A p l a n o f a c t i o n f o r l i f e Reference Guide for Group Education Session 5 Plan of Action: Part I Overview of the Plan of Action and Management of Respiratory Infections Plan of Action: Objectives and Structure Signs and Symptoms of a Respiratory Infection Factors Increasing the Risk for Developing a Respiratory Infection Strategies to Prevent a Respiratory Infection Strategies to Treat a Respiratory Infection: Plan of Action 1 st Edition 2007
Education Plan and Methods Session Length: 1 h 1 h 15 m Introduction Working Phase 1. Plan of Action 1.1 Presentation of the objectives and structure of the Plan of Action. Interactive lecturing. 1.2 Presentation of the section Contact List of the written Plan of Action. Interactive lecturing. 1.3 Presentation of the section I Feel Well of the written Plan of Action. Interactive lecturing. 2. Signs and symptoms of a respiratory infection. Interactive lecturing. 3. Factors increasing the risk for developing a respiratory infection. Interactive lecturing. 4. Strategies to prevent a respiratory infection. Interactive lecturing. 5. Strategies to treat an aggravation of symptoms (exacerbation) due to a respiratory infection. 5.1 Presentation of the section I Feel Worse of the written Plan of Action. Interactive lecturing. 5.2 Presentation of the section I Feel Much Worse and I Feel I Am in Danger of the written Plan of Action. Interactive lecturing. 6. Reinforcement of participants understanding. 6.1 Expert patient testimony on the use of the Plan of Action. Expert patient. 6.2 Integration of strategies to treat an aggravation of symptoms due to a respiratory infection. Case scenario. 7. Assessment of participants level of self-efficacy. Group discussion. Closing of the session Human Resources PLAN OF ACTION PART I: RESPIRATORY INFECTION SESSION SUMMARY 1. Two healthcare professionals (nurses if possible) 2. One physician, if available 3. One expert patient, if available 2
Living Well with COPD Resources 1. Modules: Integrating a Plan of Action into your life Preventing your symptoms and taking your medications, p. 9-13 2. Written Plan of Action Prior to the session, ask participants to bring their own written Plan of Action Additional Resources 1. Board / Flipchart Environment PLAN OF ACTION PART I: RESPIRATORY INFECTION SESSION SUMMARY 1. Use a quiet and comfortable room for 10 to 15 people. Ensure proper ventilation. 2. Place the chairs in semi-circle around the board. 3
Introduction Presentation of the Facilitator Identification of the expectations and interests of the group Review of the COPD symptoms and focus on the need to have an adequate pharmacological treatment. Reinforce the importance of taking the medication as prescribed and using the appropriate inhalation technique. Make links with the present session. Establishment of common goals for the session Working Phase Educational Interventions 1. Plan of Action PLAN OF ACTION PART I: RESPIRATORY INFECTION 1.1 PRESENTATION OF THE OBJECTIVES AND STRUCTURE OF THE PLAN OF ACTION Present this section in an interactive way Provide a copy of the written Plan of Action to the participants or ask them to use their own Plan of Action. Describe the objectives of the Plan of Action Living Well with COPD TM. Briefly describe the content of the different sections of a Plan of Action. Note to the facilitator: The Plan of Action is a personalized tool to help patients in their decision-making process. The goal of this session is to present an overview of the Plan of Action to foster participants understanding. Please refer participants to their resource person and treating physician in order to get a written Plan of Action with or without a self-administered prescription. Suggested script for the facilitator: Plan of Action Your Plan of Action 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 Plan of Action properly, you will become more independent and feel more in control when your symptoms get worse. Your Plan of Action may make the difference between a trip to the hospital and treatment at home! 4
Your Plan of Action will help you to: Better recognize your everyday symptoms. List what you are doing every day to remain well, including taking your medication as prescribed. Recognize a worsening of your symptoms (exacerbation) and the aggravating factors. Know what to do to prevent a 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. A Plan of Action includes the following sections: Contact List I feel well I feel worse (additional treatment if needed) I feel much worse I feel I am in danger 1.2 PRESENTATION OF THE SECTION CONTACT LIST OF THE WRITTEN PLAN OF ACTION Present this section in an interactive way Review the section Contact List of the written Plan of Action to guide the participants to identify their key resources. Suggested script for the facilitator: Let us explore your Plan of Action. We will start by creating your Contact List. An essential part of your Plan of Action 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. Contact List Service Name Phone Number Resource Person Family Physician Respirologist Pharmacist 5
