All respiratory diseases characterized by chronic obstruction to airflow fall under the broad classification of COPD, also known as chronic airflow limitations (CAL). COPD is a condition of chronic dyspnea with expiratory airflow limitation that does not significantly fluctuate. Within that broad category, the primary cause of the obstruction may vary; examples include airway inflammation, mucous plugging, narrowed airway lumina, or airway destruction. The term COPD includes chronic bronchitis and emphysema. Although asthma also involves airway inflammation and periodic narrowing of the airway lumina (hyperreactivity), the condition is the result of individual response to a wide variety of stimuli/triggers and is therefore episodic in nature with fluctuations/exacerbations of symptoms. Because client response and therapy needs can be similar, asthma has been included in this plan of care.
Asthma: Sometimes called chronic reactive airway disease, asthma is a chronic inflammatory disorder characterized by episodic exacerbations of reversible inflammation and constriction of bronchial smooth muscle, hypersecretion of mucus, and edema. Precipitating factors include allergens (e.g., foods, animals, latex, plants, molds), emotional upheaval, air pollution, cold weather, exercise, chemicals, medications, and viral infections. The prevalence of asthma is rising, accounting for the sixth most common chronic disease in the United States.
Chronic bronchitis: Widespread inflammation of airways with narrowing or blocking of airways, increased production of mucous sputum (productive cough), 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). Clinically, emphysema typically presents with nonproductive or minimally productive cough and progressive dyspnea.
Note: Chronic bronchitis and emphysema coexist in many clients and are most commonly seen in hospitalized COPD clients when acute exacerbations occur. Chronic bronchitis and emphysema are usually irreversible, although some effects can be mediated.
COPD, or chronic obstructive pulmonary (PULL-mun-ary) disease, is a progressive disease that makes . In chronic obstructive bronchitis, the lining of the . ->
COPD - Chronic Obstructive Pulmonary Disease - symptoms, causes, and .
Learn about COPD - Chronic Obstructive Pulmonary Disease which is primarily two related diseases - chronic bronchitis and emphysema. ->Lung diseases - COPD - What is COPD? : Canadian Lung Association
The Canadian Lung Association - asthma, COPD, tuberculosis, sleep apnea, emphysema, . What is COPD? COPD stands for Chronic Obstructive Pulmonary Disease. . ->
Chronic Obstructive Pulmonary Disease (COPD) -- familydoctor.org
Information about chronic obstructive pulmonary disease (COPD) from the . What is chronic obstructive pulmonary disease? What are the symptoms of COPD? . ->
Chronic Obstructive Pulmonary Disease, THE MERCK MANUAL OF HEALTH & AGING
Chronic Obstructive Pulmonary Disease. Chronic Obstructive Pulmonary Disease. Chronic obstructive pulmonary disease (COPD) is the collective name for two . ->
COPD - What is COPD - Chronic Obstructive Pulmonary Disease Emphysema
Chronic Obstructive Pulmonary Disease, otherwise known as COPD is a blanket term that covers both chronic bronchitis and emphysema. ->
Chronic obstructive pulmonary disease - Wikipedia, the free encyclopedia
People who have chronic obstructive pulmonary disease (COPD) usually have some . Next Article: Chronic Obstructive Pulmonary Disease (COPD) Topics. Overview . ->
Care Setting
Primarily community level; however, severe exacerbations may necessitate emergency and/or inpatient hospital stay.
