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 patient response and therapy needs can be similar, asthma has been included in this plan of care.
Asthma:Also known as chronic reactive airway disease, asthma is characterized by reversible inflammation and constriction of bronchial smooth muscle, hypersecretion of mucus, and edema. Precipitating factors include allergens, emotional upheaval, cold weather, exercise, chemicals, medications, and viral infections.
Chronic bronchitis:
Widespread inflammation of airways with narrowing or blocking of airways, increased production of mucoid sputum, and marked cyanosis.
Emphysema: Most severe form of COPD, characterized by recurrent inflammation that damages and eventually destroys alveolar walls to create large blebs or bullae (air spaces) and collapsed bronchioles on expiration (air-trapping).
Note: Chronic bronchitis and emphysema coexist in many patients and are most commonly seen in hospitalized COPD patients when acute exacerbations occur. Chronic bronchitis and emphysema are usually irreversible, although some effects can be mediated.
CARE SETTING
Primarily community level; however, severe exacerbations may necessitate emergency and/or inpatient stay.
RELATED CONCERNS
Heart failure: chronic
Pneumonia: microbial
Psychosocial aspects of care
Ventilatory assistance (mechanical)
Surgical intervention
Patient 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, 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, body odor
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 alpha1-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, 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)
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 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.
DIAGNOSTIC STUDIES
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.
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.
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, 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, body odor
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 alpha1-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, 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)
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 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.
DIAGNOSTIC STUDIES
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.
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.
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