1.3 PRESENTATION OF THE SECTION I FEEL WELL OF THE WRITTEN PLAN OF ACTION Present this section in an interactive way 1.3.1 Introduce the section I Feel Well of the written Plan of Action Suggested script for the facilitator: To remain well, use your Plan of Action 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 your Plan of Action section I Feel Well. 1.3.1.1 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 respiratory symptoms (baseline). Guide participants to identify the following symptoms: SOB: Their normal level of shortness of breath and the type of activities that make them feel short of breath (e.g. walking, climbing stairs, etc.). Attachment 1 MRC visual dyspnea scale can be used to give an idea of the level of dyspnea in day-to-day life. Sputum: Whether they cough up sputum (phlegm) daily and the characteristics of their sputum: colour, amount (volume), consistency. Cough: Whether cough is present as part of their regular symptoms. 1.3.1.2 Present the sub-section My actions to the participants Review with the participants the elements that should be covered in this section and that will help them to identify: The healthy behaviours they should maintain in the long term. The activities they are able to perform when they feel well. 1.3.1.3 Present the sub-section My regular treatment 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. 6
I Feel Well My Usual Symptoms I feel short of breath: I cough up sputum daily. No Yes, colour: I cough regularly. No Yes My Actions I sleep and eat well, I do my usual activities and exercises My Regular Treatment Medication Dose Puffs/pills Frequency 7
2. Signs and symptoms of a respiratory infection 2.1 PRESENTATION OF THE SIGNS AND SYMPTOMS OF A RESPIRATORY INFECTION Present this section in an interactive way Invite each participant to describe the symptoms of a respiratory infection. Write on the board all the symptoms described; differentiate the symptoms specific to a respiratory infection from the other symptoms related. Suggested question: What are the symptoms of a respiratory infection? Answers expected from the participants: Specific Symptoms 1. 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. 2. More shortness of breath than usual. You find it harder to perform your usual activities. 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 patients are able to recognize the difference between the baseline usual symptoms and an aggravation of symptoms (exacerbation) due to a respiratory infection.
3. Factors that increase the risk for developing a respiratory infection 3.1 PRESENTATION OF FACTORS THAT INCREASE THE RISK FOR DEVELOPING A RESPIRATORY INFECTION Present this section in an interactive way Invite each patient to name a risk factor for developing a respiratory infection. Write on the board the factors mentioned, complete and correct as needed. Suggested question: What can put you at risk for developing 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 myself 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.
4. Strategies to prevent respiratory infections 4.1 PRESENTATION OF THE STRATEGIES TO PREVENT RESPIRATORY INFECTIONS Present this section in an interactive way Invite patients to describe the strategies that they use to prevent a respiratory infection. Write the mentioned strategies on the board, complete and correct as needed. Note to the facilitator: Emphasize the importance of prevention by avoiding as much as possible or reducing the exposure to the risk factors for a respiratory infection. 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 a respiratory infection? Answers expected from the participants: Avoid people suffering from a respiratory infection flu, bronchitis, cold Wash my hands Vaccine against influenza (flu) every fall and against pneumonia (pneumococcal vaccine) at least once in my life Take good care of myself, adopt a healthy lifestyle: sleep, eat healthy food, exercise regularly Avoid smoking and cigarette smoke Get help to solve problems Do not use a humidifier (unless I provide my equipment with the proper maintenance) Ensure proper ventilation at home Note to the facilitator: Sometimes patients have wrong or different beliefs with regards to respiratory infections and risk factors. The objective is not to destroy those beliefs but to offer another explanation, another meaning. E.g.: humidifier, vaccines. 10
5. Strategies to treat an aggravation of symptoms (exacerbation) due to a respiratory infection: Plan of Action 5.1 PRESENTATION OF THE SECTION I FEEL WORSE OF THE WRITTEN PLAN OF ACTION Present this section in an interactive way 5.1.1 Introduce the section I Feel Worse of the written Plan of Action Suggested script for the facilitator: When you feel worse, your Plan of Action helps you identify an aggravation of symptoms and take the appropriate actions to manage it. Now let us see how to use the section I Feel Worse from your written Plan of Action. 5.1.1.1 Present the sub-section My symptoms to participants Review with the participants the specific respiratory symptoms that can be aggravated by a respiratory infection. Suggested script for the facilitator: We have seen before how to identify an aggravation of respiratory symptoms. Here at the section I Feel Worse, you will find the list of symptoms you need to look for and that will indicate the presence of a respiratory infection. I Feel Worse My Symptoms Changes in my sputum (colour, volume, consistency) More shortness of breath than usual Note that these changes may happen after a cold or flu-like illness and/or sore throat 11
