Nursing Care Plans Pneumothorax

Definition of Pneumothorax (collapsed lung), Pneumothorax is is defined as the presence of air in the pleural space. Air in the pleural space occurring spontaneously or from trauma. In patients with chest trauma, it is usually the result of a laceration to the lung parenchyma, tracheobronchial tree, or esophagus. The patient’s clinical status depends on the rate of air leakage and size of wound. The amount of air or gas trapped in the intrapleural space determines the degree of lung collapse. 

Classification of Pneumothorax 

• Spontaneous Pneumothorax sudden onset of air in the pleural space with deflation of the affected lung in the absence of trauma. 
• Open Pneumothorax (sucking wound of chest) implies an opening in the chest wall large enough to allow air to pass freely in and out of thoracic cavity with each attempted respiration. 
• Tension Pneumothorax buildup of air under pressure in the pleural space resulting in interference with filling of both the heart and lungs. 
• Traumatic Pneumothorax; Traumatic Pneumothorax may result from insertion of a central venous line, thoracic surgery, or a penetrating chest injury, such as a gunshot or knife wound, or it may follow a transbronchial biopsy. It may also occur during thoracentesis or a closed pleural biopsy. When traumatic Pneumothorax follows a penetrating chest injury, hemothorax (blood in the pleural space) may also occur. 

Other classification of Pneumothorax : Primary spontaneous Pneumothorax Secondary spontaneous Pneumothorax Iatrogenic Pneumothorax Traumatic Pneumothorax 

Clinical Manifestations of Pneumothorax Hyperresonance; 

diminished breath sounds. Reduced mobility of affected half of thorax. Tracheal deviation away from affected side in tension pneumothorax Clinical picture of open or tension pneumothorax is one of air hunger, agitation, hypotension, and cyanosis Mild to moderate dyspnea and chest discomfort may be present with spontaneous pneumothorax 

Pneumothorax Etiology 

Primary spontaneous: rupture of pleural blebs typically occurs in young people without parenchymal lung disease or occurs in the absence of traumatic injury to the chest or lungs Secondary spontaneous: occurs in the presence of lung disease, primarily emphysema, but can also occur with tuberculosis (TB), sarcoidosis, cystic fibrosis, malignancy, and pulmonary fibrosis Iatrogenic: complication of medical or surgical procedures, such as therapeutic thoracentesis, tracheostomy, pleural biopsy, central venous catheter insertion, positive pressure mechanical ventilation, inadvertent intubation of right mainstem bronchus Traumatic: most common form of pneumothorax and hemothorax, caused by open or closed chest trauma related to blunt or penetrating injuries 

Complications 

Acute respiratory failure. Cardiovascular collapse with tension Pneumothorax Hypoxemia 

Pneumothorax Treatment. 

Treatment is conservative for spontaneous pneumothorax in which no signs of increased pleural pressure appear (indicating tension Pneumothorax), lung collapse is less than 30%, and the patient shows no signs of Dyspnea or other indications of physiologic compromise. Such treatment consists of bed rest, careful monitoring of blood pressure, pulse rate, and respirations, oxygen administration, and needle aspiration. If more than 30% of the lung is collapsed, treatment to reexpand the lung includes placing a thoracostomy tube in the second or third intercostal space in the midclavicular line, connected to an underwater seal or low-pressure suction. Oxygen therapy and mechanical ventilation are prescribed as needed. Surgical interventions include removing the penetrating object, exploratory thoracotomy if necessary, thoracentesis, and thoracotomy for patients with two or more episodes of spontaneous pneumothorax or patients with pneumothorax that does not resolve within 1 week. 

Spontaneous Pneumothorax 

Treatment is generally nonoperative if Pneumothorax is not too extensive; Observe and allow for spontaneous resolution for less than 50% pneumothorax in otherwise healthy person, Needle aspiration or chest tube drainage may be necessary to achieve reexpansion of collapsed lung if greater than 30% pneumothorax. Surgical intervention by pleurodesis or thoracotomy with resection of apical blebs is advised for patients with recurrent spontaneous pneumothorax. 

Tension Pneumothorax Immediate decompression to prevent cardiovascular collapse by thoracentesis or chest tube insertion to let air escape. Chest tube drainage with underwater-seal suction to allow for full lung expansion and healing 

Open Pneumothorax

Close the chest wound immediately to restore adequate ventilation and respiration. Patient is instructed to inhale and exhale gently against a closed glottis (Valsalva maneuver) as a pressure dressing (petroleum gauze secured with elastic adhesive) is applied. This maneuver helps to expand collapsed lung. Chest tube is inserted and water-seal drainage set up to permit evacuation of fluid/air and produce reexpansion of the lung. Surgical intervention may be necessary to repair trauma. Recurring spontaneous pneumothorax treated by instilling a sclerosing agent through a thoracostomy tube or during thoracostomy. Thoracotomy and pleurectomy are other procedures that prevent recurrence by causing the lung to adhere to the parietal pleura. Traumatic and tension pneumothoraces require chest tube drainage. Traumatic Pneumothorax may also require surgical repair. 

