The potential of palliative care for patients with respiratory diseases.

Based on the demonstrated effectiveness of palliative care in the alleviation of symptoms and enhancement of life quality, it is important to incorporate palliative care early in the respiratory disease trajectory. Quality palliative care addresses eight domains that are all patient and family centred. Palliative care interventions in respiratory conditions include management of symptoms such as dyspnoea, cough, haemoptysis, sputum production, fatigue and respiratory secretion management, especially as the end-of-life nears. A practical checklist of activities based on the domains of palliative care can assist clinicians to integrate palliative care into their practice. Clinical management of patients receiving palliative care requires consideration of human factors and related organisational characteristics that involve cultural, educational and motivational aspects of the patient/family and clinicians. EDUCATIONAL AIMS: To explain the basic domains of palliative care applicable to chronic respiratory diseases.To review palliative care interventions for patients with chronic respiratory diseases.To outline a checklist for clinicians to use in practice, based on the domains of palliative care.To propose recommendations for clinical management of patients receiving palliative care for chronic respiratory diseases.

Coping with stigma: the experiences of Chinese patients living with lung cancer.

PURPOSE/OBJECTIVES: To describe the experiences of stigma and coping strategies among patients with lung cancer in China. RESEARCH APPROACH: Qualitative. SETTING: The oncology department at Liaocheng Peoples Hospital. PARTICIPANTS: A purposive sample of 17 patients experiencing stigma related to lung cancer voluntarily participated in data collection. METHODOLOGIC APPROACH: Individual, semistructured qualitative interviews were chosen. Participants completed about a 30-min focused interview. Exploratory qualitative approach guided data analysis. FINDINGS: Three main thematic elements emerged from the interview data:(1) sources of stigma, such as smoking, decreased ability to work, difficulties caring for self and family, damage to self-image, and cough and expectoration; (2) experiences of stigma, including feelings of stigma, remorse, loss of dignity, uselessness, social isolation, perceived exclusion, rejection, and discrimination; and (3) coping strategies, such as concealing the fact of sickness, reducing social activities, seeking medical assistance, adhering to treatment, and disclosing dissatisfaction. CONCLUSIONS: Our results indicate the presence of perceived stigma among patients with lung cancer. Future work should address the stigma associated with lung cancer and its related factors. INTERPRETATION: As point-of-care providers, staff nurses are well positioned to develop effective interventions to help patients deal with stigma and to accomplish the goal of providing holistic nursing care.

Characteristics influencing weight reduction among veterans in the MOVE!® Program.

Obesity is a common health problem for veterans. This study explored background and program characteristics associated with a 5% weight reduction for veterans enrolled in MOVE!(®), a weight management program. For data analysis, 404 veteran records were examined using logistic regression. Background characteristics included socio-demographic variables, comorbidity, body mass index, rurality, and Veterans Administration (VA) priority group. Program characteristics included the program type (group attendee or self-managed) as well as the number and type of provider contacts. Thirteen percent of participants achieved a 5% weight reduction. Age in years (odds ratio [OR] = 1.04) and the number of group visits (OR = 1.05) were significant predictors for achieving a 5% weight reduction. Given the importance of weight reduction, health professionals should consider these significant predictors when planning weight-reduction programs for veterans.

Feasibility study: home telemonitoring for patients with lung cancer in a mountainous rural area.

PURPOSE/OBJECTIVES: To explore the feasibility of rural home telemonitoring for patients with lung cancer. DESIGN: Exploratory, descriptive, observational. SETTING: Patient homes within a 75-mile radius of the study hospital in West Virginia. SAMPLE: 10 patients hospitalized with lung cancer as a primary or secondary-related diagnosis. METHODS: Data included referral and demographics, chart reviews, and clinical data collected using a HomMed telemonitor. Five patients received usual care after discharge; five had telemonitors set up at home for 14 days with daily phone calls for nurse coaching; mid- and end-study data were collected by phone and in homes through two months. MAIN RESEARCH VARIABLES: Enrollment and retention characteristics, physiologic (e.g., temperature, pulse, blood pressure, weight, O2 saturation) and 10 symptom datapoints, patient and family telemonitor satisfaction. FINDINGS: Of 45 referred patients, only 10 consented; 1 of 5 usual care and 3 of 5 monitored patients completed the entire study. Telemonitored data transmission was feasible in rural areas with high satisfaction; symptom data and physiologic data were inconsistent but characteristic of lung cancer. CONCLUSIONS: Challenges included environment, culture, technology, and overall enrollment and retention. Physiologic and symptom changes were important data for nurse coaching on risks, symptom management, and clinician contact. IMPLICATIONS FOR NURSING: Enrollment and retention in cancer research warrants additional study. Daily monitoring is feasible and important in risk assessment, but length of time to monitor signs and symptoms, which changed rapidly, is unclear. Symptom changes were useful as proxy indicators for physiologic changes, so risk outcomes may be assessable by phone for patient self-management coaching by nurses.