5.1.1.2 Present the sub-section My actions to the participants Identify with participants the strategies that they already use to manage a respiratory infection. Suggested questions: What are the actions that you usually take to manage a respiratory infection? Do you take additional medication to treat a respiratory infection? Review with participants the actions to be taken once they have recognized the presence of an aggravation of symptoms (exacerbation) due to a respiratory infection. Complete the list of actions mentioned by the participants. Discuss with them the expected effects of these actions. Actions 1. Take the additional treatment prescribed by your doctor according to the changes in your symptoms (changes in your sputum, more shortness of breath than usual). 2. Avoid things that may make your symptoms worse. 3. Use your breathing, relaxation, body position and energy conservation techniques. Expected Effects Treatment of infection Reduction or elimination of symptoms Prevention of symptoms from further deterioration Reduction in shortness of breath, anxiety and energy demand 4. Notify your resource person. Support in case of uncertainty Better follow-up I Feel Worse My Symptoms Changes in my sputum (colour, volume, consistency) More shortness of breath than usual Note that these changes may happen after a cold or flu-like illness and/or sore throat My Actions I take the additional treatment prescribed by my doctor I avoid things that make my symptoms worse I use my breathing, relaxation, body position and energy conservation techniques I notify my resource person 12
5.1.1.3 Introduce the sub-section My additional treatment to the participants Explain to the participants the decision process to initiate the Additional Treatment (Customized Prescription) based on symptoms presentation. Suggested script for the facilitator: You have to look at the changes in your symptoms in order to decide if you need to start the additional treatment included in your Plan of Action: 1. Observe the 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 and you need to start the ANTIBIOTIC prescribed by your doctor. Do not wait more than 48 hours to start your antibiotic. For any other changes in your sputum (volume, consistency) discuss with your physician the need for antibiotics. CHANGES IN MY SPUTUM My additional treatment is: I start my ANTIBIOTIC if my SPUTUM becomes I check my sputum colour, volume and consistency (not only in the morning). I do not wait more than 48 hours to start my antibiotic. Antibiotic Dose Number of Pills Frequency/days Comments: 13
2. Look at your shortness of breath If you have more shortness of breath than usual, you should first try to increase your RELIEVER (BRONCHODILATOR) as prescribed by your doctor. If after increasing your reliever (bronchodilator), your shortness of breath does not improve and you have difficulty performing your usual activities, you need to start the PREDNISONE treatment prescribed by your doctor. Do not wait more than 48 hours to start your prednisone. MORE SHORTNESS OF BREATH THAN USUAL My additional treatment is: I increase my reliever (BRONCHODILATOR) if I am MORE SHORT OF BREATH than usual. Bronchodilator Dose Number of Puffs Frequency/days Comments: I start my PREDNISONE if after increasing my bronchodilator, MY SHORTNESS OF BREATH DOES NOT IMPROVE and I have difficulty performing my usual activities. I do not wait more than 48 hours to start my prednisone. Prednisone Dose Number of Pills Frequency/days Comments: 14
5.2 PRESENTATION OF THE SECTIONS I FEEL MUCH WORSE AND I FEEL I AM IN DANGER OF THE WRITTEN PLAN OF ACTION Present this section in an interactive way 5.2.1 Introduce the section I Feel Much Worse of the written Plan of Action Identify with the participants the strategies that they already use when their symptoms get worse or do not improve despite taking the additional treatment. Suggested question: What do you do when your symptoms get worse or do not improve even after taking the additional actions? Review with participants the actions to be taken once they have recognized that their symptoms further deteriorate or do not improve despite taking the additional treatment. Complete the list of actions mentioned by the participants. Discuss with them the expected effects of these actions. Suggested script for the facilitator: When you feel much worse, your Plan of Action helps you recognize whether your symptoms are getting worse or are not improving despite taking your additional treatment and taking the necessary additional actions. Now let us see how to use the section I Feel Much Worse from your written Plan of Action. Actions If your symptoms get worse or do not improve after 48 hours of treatment, contact your resource person or go to the hospital emergency department. I Feel Much Worse My Symptoms My symptoms get worse. After 48 hours of treatment my symptoms are not better. Expected Effects Intervene on time Avoid further deterioration of your symptoms Ensure a better follow-up My Actions I call my contact person. After 5 p.m. or on the weekend, I go to the hospital emergency department. 15