Nursing Assessment 

Patient History, Obtain history for chronic respiratory disease, trauma, and onset of symptoms. The patient history reveals sudden, sharp, pleuritic pain. The patient may report that chest movement, breathing, and coughing exacerbate the pain. He may also report shortness of breath. Ask about chest pain; determine its onset, intensity, and location. Ask if the patient has shortness of breath or difficulty in breathing or fatigue. Elicit a history of COPD or emphysema or if the patient has had a thoracotomy, thoracentesis, or insertion of a central line. Ask if the patient smokes cigarettes For patients who have experienced chest trauma, establish a history of the mechanism of injury by including a detailed report from the prehospital professionals, witnesses, or significant others. Specify the type of trauma (blunt or penetrating). Physical Examination The severity of the symptoms depends on the extent of any underlying disease and the amount of air in the pleural space. Examine the patient’s chest for a visible wound that may have been caused by a penetrating object. Patients with an open Pneumothorax also exhibit a sucking sound on inspiration. Inspection typically reveals asymmetrical chest wall movement with overexpansion and rigidity on the affected side. The patient may appear cyanotic. In tension pneumothorax, he may have distended neck veins and pallor, and he may exhibit anxiety. Observe whether the patient has a flail chest. Examine the thorax area, including the anterior chest, posterior chest, and axillae, for contusions, abrasions, hematomas, and penetrating wounds. Note that even small penetrating wounds can be life-threatening if vital structures are perforated. Observe the patient carefully for pallor. Take the patient’s blood pressure and pulse rate, noting the early signs of shock or massive bleeding, such as a falling pulse pressure, a rising pulse rate, and delayed capillary refill. Continue to monitor the vital signs frequently during periods of instability to determine changes in the condition or the development of complications. Palpation, note any tracheal deviation toward the unaffected side, subcutaneous emphysema (also known as crepitus; a dry, crackling sound caused by air trapped in the subcutaneous tissues), or decreased to absent tactile fremitus over the affected area. Percussion may elicit a hyperresonant or tympanitic sound. Auscultation reveals decreased or absent breath sounds over the affected area and no adventitious sounds other than a possible pleural rub. Auscultate chest for diminished breath sounds and percuss for hyperresonance. Percussion may reveals hyperresonance on the affected side 

Diagnostic Test For Pneumothorax 

Blood Tests Arterial blood gases (ABGs): Measures oxygen and carbon dioxide levels to rule out hypoxemia or hypercapnia. Hemoglobin/hematocrit (Hgb/Hct): Assesses relationship of red blood cells (RBCs) to fluid volume or viscosity. Other Diagnostic Studies Chest x-ray: Evaluates organs or structures within the chest and is the initial study of choice in blunt force chest trauma. Thoracic computed tomography (CT): Enhance anatomic views of the chest and locates abnormalities. Early CT may influence therapeutic management. Thoracic ultrasound: Assists in determining abnormalities in the chest. Thoracentesis: Performed to relieve the intrathoracic pressure due to accumulation of fluid in the pleural space. 

Nursing diagnosis Pneumothorax 

Common Nursing Diagnosis That Could Be Found In Patient with Pneumothorax: 

Ineffective Breathing Pattern Risk for Trauma/Suffocation Deficient Knowledge [Learning Need] regarding condition, treatment regimen, self-care, and discharge needs Acute pain Anxiety Fear Impaired gas exchange related to decreased oxygen diffusion capacity Ineffective coping Ineffective tissue perfusion: Cardiopulmonary Risk for infection 

Nursing Interventions Nursing Diagnosis Ineffective Breathing Pattern 

Respiratory Monitoring 

Identify etiology or precipitating factors, such as spontaneous collapse, trauma, malignancy, infection, and complication of mechanical ventilation. Evaluate respiratory function, noting rapid or shallow respirations, Dyspnea, reports of “air hunger,” development of cyanosis, and changes in vital signs. Monitor for synchronous respiratory pattern when using mechanical ventilator. Note changes in airway pressures. Auscultate breath sounds. Note chest excursion and position of trachea. Assess fremitus. 

Ventilation Assistance 

Assist client with splinting painful area when coughing, or during deep breathing. Maintain position of comfort, usually with head of bed elevated. Turn to affected side. Encourage client to sit up as much as possible. Maintain a calm attitude, assisting client to “take control” by using slower, deeper respirations. 

Tube Care: Chest

If thoracic catheter is disconnected or dislodged: Observe for signs of respiratory distress. If possible, reconnect thoracic catheter to tubing and suction, using clean technique. If the catheter is dislodged from the chest, cover insertion site immediately with petrolatum dressing and apply firm pressure. Notify physician at once. After thoracic catheter is removed: Cover insertion site with sterile occlusive dressing. Observe for signs or symptoms that may indicate recurrence of pneumothorax, such as shortness of breath and reports of pain. Inspect insertion site, noting character of drainage. 

Ventilation Assistance 

Monitor and graph serial ABGs and pulse oximetry. Review vital capacity and tidal volume measurements. Administer supplemental oxygen via cannula, mask, or mechanical ventilation, as indicated. Administer analgesics and sedatives, as indicated. 

