternate exercises that you find more difficult with ones you find easier. 18

19 ATTACHMENTS Attachment 3: Blow-as-you-go To help manage your breathing, breathe out when effort is needed, for example when lifting weights. 19

20 ATTACHMENTS Attachment 4: ATTACHMENT 4 Version 2: 4 th November 2011 Name: COPD Self-management Action Plan Date: Issued by: Important Contact Name Telephone number GP Community Respiratory Team Pharmacy Out of Hours Service Part 1: My Usual Symptoms Shortness of breath I can usually walk (insert distance or where) before I become short of breath and need to stop and rest Activities that usually make me short of breath are (insert): Sputum I usually have no sputum unless I have a chest infection I usually cough up sputum everyday clear white yellow green 1 teaspoon 1 eggcup half a cup 1 cup watery sticky Other usual symptoms e.g. wheezing, anxiety or panic My Usual COPD Medication Medication Prescribed dose Inhaled medication Amount Times per day Delivery device e.g. spacer, MDI Other respiratory medication Other actions which help control my usual symptoms 20 20

21 ATTACHMENTS Part 2 - There may be times when your symptoms are worse. Talk to your nurse/doctor/healthcare professional to work out what might help when your symptoms are a little worse. My actions if my shortness of breath is worse Use positions of ease, breathing techniques and pacing Take my blue inhaler more often: puffs /day. *Do not take more than a total of puffs/day Take my nebuliser: nebules /day. *Do not take more than a total of nebules/day Seek advice from: If I am not feeling better within hours/days then I should: My actions if my sputum is worse (colour, volume, stickiness) Do short sessions of breathing exercises and huffing Seek advice from If I am not feeling better within hours/days then I should: Start antibiotics as recommended if I keep these at home and contact Contact to request antibiotics Start corticosteroids as recommended if I keep these at home and contact Contact to request corticosteroids Note: If you have been prescribed oxygen do not change the flow unless advised. Part 3 - Warning Signs If you experience any of the following symptoms, contact your GP practice or out-of-hours service immediately or you may need to visit your A&E department. Extremely short of breath Hot and shivery Drowsy and/or confused Chest pain If at any stage you feel you are in danger phone 999. If you have an Oxygen Alert Card, please show this to the ambulance staff and also take it with you to the hospital. 21

22 ATTACHMENTS Attachment 5: ATTACHMENT 5 Version 2: 4 th November 2011 COPD Self Management Action Plan: Guidelines for Health Professionals Important contacts: Help the patient to complete the list of their important contacts. Part 1: This section helps the patient identify their usual symptoms and the medications and actions to control their usual symptoms. 1. Help the patient complete this section about their usual symptoms. 2. Guide patients to identify the following symptoms. Inform them to select only the symptoms that apply to them: SOB: Encourage the patient to use their own language to describe their shortness of breath. In response to I can usually walk before I become short of breath and need to stop and rest insert either the distance e.g. 20metres, or use the patient s own words e.g. usually down to the newsagents and back. Sputum: Whether they cough up sputum (phlegm) daily and the characteristics of their sputum: colour, amount (volume), consistency. Other symptoms: Whether other usual symptoms are present daily, such as cough, wheeze, fatigue, limited sleep, loss of appetite, low mood, anxiety, panic and pain. 3. Write the patient s usual medications (name, dose, delivery device) on their Action Plan and check their inhaler technique. If the patient has been prescribed LTOT and/or if they have been given an oxygen alert card, record this under other respiratory medications. Other respiratory medicines may also include, for example oxygen, mucolytics, home supply antibiotics home supply corticosteroids. Ask patients to check the expiratory date of home medications. 4. Go through each symptom indicated by the patient and talk about the actions they need to take to remain well. 5. Talk about any additional actions they need to take to ensure optimal management. Write all relevant actions on the patient s action plan. * If patient is linked with COPD MET office record this under other actions and make sure they are receiving consistent information. Part 2: This section helps the patient recognise the symptoms of an exacerbation and understand the appropriate actions to take 1. Talk about the patient s experience of an exacerbation by asking them if they know what an exacerbation is, and how to recognise an exacerbation. If required, discuss symptoms of an exacerbation. Help the patient identify the difference between anxiety-related dyspnoea and exacerbation-related dyspnoea. 2. Discuss with the patient when they may need increased medication (inhaled bronchodilators, corticosteroids and/or antibiotics) or help. Discuss with the patient the decision process to initiate their actions based on symptoms presentation: Shortness of breath is worse Sputum is worse (colour, volume, stickiness) Discuss when they might need to use breathing techniques or increase their short-acting bronchodilator (blue inhaler). Discuss when they should seek help and who they should contact and indicate this on the action plan. Discuss how long they should wait before starting corticosteroids and/or antibiotics. Insert the agreed time scale in the space provided (for example, 48 hours) and indicate who they should contact. 3. Consider the frequency of use of rescue medications, home corticosteroids or antibiotics and note this. 4. Make sure the patient is confident with recognising an exacerbation, knowing the appropriate actions to take and when they should seek help and from whom. Write all relevant actions on the patient s action plan. Part 3: This section helps the patient to identify warning signs 1. Discuss the warning signs that indicate that they need to get help immediately, for example, extreme shortness of breath, chest pain, drowsiness and confusion. Discuss who they should contact and when, e.g. GP practice, out-of-hours service, 999. Write all relevant actions on the patient s action plan. Note: This Action Plan does not replace the need to conduct individual patient assessment or review 22

