Download ACUTE PHASE

COPD Exacerbation Clinical Pathway
Exclusion Criteria: Requires mechanical ventilation or other
unstable medical conditions
ACUTE PHASE
TRANSITION PHASE
PRE-DISCHARGE PHASE
Day 1-2
Day 3-5
Day 6-7
 SpO2 >88% on NP or RA:
___/_______
 Normal temperature: ___/_______
Blood work normalizing: __/_______
 Pt free from GI irritability (ex. nausea,
diarrhea): ___/________
 Pt mobilizing independently or at preadmission level without  SpO2
<88%: ___/_______
 Pt able to eat and sleep without
frequent disruption from dyspnea:
____/________
If indicators not met, consider:
 Is pt on appropriate antibiotics?
 Possible CHF or cardiac arrhythmia?
 Possible pleural effusion?
 Possible PE?
 SpO2 >90% at rest & activity on RA or
pre-admission O2 and: ___/_______
 Blood work normal & ABG stable for 1224 hours: ___/__________
 Pt able to do baseline ADLs:
___/_________
 Minimal sputum production (or equal to
pre-admission): ___/__________
 Β-agonist required < Q4H: ___/_______
 Dyspnea < 3/10 or at pre-hospital level:
___/_________
 Inhaler technique reviewed and
demonstrated by patient: ____
 Smoking cessation strategies in
place (if appropriate): ____
 Review and reinforce:
 Secretion clearance: ____
 Purse lip breathing: ____
 Energy Conservation: ____
 Patient Pathway: ____
 Reviewed COPD Info booklet
#FN.510.C57 (or other education
material)____
 Patient has received teaching on the
following:
 Inhaler technique checked: ____
 Coping strategies: ____
 Exercise & strength building (chair
exercises (PT): ____
 Review COPD Discharge Plan: ____
 Smoking cessation material (if
warranted)
 Review COPD Info booklet #FN.510.C57
(or other education material)): ____
Target # of days:
Actual # of days in phase:
PATIENT OUTCOMES/
CLINICAL INDICATORS
(patient must meet these
to move to next phase)
*Tick box and initial and
date when indicator has
been met*
 SpO2 88-92% on NP or RA:
____/______
 RR < 30: ____/_______
 HR < 100 BPM: ____/_______
 ABGs normal (or back to
baseline): ___/________
 Decreased Temp: ___/_______
 No Acute Resp Distress:
__/_______
 No evidence of delirium:
___/_______
If indicators not met, consider:
 Contact RT if  O2 needs (>40%
O2 to maintain SpO2)
 If  temp repeat blood cultures
 Possible pneumothorax?
 Is patient palliative?
 Need for Respiratory Consult
TEACHING
DISCHARGE PLANNING
Purse lip breathing
Positioning
Relaxation
Effective coughing techniques (if
pt has sputum production)
 Proper drug delivery
 Pt/Family Information re: Care

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 Refer to Respiratory Educator:
_____
Name & Discipline
SIGNATURES
_____________________
_____________________
_____________________
_____________________
_____________________
Initials
_____
_____
_____
_____
_____
IF patient has been admitted >1 time in
past year:
 Consider referral to Respirologist for
follow up post discharge.
 Does patient qualify for IHN?
 Advanced Care Plan in place?
Name & Discipline
_____________________
_____________________
_____________________
_____________________
_____________________
Initials
_____
_____
_____
_____
_____
If indicators not met, consider:
 Home oxygen assessment if patient
SpO2 < 90% on room air at rest or on
exertion (RT). If paitent qualified for
Home O2 Clinical Indicator is met
 Patient needs alternate level of care?