Related Concerns
Heart failure: chronic
Pneumonia: microbial
Psychosocial aspects of care
Ventilatory assistance (mechanical
Surgical intervention
Client Assessment Database
Activity/Rest
May report: Fatigue, exhaustion, malaise
Inability to perform basic activities of daily living (ADLs) because of breathlessness
Inability to sleep, need to sleep sitting up
Dyspnea at rest or in response to activity or exercise
May exhibit: Fatigue
Restlessness, insomnia
General debilitation/loss of muscle mass
Circulation
May report: Swelling of lower extremities
May exhibit: Elevated blood pressure (BP)
Elevated heart rate/severe tachycardia, dysrhythmias
Distended neck veins (advanced disease)
Dependent edema, may not be related to heart disease
Faint heart sounds (due to increased anteroposterior [AP] chest diameter)
Skin color/mucous membranes may be pale or bluish/cyanotic, clubbing of nails and peripheral cyanosis, pallor (can indicate anemia)
Ego Integrity
May report: Increased stress factors
Changes in lifestyle
Feelings of hopelessness, loss of interest in life
May exhibit: Anxious, fearful, irritable behavior, emotional distress
Apathy, change in alertness, dull affect, withdrawal
Food/Fluid
May report: Nausea (side effect of medication/mucus production)
Poor appetite/anorexia (emphysema)
Inability to eat because of respiratory distress
Persistent weight loss, decreased muscle mass/subcutaneous fat (emphysema) or weight gain may reflect edema (bronchitis, prednisone use)
May exhibit: Poor skin turgor
Dependent edema
Diaphoresis
Abdominal palpation may reveal hepatomegaly (bronchitis)
Hygiene
May report: Decreased ability/increased need for assistance with ADLs
May exhibit: Poor hygiene
Respiration
May report: Variable levels of dyspnea, such as insidious and progressive onset (predominant symptom in emphysema), especially on exertion; seasonal or episodic occurrence of breathlessness (asthma); sensation of chest tightness, inability to breathe (asthma); chronic “air hunger”
Persistent cough with sputum production (gray, white, or yellow), which may be copious (chronic bronchitis); intermittent cough episodes, usually nonproductive in early stages, although they may become productive (emphysema); paroxysms of cough (asthma)
History of recurrent pneumonia, long-term exposure to chemical pollution/respiratory irritants (e.g., cigarette smoke), or occupational dust/fumes (e.g., cotton, hemp, asbestos, coal dust, sawdust)
Familial and hereditary factors; i.e., deficiency of α1-antitrypsin (emphysema)
Use of oxygen at night or continuously
May exhibit: Respirations: Usually rapid, may be shallow; prolonged expiratory phase with grunting, pursed-lip breathing (emphysema)
Assumption of three-point (“tripod”) position for breathing (especially with acute exacerbation of chronic bronchitis)
Use of accessory muscles for respiration; e.g., elevated shoulder girdle, retraction of supraclavicular fossae, flaring of nares
Chest may appear hyperinflated with increased AP diameter (barrel-shaped), minimal diaphragmatic movement
Breath sounds may be faint with expiratory wheezes (emphysema); scattered, fine, or coarse moist crackles (bronchitis); rhonchi, wheezing throughout lung fields on expiration, and possibly during inspiration, progressing to diminished or absent breath sounds (asthma)
Percussion may reveal hyperresonance over lung fields (e.g., air-trapping with emphysema) or dullness over lung fields (e.g., consolidation, fluid, mucus)
Difficulty speaking sentences of more than four or five words at one time, loss of voice
Color: Pallor with cyanosis of lips, nail beds; overall duskiness; ruddy color (chronic bronchitis, “blue bloaters”); normal skin color despite abnormal gas exchange and rapid respiratory rate (moderate emphysema, known as “pink puffers”)
Clubbing of fingernails (not characteristic of emphysema and if present should alert clinician to another condition; e.g., pulmonary fibrosis, cystic fibrosis, lung cancer or asbestosis)
Safety
May report: History of allergic reactions or sensitivity to substances/environmental factors
Recent/recurrent infections
Flushing/perspiration (asthma)
Sexuality
May report: Decreased libido
Social Interaction
May report: Dependent relationship(s)
Insufficient support from/to partner/significant other (SO), lack of support systems
Prolonged disease or disability progression
May exhibit: Inability to converse/maintain voice because of respiratory distress
Limited physical mobility
Neglectful relationships with other family members
Inability to perform/inattention to employment responsibilities, absenteeism/confirmed disability
Teaching/Learning
May report: Use/misuse of respiratory drugs
Use of herbal supplements (e.g., astragalus, coleus, echinacea, elderberry, elencampe, ephedra, garlic, ginkgo, horehound, licorice, marshmallow, mullein, onion, tumeric, goldenseal, Oregon graperoot, wild cherry bark, peppermint, hyssop)
Smoking/difficulty stopping smoking, chronic exposure to second-hand smoke, smoking substances other than tobacco
Regular use of alcohol
Failure to improve over long period of time
Discharge plan
considerations: Changes in medication/therapeutic treatments, use of supplemental oxygen, ventilator support; end-of-life issues
Refer to section at end of plan for postdischarge considerations.
