Asthma: Also known as chronic reactive airway disease, asthma is characterized by reversible inflammation and constriction of bronchial smooth muscle, hypersecretion of mucus, and edema. Precipitating factors include allergens, emotional upheaval, cold weather, exercise, chemicals, medications, and viral infections.
Chronic bronchitis: Widespread inflammation of airways with narrowing or blocking of airways, increased production of mucoid sputum, and marked cyanosis.
Emphysema: Most severe form of COPD, characterized by recurrent inflammation that damages and eventually destroys alveolar walls to create large blebs or bullae (air spaces) and collapsed bronchioles on expiration (air-trapping).
- Chest x-ray: May reveal hyperinflation of lungs, flattened diaphragm, increased retrosternal air space, decreased vascular markings/bullae (emphysema), increased bronchovascular markings (bronchitis), normal findings during periods of remission (asthma).
- Pulmonary function tests: Done to determine cause of dyspnea, whether functional abnormality is obstructive or restrictive, to estimate degree of dysfunction and to evaluate effects of therapy, e.g., bronchodilators. Exercise pulmonary function studies may also be done to evaluate activity tolerance in those with known pulmonary impairment/progression of disease.
- The forced expiratory volume over 1 second (FEV1): Reduced FEV1 not only is the standard way of assessing the clinical course and degree of reversibility in response to therapy, but also is an important predictor of prognosis.
- Total lung capacity (TLC), functional residual capacity (FRC), and residual volume (RV): May be increased, indicating air-trapping. In obstructive lung disease, the RV will make up the greater portion of the TLC.
- Arterial blood gases (ABGs): Determines degree and severity of disease process, e.g., most often Pao2is decreased, and Paco2 is normal or increased in chronic bronchitis and emphysema, but is often decreased in asthma; pH normal or acidotic, mild respiratory alkalosis secondary to hyperventilation (moderate emphysema or asthma).
- DL CO test: Assesses diffusion in lungs. Carbon monoxide is used to measure gas diffusion across the alveocapillary membrane. Because carbon monoxide combines with hemoglobin 200 times more easily than oxygen, it easily affects the alveoli and small airways where gas exchange occurs. Emphysema is the only obstructive disease that causes diffusion dysfunction.
- Bronchogram: Can show cylindrical dilation of bronchi on inspiration; bronchial collapse on forced expiration (emphysema); enlarged mucous ducts (bronchitis).
- Lung scan: Perfusion/ventilation studies may be done to differentiate between the various pulmonary diseases. COPD is characterized by a mismatch of perfusion and ventilation (i.e., areas of abnormal ventilation in area of perfusion defect).
- Complete blood count (CBC) and differential: Increased hemoglobin (advanced emphysema), increased eosinophils (asthma).
- Blood chemistry: alpha1-antitrypsin is measured to verify deficiency and diagnosis of primary emphysema.
- Sputum culture: Determines presence of infection, identifies pathogen.
- Cytologic examination: Rules out underlying malignancy or allergic disorder.
- Electrocardiogram (ECG): Right axis deviation, peaked P waves (severe asthma); atrial dysrhythmias (bronchitis), tall, peaked P waves in leads II, III, AVF (bronchitis, emphysema); vertical QRS axis (emphysema).
- Exercise ECG, stress test: Helps in assessing degree of pulmonary dysfunction, evaluating effectiveness of bronchodilator therapy, planning/evaluating exercise program.
- Maintain airway patency.
- Assist with measures to facilitate gas exchange.
- Enhance nutritional intake.
- Prevent complications, slow progression of condition.
- Provide information about disease process/prognosis and treatment regimen.
- Ventilation/oxygenation adequate to meet self-care needs.
- Nutritional intake meeting caloric needs.
- Infection treated/prevented.
- Disease process/prognosis and therapeutic regimen understood.
- Plan in place to meet needs after discharge.