Complete Sample Nursing Care Plans for Pneumothorax

Nursing Diagnosis	Intervention	Rational	Evaluation (Expected Out Come)
Ineffective Breathing Pattern related to : Decreased lung expansion due to air or fluid accumulation Musculoskeletal impairment Pain and anxiety Inflammatory process	Respiratory Monitoring        1.      Identify etiology or precipitating factors, such as spontaneous collapse, trauma, malignancy, infection, and complication of mechanical ventilation.       2.      Evaluate respiratory function, noting rapid or shallow respirations, dyspnea, reports of “air hunger,” development of cyanosis, and changes in vital signs.        3.      Monitor for synchronous respiratory pattern when using mechanical ventilator. Note changes in airway pressures.       4.      Auscultate breath sounds.       5.      Note chest excursion and position of trachea.       6.      Assess fremitus. Ventilation Assistance 1.     Assist client with splinting painful area when coughing, or during deep breathing. 2.     Maintain position of comfort, usually with head of bed elevated. Turn to affected side. Encourage client to sit up as much as possible. 3.     Maintain a calm attitude, assisting client to “take control” by using slower, deeper respirations. Tube Care: Chest 1.    If thoracic catheter is disconnected or dislodged: Observe for signs of respiratory distress. If possible, reconnect thoracic catheter to tubing and suction, using clean technique. If the catheter is dislodged from the chest, cover insertion site immediately with petrolatum dressing and apply firm pressure. Notify physician at once. 2.    After thoracic catheter is removed: Cover insertion site with sterile occlusive dressing. Observe for signs or symptoms that may indicate recurrence of pneumothorax, such as shortness of breath and reports of pain. Inspect insertion site, noting character of drainage. Ventilation Assistance 1.    Monitor and graph serial ABGs and pulse oximetry. Review vital capacity and tidal volume measurements.  2.    Administer supplemental oxygen via cannula, mask, or  mechanical ventilation, as indicated. 3.    Administer analgesics and sedatives, as indicated.	1.        Understanding the cause of lung collapse is necessary for proper chest tube placement and choice of other therapeutic measures.  2.        Respiratory distress and changes in vital signs occur because of physiological stress and pain or may indicate development of shock due to hypoxia or hemorrhage. 3.        Difficulty breathing with ventilator or increasing airway pressures suggests worsening of condition and development of complications, such as spontaneous rupture of a bleb creating a new pneumothorax. 4.        Breath sounds may be diminished or absent in a lobe, lung segment, or entire lung field (unilateral). Atelectatic area will have no breath sounds, and partially collapsed areas have decreased sounds. Regularly scheduled evaluation also helps determine areas of good air exchange and provides a baseline to evaluate resolution of  pneumothorax. 5.        Chest excursion is unequal until lung reexpands. Trachea deviates from affected side with tension pneumothorax. 6.        Voice and tactile fremitus (vibration) is reduced in fluid-filled or consolidated tissue.  1.        Supporting chest and abdominal muscles makes coughing more effective and less traumatic. 2.        Promotes maximal inspiration; enhances lung expansion and ventilation in unaffected side. 3.        Assists client to deal with the physiological effects of hypoxia, which may be manifested as anxiety or fear.    1.         Pneumothorax may recur, requiring prompt intervention to prevent fatal pulmonary and circulatory impairment.    2.        Early detection of a developing complication, such as recurrence of pneumothorax or presence of infection, is essential.         1.      Assesses status of gas exchange and ventilation and need for continuation or alterations in therapy.         2.      Aids in reducing work of breathing; promotes relief of respiratory distress and cyanosis associated with hypoxemia.     3.      Given to manage pleuritic pain and reduce anxiety and tachycardia associated with impaired respiratory function, especially when client is on a ventilator.	Establish a normal and effective respiratory pattern with ABGs within client’s normal range. Be free of cyanosis and other signs or symptoms of hypoxia.
Risk for Trauma/Suffocation	Teaching: Procedure/Treatment 1.    Review with client purpose and function of CDU, taking note of safety features. 2.    Instruct client to refrain from lying or pulling on tubing. 3.     Identify changes and situations that should be reported to caregivers, such as change in sound of bubbling, sudden “air hunger” and chest pain, and disconnection of equipment. Tube Care: Chest 1.    Anchor thoracic catheter to chest wall and provide extra length of tubing before turning or moving client. 2.    Secure tubing connection sites. Pad banding sites with gauze or tape. 3.    Secure drainage unit to client’s bed or on stand or cart placed in low-traffic area. 4.    Provide safe transportation if client is sent off unit for diagnostic purposes. Before transporting, check water-seal chamber for correct fluid level; presence or absence of bubbling; and presence, degree, and timing of tidaling. Ascertain whether chest tube can be clamped or disconnected from suction source. 5.    Monitor thoracic insertion site, noting condition of skin and presence and characteristics of drainage from around the catheter. 6.    Change and reapply sterile occlusive dressing as needed. 7.    Observe for signs of respiratory distress if thoracic catheter is disconnected or dislodged.	1.      Information on how system works provides reassurance, reducing client anxiety. 2.        Reduces risk of obstructing drainage or inadvertently disconnecting tubing. 3.        Timely intervention may prevent serious complications. 1.        Prevents thoracic catheter dislodgment or tubing disconnection and reduces pain and discomfort associated with pulling or jarring of tubing. 2.        Prevents tubing disconnection. 3.        Protects skin from irritation and pressure. 4.        Maintains upright position and reduces risk of accidental tipping and breaking of unit. 5.        Promotes continuation of optimal evacuation of fluid or air during transport. If client is draining large amounts of chest fluid or air, tube should not be clamped or suction interrupted because of risk of accumulating fluid or air, compromising respiratory status. 6.        Provides for early recognition and treatment of developing skin or tissue erosion or infection. 7.        Pneumothorax may recur or worsen, compromising respiratory function and requiring emergency intervention.	Correct and avoid environmental and physical hazards.
Deficient Knowledge [Learning Need] regarding condition, treatment regimen, self-care, and discharge needs related to Lack of exposure to information	Teaching: Disease Process 1.    Review pathology of individual problem. 2.    Identify likelihood for recurrence or long-term complications. 3.    Review signs and symptoms requiring immediate medical evaluation, for example, sudden chest pain, dyspnea, air hunger, and progressive respiratory distress.  4.    Review significance of good health practices, such as adequate nutrition, rest, and exercise. 5.    Emphasize need for smoking cessation when indicated.	1.      Information reduces fear of unknown. Provides knowledge base for understanding underlying dynamics of condition and significance of therapeutic interventions.       2.      Certain underlying lung diseases, such as severe COPD and malignancies, may increase incidence of recurrence. In otherwise healthy clients who suffered a spontaneous pneumothorax, incidence of recurrence is 10% to 50%.Those who have a second spontaneous episode are at high risk for a third incident (60%). 3.        Recurrence of pneumothorax and hemothorax requires medical intervention to prevent and reduce potential complications. 4.        Maintenance of general well-being promotes healing and may prevent or limit recurrences. 5.        Prevents recurrence of pneumothorax or respiratory complications, such as fibrotic changes.	Verbalize understanding of cause of problem (when known). Identify signs or symptoms requiring medical follow-up. Follow therapeutic regimen and demonstrate lifestyle changes, if necessary, to prevent recurrence.

