2. COPD It Takes Your Breath Away Patti J. Pagel, RN, BSN Alverno College MSN Program April, 2007 patti.pagel@aurora.org

3. Self-Study Tutorial Guide Instruction Page Click on to go back to previous slide Click on to go to the next slide Click on to return to objectives Click on True/False and learn the correct answer when presented in a slideTrue/False Click on Answer for multiple choice to check for correct answerAnswer Click here to go back to review slideshere Click on website link for further informationwebsite link

4. Welcome! Main Menu Click on subject to navigate to: Or click on forward arrow to go to next slide Objectives Nursing Outcomes Respiratory Review Pathophysiology Respiratory Quiz Patho Quiz Patho Quiz Signs & Symptoms Signs & Symptoms Interventions Case Study Case Study References

5. Intended Audience This self-study tutorial on Chronic Obstruction Pulmonary Disease is intended for the following people:  Registered Nurses  Medical Assistants  Anyone interested in learning about COPD

6. Tutorial Objectives Review respiratory system anatomy. Increase understanding of the pathophysiology of COPD. Recognize signs and symptoms of COPD. Identify treatment options: Non-pharmaceutical nursing interventions Pharmaceutical interventions

7. Nursing Outcomes: Respiratory Status: Ventilation - movement of air in and out of lungs Respiratory Status: Airway Patency - open, clear tracheobronchial passages Knowledge: Medications - extent of understanding conveyed about the safe use of medication Source: (Moorhead et al 2004) Microsoft clipart

8. Let’s Review: Respiratory Anatomy Upper Respiratory Tract: Mouth, nose, throat (pharynx), larynx, trachea Lower Respiratory Tract: Lungs, bronchi, alveoli Medulla Oblongata Controls inspiration/expiration Microsoft clipart

9. Anatomy Review

10. Respiratory Review Let’s Take a Breath Together: Air is warmed and humidified. Cilia filter out dust particles. Macrophages destroy germs. Air goes to L and R bronchi. Then to the bronchioles. Through to the Alveoli. Oxygen and CO 2 exchange takes place. Used with permission: Jensen M.S., Webanatomy 2007

11. Respiratory Review: Now your Breath is… Alveoli fill with air. Oxygen diffuses thru alveoli walls. Oxygen diffuses to Capillaries and bloodstream. Hemoglobin for transport of oxygen. Oxygen to the heart and to the body. Used with permission: Jensen, M.S., Webanatomy (2007).

12. Respiratory Review Let your air out… Hemoglobin frees oxygen. O 2 to cells. CO 2 is the waste product. Veins return CO 2 to heart. Heart pumps CO 2 to lungs. CO 2 passes alveoli to be exhaled Use with permission: Jensen, M.S., Webanatomy (2007)

13. Respiratory Quiz Respiratory Assessment: Understanding the anatomy of the lungs, where does the exchange of oxygen and CO 2 occur: A. BronchiolesBronchioles B. AveoliAveoli C. Bronchial TubesBronchial Tubes Click on underlined best answer.

14. Respiratory Quiz: Respiratory Assessment: What part of the body controls inspiration and expiration? A. Pituitary GlandPituitary Gland B. Sympathetic Nervous SystemSympathetic Nervous System C. Medulla OblongataMedulla Oblongata Click on underlined best answer.

15. What is COPD? Chronic Obstructive Pulmonary Disease COPD is a group of respiratory disorders characterized by chronic, recurrent, irreversible obstruction of airflow in the pulmonary airways not fully reversible with inhaled bronchodilators. (Porth, 2005) (Punturieli, 2007)

16. Chronic Obstructive Pulmonary Disease (COPD) FACTS YOU SHOULD KNOW: FOURTH leading cause of death in United States. COPD refers to two lung diseases: Chronic Bronchitis & Emphysema. Smoking is a primary risk factor. Air pollution, second-hand smoke, history of childhood respiratory infections and heredity are other causes. Female smokers are almost 13 times as likely to die from COPD than women who have never smoked. 11.4 million U.S. adults affected. $37.2 billion cost to nation. Important cause of hospitalization in our aged population. Source:American Lung Association Fact Sheet August 2006

17. Chronic Obstructive Pulmonary Disease Fact you might not know… COPD patients most likely have been smoking 20 cigarettes per day for 20 or more years before they even get symptoms (Snider, 2006). Microsoft clipart

