Primarily community level; however, severe exacerbations may necessitate emergency and/or inpatient stay.
- Heart failure: chronic
- Pneumonia: microbial
- Psychosocial aspects of care
- Ventilatory assistance (mechanical)
- Surgical intervention
- Patient Assessment Database
- 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
- Restlessness, insomnia
- General debilitation/loss of muscle mass
Swelling of lower extremities
- 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)
- Increased stress factors
- Changes in lifestyle
- Feelings of hopelessness, loss of interest in life
- Anxious, fearful, irritable behavior, emotional distress
- Apathy, dull affect, withdrawal
- 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)
- Poor skin turgor
- Dependent edema
- Abdominal palpation may reveal hepatomegaly (bronchitis)
Decreased ability/increased need for assistance with ADLs
Poor hygiene, body odor
- 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 alpha1-antitrypsin (emphysema)
- Use of oxygen at night or continuously
- 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, nailbeds; 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 (emphysema)
- History of allergic reactions or sensitivity to substances/environmental factors
- Recent/recurrent infections
- Flushing/perspiration (asthma)
- Dependent relationship(s)
- Insufficient support from/to partner/significant other (SO); lack of support systems
- Prolonged disease or disability progression
- 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
- Use/misuse of respiratory drugs Smoking/difficulty stopping smoking; chronic exposure to second-hand smoke, smoking substances other than tobacco
- Regular use of alcohol
- Failure to improve
Discharge plan consideration:
- DRG projected mean length of inpatient stay: 5.2 days
- Episodic or long-term assistance with shopping, transportation, self-care needs, homemaker/home maintenance tasks
- Changes in medication/therapeutic treatments, use of supplemental oxygen, ventilator support
- Refer to section at end of plan for postdischarge considerations.
- 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 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).
- 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.