Diagnostic Studies
Chest x-ray: May reveal hyperinflation of lungs with increased anterior-posterior (AP) diameter, 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: Spirometry is an established method of measuring lung function, recommended for diagnosis and management of persons with COPD, those at risk of COPD, and follow-up of persons with documented COPD 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.
Tidal volume (VT): Decreased VT may indicate restrictive disease.
Minute volume (MV): Decreased MV may indicate pulmonary edema; increased MV can occur with acidosis, increased CO2, decreased Pao2 ,and low compliance states.
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. Measurements done pre and postbronchodilator help to distinguish obstructive disease (COPD) from restrictive disease (asthma).
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.
Thoracic gas volume (TCV): Increased TCV indicates air-trapping such as might occur with COPD. Body plethysmography may be used to measure pressure and flow or volume changes (e.g., TCV, airway resistance, and conductance).
Maximal voluntary ventilation (MVV), also known as maximum breathing capacity: Decreased in obstructive disease and normal or decreased in restrictive disease.
DLCO: 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.
Arterial blood gases (ABGs): Determines degree and severity of disease process, e.g., most often Pao2 is 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).
Pulse Oximetry: A continuous noninvasive study of arterial blood oxygen diffusion and saturation using a clip or probe attached to a sensor site (usually fingertip or earlobe). The percentage expressed is the ratio of oxygen to hemoglobin. Abnormally low levels (Peak Expiratory Flow (PEFor PEFR): Noninvasive meter used by client to monitor disease status by assessing speed at which air is forced out of lungs after deep inhalation.
Bronchogram: Can show cylindrical dilation of bronchi on inspiration, bronchial collapse on forced expiration (emphysema), enlarged mucous ducts (bronchitis).
Lung scan: Perfusion scanning can confirm vascular obstruction such as pulmonary or septic emboli. Ventilation studies may be done to differentiate between the various pulmonary diseases, such as PE, atelectasis, obstruction, tumors and COPD. 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). WBCs can be elevated in severe respiratory infection.
Blood chemistry: α1-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: May be done for evaluation of hypoxemia and/or desaturation in the presence of dyspnea, known pulmonary disease, abnormal diagnostic tests (e.g., diffusing capacity). Helps in assessing degree of pulmonary dysfunction, evaluating effectiveness of bronchodilator therapy, planning/evaluating exercise program.
Nursing Priorities
1. Maintain airway patency.
2. Assist with measures to facilitate gas exchange.
3. Enhance nutritional intake.
4. Prevent complications, slow progression of condition.
5. Provide information about disease process/prognosis and treatment regimen.
Discharge Goals
1. Ventilation/oxygenation adequate to meet self-care needs.
2. Nutritional intake meeting caloric needs.
3. Infection treated/prevented.
4. Disease process/prognosis and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.
NURSING DIAGNOSIS
NURSING DIAGNOSIS: ineffective Airway Clearance
May be related to
Bronchospasm
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
DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:
Respiratory Status: Airway Patency (NOC)
Maintain patent airway with breath sounds clear/clearing.
Demonstrate behaviors to improve airway clearance; e.g., cough effectively and expectorate secretions.
| ACTIONS/INTERVENTIONS | RATIONALE |
| Airway Management (NIC)
Independent Auscultate breath sounds. Note adventitious breath sounds; e.g., wheezes, crackles, rhonchi.
Assess/monitor respiratory rate. Note inspiratory/expiratory ratio.
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. Assist client to assume position of comfort; e.g., elevate head of bed, have client lean on overbed table or sit on edge of bed.
Keep environmental pollution to a minimum (e.g., dust, smoke, and feather pillows), according to individual situation. Encourage/assist with abdominal or pursed-lip breathing exercises.
Observe characteristics of cough; e.g., persistent, hacking, moist. Assist with measures to improve effectiveness of cough effort.
Increase fluid intake to 3000 mL/day within cardiac tolerance. Provide warm/tepid liquids. Recommend intake of fluids between instead of during meals
| 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).
