NR 519 Week 5 Patient Teaching Plan, Stiff Lung Example

Patient Teaching Plan: Five Things Mr. L. and His Wife Will Do Every Week, Each Taught With the Picture of the Stiff Lung That Makes It Worth Doing

Student Name

College of Nursing, Chamberlain University

NR 519: Adv Nursing Practice Across the Health Continuum: Health Assessment, Pathophysiology, & Pharmacology

Instructor Name

Month Day, Year

Patient Teaching Plan: Five Things Mr. L. and His Wife Will Do Every Week, Each Taught With the Picture of the Stiff Lung That Makes It Worth Doing

Learners, Setting and Starting Point

The learners are Mr. L., 66, who learned he had pulmonary fibrosis two seasons ago, and his wife, who manages most of the household's appointments. The teaching takes place over two 30-minute visits at the pulmonary clinic, a week apart. Mr. L. was a high school chemistry teacher and likes to know why; he has said that he stops doing things when he does not understand the point. His wife worries that he is doing too much and wants to know what is dangerous. Both read English well. At the start, he could describe his disease as "scarring in the lungs" but not why his breathing is worse on stairs, and he had stopped using his oxygen on walks because "my numbers are fine at home."

The Picture That Holds the Plan Together

The whole plan rests on one picture, drawn for them on paper at the first visit. The walls of the tiny air sacs in his lungs are normally as thin as tissue paper, so oxygen crosses quickly. In his lungs, scar has made the walls more like cardboard. Sitting still, blood passes the walls slowly enough that oxygen still gets through. Climbing stairs, his heart pumps blood past the walls faster, and there is no longer enough time for oxygen to cross the cardboard. That is why his oxygen level is fine in his chair and low on the stairs, and why the fix is to add oxygen, and slow down, when he moves. Every instruction below is taught as a consequence of this picture.

The picture also serves his wife's question about danger. It shows her that the risk is not activity itself but activity without enough oxygen, which she can help him manage, and that the signs worth worrying about are changes at rest, not breathlessness on the stairs that settles when he sits. Giving her a job in the plan, watching the oximeter on their walks, turns her worry into something useful rather than a reason for him to stay in his chair.

Objective 1: Check Oxygen During Activity, Not Only at Rest

By the end of visit 1, Mr. L. will demonstrate using a finger pulse oximeter while walking and state the number at which he should stop and rest.

Because: the cardboard walls only fail when blood moves fast, so a reading in the chair cannot show what happens on the stairs. He practices walking the clinic hallway with the oximeter on, watching the number fall, and sitting when it reaches 88%. He is taught to wait for the reading to settle after a few seconds, and that cold fingers or nail polish can give false readings.

Evaluation: teach-back of the stopping number and a return demonstration during a hallway walk.

Objective 2: Use Oxygen With Every Walk and Every Flight of Stairs

By the end of visit 1, Mr. L. will state when his oxygen should be on and will set up the portable concentrator himself.

Because: oxygen added to the air he breathes raises the amount available at the wall, so more crosses in the short time available. He is told plainly that feeling fine at home does not mean his oxygen is fine on the stairs, which is the belief that had stopped him using it.

Evaluation: his wife reports at visit 2 how many walks he took with oxygen that week.

Objective 3: Pace, and Join Pulmonary Rehabilitation

By visit 2, Mr. L. will describe pacing, resting ahead of the drop in saturation instead of once it has happened, and will have an intake date for pulmonary rehabilitation.

Because: the scarred lung will not loosen, but trained muscles use oxygen more economically, so a flight of stairs asks less of the lung. A Cochrane review found that pulmonary rehabilitation improves exercise capacity, breathlessness and quality of life in people with interstitial lung disease (Dowman et al., 2021). His wife's worry is addressed directly: exercise is safe when it is paced and done with oxygen.

Evaluation: rehabilitation intake date on the calendar at visit 2.

Objective 4: Take Nintedanib With Food and Manage Diarrhea Early

By visit 2, Mr. L. will state how to take nintedanib and what to do if loose stools start.

Because: nintedanib slows the scar-making cells, which is why it matters to keep taking it. Diarrhea is its most common side effect (Richeldi et al., 2014), and uncontrolled diarrhea is the most common reason people stop. He learns to swallow every capsule with a meal, to start loperamide at the first loose stool as prescribed, to drink extra fluids, and to call if he has more than four loose stools in a day despite loperamide, or if he notices yellowing of his eyes or dark urine, which could signal a liver problem.

Evaluation: teach-back of the call rules; his wife writes them on the refrigerator sheet.

Objective 5: Know the Signs That Cannot Wait

By visit 2, both will name three signs that mean calling the same day.

Because: the scarring usually changes slowly, over months. A sudden change over days, more breathless at rest, oxygen low in the chair, or a new fever, means something else is happening, such as an infection or a sudden flare of the fibrosis, which an international group describes as an acute worsening within about a month (Collard et al., 2016). These are treated as emergencies because they can progress quickly.

Evaluation: each names the three signs without prompting. Vaccines against influenza and other respiratory infections are reviewed with his primary care clinician.

How the Plan Will Be Judged

At visit 2, success means five things: he walks with the oximeter and oxygen, he paces, rehabilitation is booked, he can state the nintedanib and diarrhea rules, and both know the three urgent signs. At three months, the pulmonary team will look for fewer days with uncontrolled diarrhea, regular oxygen use during activity and attendance at rehabilitation. A plan that he understands but does not follow will be revisited by asking him which part of the picture he does not believe.

At both visits the teaching ends the same way: Mr. L. explains the cardboard picture back in his own words. When he can do that, the five objectives stop being rules to remember and become consequences he can work out for himself.

References

Collard, H. R., Ryerson, C. J., Corte, T. J., Jenkins, G., Kondoh, Y., Lederer, D. J., Lee, J. S., Maher, T. M., Wells, A. U., Antoniou, K. M., Behr, J., Brown, K. K., Cottin, V., Flaherty, K. R., Fukuoka, J., Hansell, D. M., Johkoh, T., Kaminski, N., Kim, D. S., . . . Martinez, F. J. (2016). Acute exacerbation of idiopathic pulmonary fibrosis: An international working group report. American Journal of Respiratory and Critical Care Medicine, 194(3), 265-275. https://doi.org/10.1164/rccm.201604-0801CI

Dowman, L., Hill, C. J., May, A., & Holland, A. E. (2021). Pulmonary rehabilitation for interstitial lung disease. Cochrane Database of Systematic Reviews, 2021(2), Article CD006322. https://doi.org/10.1002/14651858.CD006322.pub4

Richeldi, L., du Bois, R. M., Raghu, G., Azuma, A., Brown, K. K., Costabel, U., Cottin, V., Flaherty, K. R., Hansell, D. M., Inoue, Y., Kim, D. S., Kolb, M., Nicholson, A. G., Noble, P. W., Selman, M., Taniguchi, H., Brun, M., Le Maulf, F., Girard, M., . . . Collard, H. R. (2014). Efficacy and safety of nintedanib in idiopathic pulmonary fibrosis. New England Journal of Medicine, 370(22), 2071-2082. https://doi.org/10.1056/NEJMoa1402584