NUR 3380 Module 3 COPD Paper: Inhaler Technique Errors and Pulmonary Rehabilitation Example

Watching the Inhaler: Discharge Planning for COPD in Phillipsburg

Student Name

B.S.N., Accelerated Second Degree, Thomas Edison State University

NUR-3380: Applying the Nursing Process to Alteration in Health

Mentor Name

Month Day, Year

Watching the Inhaler: Discharge Planning for COPD in Phillipsburg

The Patient

Neither Mr. Kowalczyk nor his hospital is real. Mr. Kowalczyk, 71, worked forty years for the railroad and smoked until five years ago. He was admitted with increased breathlessness and cough after a cold and is improving on steroids and nebulized bronchodilators. At home he uses a combination inhaler twice a day and a rescue inhaler several times a day. He lives with his wife in a split-level house, avoids the stairs because they leave him breathless and no longer goes to watch his grandson play baseball.

Assessment

The student assessed his breathing, oxygen saturation, sputum and activity tolerance, and asked how he uses his inhalers. When she asked him to show her, he shook the maintenance inhaler, breathed in quickly while pressing the canister, and breathed out immediately. With the rescue inhaler, he pressed the canister before starting to breathe in. He said no one had watched him use them since they were prescribed. He also said he takes the maintenance inhaler only when he feels worse, to make it last.

The Strategy Report

The current strategy report (Global Initiative for Chronic Obstructive Lung Disease, 2023) recommends that management of stable COPD include assessing symptoms and exacerbation history to guide treatment, using maintenance bronchodilators regularly rather than as needed, checking inhaler technique and adherence before changing medication, encouraging physical activity, referring patients for pulmonary rehabilitation and providing an action plan for flares. It notes that poor technique and adherence are common reasons treatment fails.

How Often Technique Fails

Sanchis et al. (2016) systematically reviewed studies of errors in inhaler use over four decades. They found roughly equal thirds: patients who used their inhalers correctly, patients whose technique was acceptable but flawed and patients whose technique was poor. The most common errors with pressurized metered-dose inhalers were poor coordination between pressing and breathing in, breathing in too quickly and failing to hold the breath afterward. Despite decades of education efforts, technique had not improved over time.

Pulmonary Rehabilitation

McCarthy et al. (2015) reviewed randomized trials of pulmonary rehabilitation, which combines exercise training with education, for people with COPD. Rehabilitation improved health-related quality of life and exercise capacity, including the distance people could walk in six minutes, and the improvements exceeded the amounts considered meaningful to patients. The authors concluded that further trials comparing rehabilitation with usual care were not needed.

Nursing Diagnoses

The care plan named an ineffective breathing pattern related to airflow limitation, ineffective health self-management related to incorrect inhaler technique and use of maintenance medication only when symptomatic and activity intolerance related to breathlessness.

Planning

Before discharge, Mr. Kowalczyk will demonstrate correct technique with both inhalers and explain the difference between his maintenance and rescue inhalers. He will describe what to do when his symptoms worsen, using a written action plan. Within a month, he will attend his first pulmonary rehabilitation session.

Implementation

The student taught inhaler technique one step at a time with the inhalers he would use at home. For the metered-dose rescue inhaler, she showed him how to breathe out fully, start a slow breath in, press the canister at the start of the breath, keep breathing in slowly and hold his breath for up to ten seconds. She suggested a spacer, which the nurse practitioner ordered, to reduce the need for coordination. For the maintenance inhaler, she explained that it prevents flares only when used every day. After each demonstration, he showed her. On the first attempt he still breathed in too fast; on the third, his technique was correct.

She went over a written action plan divided into three colored zones, describing what to do when his breathing is usual, worse or severe. She also explained pursed-lip breathing for the stairs, and he practiced it on the hospital stairwell with her.

Rehabilitation and Activity

The student talked with Mr. Kowalczyk about rehabilitation. He was doubtful that exercise would help someone who gets breathless walking. She explained the review's findings in plain words and that programs start at each person's level. With his agreement, the case manager scheduled an intake at a program twenty minutes from his home, and his wife agreed to drive him.

Medicines and Cost

While reviewing his inhalers, the student learned that Mr. Kowalczyk rationed his maintenance inhaler partly because of its cost under his Medicare plan. She asked the case manager to check his coverage, and a lower-cost inhaler with the same type of medicine was available on his plan. The nurse practitioner switched him before discharge, and the student taught him the new device. Cost is a common reason patients use maintenance inhalers only when they feel worse, and asking about it uncovered a barrier that teaching alone would not have fixed.

His Wife's Role

His wife attended the final teaching session and learned the action plan and the signs that mean a call to the doctor. She also agreed to remind him about rehabilitation days.

Evaluation

At discharge, Mr. Kowalczyk used both inhalers correctly with the spacer and explained his action plan. A follow-up call at two weeks found him using the maintenance inhaler daily and his rescue inhaler less often. He had attended his rehabilitation intake and planned to go to a baseball game in the spring.

Limits

Technique taught in the hospital may slip at home, as the review's findings suggest. Rehabilitation programs have limited capacity and require transportation. A single patient's improvement may reflect recovery from the flare as well as the plan.

Conclusion

Mr. Kowalczyk's inhalers were not working because of how he used them. The GOLD report put technique and rehabilitation at the center of management, the review of inhaler errors showed how common his mistakes are and the Cochrane review showed what rehabilitation can do. Watching, correcting and checking his technique, an action plan and a rehabilitation referral gave him a better chance to stay out of the hospital.

References

Global Initiative for Chronic Obstructive Lung Disease. (2023). Global strategy for the prevention, diagnosis and management of chronic obstructive pulmonary disease: 2023 report. Global Initiative for Chronic Obstructive Lung Disease.

McCarthy, B., Casey, D., Devane, D., Murphy, K., Murphy, E., & Lacasse, Y. (2015). Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews, (2), Article CD003793. https://doi.org/10.1002/14651858.CD003793.pub3

Sanchis, J., Gich, I., & Pedersen, S. (2016). Systematic review of errors in inhaler use: Has patient technique improved over time? Chest, 150(2), 394-406. https://doi.org/10.1016/j.chest.2016.03.041