Surgical intervention, page 782
Client Assessment Database
A
CTIVITY/R
EST•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
C
IRCULATION•Swelling of lower extremities
E
GOI
NTEGRITY•Increased stress factors
•Changes in lifestyle
•Feelings of hopelessness, loss of interest in life
F
OOD/F
LUID•Nausea—side effect of medication or mucus production
•Poor appetite, anorexia (emphysema)
•Inability to eat because of respiratory distress
•Persistent weight loss, decreased muscle mass or subcuta-
neous fat (emphysema)
•Weight gain reflecting edema (bronchitis, prednisone use)
H
YGIENE•Decreased ability and increased need for assistance with
ADLs
R
ESPIRATION•Variable levels of dyspnea, with 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”
•Fatigue
•Restlessness, insomnia
•General debilitation or loss of muscle mass
•Elevated blood pressure (BP)
•Elevated heart rate or severe tachycardia, dysrhythmias
•Distended neck veins, with advanced disease
•Dependent edema, which may not be related to heart disease
•Faint heart sounds due to increased anteroposterior (AP) chest
diameter
•Skin color and mucous membranes may be pale or bluish and
cyanotic, clubbing of nails and peripheral cyanosis, pallor (can indicate anemia)
•Anxious, fearful, irritable behavior, emotional distress
•Apathy, change in alertness, dull affect, withdrawal
•Poor skin turgor
•Dependent edema
•Diaphoresis
•Abdominal palpation may reveal hepatomegaly
•Poor hygiene
•Respirations are usually rapid and 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
D I A G N O S T I C D I V I S I O N
M AY R E P O R T
M AY E X H I B I T
D I A G N O S T I C D I V I S I O N
M AY R E P O R T
(continued)M AY E X H I B I T
(continued)•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 or respiratory irritants, such as with cigarette smoke; or, occupational dust and fumes, such as with cotton, hemp, asbestos, coal dust, sawdust
•Familial and hereditary factors, that is, deficiency of
1-antitrypsin (emphysema)
•Use of oxygen at night or continuously
S
AFETY•History of allergic reactions or sensitivity to substances or
environmental factors
•Recent or recurrent infections
S
EXUALITY•Decreased libido
S
OCIALI
NTERACTION•Dependent relationship(s)
•Insufficient support from or to partner or significant other
(SO), lack of support systems
•Prolonged disease or disability progression
T
EACHING/L
EARNING•Use or misuse of respiratory drugs
•Use of herbal supplements, such as astragalus, coleus, echi-
nacea, elderberry, elecampe, ephedra, garlic, ginkgo, horehound, licorice, marshmallow, mullein, onion, turmeric, goldenseal, Oregon grape root, wild cherry bark, peppermint, hyssop
•Smoking or difficulty stopping smoking, chronic exposure to
secondhand smoke, smoking substances other than tobacco
•Regular use of alcohol
•Failure to improve over long period of time
D
ISCHARGEP
LANC
ONSIDERATIONS•Episodic or long-term assistance with shopping, transporta-
tion, self-care needs, homemaker or home maintenance tasks
•Changes in medication and therapeutic treatments, use of
supplemental oxygen, ventilator support; end-of-life issues
➧Refer to section at end of plan for postdischarge considerations.
•Use of accessory muscles for respiration, such as 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
(air-trapping with emphysema) or dullness over lung fields (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 (not characteristic of emphysema, and
if present, should alert clinician to another condition such as pulmonary fibrosis, cystic fibrosis, lung cancer, or asbestosis)
•Flushing, perspiration (asthma)
•Inability to converse or maintain voice because of respiratory
distress
•Limited physical mobility
•Neglectful relationships with other family members
•Inability to perform or inattention to employment responsibilities,
absenteeism, confirmed disability
Client Assessment Database
(continued)CHAPTER 5
RESPIRA
T
OR
Y—COPD AND ASTHMA
T E S T
W H Y I T I S D O N E
W H AT I T T E L L S M E
Diagnostic Studies
B
LOODT
ESTS• Arterial blood gases (ABGs):Measures oxygen and carbon dioxide levels to rule out hypoxemia or hypercapnia.