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.
Respiratory dysfunction is variable depending on the underlying process; e.g., infection, allergic reaction, and the stage of chronicity in a client 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.
Elevation of the head of the bed facilitates respiratory function by use of gravity; however, client 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.
Precipitators of allergic type of respiratory reactions that can trigger/exacerbate onset of acute episode.
Provides client with some means to cope with/control dyspnea and reduce air- trapping. Cough can be persistent but ineffective, especially if client is elderly, acutely ill, or debilitated. Coughing is most effective in an upright or in a head-down position after chest percussion.
Hydration helps decrease the viscosity of secretions, facilitating expectoration. Using warm liquids may decrease bronchospasm. Fluids during meals can increase gastric distention and pressure on the diaphragm |
| Collaborative
Administer medications as indicated: β-Agonists: epinephrine (Adrenalin, AsthmaNefrin, Primatene, Sus-Phrine); albuterol (Proventil, Velmax,Ventolin, AccuNeb, Airet); formoterol (Foradil); levalbuterol (Xopenex); metaproterenol (Alupent): pirbuterol (Maxair): salmeterol, terbutaline (Brethine); salmeterol (Serevent);
Bronchodilators; e.g., anticholinergic agents: ipratropium (Atrovent);
Leukotriene antagonists: montelukast (Singulair); zafirlukast (Accolate); zileuton (Zyflo);
Anti-inflammatories: oral, IV, and inhaled steroids; e.g., prednisone (Cordrol, Deltasone, Pred-Pak, Liquid Pred), methylprednisolone (Medrol), dexamethasone (Decadron), beclomethasone (Beclovent, Vanceril), budesonide (Pulmacort), fluticasone (Flovent), triamcinolone (Azmacort);
Antimicrobials; |
Inhaled β2-adrenergic agonists are first-line therapies for rapid symptomatic improvement of bronchoconstriction. These medications relax smooth muscles and reduce local congestion, reducing airway spasm, wheezing, and mucus production. Medications may be oral, injected, or inhaled. Inhalation by metered- dose inhaler (MDI) with a spacer is recommended, but medications may be nebulized in the event client has severe coughing or is too dyspneic to retain a puff effectively.
Inhaled anticholinergic agents are now considered the first-line drugs for clients with stable COPD because studies indicate they have a longer duration of action with less toxicity potential, whereas still providing the effective relief of the β-agonists. Some of these medications are available in combinations; e.g., Albuterol and Atrovent are available as Combivent. Reduce leukotriene activity to limit inflammatory response. In mild to moderate asthma, reduces need for inhaled β2-agonists and systemic corticosteroids. Not effective in acute exacerbations because there is no bronchodilator effect. Note: This drug class is not recommended for clients with COPD because of insufficient testing. Decrease local airway inflammation and edema by inhibiting effects of histamine and other mediators, to reduce severity and frequency of airway spasm, respiratory inflammation, and dyspnea. Studies have shown benefits of systemic steroids in the management of COPD exacerbations. Inhaled steroids may serve as a systemic steroid-sparing agent. Various antimicrobials may be indicated for control of bacterial exacerbations of COPD; e.g., pneumonia. Refer to CP, Pneumonia, microbial, page 000.)
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| Methylxanthine derivatives; e.g., aminophylline, oxtriphylline (Choledyl), theophylline (Bronkodyl, Theo-Dur, Elixophyllin, Slo-Bid, Slo-Phyllin);
Analgesics, cough suppressants, or antitussives; e.g., codeine, dextromethorphan products (Benylin DM, Comtrex, Novahistine);
Artificial surfactant; e.g., colfosceril palmitate (Exosurf).
Provide supplemental humidification; e.g., ultrasonic nebulizer, aerosol room humidifier.
Assist with respiratory treatments; e.g., spirometry, chest physiotherapy.