Nursing Care Plans
Ineffective Airway Clearance
NURSING DIAGNOSIS: Ineffective Airway Clearance
May be related to
- Increased production of secretions; retained secretions; thick, viscous secretions
- Decreased energy/fatigue
Possibly evidenced by
- Statement of difficulty breathing
- Changes in depth/rate of respirations, use of accessory muscles
- Abnormal breath sounds, e.g., wheezes, rhonchi, crackles
- Cough (persistent), with/without sputum production
- Maintain patent airway with breath sounds clear/clearing.
- Demonstrate behaviors to improve airway clearance, e.g., cough effectively and expectorate secretions.
|Auscultate breath sounds. Note adventitious breath sounds, e.g., wheezes, crackles, rhonchi.||Some degree of bronchospasm is present with obstructions in airway and may/may not be manifested in adventitious breath sounds, e.g., scattered, moist crackles (bronchitis); faint sounds, with expiratory wheezes (emphysema); or absent breath sounds (severe asthma).|
|Assess/ monitor respiratory rate. Note inspiratory/ expiratory ratio.||Tachypnea is usually present to some degree and may be pronounced on admission or during stress/ concurrent acute infectious process. Respirations may be shallow and rapid, with prolonged expiration in comparison to inspiration.|
|Note presence/ degree of dyspnea, e.g., reports of “air hunger,” restlessness, anxiety, respiratory distress, use of accessory muscles. Use 0–10 scale or American Thoracic Society’s “Grade of Breathlessness Scale” to rate breathing difficulty. Ascertain precipitating factors when possible. Differentiate acute episode from exacerbation of chronic dyspnea.||Respiratory dysfunction is variable depending on the underlying process, e.g., infection, allergic reaction, and the stage of chronicity in a patient with established COPD. Note: Using a 0–10 scale to rate dyspnea aids in quantifying and tracking changes in respiratory distress. Rapid onset of acute dyspnea may reflect pulmonary embolus.|
|Assist patient to assume position of comfort, e.g., elevate head of bed, have patient lean on overbed table or sit on edge of bed.||Elevation of the head of the bed facilitates respiratory function by use of gravity; however, patient in severe distress will seek the position that most eases breathing. Supporting arms/legs with table, pillows, and so on helps reduce muscle fatigue and can aid chest expansion.|
|Keep environmental pollution to a minimum, e.g., dust, smoke, and feather pillows, according to individual situation.||Precipitators of allergic type of respiratory reactions that can trigger/ exacerbate onset of acute episode.|
|Encourage/ assist with abdominal or pursed-lip breathing exercises.||Provides patient with some means to cope with/ control dyspnea and reduce air-trapping.|
|Observe characteristics of cough, e.g., persistent, hacking, moist. Assist with measures to improve effectiveness of cough effort.||Cough can be persistent but ineffective, especially if patient is elderly, acutely ill, or debilitated. Coughing is most effective in an upright or in a head-down position after chest percussion.|
|Increase fluid intake to 3000 mL/day within cardiac tolerance. Provide warm/ tepid liquids. Recommend intakeof fluids between, instead of during, meals.||Hydration helps decrease the viscosity of secretions, facilitating expectoration. Using warm liquids may decrease bronchospasm. Fluids during meals can increase gastric distension and pressure on the diaphragm.|
|Monitor/ graph serial ABGs, pulse oximetry, chest x-ray.||Establishes baseline for monitoring progression/ regression of disease process and complications. Note: Pulse oximetry readings detect changes in saturation as they are happening, helping to identify trends before patient is symptomatic. However, studies have shown that the accuracy of pulse oximetry may be questioned if patient has severe peripheral vasoconstriction.|
Impaired Gas Exchange
NURSING DIAGNOSIS: Impaired Gas Exchange
May be related to
- Altered oxygen supply (obstruction of airways by secretions, bronchospasm; air-trapping)
- Alveoli destruction
Possibly evidenced by
- Confusion, restlessness
- Inability to move secretions
- Abnormal ABG values (hypoxia and hypercapnia)
- Changes in vital signs
- Reduced tolerance for activity
- Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within patient’s normal range and be free of symptoms of respiratory distress.