The West Virginia WISEWOMAN Program.

This article describes moving The Well-Integrated Screening and Evaluation for WOMen Across the Nation (WISEWOMAN) Program from research to practice in a population of low-income, uninsured, or underinsured women in West Virginia (WV) between the ages of 40 and 64 years. Cardiovascular disease risk factors were evident using screening and health history data from women in all stages of change as well as in different phases of the program. An indicator of program success was women's increased activities to improve their cardiovascular health. Women using an interactive Web program, coupled with appropriately delivered health information, can and do make behavior changes. As the WV WISEWOMAN Program moved from research to practice, clinician training and changes to policies and procedures were needed. Clinicians became skilled at motivational interviewing and targeting information to connect women to community resources for ongoing support. The program continues to help clinicians alert women to cardiovascular risks and guide them to take responsibility for their health. Partnerships between women and their providers are the key to successful implementation of healthier lifestyles.

Predictors of survival in patients with non-small cell lung cancer.

PURPOSE/OBJECTIVES: To examine how routine laboratory biomarkers and clinical parameters available within medical records related to overall survival in patients with non-small cell lung cancer (NSCLC). DESIGN: Retrospective chart review. SETTING: University-based cancer center in rural West Virginia. SAMPLE: 110 patients from the U.S. Appalachian region with a primary diagnosis of NSCLC at initial hospitalization. METHODS: Electronic medical records were reviewed for one year after discharge or until death. The Kaplan-Meier method was used to compare survival curves for each prognostic factor. Cox proportional hazards model was used for multivariate analyses. MAIN RESEARCH VARIABLES: Total white blood cell, neutrophil, lymphocyte, and platelet counts; hemoglobin level; body mass index (BMI); performance status; and cancer stage. FINDINGS: Low BMI (lower than 18.5 lb/in2), advanced cancer stage (IIIB or IV), and elevated neutrophil (higher than 8 x 103/mcl) and platelet (300-826 x 1012/L) counts were significant, independent prognostic factors for shorter survival time in NSCLC. BMI (hazard ratio [HR] = 2.15, 95% confidence interval [CI] [0.94, 4.9]) and neutrophil (HR = 2.93, 95% CI [1.53, 5.59]) and platelet (HR = 2.65, 95% CI [1.25, 5.62]) counts were overall prognostic predictors for patients with advanced NSCLC and remained in the multivariate survival model. CONCLUSIONS: This study detected two known clinical parameters, cancer stage and nutritional status (i.e., BMI and neutrophil and platelet counts), as having independent prognostic significance for shorter survival in NSCLC. Research on survival in patients with NSCLC should include those identified laboratory biomarkers and clinical parameters for screening patients at risk for shorter survival time following hospitalization. Investigation of whether treatments tailored to address neutrophil and platelet counts and BMI can improve survival outcomes also is warranted. IMPLICATIONS FOR NURSING: Attention to common biomarkers recorded in patient charts (e.g., neutrophil and platelet counts) as well as BMI could allow nurses to identify patients at risk for low survival. Interventions should be identified and initiated. Longitudinal studies in clinical settings that follow the survival of patients with NSCLC are essential.

The development and psychometric analysis of the short-form Pulmonary Functional Status Scale (PFSS-11).

This article describes the development and psychometric evaluation of the short-form Pulmonary Functional Status Scale (PFSS-11©) derived from the previously validated 35-item PFSS, using data from 179 subjects (120 Chronic Obstructive Pulmonary Disease [COPD]/59 normative, non-COPD). Items were extracted based on item-response distribution and commonality >.60. Factor analysis yielded a three-factor solution, accounting for 65.6% of total variance. Construct validity was supported by PFSS-11© scores for COPD versus norms (p < .001). The PFSS-11© was robustly associated with the PFSS-35 (r = .93), accounting for 88% of variance in the longer version. Internal consistency was satisfactory and significant response to treatment was shown by score changes pre/post-rehabilitation. The PFSS-11© has solid psychometric properties useful in research and clinical practice, similar to the PFSS-35.

