NR 324 Week 4 COPD Home Discharge Care Plan Example

Care Plan: A 68-Year-Old Retired Bank Teller With COPD Going Home to Fourteen Stairs and the Only Bathroom at the Top

Student Name

College of Nursing, Chamberlain University

NR 324: Adult Health I

Instructor Name

Month Day, Year

Care Plan: A 68-Year-Old Retired Bank Teller With COPD Going Home to Fourteen Stairs and the Only Bathroom at the Top

Assessment That Shaped the Plan

Mrs. J. is 68, a retired bank teller with chronic obstructive pulmonary disease, admitted four days ago with a flare after a chest cold, now ready for discharge tomorrow. Her oxygen saturation is 91% on room air at rest and drops to 86% after walking 30 meters in the hallway; her breathing rate rises from 20 to 28 with that walk, and she rates her breathlessness 6 on the 0 to 10 Borg scale. She uses a tiotropium inhaler once daily and an albuterol metered-dose inhaler as needed. When asked to show how she uses the albuterol, she pressed the canister before breathing in, breathed in fast, and did not hold her breath; she has no spacer.

Before writing goals, I asked about her home. She lives alone in a two-story townhouse. The only bathroom and her bedroom are upstairs, reached by 14 steps with no landing and a rail on the right going up. She spends her day in a recliner downstairs, about 6 meters from the foot of the stairs, and says she has been "holding it" rather than climbing to the bathroom. Her daughter lives 20 minutes away and visits on weekends. Those facts decided which goals were realistic, as shown below.

Which Problem Is Answered First, and Why

Three problems are active: her inhaler technique delivers little medicine to her lungs; she cannot manage 14 stairs to the only bathroom without severe breathlessness; and she has no plan for recognizing the next flare early. I am answering the inhaler problem first, because both of the others depend on it. A rescue inhaler that does not reach her lungs will not help her on the stairs, and it will not help her through the early stage of a flare. Getting the technique right also takes the least time of the three, which matters with discharge planned for tomorrow morning. Sanchis et al. (2016) reviewed four decades of studies on inhaler use and found that errors were common and had not declined over time, which makes her technique a real problem and not a detail. The stairs come second because she faces them several times a day from tomorrow. The flare plan comes third because it matters over weeks, and she will have follow-up in seven days.

Problem 1: Inhaler Technique

Goal: by discharge, Mrs. J. uses her albuterol inhaler with a valved holding chamber (spacer) correctly on three consecutive observed doses, without prompting, following all six steps on the checklist.

Intervention: provide a spacer before discharge (ordered today); demonstrate the six steps with a placebo inhaler: shake, attach the spacer, breathe out fully, seal lips around the mouthpiece, press once and breathe in slowly and deeply, hold the breath for up to 10 seconds; she then does it back.

Intervention: teach her to wash the spacer weekly in warm soapy water and let it air-dry, which keeps the medicine from sticking to the plastic.

Intervention: observe her using the tiotropium inhaler, which has its own technique, and correct any step.

Evaluation: watch three doses before discharge using the six-step checklist; if she misses a step, reteach and observe again.

Problem 2: Fourteen Stairs and the Bathroom

Goal: by discharge, Mrs. J. climbs 14 stairs in the physical therapy gym with one planned standing rest at step 7, using pursed-lip breathing, with oxygen saturation staying at 88% or above and breathlessness no higher than 4 on the Borg scale at the top.

Goal: for the first two weeks at home, she climbs the stairs no more than twice a day, using a bedside commode downstairs during the day.

Intervention: teach pursed-lip breathing as something she practices, not something she is told about: breathe in through the nose for a count of two, out through pursed lips for a count of four, rehearsed in the chair and then on the stairs with the physical therapist.

Intervention: arrange a bedside commode for the downstairs living room through the case manager, delivered before she gets home, and ask her daughter to set it up behind the living room screen for privacy.

Intervention: plan the stairs: climb once in the evening to bed and once in the morning to come down; carry nothing; use the rail; stop at step 7 and breathe; use the albuterol with the spacer 15 minutes before if breathless at rest.

Intervention: referral to outpatient pulmonary rehabilitation, which an American Thoracic Society and European Respiratory Society statement describes as improving breathlessness and exercise capacity in people with chronic lung disease (Spruit et al., 2013).

Evaluation: physical therapist observes a stair climb before discharge with pulse oximetry and Borg score; the home health nurse asks at the first visit how often she has climbed the stairs and whether she used the commode.

Problem 3: Recognizing the Next Flare

Goal: by discharge, Mrs. J. names three signs of a flare in her own words and says what she will do for each, using a written action plan kept on the refrigerator.

Intervention: give her a one-page action plan: more breathless than usual for two days, more mucus or a change to yellow or green, or needing albuterol more than four times a day means calling the clinic the same day; breathlessness at rest that does not ease after albuterol, or lips turning blue, means calling 911. The Global Initiative for Chronic Obstructive Lung Disease (2024) report describes increased breathlessness, sputum volume and sputum purulence as the key features of an exacerbation.

Evaluation: teach-back before discharge.

What the Plan Does Not Assume

The plan does not assume someone is at home during the week, which is why the commode is delivered before discharge and not left for the daughter's weekend visit. It does not assume she can carry things upstairs, which is why she carries nothing. And it does not assume she will remember the inhaler steps at home, which is why she is observed three times, not told once. Finally, it does not assume the hospital's walking test predicts her stairs; the physical therapist's stair climb is the evidence the goal rests on, and if she cannot meet it, the plan changes to a bed downstairs for the first week rather than a discharge that sends her home to a climb she cannot manage.

References

Global Initiative for Chronic Obstructive Lung Disease. (2024). Global strategy for the prevention, diagnosis, and management of chronic obstructive pulmonary disease: 2024 report.

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

Spruit, M. A., Singh, S. J., Garvey, C., ZuWallack, R., Nici, L., Rochester, C., Hill, K., Holland, A. E., Lareau, S. C., Man, W. D.-C., Pitta, F., Sewell, L., Raskin, J., Bourbeau, J., Crouch, R., Franssen, F. M. E., Casaburi, R., Vercoulen, J. H., Vogiatzis, I., . . . Wouters, E. F. M. (2013). An official American Thoracic Society/European Respiratory Society statement: Key concepts and advances in pulmonary rehabilitation. American Journal of Respiratory and Critical Care Medicine, 188(8), e13-e64. https://doi.org/10.1164/rccm.201309-1634ST