18. What Causes COPD? What do you think are the two causes of COPD? Find the two causes- click on word Cigarette Smoking Factory Work ObesityCancer DiabetesDiabetes StrokeStroke Alcohol AbuseInactivity Coronary Heart Disease Alpha1-antitripsin Deficiency Click HERE to learn more about COPD.HERE

19. Pathogenesis of COPD Inflammation bronchial wallsCause airway Fibrous bronchial walls obstruction & problems Hypertrophy of submucosal glands with ventilation Hypersecretion of mucus & perfusion Loss of elastic lung fibers and alveoli tissue (Porth, 2005)

20. Types of COPD: Chronic Bronchitis ----- -Obstruction of small airway -Inflammation of major & small airways Emphysema -Enlargement of air spaces -Destruction of tissues Alpha1- antitrypsin deficiency -inherited disorder -protective material produced in liver and transported to lungs to help combat inflammation -leads to destruction of alveoli (Porth, 2005)

21. Characteristics of: Chronic Bronchitis Cough with phlegm Shortness of breath Exercise Intolerance Expiratory phase of respiration long Wheezes and Crackles on auscultation Inability to maintain stable arterial blood gases Hypoxemia (Porth, 2005)

22. Characteristics of: Chronic Bronchitis Doesn’t strike suddenly Damage occurs before patients seek treatment Pulmonary hypertension Right heart failure with peripheral edema (Porth, 2005)

23. Chronic Bronchitis Diagnosis Mucus producing cough most days of the month, three months of a year for two consecutive years (ALA). Microsoft Clipart

24. Characteristics: Emphysema Dyspnea, slowly progressive Abnormal Arterial Blood Gases Use accessory muscles Weight loss Sputum production in morning, scant Cough- minimal Loss of lung elasticity Destruction of alveoli walls and capillary beds (Porth, 2005)

25. Emphysema Diagnosis Careful history and physical examination Pulmonary function studies Forced Expiratory Volumes Chest radiographs Laboratory tests Microsoft clipart

26. COPD- Let’s Review COPD is the fourth leading cause of death in the United States. TRUE FALSE Heredity is the most common cause of COPD TRUE FALSE Click here to proceed to next slidehere

27. CORRECT! Smoking is the leading cause of COPD! Click here to go back to reviewhere Microsoft clipart

28. Recheck… Click here to go back to reviewhere hereditary Though hereditary plays a role in COPD, it is not the primary cause. Try Again!

29. Actually… COPD is the Fourth leading cause of death in the United States #1 is Heart Disease #2 is Cancer #3 is Stroke cdc.gov/nchs/fastats/death.htm Click here to go back to review.here

30. CORRECT! COPD is the Fourth leading cause of death in the United States. #1 is Heart Disease #2 is Cancer #3 is Stroke cdc.gov/nchs/fastats/death.htm Click here to go back to review here

31. Pathophysiology Autonomic Nervous System Respiratory Centers: MEDULLARY & PONS Ventilation Central Chemoreceptor Peripheral Chemoreceptor Respond to Arterial PCO 2 Respond to Arterial PO 2 & PCO 2 Stretch Receptors Irritant Receptors Monitor Stretch of Lungs & Chest Wall Involved With Reflexes Causing Coughing & Sneezing (Freudenrich, 2007)

32. Factors that Influence the Respiratory Centers: Craig C. Freudenrich, Ph.D.. "How Your Lungs Work". October 06, 2000 http://health.howstuffworks.com/lung.htm (April 12, 2007) Oxygen: Peripheral Receptor Monitors O 2 concentration of blood Carbon Dioxide: Central Receptor Monitors CO 2 Concentration in CSF Hydrogen Ion (pH): Peripheral & Central Sensitive to pH of Blood and CSF  oxygen Concentration=  Rate and Depth Breathing  CO 2 =  Rate and Depth Breathing  Hydrogen Ion=  Rate and Depth Breathing

33. The single most important driver of ventilation is CO 2 But can be deadly for the COPD Patient Microsoft clipart CO 2

34. Example of receptors at work: You administer high flow supplemental oxygen to a patient with COPD and the patient stops breathing. What Happened to your patient?

35. You removed his drive to breathe! Specifically, patients with COPD retain CO 2 chronically. Administering oxygen removes the central chemoreceptor drive to breathe. The central chemoreceptor is not sensitive to small oxygen changes like when a person breathes deep but high flow oxygen administration extinguished the stimulus to breathe.

