Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with ...

Nursing Best Practice GuidelineDiscussion of Evidence:The Registered Nurses’ Association of Ontario (through a panel of nurses, researchers and administrators)has developed the Toolkit: Implementation of Clinical Practice Guidelines (RNAO, 2002b), based on availableevidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding theimplementation of the RNAO Best Practice Guideline, Nursing Care of Dyspnea: The 6th Vital Sign forIndividuals with Chronic Obstructive Pulmonary Disease (COPD). Successful implementation of bestpractice guidelines requires the use of a structured, systematic planning process and strong leadershipfrom nurses who are able to transform the evidence-based recommendations into policies and proceduresthat impact on practice within the organization. The RNAO Toolkit (2002b) provides a structured model forimplementing practice change. Please refer to Appendix Q for a description of the Toolkit.Programs/ServicesRecommendation 8.0:Pulmonary rehabilitation programs must be available for individuals with COPD to enhancequality of life and reduce healthcare costs. (Level of Evidence = 1a)Discussion of Evidence:A meta-analysis of 23 randomized controlled trials in COPD showed that pulmonary rehabilitationsignificantly improved dyspnea, exercise endurance and quality of life compared with standard care (Lacasseet al., 1996). According to the Canadian Thoracic Society guidelines (O’Donnell et al., 2003), it was estimated in1999 that there were only 36 pulmonary rehabilitation programs in Canada, serving less than 1% of theCanadian COPD population. The RNAO guideline development panel concurs with the Canadian ThoracicSociety recommendations that there is a need to develop strategies to improve the availability ofpulmonary rehabilitation, deliver rehabilitation at a lower cost per patient and implement self-monitored,but supervised, home-based rehabilitation programs.Recommendation 8.1:Palliative care services must be available for individuals living with COPD and their caregivers.(Level of Evidence = III)Discussion of Evidence:Abrahm and Hansen-Flaschen (2002) and Hansen-Flaschen (1997) suggest that the quality of life ofpatients with advanced COPD is often poor and can be challenging. According to the Canadian ThoracicSociety guideline (O’Donnell et al., 2003), lack of access to formal palliative care services means that discussionof end-of-life issues often occur too late, are held in inappropriate settings and do not meet theexpectations of patients. Abrahm and Hansen-Flaschen (2002) suggest that patients with terminal, nonmalignantlung diseases are underserved. Better access to palliative care services is necessary. TheCanadian Thoracic Society further recommends that healthcare organizations should consider whetherchanges are warranted to institutional policies and procedures to identify hospitalized patients at risk ofdying and to systematically ensure that end-of-life care discussions take place between clinicians, andpatients and their families49