Appendix G: Sample COPD Assessment Form
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1 Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with Chronic Obstructive Pulmonary Disease (COPD) Appendix G: Sample COPD Assessment Form CHRONIC OBSTRUCTIVE PULMONARY DISEASE CLINIC RETURN VISIT NAME Cr# Date ALLERGIES Medication: Environmental: CLINICAL EXAMINATION BP Resting HR Weight Recent Weight Loss O 2 Sat Home O 2 : L/min at rest; L/min with activity; Hrs/Day General Appearance: Breath Sounds: Accessory muscles: Air gulping: Apical breathing: Diaphragmatic: Intercostal indrawing: Lateral costal: Paradoxical: Pursed lip: Chest wall appearance/chest wall mobility: Heart Sounds: JVP: Central cyanosis: Peripheral cyanosis: Peripheral edema: Clubbing of fingernails: PULMONARY FUNCTION TESTS Pre-bronchodilator Post-bronchodilator FEV 1 (%) predicted of normal value Severity of Disease: (Gold, 2001) % Predicted FEV 1 Stage I ( mild- > 80%) Stage II ( moderate %) Stage III (severe- <30%) FEV 1 /FVC (%) predicted of normal value Diffusion 100
2 Nursing Best Practice Guideline SYMPTOMS Cough: Sputum: Wheezing: Dyspnea: MRC Score: Grade I (Shortness of breath [SOB] with strenuous exercise) Grade II (SOB hurrying on level or up slight hill) Grade III (SOB on level, stop for breath when walking at own pace on level) Grade IV (Stop for breath after walking 100 yards or after a few minutes on level) Grade V (Too breathless to leave the house) # Exacerbations/respiratory infections since # ER visits since last appointment: last appointment: COPD: Dates: # Admissions since last appointment: # Family Dr. visits since last appointment: COPD: Scheduled: LOS: Unscheduled: ICU admissions since last appointment: Intubations since last appointment: Diet: Appetite: Fluid Intake: Exercise: Present Pulmonary Rehabilitation MEDICATIONS Prescription: Herbals: Over the Counter (OTC): Influenza Vaccination- Date: Pneumococcal Vaccination- Date: 101
3 Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with Chronic Obstructive Pulmonary Disease (COPD) INTERVENTIONS Device Demonstration: Return Demonstration: Smoking Cessation Counselling: Education: Disease/disease process Medications/devices Signs and symptoms of infection Development of Action Plan Breathing techniques Coughing techniques Oxygen therapy End-of-life decision-making Sample medications sent with patient: Drug Plan: Insurer: Drug Store: Telephone: PLAN OF CARE Referrals: Respirologist O 2 Assessment Education Centre Pulmonary Rehabilitation Access Centre Dietitian Social Worker Psychologist Signature: 102
4 Nursing Best Practice Guideline COPD Clinic & Education Centre Initial Visit Family Physician Marital Status Age Date Respirologist Support System Living Accommodations: Community Resources: ALLERGIES Medication: Environmental: CLINICAL EXAMINATION BP Resting HR Weight Recent Weight Loss O 2 Sat Home O 2 : L/min at rest; L/min with activity; Hrs/Day General Appearance: Breath Sounds: Accessory muscles: Air gulping: Apical breathing: Diaphragmatic: Intercostal indrawing: Lateral costal: Paradoxical: Pursed lip: Chest wall appearance/chest wall mobility: Heart Sounds: JVP: Central cyanosis: Peripheral cyanosis: Peripheral edema: Clubbing of fingernails: PULMONARY FUNCTION TESTS Pre-bronchodilator Post-bronchodilator FEV 1 (%) predicted of normal value Severity of Disease: (Gold, 2001) % Predicted FEV 1 Stage I ( mild- > 80%) Stage II ( moderate %) Stage III (severe- <30%) FEV1/FVC (%) predicted of normal value Diffusion 103
5 Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with Chronic Obstructive Pulmonary Disease (COPD) HISTORY Cough: Wheezing: Duration: Diurnal Pattern: Productive: Precipitating Factors: Sputum: Dyspnea: Colour: Amount: Diurnal Pattern: Precipitating Factors: # Pillows MRC Score: Grade I (SOB with strenuous exercise) Grade II (SOB hurrying on level or up slight hill) Grade III (SOB on level, stop for breath when walking at own pace on level) Grade IV (Stop for breath after walking 100 yards or after a few minutes on level) Grade V (Too breathless to leave the house) Panic Attacks: Ability to perform ADLs: Acute Respiratory Infections: Timing: Symptoms: Antibiotics: Systemic Corticosteroids: Environmental Exposure: Smoking History: Work: Current: Amount: Cessation: When: Second-Hand Smoke: # of Attempts: Duration: # Package Years: 104
6 Nursing Best Practice Guideline # Exacerbations/respiratory infections # ER visits in past 12 months: in past 12 months: COPD: Dates: # Admissions in past 12 months: # Family Dr. visits in past 12 months: COPD: Scheduled: LOS: Unscheduled: # ICU Admissions: # Intubations: Diet: Appetite: Fluid Intake: Exercise: Present Previous Pulmonary Rehabilitation Date MEDICATIONS Prescription: Herbals: OTC: Influenza Vaccination- Date: Pneumococcal Vaccination- Date: 105
7 Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with Chronic Obstructive Pulmonary Disease (COPD) PAST MEDICAL HISTORY Family History: Mother: Smoker: Father: Smoker: Siblings: Smoker: Childhood: Exposure to ETS (environmental tobacco smoke) as child: Adult: Medical: Asthma: Pneumonia: Hypertension: Diabetes: Cardiac: Gastrointestinal: Post Nasal Drip: Sinusitis: Surgical: Psychiatric: INTERVENTIONS Device Demonstration: Return Demonstration: Smoking Cessation Counseling: Education: Disease/disease process Medications/devices Signs and symptoms of infection Development of Action Plan Breathing techniques Coughing techniques Oxygen therapy End-of-life decision-making Sample medications sent with patient: Drug Plan: Insurer: Drug Store: Telephone: 106
8 Nursing Best Practice Guideline PLAN OF CARE Referrals: Respirologist O 2 Assessment Education Centre Pulmonary Rehabilitation Access Centre Dietitian Social Worker Psychologist Signature: Reprinted with permission: Gail Beatty, RN, BNSc, MN, ACNP, Clinical Nurse Specialist/Nurse Practitioner COPD Ambulatory Program, Kingston General Hospital. 107
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