36. Arterial Blood Gases (ABG’s) SNAP SHOT OF YOUR PATIENT”S OXYGEN STATUS COPD PATIENT- 3L O 2 Normal ABG ResultsAbnormal ABG Results pH 7.35-7.45pH7.32 PaCO 2 35-45PaCO 2 69 HCO 3 22-26HCO 3 32 PaO 2 80-100PaO 2 86 The abnormal ABG finding indicates your patient is retaining CO 2. What we don’t know just from the ABG result is if your patient is compensating or uncompensated. A complete history needs to be obtained. (Perry & Potter, 2006)

37. Pathophysiology COPD Emphysema type of COPD:  Walls between many of the air sacs are destroyed leading to few large air sacs.  These large air sacs have less surface area for O 2 and CO 2 exchange.  Poor exchange of O 2 and CO 2 causes shortness of breath.

38. Pathophysiology COPD Bronchitis type of COPD:  Airways inflamed and thickened  Increase number & size of mucus producing cells  Excessive mucus production  Coughing to remove mucus  Difficulty getting air in & out Used with permission: Jensen, M.S., Webanatomy (2007).

39. Pathophysiology COPD Take a look at the next slide and note where the oxygen exchange takes place in the lungs.

40. O 2 and CO 2 Exchange Used with permission:http://www.pbs.org/wgbh/nova/everest/exposure/body.htmlhttp://www.pbs.org/wgbh/nova/everest/exposure/body.html

41. Pathophysiology COPD Now take a look at the comparison of a healthy lung and a COPD emphysema lung.

42. With permission Copyright 2007 American Lung Association Association For more information about the American Lung Association or to support the work it does, call 1-800-LUNG-USA (1-800-586-4872) or log on to www.lungusa.org.

43. Pathophysiology COPD Probably a good time to share with you the… WISCONSIN TOBACCO QUIT LINE: 1-800-QUIT-NOW (1-800-784-8669) (UW WI Madison, 2005) Microsoft clipart

44. Pathophysiology Quiz Let’s see how you are doing- Which type of COPD leads to destruction of the surface area of the alveoli? Chronic Bronchitis or Chronic Bronchitis Emphysema

45. Pathophysiology Quiz What causes the central chemoreceptor in the medulla to signal the respiratory center to increase the rate and depth of respirations? A. Low oxygen in bloodoxygen B. High oxygen in blood C. High CO2 level in blood D. Gee, I need to review. CLICK HERECLICK HERE

46. Just checking in with you- How are you doing? Need to review more? Ready to move on? You are doing very well. We’re almost finished! Microsoft clipart

47. COPD- Signs and Symptoms Review… Chronic Cough- Major Factor in seeking care. Exercise intolerance- Fatigue Shortness of breath- At rest or activity (Kessenich & Dayer-Berenson, 2007)

48. What happens when your patient has an Exacerbation of COPD? These patients have sustained worsening of their usual state of health. They will exhibit: Worsening breathlessness Increased cough Increased sputum production (to yellow/green) (Bellamy, D. 2006)

49. What triggers a COPD Exacerbation? INFECTION AIR POLLUTION COLD WEATHER Weakened Immune System

50. COPD Patients PINK PUFFER: early disease Emphysema Over ventilate to maintain relatively normal ABG’s until late in disease Red face BLUE BLOATER: Chronic Bronchitis Bronchial secretions and airway obstruction cause poor ventilation and perfusion; unable to compensate leading to hypoxia and cyanosis Clubbing Circumoral cyanosis (Porth, 2005) Microsoft Clipart

51. Barrel Chest- What’s this? COPD patients chest often looks barrel shaped. Why? These patients have a loss of lung elasticity. Airways collapse during expiration because pressure in lung tissue exceeds airway pressure. Air gets trapped causing increase in anteroposterior dimensions of the chest (Porth, 2005). Simply: Their lungs are chronically over inflated with air. Microsoft clipart

52. Pursed Lip Breathing- What’s this? COPD patients purse their lips to breath. WHY? Pursing your lips increases the resistance to the outflow of air. It helps to prevent airway collapse by increasing pressure (Porth, 2005). Simply: Pucker up. Try to blow air out. Feel the resistance? Microsoft clipart