 COPD Discharge Plan completed: ____
Date completed: _________________
 Home O2 assessment if warranted (see
Patient Outcomes): ____
 Pneumococcal vaccine up to date: ____
Date received: __________________
 Infuenza vaccine up to date: _____
Date received: __________________
 Referral to Pulmonary Rehab: ____
 Refer to COPD/GP/Specilaist: ____
 Refer to smoking cessation program:
_____
 Refer to Home Health if pt requires
support at home: ___
Name & Discipline
_____________________
_____________________
_____________________
_____________________
_____________________
Initials
_____
_____
_____
_____
_____
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COPD Exacerbation Clinical Pathway
INTERVENTIONS
Assessments
Consults
Diagnostics and
Laboratory
TRANSITION PHASE
Day 3-5
PRE-DISCHARGE PHASE
Day 6-7
 History & Physical
 Assessment as per Patient Care
Flowsheet
 Vital Signs & Monitoring as per
admission orders
 Pain < 4 on pain scale or acceptable to
patient
 List of home medications
 Family aware of admission
 Family/Psychosocial Supports
 Assessment as per Patient Care
Flowsheet
 VS & Monitoring BID
 Pain < 4 on pain scale or
acceptable to patient
 Improving breath sounds
 Bilateral chest expansion
 Assessment as per Patient Care
Flowsheet
 VS daily and PRN
 Home O2 prescription assessed if
needed
 Assess ADL (OT)
 Patient/Family emotional needs
assessed
 No adventitious breath sounds
 OT as necessary
 Home care if necessary (PT/OT)
 RT to do Home O2 assessment if
needed
 Social Work to re-assess home
needs (if necessary)
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As per Admission orders
Respirology/Internist
Physiotherapy
Pharmacy
Social Work
Dietitian
COPD/Respiratory Educator (if
available)
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As per Admission orders
Hematology blood work
Blood cultures if temp > 38.5°C
Sputum Culture if sputum purulent
 O2 to achieve SpO2 88%-92%
 Saline lock or IV
 Initate Nicotine replacement Therapy if
needed
 Diet as per Admission Orders
Treatments
Activity/Safety
 Patient tolerating RA or pre hospital
level of O2
Bronchodilators
Corticosteriods
Antibiotics (if sputum purulent)
DVT Prophylaxis
Bowel Protocol
If palliative, consider opioid for dyspnea
 IV meds to progress to PO
 Nebulized meds to progress to
MDI & Spacer
 Reassess need for DVT
prophylaxis
 Ensure patient on PO meds
 Ensure patient has discharge
prescriptions
 Pneumococcal and influenza
vaccine if needed (refer to site
specific Pre Printed Order)
 Activity based on patient ability (without
 SpO2 <88%)
 Deep Breath & Cough Q1H while awake
if productive cough present
 Up in chair × 2 per day minimum (with
Oximetry)
 Oximetry with ADL
 Re-assess mobility if needed
(PT)
 Encourage bed exercises and
independent transfer &
ambulation
 Oximetry with ADL
 Re-assess mobility & determine
needs for discharge (PT/OT)
 Ambulate without exacerbation of
symptoms
 Bowel Protocol
 Urine output > 30 cc/hr
 Diet as per Admission orders
Pathway Discontinued
 Spirometry pre and post
bronchodilator if no previous testing
done (pt must be stable and able)
 O2 to achieve SpO2 88%-92%
 Tolerating recommended diet
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Medications
GI/GU
ACUTE PHASE
Day 1-2
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Oral Intake > 75% per meal
Push fluid and snack
Urine output > 30 cc/hr
No evidence of GI irritability (ex.
diarrhea, nausea, vomiting)
 Oral Intake > 75% per meal
 Normal output
Date: ___________________________
Reason: _____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
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References:
Adapted with permission from Credit Valley Hospital
1. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary
disease 2007 update. Can Respir J Sept 2007; 14 (Suppl B)
2. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary
diseases (GOLD) guidelines (updated 2009).
3. Snow V, Lascher S, Mottur-Pilson C. The Evidence Base for Management of Acute Exacerbations of
COPD. Chest 2001;119: 1185-1189
4. Stoller J. Acute Exacerbations of Chronic Obstructive Pulmonary Disease. New England Journal of
Medicine 2002;346(13): 988-994
Legend of Abbreviations
ABG – Arterial Blood Gas
ADL – Activities of Daily Living
CHF – Congestive Heart Failure
COPD – Chronic Obstructive Pulmonary Disease
GP – General Practitioner (Family Physician)
HR – Heart rate
IHN – Integrated Health Network
NP – Nasal Prongs
O2 – Oxygen
OT – Occupational Therapist
PE – Pulmonary Embolism
Pt – Patient
PT – Physiotherapist
RA – Room air
RR – Respiratory rate
RT – Respiratory Therapist
SpO2 – Oxygen Saturation (measured by Pulse Oximetry)
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