• Complete blood count (CBC) and differential:Provides baseline data about the hematologic system and yields information related to oygenation and infection.
•-1antitrypsin (A1AT):Verify deficiency of this enzyme and
diagnosis of primary emphysema.
P
ULMONARYS
TUDIES• Spirometry testing, including FVC and FEV1:Measures
lung function; recommended for diagnosis and management of persons with COPD, those at risk for COPD, and follow- up of persons with documented COPD. Used to stage COPD (GOLD, 2007).
• Total lung capacity (TLC), functional residual capacity
(FRC), and residual volume (RV):Provides information on the extent of the pulmonary abnormality and if there is air-trapping in the lungs.
• Tidal volume (VT) and minute volume (MV):Measures
respiratory function and extent of pulmonary abnormality.
• Thoracic gas volume (TCV):Measures lung volumes and diffusing capacity of the lung.
• Body plethysmography:May be used to measure pressure and flow or volume changes, such as TCV, airway resistance, and conductance.
• Diminished carbon monoxide diffusion in the lung
(DLCO):Assesses diffusion in lungs. Carbon monoxide is used to measure gas diffusion across the alveocapillary mem- brane. Because carbon monoxide combines with hemoglobin 200 times more easily than oxygen, it easily affects the alveoli and small airways where gas exchange occurs.
O
THERD
IAGNOSTICS
TUDIES• Pulse oximetry:Noninvasive measure of arterial blood oxygen diffusion and saturation.
• Chest x-ray:Evaluates organs or structures within the chest.
• Sputum culture and cytological examination:Rule out other causes of increased sputum production.
• Electrocardiogram (ECG):Record of the electrical activity of the heart, which can demonstrate conduction disturbances, enlarged heart, and chamber strain patterns.
Most often PaO2is decreased, and PaCO2is normal or increased in
chronic bronchitis and emphysema, but is often decreased in asthma; pH normal or acidotic, mild respiratory alkalosis second- ary to hyperventilation (moderate emphysema or asthma). Increased hemoglobin (advanced emphysema) and increased
eosinophils (asthma); white blood cells (WBCs) can be elevated in severe respiratory infection.
Decreased levels are seen in early onset emphysema in adults; increased levels are present in acute and chronic inflammatory disorders.
Provides information on the degree of obstruction or restriction and evaluates effects of therapy, for example, bronchodilators.
May be increased, indicating air-trapping. In obstructive lung disease, the RV will make up the greater portion of the TLC.
Decreased VTmay indicate restrictive disease. Decreased MV
may indicate pulmonary edema; increased MV can occur with
acidosis, increased CO2, decreased PaO2, and low compliance
states.
Increased TCV indicates air-trapping, such as might occur with COPD.
Measures changes in lung volumes, airway resistance, and compliance.
DLCO is seen in patients with emphysema. This helps distin- guish COPD from asthma, as DLCO is normal in patients with asthma.
The percentage expressed is the ratio of oxygen to hemoglobin. Abnormally low levels (<88%) indicate impaired gas exchange and impending respiratory failure.
May reveal hyperinflation of lungs with increased AP diameter, flattened diaphragm, increased retrosternal air space, decreased vascular markings/bullae (emphysema), increased bronchovas- cular markings (bronchitis), and normal findings during periods of remission (asthma).
Determines presence of infection and identifies pathogen, if present. Cytological examination may reveal a malignancy or allergic disorder.
Right axis deviation and peaked P waves are seen in severe asthma. Atrial dysrhythmias may be present in bronchitis. Tall, peaked P waves in leads II, III, AVF may be present in bronchitis or emphysema. Vertical QRS axis may be present in emphysema.