53. Signs and Symptoms of CO 2 RETAINERS Labored Breathing Feeling of Air Hunger Nausea Confusion Dizziness Headache

54. Nursing Interventions Non Pharmaceutical SMOKING CESSATION AVOID EXPOSURE TO RESPIRATORY INFECTIONS ENCOURAGE FLU & PNEUMOCOCCAL VACCINES Microsoft clipart

55. Nursing Interventions Non Pharmaceutical POSITIONING: Sit patient on side of bed with bed side table. BREATHING: Encourage pursed lip breathing. Incentive Spirometry DIET: Small frequent nutritious meals Easily swallowed food Microsoft clipart

56. Nursing Interventions Non Pharmaceutical PULMONARY REHABILITATION PHYSICAL CONDITIONING SUPPORT IN PATIENT CARE COMMUNITY CARE Microsoft clipart

57. Nursing Interventions Pharmaceutical OXYGEN IS a drug not just something that sometimes makes the patient breathe better. Keep oxygen saturation above 90%. Follow physician order. Monitor ABG’s as ordered by physician. Dangerous side effects: Atelectasis Oxygen toxicity CO 2 retention (Perry & Potter, 2005)

58. Nursing Interventions Pharmaceutical BRONCHODILATORS Inhaled B2-adrenergic antagonists Anticholinergic agents- long and short acting Inhaled corticosteroids Oral corticosteroids IV corticosteroids Dangerous side effects: Monitor blood sugars Can increase heart rate Patients with fungal infections should use with caution (Perry & Potter, 2005)

59. Nursing Interventions Pharmaceutical- In patient care GIVING SOLUMEDROL:Methylprednisolone Sodium Succinate INDICATION FOR COPD: Inflammation DOSING: 40mg-125mg q 6-8 hours IV NURSING CONSIDERATION: Give IV slow, over one minute Don’t discontinue abruptly Monitor for fungal infection Monitor blood glucose (Perry & Potter, 2005)

60. Nursing Interventions Pharmacologic ANTIBIOTICS Can be used to treat an acute exacerbation of COPD due to bacterial infections. No evidence to support prophylactic use to prevent COPD exacerbation. Nursing: Check for patient allergies before administering antibiotic therapy. Patient education to take all medication is important. (Porth, 2005)

61. Nursing Interventions Pharmaceutical Anti-anxiety Medication COPD patients tend to become very anxious during an exacerbation. Collaborate with the physician to assess appropriate medication for your patient. This aspect of patient care is often times overlooked. Microsoft clipart

62. Nursing Intervention In Patient Care Often times the physician will order Solumedrol intravenously. Can you tell me what the normal dosing schedule would be for giving this drug on your unit? A. IV Solumedrol 300mg every 2 hours IV Solumedrol 300mg every 2 hours B. IV Solumedrol 60 mg every 8 hours IV Solumedrol 60 mg every 8 hours C. IV Solumedrol 2gm every 6 hours for 72 hours IV Solumedrol 2gm every 6 hours for 72 hours D. IV Solumedrol 3gm every 8 hours for 48 hours IV Solumedrol 3gm every 8 hours for 48 hours Click here to go to next slide. here

63. Nursing Intervention In Patient Care Complete Respiratory Assessment Assess Co-morbidities Confirm allergies Review medications Monitor lab values: CBC, ABG’s, Lytes Collaborate with physician Educate patient and family Administer IV medications as ordered EVALUATE RESPONSE TO TREATMENT

64. Case Study Mr. Sigh A. Nosis Mr. Nosis is a 64 year-old- male who presents to the ER with complaints of SOB, wheezing and fatigue. His past medical history indicates a 32-year history of smoking two packs of cigarettes a day. With only this information, what can you anticipate the ER physicians orders to include? A. Chest x-ray, Ct scan and lasix Chest x-ray, Ct scan and lasix B. Chest x-ray, ABG’s, IV access Chest x-ray, ABG’s, IV access C. Chest x-ray, ABG’s, exercise stress test Chest x-ray, ABG’s, exercise stress test

65. Case Study: Mrs. Bronk I. Tis Mrs.Tis comes to the clinic today for a follow up post hospital visit with acute exacerbation of COPD. She is a widow, elderly, frail looking woman. Which of the following concerns you? A. Oxygen saturation is 92% after a walk in the hall with you on room air. Oxygen saturation is 92% after a walk in the hall with you on room air B. A weight loss of six pounds since her discharge four weeks ago. A weight loss of six pounds since her discharge four weeks ago.