Monitor/graph serial ABGs, pulse oximetry, chest x-ray. | Decrease mucosal edema and smooth muscle spasm (bronchospasm) by indirectly increasing cyclic adenosine monophosphate (AMP). May also reduce muscle fatigue/respiratory failure by increasing diaphragmatic contractility. Use of theophylline may be of little or no benefit in the presence of adequate β-agonist regimen; however, it may sustain bronchodilation because effect of β-agonist diminishes between doses. Note: Theophylline products are used with less frequency now and are shied away from in older clients because of their potentially adverse cardiovascular effects. Persistent, exhausting cough may need to be suppressed to conserve energy and permit client to rest. Note: Regular use of antitussives is not recommended in COPD since cough can have a significant protective effect. Research suggests aerosol administration may enhance expectoration of sputum, improve pulmonary function, and reduce lung volumes (air trapping). Humidity helps reduce viscosity of secretions, facilitating expectoration, and may reduce/prevent formation of thick mucous plugs in bronchioles. Breathing exercises help enhance diffusion; aerosol/nebulizer medications can reduce bronchospasm and stimulate expectoration. Postural drainage and percussion enhance removal of excessive/sticky secretions and improve ventilation of bottom lung segments. Note: Chest physiotherapy may aggravate bronchospasm in asthmatics. 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 possibly before client is symptomatic. However, studies have shown that the accuracy of pulse oximetry may be questioned if client has severe peripheral vasoconstriction. |
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
Dyspnea
Confusion, restlessness
Inability to move secretions
Abnormal ABG values (hypoxia and hypercapnia)
Changes in vital signs
Reduced tolerance for activity
DESIRED OUTCOMES/EVALUATION CRITERIA—-CLIENT WILL:
Respiratory Status: Gas Exchange (NOC)
Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within client’s normal range and be free of symptoms of respiratory distress.Participate in treatment regimen within level of ability/situation.
| INTERVENTIONS | RATIONALE |
| Acid/Base Management (NIC)
Independent
Assess respiratory rate, depth. Note use of accessory muscles, pursed-lip breathing, and inability to speak/converse. Elevate head of bed, assist client 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. Assess/routinely monitor skin and mucous membrane color.
Encourage expectoration of sputum; suction when indicated.
Auscultate breath sounds, noting areas of decreased airflow and/or adventitious sounds.
Palpate for fremitus.
Monitor level of consciousness/mental status. Investigate changes.
Evaluate level of activity tolerance. Provide calm, quiet environment. Limit client’s activity or encourage bed/chair rest during acute phase. Have client resume activity gradually and increase as individually tolerated.
Evaluate sleep patterns, note reports of difficulties and whether client 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.
Monitor vital signs and cardiac rhythm | Useful in evaluating the degree of respiratory distress and/or chronicity of the disease process. 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. Cyanosis may be peripheral (noted in nail beds) or central (noted around lips/or earlobes). Duskiness and central cyanosis indicate advanced hypoxemia. 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. 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.
Decrease of vibratory tremors suggests fluid collection or air trapping.
Restlessness and anxiety are common manifestations of hypoxia. Worsening ABGs accompanied by confusion/somnolence are indicative of cerebral dysfunction due to hypoxemia. During severe/acute/refractory respiratory distress, client 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 improving aerobic capacity and functional performance, increasing endurance and strength without causing severe dyspnea and can enhance sense of well-being.
Multiple external stimuli and presence of dyspnea and/or hypoxemia may prevent relaxation and inhibit sleep.
Tachycardia, dysrhythmias, and changes in blood pressure (BP) can reflect effect of systemic hypoxemia on cardiac function. |
| Collaborative Monitor/graph serial ABGs and pulse oximetry.
Administer supplemental oxygen judiciously, using appropriate delivery method (e.g., cannula, mask, mechanical ventilator) and titrate as indicated by ABG results and client tolerance.
Administer antianxiety, sedative, or narcotic agents (e.g., morphine) with caution.
Assist with noninvasive (or nasal intermittent) positive-pressure ventilation (NIPPV) or intubation, institution/maintenance of mechanical ventilation; transfer to critical care area depending on client directives.
Prepare for additional referrals/interventions; e.g., pulmonary specialist, pulmonary rehabilitation program, surgical intervention, as appropriate. |
PaCO2 usually elevated (bronchitis, emphysema), and PaO2 is generally decreased, so that hypoxia is present in a greater or lesser degree. Note: A “normal” or increased PaCO2 signals impending respiratory failure for asthmatics.
Used to correct/prevent worsening of hypoxemia, improve survival, and quality of life. Supplemental oxygen can be provided during exacerbations only, or as a long-term therapy.