5.2.2 Introduce the section I Feel I Am in Danger of the written Plan of Action Identify with the participants the symptoms that indicate that their life is in danger. Suggested question: What are the symptoms that can indicate that your life is in danger and 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 Plan of Action helps you recognize the symptoms that tell you that your life is in danger, as well as the actions that you need to take in an emergency situation. Now let us see how to use the section I Feel I Am in Danger from your written Plan of Action. 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: Call 911. Expected Effects Intervene to save your life I Feel I am in Danger My Symptoms In any situation if: I am extremely short of breath I am confused and/or drowsy I have chest pain My Actions I dial 911 for an ambulance to take me to the hospital emergency department. Note to the facilitator: Stress that a correct utilization of the Plan of Action will allow the patient to be more independent, to initiate a treatment at home and to avoid a visit to the emergency room or a hospitalization. 16
6. Reinforcement of participants understanding 6.1 EXPERT PATIENT TESTIMONY ON THE USE OF THE PLAN OF ACTION Expert patient testimony 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 in managing 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 Plan of Action: 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? 17
6.2 INTEGRATION OF STRATEGIES TO TREAT AN AGGRAVATION OF SYMPTOMS DUE TO A RESPIRATORY INFECTION Case scenario Reinforce comprehension of the Plan of Action 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 a respiratory infection? Which symptom of a respiratory infection tells you to start taking 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 prednisone? 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. Take note of those suggestions supporting the compliance with the instructions given in the Plan of Action. 18
7. Assessment of Participants level of self-efficacy 7.1 ASSESSMENT OF PARTICIPANTS LEVEL OF SELF-EFFICACY TO PREVENT AND MANAGE RESPIRATORY INFECTIONS Present this section using group discussion Evaluate participants level of self-efficacy to prevent and manage respiratory infections by using the strategies included in the Plan of Action. Suggested questions: Do you feel capable of preventing respiratory infections? Do you feel capable of recognizing changes in your symptoms? Do you feel capable of properly using the additional treatment (customized prescription)? Do you think your Plan of Action will help you to prevent and manage an aggravation of your symptoms caused by a respiratory infection? Do you think your Plan of Action will help you to prevent a visit to ER and hospitalization? If participants feel capable of preventing and managing respiratory infections using the strategies included in their Plan of Action, ask them to continue applying these strategies. If some participants do not feel capable of preventing or managing respiratory infections using their Plan of Action, make sure to refer these participants to their resource person to see them on an individual basis to investigate the reasons and reinforce the use of the Plan of Action. Remind participants to contact their resource person/physician to review their Plan of Action and how they use it. 19
Closing the session Answer the questions of the participants. Summarize the points to remember and ask participants to repeat them. Underline the importance of the use of the written Plan of Action Living Well with COPD (decisional tree or reference tool for the self-management of the illness). Learning contract: Ask the participants to review their Plan of Action and to meet their physician or resource person in order to customize it. Evaluate the satisfaction of the participants with regards to the present session. Ask the group about the level of general satisfaction; use an evaluation questionnaire that can measure the level of response to the group expectations in terms of: development, length, content, methods, facilitator and environment. CONTRACT 20
ATTACHMENTS Attachment 1 MRC Dyspnea Scale 0. No dyspnea. 1. Breathless with strenuous exercise. 2. Short of breath when hurrying on the level or walk up a slight hill. 3. Walks slower than people of the same age on the level or stops for breath while walking at own pace on the level. 4. Stops for breath after walking 300 feet (100 meters). 5. Too breathless to leave the house or breathless when dressing. 21
ACKNOWLEDGEMENTS This session has been developed in collaboration with the Multidisciplinary Team of the Pulmonary Rehabilitation Program PEP at the Montreal Chest Institute. Authors: D. Nault, RN, MSc M. Sedeno, BEng, MM. I. Ouellet, RN L. Soto, RN A. Joubert, RN J. Bourbeau, MD, MSc, FRCPC Last Update April 2007 BreathWorks toll-free Helpline 1-866-717-COPD (2673) www.lung.ca/breathworks www.livingwellwithcopd.com
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