Patient teaching Discharge and home healthcare guidance for patient with Pneumothorax;

Review all follow-up appointments, which often involve chest x-rays, arterial blood gas analysis, and a physical exam. Refer for counseling, if necessary. Teach the patient when to notify the physician of complications and to report any sudden chest pain or difficulty breathing 

• Reassure the patient. Explain what Pneumothorax is, what causes it, and all diagnostic tests and procedures. 
• If the patient is having surgery or chest tubes inserted, explain why he needs these procedures. Reassure him that the chest tubes are inserted to make him more comfortable. 
• Encourage the patient to perform deep-breathing exercises every hour when awake. 
• Discuss the potential for recurrent spontaneous Pneumothorax, and review its signs and symptoms. Emphasize the need for immediate medical intervention if these should occur. 
• Instruct patient to continue use of the incentive spirometer at home. 
• For patients with spontaneous Pneumothorax, there is an increased risk for repeat occurrence; therefore, encourage these patients to report sudden Dyspnea immediately.

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Nursing care plans Chronic Obstructive Pulmonary Disease (COPD)

Chronic Obstructive Pulmonary Disease (COPD) is a disease state characterized by airflow limitation that is not fully reversible, sometimes referred to as chronic airway obstruction or chronic obstructive lung disease. The airflow limitation is generally progressive and is normally associated with an inflammatory response of the lungs due to irritants. COPD includes chronic bronchitis and pulmonary emphysema. Chronic bronchitis is a chronic inflammation of the lower respiratory tract characterized by excessive mucous secretion, cough, and Dyspnea associated with recurring infections of the lower respiratory tract. Pulmonary emphysema is a complex lung disease characterized by destruction of the alveoli, enlargement of distal airspaces, and a breakdown of alveolar walls. There is a slowly progressive deterioration of lung function for many years before the development of illness. 

Clinical Manifestations 

Chronic Bronchitis (usually insidious, developing over a period of years) : 

• Presence of a productive cough lasting at least 3 months a year for 2 successive years. 
• Production of thick, gelatinous sputum; greater amounts produced during superimposed infections. 
• Wheezing and dyspnea as disease progresses 

Emphysema (Gradual in onset and steadily progressive): 

• Dyspnea, decreased exercise tolerance. 
• Cough may be minimal, except with respiratory infection. 
• Sputum expectoration mild. 
• Increased anteroposterior diameter of chest (barrel chest) due to air trapping with diaphragmatic flattening. 

Causes

The etiology of Chronic Obstructive Pulmonary Disease COPD includes:

• Cigarette smoking. 
• Air pollution, occupational exposure. 
• Allergy, autoimmunity.
• Infection. 
• Genetic predisposition, aging. 