- Participate in treatment regimen within level of ability/situation.
|Assess respiratory rate, depth. Note use of accessory muscles, pursed-lip breathing, inability to speak/ converse.||Useful in evaluating the degree of respiratory distress and/or chronicity of the disease process.|
|Elevate head of bed, assist patient to assume position to ease work of breathing. Include periods of time in prone position as tolerated. Encourage deep-slow or pursed-lip breathing as individually needed/ tolerated.||Oxygen delivery may be improved by upright position and breathing exercises to decrease airway collapse, dyspnea, and work of breathing. Note: Recent research supports use of prone position to increase Pao2.|
|Assess/ routinely monitor skin and mucous membrane color.||Cyanosis may be peripheral (noted in nailbeds) or central (noted around lips/or earlobes). Duskiness and central cyanosis indicate advanced hypoxemia.|
|Encourage expectoration of sputum; suction when indicated.||Thick, tenacious, copious secretions are a major source of impaired gas exchange in small airways. Deep suctioning may be required when cough is ineffective for expectoration of secretions.|
|Auscultate breath sounds, noting areas of decreased airflow and/or adventitious sounds.||Breath sounds may be faint because of decreased airflow or areas of consolidation. Presence of wheezes may indicate bronchospasm/ retained secretions. Scattered moist crackles may indicate interstitial fluid/ cardiac decompensation.|
|Palpate for fremitus.||Decrease of vibratory tremors suggests fluid collection or air-trapping.|
|Monitor level of consciousness/ mental status. Investigate changes.||Restlessness and anxiety are common manifestations of hypoxia. Worsening ABGs accompanied by confusion/ somnolence are indicative of cerebral dysfunction due to hypoxemia.|
|Evaluate level of activity tolerance. Provide calm, quiet environment. Limit patient’s activity or encourage bed/chair rest during acute phase. Have patient resume activity gradually and increase as individually tolerated.||During severe/ acute/ refractory respiratory distress, patient may be totally unable to perform basic self-care activities because of hypoxemia and dyspnea. Rest interspersed with care activities remains an important part of treatment regimen. An exercise program is aimed at increasing endurance and strength without causing severe dyspnea and can enhance sense of well-being.|
|Evaluate sleep patterns, note reports of difficulties and whether patient feels well rested. Provide quiet environment, group care/ monitoring activities to allow periods of uninterrupted sleep; limit stimulants, e.g., caffeine; encourage position of comfort.||Multiple external stimuli and presence of dyspnea may prevent relaxation and inhibit sleep.|
|Monitor vital signs and cardiac rhythm.||Tachycardia, dysrhythmias, and changes in BP can reflect effect of systemic hypoxemia on cardiac function.|
NURSING DIAGNOSIS: Nutrition: imbalanced, less than body requirements
May be related to
- Dyspnea; sputum production
- Medication side effects; anorexia, nausea/vomiting
Possibly evidenced by
- Weight loss; loss of muscle mass, poor muscle tone
- Reported altered taste sensation; aversion to eating, lack of interest in food
- Display progressive weight gain toward goal as appropriate.
- Demonstrate behaviors/lifestyle changes to regain and/or maintain appropriate weight.
|Assess dietary habits, recent food intake. Note degree of difficulty with eating. Evaluate weight and body size (mass).||Patient in acute respiratory distress is often anorectic because of dyspnea, sputum production, and medications. In addition, many COPD patients habitually eat poorly, even though respiratory insufficiency creates a hypermetabolic state with increased caloric needs. As a result, patient often is admitted with some degree of malnutrition. People who have emphysema are often thin with wasted musculature.|
|Auscultate bowel sounds.||Diminished/ hypoactive bowel sounds may reflect decreased gastric motility and constipation (common complication) related to limited fluid intake, poor food choices, decreased activity, and hypoxemia.|
|Give frequent oral care, remove expectorated secretions promptly, provide specific container for disposal of secretions and tissues.||Noxious tastes, smells, and sights are prime deterrents to appetite and can produce nausea and vomiting with increased respiratory difficulty.|
|Encourage a rest period of 1 hr before and after meals. Provide frequent small feedings.||Helps reduce fatigue during mealtime, and provides opportunity to increase total caloric intake.|
|Avoid gas-producing foods and carbonated beverages.||Can produce abdominal distension, which hampers abdominal breathing and diaphragmatic movement and can increase dyspnea.|
|Avoid very hot or very cold foods.||Extremes in temperature can precipitate/ aggravate coughing spasms.|
|Weigh as indicated.||Useful in determining caloric needs, setting weight goal, and evaluating adequacy of nutritional plan. Note: Weight loss may continue initially, despite adequate intake, as edema is resolving.|
|Administer supplemental oxygen during meals as indicated.||Decreases dyspnea and increases energy for eating, enhancing intake.|
Risk for Infection
NURSING DIAGNOSIS: Risk for Infection
Risk factors may include
- Inadequate primary defenses (decreased ciliary action, stasis of secretions)
- Inadequate acquired immunity (tissue destruction, increased environmental exposure)
- Chronic disease process
- Verbalize understanding of individual causative/risk factors.