66. This concludes the COPD Tutorial I hope you have enjoyed and learned about COPD. You can make an impact in the lives of the patients you care for with this disabling but many times preventable disease. Patti Pagel RN BSN Alverno College

67. References American Lung Association. (2006). Chronic obstructive pulmonary disease fact sheet. Retrieved February 16, 2007 from http://lungusa.org. http://lungusa.org Anugwom, C., & Dachs, R. (2006). Beta-blocker use in patients with COPD. American Family Physician. (74)11., p1858. Bay Area Medical Information. (2006). Overview of the respiratory system. Retrieved March 7, 2007 from http://www.bami.us/Resp/COPD2.html. http://www.bami.us/Resp/COPD2.html Bellamy, D., (2006). COPD exacerbations. Practice Nurse (32)6., p35- 42. Retrieved February 15, 2007 from http://web.ebscohost.com/ehost/delivery?vid=4&hid=7&sid=cef94c2 1-be5a-4615-a3a7-33. http://web.ebscohost.com/ehost/delivery?vid=4&hid=7&sid=cef94c2 1-be5a-4615-a3a7-33 Freudnenrich, C.C., (2007). How your lung works. Retrieved April 13, 2007 from http://health.howstuffworks.com/lung.htm/printable.http://health.howstuffworks.com/lung.htm/printable Goldsmith, C., (2007). Fighting for breath with COPD. Nurseweek. Retrieved March 1, 2007 from http://www.nurseweek.net.http://www.nurseweek.net

68. References continued Kessenich, C.R., & Dayer-Berenson, L., (2007). Polypharmacy in the elderly. Nurseweek. Retrieved March 1, 2007 from http://www.nurseweek.net http://www.nurseweek.net Moorhead, S., Johnson, M., & Maas, M., (2004). Nursing outcomes classification. Iowa outcome project (3 rd ed.). St Louis, MO: Mosby. Nova. How the body uses O2. Retrieved on March 19, 2007 from http://www.pbs.org/wgbh/nova/everest/exposure/body.htm. http://www.pbs.org/wgbh/nova/everest/exposure/body.htm Porth, C. M., (2005). Pathophysiology: Concepts of altered health states. (7th ed. ). Philadelphia: Lippincott, Williams & Wilkins. Perry, A.G., & Potter, P. A., (2006). Clinical nursing skills and techniques. (6 th ed.). St. Louis, MO: Mosby, Elsevier. Punturieri, A., Croxton, T., Weinman, G., & Kiley, J.P., (2007). The changing face of COPD. American Academy of Family Physicians. (75)3., February 1, 2007. Snider, G.L., (2006). Diagnosis of chronic obstructive pulmonary disease. Uptodate. Retrieved February 12, 2007 from http://www.utdol.com.http://www.utdol.com University Wisconsin Madison (2005). Report: State tobacco quit line saves millions in health care costs. Retrieved April 16, 2007 from http://www.news.wisc.edu/11228.html. http://www.news.wisc.edu/11228.html

69. Illustration References: American Lung Association website. Retrieved March 22, 2007 from www.lungusa.org.www.lungusa.org Jensen, M., website. Retrieved April 12, 2007 from http://www.msjensen.gen.umn.edu/webanatomy/default.htm.http://www.msjensen.gen.umn.edu/webanatomy/default.htm Microsoft Corp. (2006). Microsoft clipart. Retrieved February 26, 2007 from www.microsoftclipart.com.www.microsoftclipart.com Nova website. Retrieved April 9, 2007 from http://ww.pbs.org/nova/teachers. http://ww.pbs.org/nova/teachers Rose, L., website. Retrieved March 18, 2007 from http://webschoolsolutions.com/patts/systems/ lungs.htm. http://webschoolsolutions.com/patts/systems/ lungs.htm

70. Special thank you… To everyone who supported the time, ideas, energy, frustrations, excitement, & trial runs to the completed project. I sincerely thank you. RogerPamChristineDavid(s) ElizabethPaulaGeorgiaKim NicholasVickiPatti Debbie MomKathy(s)SusanneLinda RandyMarciaJeaninePat Kris