Etiology of emphysema includes: 

Exposure to tobacco smoke due to smoking preventable cause Secondhand smoke or passive smoking: nitric oxide, component of smoke, is a potent bronchodilator Ambient air pollution Alpha 1 -antitrypsin deficiency: genetic abnormality accounts for less than 1% of Chronic Obstructive Pulmonary Disease (COPD) 

Etiology of chronic bronchitis includes: 

Exposure to tobacco smoke due to cigarette smoking Secondhand smoke or passive smoking Ambient air pollution and occupational irritants Sex, race, and socioeconomic status: higher prevalence of respiratory symptoms in men, higher mortality rates in whites, and higher morbidity and mortality in blue-collar workers. Occupational dusts and chemicals: vapors, irritants and fumes, particulate matter, organic dust 

Complications 

Dyspnea Cor pulmonale Respiratory failure Pneumothorax Bronchiectasis: recurrent bouts of bronchitis Decreased quality of life and functional status Decreased independence due to difficulty breathing and increased oxygen demands resulting in fatigue Assistance with activities of daily living (ADLs) as disease progresses Pneumonia, overwhelming respiratory infection. Right-sided heart failure, Dysrhythmias Depression Skeletal muscle dysfunction 

Stages of COPD Based on the Global Initiative for Chronic Obstructive Lung Disease

Stage	Degree of COPD	Status of Airflow Post bronchodilator FEV1 (forced expiratory volume in 1 second)
0	At Risk	normal spirometry chronic symptoms cough and sputum production
I	Mild COPD	FEV 1/ FVC < 70%, FEV1 ≥ 80% predicted with or without chronic symptoms
II	Moderate COPD	FEV 1/ FVC < 70%, 50% ≤ FEV1 < 80% predicted with or without chronic symptoms
III	Severe COPD	FEV 1 / FVC < 70%, 30% ≤ FEV 1 or < 50% predicted plus respiratory failure or right heart failure
IV	Very Severe COPD	FEV 1 / FVC < 70% FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure

Treatment for Chronic Obstructive Pulmonary Disease (COPD)

Treatment for Chronic Obstructive Pulmonary Disease (COPD) is designed to relieve symptoms and prevent complications. Because most COPD patients receive outpatient treatment, they need comprehensive patient teaching to help them comply with therapy and understand the nature of this chronic, progressive disease. If programs in pulmonary rehabilitation are available, encourage the patient to enroll.

If the patient is to continue oxygen therapy at home, teach the patient how to use the equipment correctly. Patients with COPD rarely require more than 3 L/minute to maintain adequate oxygenation. Higher flow rates will further increase the partial pressure of arterial oxygen, but patients whose ventilatory drive is largely based on hypoxemia commonly develop a markedly increased partial pressure of arterial carbon dioxide. In such patients, chemoreceptors in the brain are relatively insensitive to the increase in carbon dioxide.

Treatment for Chronic Obstructive Pulmonary Disease (COPD) includes:

Smoking cessation. Inhaled bronchodilators reduce Dyspnea and bronchospasm; delivered by metered dose inhalers (MDI) or handheld or mask nebulizer devices. Methylxanthines, such as theophylline (Theo-Dur), given orally as sustained-release formulation for chronic maintenance therapy (less commonly used). Inhaled corticosteroids are recommended for patients with symptomatic COPD with documented spirometric improvement from glucocorticosteroids, or in those with an FEV1 that is less than 50% of the predicted value and repeated exacerbations requiring treatment with antibiotics and/or oral glucocorticosteroids. Antibiotics help treat respiratory tract infections. Pneumococcal vaccination and annual influenza vaccinations are important preventive measures. Oral corticosteroids are used in acute exacerbations for anti-inflammatory effect; may also be given I.V. in severe cases. Chest physical therapy, including postural drainage for secretion clearance and breathing retraining for improved ventilation and control of dyspnea. Supplemental oxygen therapy for patients with hypoxemia. CO2 must be monitored to determine increased CO2 retention. Pulmonary rehabilitation to improve function, strength, symptom control, disease self-management techniques, independence, and quality of life. Antimicrobial agents for episodes of respiratory infection. Lung volume reduction surgery is under investigation for treatment of heterogeneous emphysema. Treatment for alpha1-antitrypsin deficiency: Prevent damage to lungs by quitting smoking. Lung transplantation may be considered for people with severely disabling alphaantitrypsin disease.

Nursing Assessment

The typical patient with Chronic Obstructive Pulmonary Disease (COPD), have a long-term cigarette smoker, remains asymptomatic until middle age. His ability to exercise or do strenuous work gradually starts to decline, and he begins to develop a productive cough. These signs are subtle at first, but become more pronounced as the patient gets older and the disease progresses. Eventually the patient may develop Dyspnea on minimal exertion, frequent respiratory infections, intermittent or continuous hypoxemia, and grossly abnormal pulmonary function studies.