- Identify interventions to prevent/reduce risk of infection.
- Demonstrate techniques, lifestyle changes to promote safe environment.
|Monitor temperature.||Fever may be present because of infection and/or dehydration.|
|Review importance of breathing exercises, effective cough, frequent position changes, and adequate fluid intake.||These activities promote mobilization and expectoration of secretions to reduce risk of developing pulmonary infection.|
|Observe color, character, odor of sputum.||Odorous, yellow, or greenish secretions suggest the presence of pulmonary infection.|
|Demonstrate and assist patient in disposal of tissues and sputum. Stress proper handwashing (nurse and patient), and use gloves when handling/ disposing of tissues, sputum containers.||Prevents spread of fluid-borne pathogens.|
|Monitor visitors; provide masks as indicated.||Reduces potential for exposure to infectious illnesses, e.g., upper respiratory infection (URI).|
|Encourage balance between activity and rest.||Reduces oxygen consumption/ demand imbalance, and improves patient’s resistance to infection, promoting healing.|
|Discuss need for adequate nutritional intake.||Malnutrition can affect general well-being and lower resistance to infection.|
|Recommend rinsing mouth with water and spitting, not swallowing, or use of spacer on mouthpiece of inhaled corticosteroids.||Reduces localized immunosuppressive effect of drug and risk of oral candidiasis.|
|Obtain sputum specimen by deep coughing or suctioning for Gram’s stain, culture/ sensitivity.||Done to identify causative organism and susceptibility to various antimicrobials.|
|Administer antimicrobials as indicated.||May be given for specific organisms identified by culture and sensitivity, or be given prophylactically because of high risk.|
NURSING DIAGNOSIS: Knowledge Deficit
May be related to
- Lack of information/unfamiliarity with information resources
- Information misinterpretation
- Lack of recall/cognitive limitation
Possibly evidenced by
- Request for information
- Statement of concerns/misconception
- Inaccurate follow-through of instructions
- Development of preventable complications
- Verbalize understanding of condition/disease process and treatment.
- Identify relationship of current signs/symptoms to the disease process and correlate these with causative factors.
- Initiate necessary lifestyle changes and participate in treatment regimen.