71. YOU ARE CORRECT! Cigarette Smoking causes COPD Council your patients to stop smoking. Click here to go back to question. Microsoft Cliparthere

72. Obesity is on the rise… Blending a problem like obesity with COPD can cause complications… Click here to go back to the question.here

73. Top of the Day to you! YOU ARE CORRECT! Click here to go back to question.here

74. Diabetes is not a cause of COPD. But, having Diabetes can compound symptoms of COPD. Talk with your patient about keeping blood sugars in good control. Click here to go back to question.here Microsoft Clipart

75. Alcohol Abuse does not cause COPD Alcohol in moderation does not pose risk to the COPD patient but excessive alcohol consumption puts the patient at risk for malnutrition as well as many other problems. Click here to go back to question.here

76. Factory Work does not cause COPD Irritants from working in factories can exacerbate symptoms in people who have COPD. Click here to go back to question.here Microsoft Clipart

77. Coronary Artery Disease does not cause COPD. Having cardiac problems will pose challenges for the COPD patient. Click here to go back to question.here Microsoft Clipart

78. Cancer does not cause COPD. COPD does not cause Cancer. Click here to go back to question. here Microsoft Clipart

79. Strokes do not cause COPD. But people who have suffered from a Stroke and have COPD might have a longer recovery than a healthy person. Click here to go back to the question.here Microsoft Clipart

80. Inactivity does not cause COPD But, leading an inactive life style does put people at risk for developing loss of muscle mass, muscle wasting and fatigue. Discuss healthy lifestyle of being active throughout life with your patients. Click here to go back to question. Microsoft Cliparthere

81. Pathophysiology answer Well actually… Chronic Bronchitis is related to obstruction of the small airways. Click here to review characteristics of COPD.here Click here to go back to question.here

82. Pathophysiology answer HURRAY! YIPPEE SKIPPY! You are correct! Bravo! Emphysema type COPD causes destruction of the alveoli walls and capillary beds. Click here to continue to next slide.here

83. Low oxygen… Would trigger the peripheral chemoreceptors to respond and rate and depth of respirations would increase. It’s tricky to remember which chemoreceptors respond to fluctuation oxygen and CO 2. Try the question again. Click here to go back to the question.here

84. High oxygen… High flow oxygen puts your patient at risk for retaining CO 2 and signals the peripheral receptors to signal the respiratory center to increase rate and depth of respirations. Click here to go back to the question. here Microsoft clipart

85. You Got It! The central chemoreceptor responds to increased level of CO 2 and signals the respiratory center to increase rate and depth of respirations to help blow off too much CO 2. Click here to go to next slide.here Microsoft clipart

86. You would not give 300mg to a patient in one dose. Initially the dose may start at 125mg every 8 hours. Click here to go to back to question.here

87. No, when you get an order for GRAMS to be administered IV always double check the order and drug. Click here to go to back to the question.here

88. YES- this would be a usual dose of Solumedrol Initially the dose may start at 125mg every 8 hours. Click here to go to next slide.here

89. No, when you get an order for GRAMS to be administered IV always double check the order and drug. Click here to go to back to the question.here

90. No, when you get an order for GRAMS to be administered IV always double check the order and drug. Click here to go to back to the questionhere

91. YES! You would anticipate these orders because you know a person who has smoked for that period of time, would likely have a diagnosis of COPD and initial steps for diagnosis would be a chest x-ray, ABG’s and have IV access for potential corticosteroid therapy. GOOD JOB! Click here to go to next slide.here

92. Probably not, why? Well, the ER physician would probably order a chest x- ray. But most likely would not order a CT scan until the chest x-ray results have been obtained. Lasix would not be given until his labs would be back to identify if he was in heart failure. An exercise stress test would not be ordered initially. ABG’s would be an order to anticipate. Go back and try again. Click here to go back to question.here

93. Let’s think about this… Patients with COPD can often times have an O2 saturation of 88-89% on room air with activity. So, unless this was unusual for her, I probably wouldn’t be concerned. Click here to go back to the question.here

94. You are correct! Mrs. Bronk I. Tis is a frail elderly woman with COPD. A six pound weight loss is significant. A nursing intervention would be to talk to her about what foods she eats, who prepares her food and help her plan a menu that includes easy preparation, frequent small, easily chewable meals. Conserving her energy is important to allow her to continue to live on her own. Click here to go to the next slide.here