Patient History: Exposure to risk factors Past medical history including asthma, allergy sinusitis, or nasal polyps Family history of COPD or other chronic respiratory disease Chronic cough: length of time, daily or intermittent, seldom noc turnal Chronic sputum production: characteristics of sputum, change with the season amount produced Dyspnea that is progressive, persistent, worse with exercise, worse during respiratory infections History of exposure to tobacco smoke, occupational dusts and chemicals, smoke from home cooking and heating fuels Smoking history: pack years (number of packs per day multiplied by number of years smoking) Age when fi rst noticed symptoms Current functional status and ability to perform ADLs Limitation of activities Pneumonia and other respiratory illnesses Use of oxygen: liter flow and years of usage Weight loss or weight gain Sleep pattern and position during sleep: number of pillows used

Physical Examination Potential abnormal physical exam findings (will vary based on severity of illness): Assessment of severity based on level of symptoms Severity of spirometric abnormalities Characteristics of respiratory pattern: rate, depth, symmetry, and synchrony; breathlessness due to airway narrowing and bronchoconstriction Use of pursed lip breathing Breath sounds: normal and adventitious: crackles, rhonchi and wheezes; hyperresonant lung fields; may be distant due to hyperinflation Cough due to increased sputum production: usually worse in the morning Sputum production: color, amount; usually increased with chronic bronchitis Shortness of breath with speech: two or three words per breath Dyspnea on exertion Barrel chest as a result of increased RV Use of accessory muscles Resting pulse oximetry with potential drop with activity Presence of complications such as respiratory failure and right heart failure Cor pulmonale: right-sided heart failure to include edema, heart rate, blood pressure, jugular venous pressure (JVP) Check for presence of murmurs, gallops, rubs, lifts, heaves, and/or thrills Fluid retention and edema Overall appearance: thin with muscle wasting and barrel chest or overweight with barrel chest Enlarged abdominal girth or cachetic appearance Enlarged liver with right-sided heart failure Posture: hunched over with rolled shoulders Pallor skin color Generalized edema

Diagnostic Test

Chest X-ray: air trapping; hyperinfl ation; increased A-P diameter; flattened diaphragms Postbronchodilator FEV 1 Pulmonary function test: show decreased FEV 1 (up to 50% loss) and decreased FEF 25%–75%; increased functional residual capacity (FRC) due to air trapping and hyperinflation Arterial blood gases: may show increased CO 2 due to inability to expel all of the air (air trapping) and low O 2 levels due to ventilation/ perfusion mismatch Assess Dyspnea using a valid tool such as the Modified Borg scale or the Visual Analog Scale Oxygen saturation at rest and with activity Quality-of-life measure: baseline measurement Six-minute walk distance: baseline measurement

Nursing Diagnosis

Common nursing diagnosis found in Nursing care plans for Chronic Obstructive Pulmonary Disease (COPD): Ineffective Airway Clearance related to bronchoconstriction, increased mucus production, ineffective cough, possible bronchopulmonary infection Impaired Gas Exchange related to chronic pulmonary obstruction, abnormalities due to destruction of alveolar capillary membrane Imbalanced Nutrition: Less Than Body Requirements related to increased work of breathing, air swallowing, drug effects with resultant wasting of respiratory and skeletal muscles Deficient Knowledge [Learning Need] regarding condition, treatment, self-care, and discharge needs related to lack of information or unfamiliarity with information resources, Information misinterpretation, Lack of recall or cognitive limitation

Goal

Respiratory Status: Airway Patency Effective

Nursing interventions NCP COPD:

Auscultate breath sounds. Note adventitious breath sounds such as wheezes, crackles, or rhonchi. Assess and monitor respiratory rate. Note inspiratory-toexpiratory ratio. Note presence and degree of dyspnea, for example, reports of “air hunger,” restlessness, anxiety, respiratory distress, and use of accessory muscles. Use a 0 to 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 maintain a comfortable position to facilitate breathing by elevating the head of bed, leaning on or over bed table, or sitting on edge of bed. Keep environmental pollution from sources such as dust, smoke, and feather pillows to a minimum according to individual situation. Encourage and assist with abdominal or pursed-lip breathing exercises. Observe for persistent, hacking, or moist cough. Assist with measures to improve effectiveness of cough effort. Increase fluid intake to 3,000 mL/day within cardiac tolerance. Provide warm or tepid liquids. Recommend intake of fluids between, instead of during, meals. Administer medications, as indicated indicated, for example: Beta-agonists. Provide supplemental humidification, such as ultrasonic nebulizer and aerosol room humidifier. Assist with respiratory treatments, such as spirometry and chest physiotherapy. Monitor and graph serial ABGs, pulse oximetry, and chest x-ray.

