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Chronic Obstructive Pulmonary Disease
(Updated September 5th, 2018)
COPD Definition:
Chronic Obstructive Pulmonary Disease (COPD) as a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible. The more familiar terms 'chronic bronchitis' and 'emphysema' are no longer used, but are now included within the COPD diagnosis. World Health Organization
COPD Guidelines:
COPD clinical guidelines from the University of Michigan Health System
2018 GOLD Pocket Guide to COPD Diagnosis, Management and Prevention
Care Management Interventions
Click Here for an example of a COPD action plan
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Diagnosis Specific Concerns |
Care Management Intervention |
Patient Specific Interventions |
Care Manager Resources |
Patient Resources |
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Assessment |
Assess patients knowledge level on diagnosis |
Preparing for the visit |
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What to Expect at the Physician Appointment
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Diagnosis Education |
Provide education regarding COPD diagnosis
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Discuss diagnosis with care manager
Review educational materials provided
Provide teach-back |
COPD Screening Tool for Care Managers
Clinical Guidelines and Patient Education from the University of Michigan
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Shortness of Breath |
Help develop COPD action Plan
Oxygen therapy
Exacerbations: Educate on when to call the physician |
Work with care manager to establish personal goals of care
When to call your physician:
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Management of COPD in Primary Care Algorithm from the Department of Veterans Affairs Pocket Card
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Oxygen Therapy - Patient Education COPD: Learn More Feel Better from National Institute of Health |
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Medication Management |
Provide education on oral medications
Provide Teach back regarding inhaler use
Provide information on vaccinations |
Create medication list of all current medications including OTC and herbal supplements.
Demonstrate understanding of medications including:
Take medications as prescribed
Review educational material
Follow up to receive suggested vaccinations |
Visual identification of common inhaled medications
Information on Pneumococcal Vaccine
Anti-inflammatory Medications for COPD |
Video on how to use your Advair Diskus Inhaler
Video on how to use an inhaler with a spacer
Educational Sheets for Various Inhalers
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Action Plan |
Educate patient on when to call primary care physician Provide patient with HF action plan
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Demonstrate understanding of COPD action plan and when to call physician’s office versus go to Emergency Room |
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Smoking |
Provide education on smoking cessation
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Review materials provided on smoking cessation Enroll in a smoking cessation program |
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Nutrition |
Educate on diet recommended by physician Provide education on diet and tools for maintaining diet
Refer patient to a dietitian or nutritionist Create diet plan |
Demonstrate understanding of prescribed diet
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Activity |
Provide education on exercise and COPD if recommended by physician Create action plan Provide examples of different types of exercise Educate patient on signs and symptoms of when to stop exercising |
Check with provider prior to starting an exercise regimen Understand warning signs and when to stop exercising Follow recommended treatment plan
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Managing Stress |
Educate patient on healthy ways to manage stress Refer patient to a behavioral health specialist |
Demonstrate understanding of healthy ways to manage stress |
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| Common Labs and Tests |
Instruct patient on peak-flow Pulmonary function test |
Review test information Complete tests as ordered by physician |
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ABG Education for Patients |
For a printable version of the care manager interventions Click Here
This chart is not meant to be an inclusive list of interventions or resources for care management but a starting point in working with patients with COPD. Always check with your practice regarding the use of guidelines, resources and education.