The dose effect of pulmonary rehabilitation on physical activity, perceived exertion, and quality of life.

PURPOSE: Pulmonary rehabilitation (PR) programs have been shown to improve functional status, exercise performance, and quality of life (QOL) and decrease perception of exertion in individuals with chronic obstructive pulmonary disease. The purpose of this study was to identify the dose effect of PR on the outcome variables of activity level, perceived exertion, and physical and mental QOL. METHODS: The study used a retrospective explanatory design. The sample (N = 104) included records of individuals diagnosed with chronic bronchitis and emphysema who attended a PR program from 2000 to 2005 at a Midwest inner-city, academic medical center. Participants attended rehabilitation sessions 2 to 3 days per week for approximately 90 minutes each day; maximum duration of the program was 3 months (24 sessions). The PR dose was calculated by multiplying the number of PR sessions with the number of weeks attended. RESULTS: There were 32 men and 72 women, with a mean age of 59.9 years +/- 10.2 years. All patients were retired or unemployed, and 99% used oxygen during exercise. A higher PR dose was significantly related to improvement in activity level measured by maximum metabolic equivalent (MET) level achieved. A nonsignificant but minimally clinically important difference was found on the Medical Outcomes Study Short-Form 36 (SF-36) outcomes of mental and physical QOL. CONCLUSIONS: The findings of the current study support a significant relationship between PR dose and activity level (maximum MET level achieved). Physical and mental QOL improved clinically after PR. Optimal program outcomes were related to greater patient participation in supervised PR.

Factors related to depressed mood in adults with chronic obstructive pulmonary disease after hospitalization.

This study examined factors that predicted depressed mood at discharge and 3 months after discharge for 124 elders with chronic obstructive pulmonary disease (COPD). After the use of control for physiologic status (forced expiratory volume in 1 second percent predicted), the factors of anxiety, perceived health competence, daily functioning, and family emotional coping predicted depressed mood. Discharge referrals for home care services could be used to assess the 4 factors with the potential for the healthcare team to intervene. Interventions could include anxiety reduction through music or other therapies, education to enhance perceived health competence, oxygen use with activities to improve functioning, and integration of informal caregiving support from the community to increase family emotional support.

Which chronic obstructive pulmonary disease patients will be likely to attend consistently a pulmonary rehabilitation program?

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States, and millions of COPD patients are disabled and unable to work. Pulmonary rehabilitation (PR) programs are available to assist with disability, but it is not clear who is likely to consistently participate in them. The purpose of this study was to determine which participants were likely to consistently attend a PR program. METHODS: A retrospective medical record review was used to assess 104 community-dwelling adults with COPD who completed the PR program at a Midwest medical center between 2000 and 2005. SAMPLE: The sample consisted of 32 men and 72 women with a mean age of 59.9 years (±19.10 years), mean predicted one-second forced expiratory volume (FEV(1)) of 46.45% (SD = 20.1), mean percent forced vital capacity (FVC%) of 67.61 (SD = 16.61), mean FEV(1)/FVC% ratio of 51.15% (SD = 18.17), and mean residual volume (RV) of 150.66% (SD = 67.01). RESULTS: Contextual variables of current smoking (beta = -.36), male sex (beta = .19), not having emphysema (beta = -.27), and FVC% (beta = .32) were significant predictors of attendance at (a dose of) PR. The number of selected comorbidities significantly predicted the dose of PR (beta = -.20). CONCLUSION: These findings support the ability to identify factors that predict attendance at a PR program. Nurses can assess patients at risk for lack of consistent PR attendance and implement interventions to improve attendance. Specifically, smoking cessation prior to or as an integral part of PR programs may improve attendance.

Factors related to chronic obstructive pulmonary disease readmission in Taiwan.