Sample Nursing care plans Chronic Obstructive Pulmonary Disease (COPD)

NURSING DIAGNOSE	INTERVENTION	RATIONALE	EVALUATION
Ineffective Airway Clearance related to bronchoconstriction, increased mucus production, ineffective cough, possible bronchopulmonary infection	·       Auscultate breath sounds. Note adventitious breath sounds such as wheezes, crackles, or rhonchi. ·       Assess and monitor respiratory rate. Note inspiratory-toexpiratory ratio. ·       Note presence and degree of dyspnea, for example, reports of “air hunger,” restlessness, anxiety, respiratory distress, and use of accessory muscles. Use a 0 to 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 maintain a comfortable position to facilitate breathing by elevating the head of bed, leaning on or over bed table, or sitting on edge of bed. ·       Keep environmental pollution from sources such as dust, smoke, and feather pillows to a minimum according to individual situation. ·       Encourage and assist with abdominal or pursed-lip breathing exercises. ·       Observe for persistent, hacking, or moist cough. Assist with measures to improve effectiveness of cough effort. ·       Increase fluid intake to 3,000 mL/day within cardiac tolerance. Provide warm or tepid liquids. Recommend intake of fluids between, instead of during, meals. ·       Administer medications, as indicated indicated, for example: Beta-agonists, such as epinephrine (Adrenalin, AsthmaNefrin, Primatene, Sus-Phrine), albuterol (Proventil, Velmax, Ventolin, AccuNeb, Airet), formoterol (Foradil), levalbuterol (Xopenex); metaproterenol (Alupent), pirbuterol (Maxair), terbutaline (Brethine), and salmeterol (Serevent) ·       Provide supplemental humidification, such as ultrasonic nebulizer and aerosol room humidifier. ·       Assist with respiratory treatments, such as spirometry and chest physiotherapy. ·       Monitor and graph serial ABGs, pulse oximetry, and chest x-ray.	·       Some degree of bronchospasm is present with obstructions in airway and may or may not be manifested in adventitious breath sounds, such as 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, during stress, or during 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; for example, infection, allergic reaction, and the stage of chronicity in a client with established COPD. ·       Elevation of the head of the bed facilitates respiratory function using gravity; however, client in severe distress will seek the position that most eases breathing. Supporting arms and 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 or exacerbate onset of acute episode. ·       Provides client with some means to cope with and 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. ·       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 puff effectively. ·       Humidity helps reduce viscosity of secretions, facilitating expectoration, and may reduce or prevent formation of thick mucous plugs in bronchioles. ·       Breathing exercises help enhance diffusion; aerosol or nebulizer medications can reduce bronchospasm and stimulate expectoration. Postural drainage and percussion enhance removal of excessive and sticky secretions and improve ventilation of bottom lung segments. Note: Chest physiotherapy may aggravate bronchospasm in asthmatics. ·       Establishes baseline for monitoring progression or regression of disease process and complications.	Maintain patent airway with breath sounds clear or clearing. Demonstrate behaviors to improve airway clearance.
Impaired Gas Exchange related to chronic pulmonary obstruction, abnormalities due to destruction of alveolar capillary membrane	·      Assess respiratory rate and depth. Note use of accessory muscles, pursed-lip breathing, and inability to speak or converse. ·      Elevate head of bed and 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 and tolerated. ·      Assess and routinely monitor skin and mucous membrane color. ·      Encourage expectoration of sputum; suction when indicated. ·      Auscultate breath sounds, noting areas of decreased airflow and adventitious sounds. ·      Palpate chest for fremitus. ·      Monitor level of consciousness and mental status. Investigate changes. ·      Evaluate level of activity tolerance. Provide calm, quiet environment. Limit client’s activity or encourage bedrest or 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 and group care and monitoring activities to allow periods of uninterrupted sleep. Limit stimulants such as caffeine. Encourage position of comfort. ·      Monitor vital signs and cardiac rhythm. ·      Monitor and graph serial ABGs and pulse oximetry. ·      Administer supplemental oxygen judiciously via nasal cannula, mask, or mechanical ventilator, and titrate as indicated by ABG results and client tolerance.	·      Useful in evaluating the degree of respiratory distress and 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 nailbeds) 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 or retained secretions. Scattered, moist crackles may indicate interstitial fluid or cardiac decompensation. ·      Decrease of vibratory tremors suggests fluid collection or airtrapping. ·      Restlessness and anxiety are common manifestations of hypoxia. Worsening ABGs accompanied by confusion and somnolence are indicative of cerebral dysfunction due to hypoxemia. ·      During severe, acute, or 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 hypoxemia may prevent relaxation and inhibit sleep. ·      Tachycardia, dysrhythmias, and changes in BP can reflect effect of systemic hypoxemia on cardiac function. ·      PaCO2 is usually elevated in bronchitis and 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 and prevent worsening of hypoxemia, improve survival, and quality of life. Supplemental oxygen can beprovided during exacerbations only, or as a long-term therapy.	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 and situation.
Imbalanced Nutrition: Less Than Body Requirements related to increased work of breathing, air swallowing, drug effects with resultant wasting of respiratory and skeletal muscles	·      Assess dietary habits, recent food intake. Note degree of difficulty with eating. Evaluate weight and body size or mass. ·      Auscultate bowel sounds. ·      Give frequent oral care, remove expectorated secretions promptly, and provide specific container for disposal of secretions and tissues. ·      Encourage a rest period of 1 hour before and after meals. Provide frequent small feedings. ·      Avoid gas-producing foods and carbonated beverages. ·      Avoid very hot or very cold foods. ·      Weigh, as indicated.	·      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 or 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 or aggravate coughing spasms. ·      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.	Display progressive weight gain toward goal as appropriate. Demonstrate behaviors and lifestyle changes to regain and maintain appropriate weight.
Deficient Knowledge [Learning Need] regarding condition, treatment, self-care, and discharge needs related to lack of information or unfamiliarity with information resources, Information misinterpretation, Lack of recall or cognitive limitation	·      Explain and reinforce explanations of individual disease process, including factors that lead to exacerbation episodes. Encourage client and SO to ask questions. ·      Identify individual environmental factors such as excessively dry air, wind, temperature extremes, pollen, tobacco smoke, aerosol sprays, and air pollution that may trigger or aggravate condition. Encourage client and SO to explore ways to control these factors in and around the home and work setting. ·      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, and sputum cultures. ·      Discuss respiratory medications, side effects, drug interactions, and adverse reactions. ·      Demonstrate correct technique for using an MDI, such as how to hold it, pausing 2 to 5 minutes between puffs, and cleaning the inhaler.	·      Understanding decreases anxiety and can lead to improved participation in treatment plan. ·      These can induce or aggravate bronchial irritation, leading to increased secretion production and airway blockage. ·      Having this knowledge can enable client and SO to make informed choices and decisions to reduce client’s dyspnea, maximize functional level, perform most desired activities, and prevent complications. ·      Monitoring disease process allows for alterations in therapeutic regimen to meet changing needs and may help prevent complications. ·      Frequently, these clients are simultaneously on several respiratory drugs that have similar side effects and potential drug interactions. It is important that the client understands the difference between nuisance side effects (medication continued) and untoward or adverse side effects (medication possibly discontinued or dosage changed). ·      Proper administration of drug enhances delivery and effectiveness.	Verbalize understanding of condition and disease process and treatment. Identify relationship of current signs and symptoms to the disease process and correlate these with causative factors. Initiate necessary lifestyle changes and participate in treatment regimen.