May be used to reduce dyspnea by controlling anxiety and restlessness, which increases oxygen consumption/demand, exacerbating dyspnea. Must be monitored closely because depressive effect may lead to respiratory failure. Development of/impending respiratory failure requires prompt life-saving measures. Note: NIPPV provides ventilatory support by means of positive pressure typically through a nasal mask. It may be useful in the home setting as well to treat chronic respiratory failure or limit acute exacerbations in clients who are able to maintain spontaneous respiratory effort. May be indicated to confirm diagnosis and optimize appropriate treatment. A multidisciplinary approach including education. Exercise training may be helpful in improving client function and quality of life. Screened candidates (those with severe dyspnea/end-stage emphysema with FEV1 (forced expiratory volume in 1 second) less than 35% of the predicted value despite maximal medical therapy, with the ability to complete preoperative pulmonary rehabilitation programs) may benefit from lung volume reduction surgery (LVRS) in which hyperinflated giant bullae/cysts are removed; e.g., those occupying at least one-third of the involved lobe, or areas of lung tissue with small cystic disease. In the absence of fibrosis, this procedure removes ineffective lung tissue, allowing for better lung expansion and elastic recoil, enhanced blood flow to healthy tissues (correction of ventilation-perfusion mismatch), improved respiratory muscle efficiency, and increased venous return to the right ventricle.
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NURSING DIAGNOSIS: imbalanced Nutrition: less than body requirements
May be related to
Dyspnea, sputum production
Medication side effects; anorexia, nausea/vomiting
Fatigue
Possibly evidenced by
Weight loss, loss of muscle mass, poor muscle tone
Reported altered taste sensation, aversion to eating, lack of interest in food
DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:
Nutritional Status (NOC)
Display progressive weight gain toward goal as appropriate.
Demonstrate behaviors/lifestyle changes to regain and/or maintain appropriate weight.
INTERVENTIONS
Nutrition Therapy (NIC)
Independent
Assess dietary habits, recent food intake. Note degree of difficulty with eating. Evaluate weight and body size (mass).
Auscultate bowel sounds.
Give frequent oral care, remove expectorated secretions promptly, provide specific container for disposal of secretions and tissues.
Encourage a rest period of 1 hr before and after meals. Provide frequent small feedings.
Avoid gas-producing foods and carbonated beverages.
Avoid very hot or very cold foods.
RATIONALE
Client in acute respiratory distress is often anorectic because of dyspnea, sputum production, and medication effects. In addition, many COPD clients habitually eat poorly even though respiratory insufficiency creates a hypermetabolic state with increased caloric needs. As a result, client often is admitted with some degree of malnutrition. People who have emphysema are often thin with wasted musculature.
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.
Noxious tastes, smells, and sights are prime deterrents to appetite and can produce nausea and vomiting with increased respiratory difficulty.
Helps reduce fatigue during mealtime, and provides opportunity to increase total caloric intake.
Can produce abdominal distention, which hampers abdominal breathing and diaphragmatic movement and can increase dyspnea.
Extremes in temperature can precipitate/aggravate coughing spasms.
NURSING DIAGNOSIS: deficient Knowledge [Learning Need] regarding condition, treatment, self-care, and discharge needs
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
DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT WILL:
Knowledge: Illness Care (NOC)
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
INTERVENTIONS
Teaching: Disease Process (NIC)
Independent
Explain/reinforce explanations of individual disease process, including factors that lead to exacerbation episodes. Encourage client/significant other (SO) to ask questions.
Discuss self-management plan:
Avoidance of triggers, and education regarding zones as appropriate;
Review breathing exercises, coughing effectively, and general conditioning exercises;
Regular oral care/dental hygiene;
Importance of avoiding people with active respiratory infections. Stress need for routine influenza/pneumococcal vaccinations;
Identify individual environmental factors that may trigger or aggravate condition; e.g., excessively dry air, wind, environmental temperature extremes, pollen, tobacco smoke, aerosol sprays, air pollution. Encourage client/SO to explore ways to control these factors in and around the home and work setting.
RATIONALE
Understanding decreases anxiety and can lead to improved participation in treatment plan.