This study examines the relationships among physiological, psychological, and social factors and hospital readmission to develop a model predicting chronic obstructive pulmonary disease (COPD) readmission for 145 patients with COPD following hospital discharge at 14 days and 90 days in Taiwan. Daily functioning, comorbidity, severity of illness, self-efficacy, depressive symptoms, and perceived informal support were regressed on hospital readmission. Daily functioning was the only significant variable to predict COPD readmission at 90 days in the Taiwan population living in a rural area. Age was significantly correlated with 14 days readmission. Post hoc analyses examined differences in three ethnic groups. Mainlanders perceived less family support, had higher depressive symptoms and lower daily functioning than the majority culture Fukiens and Hakkas, or the Aborigines. The study reinforced the need for identification of cultural differences and low functioning as risk factors for early readmission so they can be addressed in discharge planning.

Management of community-acquired pneumonia in the home: an American College of Chest Physicians clinical position statement.

The number of patients with community-acquired pneumonia (CAP) who are being treated at home is increasing for a variety of reasons. These reasons include the increased availability and cost considerations of oral antibiotics that have been shown to be effective, as well as the consideration of patient and family preferences. However, there is still considerable variability in strategies for the management of patients with CAP. This American College of Chest Physicians position statement, which was cosponsored by the American Academy of Home Care Physicians, provides recommendations on the various aspects of home care for patients with this condition. Included are recommendations for evaluation and diagnosis in the home environment and the determination of the site of care, and an outline of an in-home management plan. The position statement also provides recommendations for issues related to patient and caregiver commitment to the plan, and for monitoring and follow-up. Recommendations are directed toward immunocompetent adult patients with CAP who are at home or in other unskilled residential facilities. These patients can include previously healthy individuals or chronically ill individuals who choose not to go to the hospital, or hospitalized patients who are completing a hospital discharge plan. The recommendations in this statement take into consideration the best course of action for the patient, as determined by incorporating the most recent evidence with clinician judgment and patient preferences. These recommendations also consider the available resources. Therefore, these recommendations may not apply to every patient, and interventions may need to be structured based on the individual. In addition to providing recommendations for the home care management of patients with CAP, we hope that this clinical policy statement will alert readers to the need for more scientific evidence related to the clinical and psychosocial issues associated with managing this condition.

One breath at a time: living with cystic fibrosis.

The purpose of this qualitative investigation was to describe the lived experiences of families caring for a child with cystic fibrosis at the time of initial diagnosis. Phenomenological research methodology as described by Colaizzi (1978) was used to guide the investigation. A purposive sample of 9 family members voluntarily participated in the study. Data were gathered through focus groups and written narratives. Data analysis yielded 3 essential theme clusters with subthemes: Falling Apart, Pulling Together, and Moving Beyond. Within the theme of Falling Apart, the subthemes of Devastation of Diagnosis, An All-Encompassing Sense of Fear and Isolation, and An Overwhelming Sense of Guilt and Powerlessness are described. The theme of Pulling Together included the subthemes of Perpetual Vigilance and Returning to Normalcy, and the third theme of Moving Beyond included the subtheme of An Optimal Unfolding of a New Kind of Consciousness. This article describes in detail the themes and subthemes identified during data analysis and the fluid nature of the relationship that exists within the essential structure of caring for a family member with cystic fibrosis. The diagnosis of cystic fibrosis most often comes as a life-shattering experience to families. Lifestyle readjustments are made in an attempt to return to some sense of family normalcy. In order to achieve stability in their daily lives, families are vigilant in the care and monitoring of the health of a child with cystic fibrosis. Ongoing support from health care professionals that is grounded in the realities of living with cystic fibrosis is critical. This study describes how families develop their own unique way of controlling the experience of living with cystic fibrosis, one day and one breath at a time.

Developing personal and community learning in graduate nursing education through community engagement.

Community engagement through service-learning was introduced into a graduate program in nursing education to develop student leadership skills, interest in learning, and social responsibility. With faculty expertise and guidance, students worked in partnership with underserved community agencies. The goal of sustainability was accomplished by developing faculty expertise in service-learning as a method of instruction and integrating community engagement into academic assignments within existing courses. Opportunities to reflect on the benefits of the experiences were considered crucial to bridging service to learning in the community. Evaluation findings indicate that students gained insight into community needs and resources as they moved outside traditional health care settings. Graduates increased their understanding of their role as a resource to the community, and community agencies saw the value of a nurse educated at an advanced practice level.