23 ATTACHMENTS Attachment 6: Action Plan Would you like to discuss your Action Plan today? Ask a member of the pulmonary rehabilitation team. 23

24 APPENDICES SECTION Appendix 1: 1. Factors that increase the risk to develop a respiratory infection 1.1 PRESENTATION OF FACTORS THAT INCREASE THE RISK TO DEVELOP A RESPIRATORY INFECTION Present this section in an interactive way Invite each participant to name a risk factor to develop a respiratory infection. Write on the board the factors mentioned, complete and correct as needed. Suggested question: What can put you at risk to develop a respiratory infection? Answers expected from the participants: Being in contact with a person that suffers from a respiratory infection: bronchitis, flu, cold Not taking good care of your own person bad habits: lack of sleep, do not eat good food, etc. Not washing hands Cigarette smoke (it paralyses the action of the cilia) Stress Lack of proper ventilation Using a humidifier without giving it the proper maintenance Note to the facilitator: The last four points can be considered as predisposing factors that are not linked directly with the transmission of the infection. 24

25 APPENDICES SECTION 2. Strategies to manage an aggravation of symptoms (exacerbation) due to Environmental Factors 2.1 ACTION PLAN FOR EXACERBATION DUE TO ENVIRONMENTAL FACTORS Present this section in an interactive way Guide the participants to recognise an aggravation of symptoms (exacerbation) caused by the exposure to environmental factors. Suggested script for the facilitator: Environmental factors such as pollutants (cigarette smoke), smog, changes in temperature, wind or humidity can make your symptoms worse, especially your shortness of breath. You may also cough more and/or have more sputum Identify with participants the strategies that they already use to manage an aggravation of symptoms caused by the exposure to environmental factors. Suggested questions: What are the actions that you usually take to manage an aggravation of symptoms due to the exposure to environmental factors? Do you take any additional medication to manage an aggravation of symptoms due to the exposure to environmental factors? 25

26 APPENDICES SECTION Review with participants the actions to be taken once they have recognised the presence of an aggravation of symptoms (exacerbation) due to environmental factors. Complete the list of actions mentioned by the participants. Discuss with them the expected effects of these actions. Actions 1. Take your reliever (bronchodilator) immediately as prescribed by your doctor. 2. Avoid or decrease your exposure to things that may make your symptoms worse. Expected Effects Reduce dyspnea symptoms Open the bronchi Facilitate the air passage Reduce or stop symptom deterioration If you cannot avoid the things that make your symptoms worse, use your reliever 20 to 30 minutes before you expose yourself to them. 3. Use your breathing, relaxation and body position techniques. Reduce shortness of breath, anxiety and energy demand Note to the facilitator: Make sure participants understand the difference between the symptoms present in an aggravation caused by a respiratory infection and the one caused by an environmental factor. Emphasise the use of a reliever as the first action to take for an aggravation of symptoms related to the environment. This type of aggravation usually should be well controlled after this step Review with participants the actions to be taken once they have recognised that their symptoms further deteriorate or do not improve despite taking the additional treatment. Discuss with them the expected effects of these actions. Actions If your symptoms get worse or do not improve, contact your resource person or go to the hospital emergency department. Intervene on time Expected Effects Avoid further deterioration of your symptoms Ensure a better follow-up 26

27 APPENDICES SECTION Review the actions to be taken in an emergency situation. Discuss with the participants the expected effects of these actions. Actions In any situation if you are extremely short of breath, confused and/or drowsy, and/or you have chest pain, do not take any risk: Expected Effects Intervene to save your life Call