Avoiding triggers (e.g., known allergens, environmental temperature extremes, chemical products and fumes) is important in the self-management of asthma and in the prevention of acute exacerbations. Zones may be divided into green (peak expiratory flow rate [PEFR] 80%–100% and no breathing difficulty), yellow (PEFR 50%–80% of baseline and some difficulty breathing with wheezing and coughing), and red (PEFR<50% baseline and does not respond to inhaled bronchodilators).
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 paced conditioning exercises (carried out regularly and perhaps timed with activity soon after taking medication or breathing treatments) can increase activity tolerance, muscle strength, and sense of well-being/quality of life.
Decreases bacterial growth in the mouth, which can lead to pulmonary infections.
Decreases exposure to and incidence of acquired acute upper respiratory diseases (URIs).
These can induce/aggravate bronchial irritation, leading to increased secretion production and airway blockage.
| Review the harmful effects of smoking, and strongly advise cessation of smoking by client and/or SO. Provide information regarding smoking cessation recourses (e.g., QUITLINES, support groups, nicotine substitutes). Provide information about benefits of regular exercise while addressing individual activity limitations.
Discuss importance of regular medical follow-up care, when to notify healthcare professional of changes in condition, and periodic spirometry testing, chest x-rays, sputum cultures. Review oxygen requirements/dosage for client who is discharged on supplemental oxygen. Discuss safe use of oxygen and refer to supplier as indicated. Instruct client/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. Instruct asthmatic client in use of peak flow meter as appropriate.
Provide information/encourage participation in support groups; e.g., American Lung Association, public health department.
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. Assist client/SO in making arrangements for access to emergency assistance (e.g., buddy system for getting help quickly, special phone numbers, “panic button”). Facilitate discussion about healthcare directives, end-of-life wishes as indicated. | Cessation of smoking may slow/halt progression of COPD. Even when client 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. Having this knowledge can enable client/SO to make informed choices/decisions to reduce client’s dyspnea, maximize functional level, perform most desired activities, and prevent complications. This may include alternating activities with rest periods to prevent fatigue, learning 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).
Monitoring disease process allows for alterations in therapeutic regimen to meet changing needs and may help prevent complications. Reduces risk of misuse (too little/too much) and resultant complications. Promotes environmental/physical safety.
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. Peak flow level can drop before client 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. These clients 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. Provides for continuity of care. May help reduce frequency of rehospitalization.
Client with chronic respiratory condition should have access to prompt assistance when needed. This is both necessary and psychologically comforting for self-management. Although many clients have an interest in discussing living wills, their wishes may be unspoken. In client with severe pulmonary disease, it is helpful to discuss specific treatment preferences (e.g., aggressive treatment, home care only, hospitalization for comfort care, full life support). It is useful also to discuss the goals of care (e.g., functional independence or continuation of life support in an extended care nursing facility). |
| Teaching: Disease Process (NIC)
Discuss respiratory medications, side effects, drug interactions, adverse reactions.
Demonstrate correct technique for using a MDI, such as how to hold it, pausing 2–5 min between puffs, cleaning the inhaler. Devise system for recording prescribed intermittent drug/inhaler usage.
Discuss use of herbals, especially when client is on multiple respiratory medications.
Recommend avoidance of sedative antianxiety agents unless specifically prescribed/approved by physician treating respiratory condition. |
Frequently these clients are simultaneously on several respiratory drugs that have similar side effects and potential drug interactions. It is important that client understand the difference between nuisance side effects (medication continued) and untoward or adverse side effects (medication possibly discontinued/dosage changed). Proper administration of drug enhances delivery and effectiveness.
Reduces risk of improper use/overdosage of prn medications, especially during acute exacerbations, when cognition may be impaired. Many interactions can occur between herbals and medications used to treat respiratory disorders. Although most herbals do not have dangerous side effects, effects can be dangerous or lethal if combined with other substances or when taken in larger doses (e.g., ephedra should only be used in very small doses and for a short time; ecchinacea can alter the actions of a variety of drugs, and is not recommended for persons with HIV infection, multiple sclerosis (MS), and other auto immune disorders). Although client 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 client is unable to avoid situations known to increase stress/trigger respiratory response. |
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