Most Chronic Obstructive Pulmonary Disease COPD patients receive outpatient treatment, so provide comprehensive patient teaching to help them comply with therapy and understand the nature of this chronic, progressive disease. 

Patient Teaching For Patient With Chronic Obstructive Pulmonary Disease COPD: 

General Health 

Teach the patient and his family how to recognize early signs of infection; warn the patient to avoid contact with people with respiratory infections. Encourage good oral hygiene to help prevent infection. Pneumococcal vaccination and annual influenza vaccinations are important preventive measures Help the patient and his family adjust their lifestyles to accommodate the limitations imposed by this debilitating chronic disease. Instruct the patient to allow for daily rest periods and to exercise daily as directed. Teach good habits of well-balanced, nutritious intake. Encourage high-protein diet with adequate mineral, vitamin, and fluid intake. Advise against excessive hot or cold fluids and foods, which may provoke an irritating cough. Advise to avoid hard-to-chew foods (causes tiring) and gas-forming foods, which cause distention and restrict diaphragmatic movement. Encourage five to six small meals daily to ease shortness of breath during and after meals. Suggest rest periods before and after meals if eating produces shortness of breath. Warn against potassium depletion. Patients with COPD tend to have low potassium levels; also, patient may be taking diuretics; Watch for weakness, numbness, tingling of fingers, leg cramps, Encourage foods high in potassium include bananas, dried fruits, dates, figs, orange juice, grape juice, milk, peaches, potatoes, tomatoes. Advise patient on restricting sodium as directed. Limit carbohydrates if CO2 is retained by patient, because they increase CO2. Use community resources, such as Meals On Wheels or a home care aide if energy level is low. 

Avoid Exposure to Respiratory Irritants 

Advise patient to stop smoking and avoid exposure to second-hand smoke. Advise patient to avoid sweeping, dusting, and exposure to paint, aerosols, bleaches, ammonia, and other respiratory irritants. Advise patient to keep entire house well-ventilated. Warn patient to stay out of extremely hot/cold weather to avoid bronchospasm and dyspnea. Instruct patient to humidify indoor air in winter; maintain 30% to 50% humidity for optimal mucociliary function. Suggest the use of a HEPA air cleaner to remove dust, pollen, and other particulates; this is controversial as to the benefit to the patient. 

Breathing Exercises 

Explain that goal is to strengthen and coordinate muscles of breathing to lessen work of breathing and help lung empty more completely. To promote ventilation and reduce air trapping, teach the patient to breathe slowly, prolong expirations to two to three times the duration of inspiration, and to exhale through pursed lips. Stress the importance of controlled breathing. Teach diaphragmatic breathing and pursed-lip breathing for episodes of dyspnea and stress. To help mobilize secretions, teach the patient how to cough effectively. If the patient with copious secretions has difficulty mobilizing secretions, teach his family how to perform postural drainage and chest physiotherapy. If secretions are thick, encourage the patient to drink 12 to 15 glasses of fluid per day. Encourage muscle toning by regular exercise. If the patient use oxygen therapy at home, teach him how to use the equipment correctly.

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