|Explain/reinforce explanations of individual disease process. Encourage patient/SO to ask questions.||Decreases anxiety and can lead to improved participation in treatment plan.|
|Instruct/reinforce rationale for breathing exercises, coughing effectively, and general conditioning exercises.||Pursed-lip and abdominal/ diaphragmatic breathing exercises strengthen muscles of respiration, help minimize collapse of small airways, and provide the individual with means to control dyspnea. General conditioning exercises increase activity tolerance, muscle strength, and sense of well-being.|
|Stress importance of oral care/ dental hygiene.||Decreases bacterial growth in the mouth, which can lead to pulmonary infections.|
|Discuss importance of avoiding people with active respiratory infections. Stress need for routine influenza/ pneumococcal vaccinations.||Decreases exposure to and incidence of acquired acute URIs.|
|Discuss individual factors that may trigger or aggravate condition, e.g., excessively dry air, wind, environmental temperature extremes, pollen, tobacco smoke, aerosol sprays, air pollution. Encourage patient/ SO to explore ways to control these factors in and around the home and work setting.||These environmental factors can induce/ aggravate bronchial irritation, leading to increased secretion production and airway blockage.|
|Review the harmful effects of smoking, and advise cessation of smoking by patient and/or SO.||Cessation of smoking may slow/ halt progression of COPD. Even when patient wants to stop smoking, support groups and medical monitoring may be needed. Note:Research studies suggest that “side-stream” or “second-hand” smoke can be as detrimental as actually smoking.|
|Provide information about activity limitations and alternating activities with rest periods to prevent fatigue; ways to conserve energy during activities (e.g., pulling instead of pushing, sitting instead of standing while performing tasks); use of pursed-lip breathing, side-lying position, and possible need for supplemental oxygen during sexual activity.||Having this knowledge can enable patient to make informed choices/ decisions to reduce dyspnea, maximize activity level, perform most desired activities, and prevent complications.|
|Discuss importance of medical follow-up care, periodic chest x-rays, sputum cultures.||Monitoring disease process allows for alterations in therapeutic regimen to meet changing needs and may help prevent complications.|
|Review oxygen requirements/ dosage for patient who is discharged on supplemental oxygen. Discuss safe use of oxygen and refer to supplier as indicated.||Reduces risk of misuse (too little/too much) and resultant complications. Promotes environmental/ physical safety.|
|Instruct patient/SO in use of NIPPV as appropriate. Problem-solve possible side effects and identify adverse signs/ symptoms, e.g., increased dyspnea, fatigue, daytime drowsiness, or headaches on awakening.||NIPPV may be used at night/ periodically during day to decrease CO2 level, improve quality of sleep, and enhance functional level during the day. Signs of increasing CO2 level indicate need for more aggressive therapy.|
|Instruct asthmatic patient in use of peak flow meter, as appropriate.||Peak flow level can drop before patient exhibits any signs/ symptoms of asthma during the “first time” after exposure to a trigger. Regular use of the peak flow meter may reduce the severity of the attack because of earlier intervention.|
|Provide information/ encourage participation in support groups, e.g., American Lung Association, public health department.||These patients and their SOs may experience anxiety, depression, and other reactions as they deal with a chronic disease that has an impact on their desired lifestyle. Support groups and/ or home visits may be desired or needed to provide assistance, emotional support, and respite care.|
|Refer for evaluation of home care if indicated. Provide a detailed plan of care and baseline physical assessment to home care nurse as needed on discharge from acute care.||Provides for continuity of care. May help reduce frequency of rehospitalization.|
|Discuss respiratory medications, side effects, adverse reactions.||Frequently these patients are simultaneously on several respiratory drugs that have similar side effects and potential drug interactions. It is important that patient understand the difference between nuisance side effects (medication continued) and untoward or adverse side effects (medication possibly discontinued/ dosage changed).|
|Demonstrate technique for using a metered-dose inhaler (MDI), such as how to hold it, taking 2–5 min between puffs, cleaning the inhaler.||Proper administration of drug enhances delivery and effectiveness.|
|Devise system for recording prescribed intermittent drug/ inhaler usage.||Reduces risk of improper use/ overdosage of prn medications, especially during acute exacerbations, when | cognition may be impaired.|
|Recommend avoidance of sedative antianxiety agents unless specifically prescribed/ approved by physician treating respiratory condition.||Although patient may be nervous and feel the need for sedatives, these can depress respiratory drive and protective cough mechanisms. Note: These drugs may be used prophylactically when patient is unable to avoid situations known to increase stress/ trigger respiratory response.|
Other Possible Nursing Diagnoses
- Self-Care deficit, specify—intolerance to activity, decreased strength/endurance, depression, severe anxiety.
- Home Maintenance, ineffective—intolerance to activity, inadequate support system, insufficient finances, unfamiliarity with neighborhood resources.
- Infection, risk for—decreased ciliary action, stasis of secretions, tissue destruction, increased environmental exposure,chronic disease process, malnutrition.