28 APPENDICES SECTION 3. Strategies to manage an aggravation of symptoms (exacerbation) due to Stress/Emotions 3.1 ACTION PLAN FOR EXACERBATION DUE TO STRESS/EMOTIONS Present this section in an Interactive Way Guide the participants to recognise an aggravation of symptoms (exacerbation) caused by stress/emotions. Suggested script for the facilitator: Remember that stress/emotions can lead to an increase of shortness of breath and other physical reactions such as increased heartbeat and perspiration Identify with participants the strategies that they already use to manage an aggravation of symptoms caused by stress/emotions. Suggested script for the facilitator: Remember that stress/emotions can lead to an increase of shortness of breath and other physical reactions such as increased heartbeat and perspiration. What are the actions that you usually take to manage an aggravation of symptoms due to stress/emotions? Review with participants the actions to be taken once they have recognised the presence of an aggravation of symptoms (exacerbation) due to stress/ emotions. Complete the list of actions mentioned by the participants. Discuss with them the expected effects of these actions. Suggested script for the facilitator: A stressful situation, in many cases, can be controlled without medication, with the help of breathing and relaxation techniques. However, if you have some physical reactions, it might be necessary to use a bronchodilator. Actions 1. Use your breathing, relaxation and body position techniques. 2. If necessary, take your reliever (bronchodilator) as prescribed by your doctor. Expected Effects Reduce shortness of breath, anxiety and energy demand. Reduce dyspnea symptoms Open the bronchi Facilitate the air passage 28

29 APPENDICES SECTION Review with participants the actions to be taken once they have recognised that their symptoms further deteriorate or do not improve despite taking the additional treatment. Discuss with them the expected effects of these actions. Additional Actions If your symptoms get worse or do not improve, contact your resource person or go to the hospital emergency department. Intervene on time Expected Effects Avoid further deterioration of your symptoms Ensure a better follow-up Review the actions to be taken in an emergency situation. Discuss with the participants the expected effects of these actions. Additional Actions In any situation if you are extremely short of breath, confused and/or drowsy, and/or you have chest pain, do not take any risk: Expected Effects Intervene to save your life Call

30 APPENDICES SECTION 4. Expert patient testimony on the use of the Action Plan 4.1 EXPERT PATIENT TESTIMONY ON THE USE OF THE ACTION PLAN Present this section in an Interactive Way Invite the expert patient to share his/her experience. Underline the actions taken by the expert patient and motivate the group discussion. Introduce the expert patient by asking him/her this question: Tell us how you succeeded to manage an aggravation of your symptoms (exacerbation) caused by a respiratory infection; please describe for us what triggered that infection, the symptoms that you had and the strategies that you used to manage the situation. Note to the facilitator: Reinforce the strategies used by the expert patient that are consistent with the instructions given in the action plan: Initiation of an additional treatment of antibiotics and prednisone according to symptoms change, and within the recommended delays (patients often tend to delay the initiation of antibiotics and/or prednisone). Foster group discussion by asking the participants: Have you already lived a similar situation? Is the situation presented by the expert patient representative of what you have felt when you have had a respiratory infection? Are the symptoms experienced by the expert patient similar to what you have felt when you have had an aggravation of your symptoms (exacerbation) caused by a respiratory infection? In the same situation, would you have used the same strategies used by the expert patient or different strategies to try to control your symptoms? 30

31 NOTES 31

32 ACKNOWLEDGEMENTS Living Well with COPD was developed in coordination with health professional educators on COPD and patients with COPD. Adaptation from the Living Well with COPD program (2nd edition), Montreal Chest Institute, Canada for Pulmonary Rehabilitation Programmes in Northern Ireland December 2011 Authors: Northern Ireland: B. O Neill, PhD, BSc, MCSP D. Cosgrove, PhD, BSc, MCSP J. MacMahon, FRCP J. M. Bradley, PhD, BSc, MCSP Canada: M. Lebel, RN, BSc M. Sedeno, BEng, MM D. Nault, RN, MSc J. Bourbeau, MD, MSc, FRCPC Participating Institutions University of Ulster, Northern Ireland Belfast Health and Social Care Trust, Northern Ireland Montreal Chest Institute, McGill University Health Center, Canada The Living Well with COPD programme for pulmonary rehabilitation has been endorsed by: The Association of Chartered Physiotherapists in Respiratory Care The Northern Ireland Regional Respiratory Forum Original Authors (Montréal, Québec, Canada, 2006) D. Nault, RN, MSc M. Sedeno, BEng, MM I. Ouellet, RN L. Soto, RN A. Joubert, RN J. Bourbeau, MD, MSc, FRCPC Participating Institution Montreal Chest Institute, McGill University Health Center, Canada Public Health Agency Belfast Health and Social Care Trust