Asthma:Chronic, reversible inflammation of the airways caused by a reaction of the airways to various stimuli.
BODE Index:A validated grading system designed to predict the risk of death from COPD based on the four factors for which
G L O S S A R Y
it was named: BMI, obstruction, dyspnea, and exercise. (Celli et al, 2004).
CAT (COPD Assessment Test) Score:Range from 0 to 40. Rep- resents disease impact; score less than 10 equals low impact;
CHAPTER 5RESPIRATORY—COPD AND ASTHMA
Care Setting
Primarily community level; however, severe exacerbations may necessitate emergency or inpatient hospital stay.
Related Concerns
Heart failure: chronic, page 43 Pediatric considerations, page 872 Pneumonia, page 129
Psychosocial aspects of care, page 729 Surgical intervention, page 762
Ventilatory assistance (mechanical), page 157
greater than 10 equals high impact A change of score of twoor more points is considered clinically significant.
Chronic bronchitis:Inflammation and scarring of the lining of the bronchi.
Chronic obstructive pulmonary disease (COPD):Disease state characterized by an airflow limitation that is not fully
G L O S S A R Y
(continued)reversible. It is usually progressive and associated with an ab- normal inflammatory response to noxious particles or gases.
Emphysema:Destruction of the alveoli, which leads to overdis- tention of the air spaces. Damage is irreversible.
FEV1:Forced expired volume in 1 second.
FVC:Forced vital capacity.
Client Assessment Database
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
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 subcutaneous fat (emphysema)
•Weight gain reflecting edema (bronchitis, prednisone use)
H
YGIENE•Decreased ability and increased need for assistance with ADLs
•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
M AY E X H I B I T
(continues on page 120)
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)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”
•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, Echinacea
•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
•Respirations are usually rapid and may be shallow:
• Prolonged expiratory phase with grunting, pursed-lip breath- ing (emphysema)
• Assumption of three-point (“tripod”) position for breathing—
especially with acute exacerbation of chronic bronchitis
•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 ab- sent breath sounds (asthma)
•Percussion may reveal hyperresonance over lung fields (air- trapping with emphysema) or dullness over lung fields (consoli- dation, 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 responsibili- ties, absenteeism, confirmed disability
M AY E X H I B I T
(continued)Client Assessment Database
(continued)CHAPTER 5RESPIRATORY—COPD AND ASTHMA
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)D
ISCHARGEP
LANC
ONSIDERATIONS•Episodic or long-term assistance with shopping, transportation, self-care needs, homemaker or home maintenance tasks
•Changes in medication and therapeutic treatments, use of sup- plemental oxygen, ventilator support; end-of-life issues ÁRefer to section at end of plan for postdischarge considerations.
M AY E X H I B I T
(continued)T E S T
W H Y I T I S D O N E B
LOODT
ESTS•Arterial blood gases (ABGs):Measures oxygen and carbon dioxide levels to assess and monitor gas exchange
•Complete blood count (CBC) and differential:Provides baseline data about the hematologic system and yields information related to oxygen-carrying capacity and infection.
•␣1-antitrypsin (AAT):A deficiency screening used to verify deficiency of this enzyme and diagnosis of primary emphy- sema. Performed when COPD develops in patients <45 years old, of Caucasian descent, with strong family history of COPD (Kee, 2010).
•Pulmonary function tests: (PFTs):Numerous specific tests are included as part of the comprehensive PFT and fall within three categories: airway flow rates, lung volumes and capacities, and gas exchange.
•Spirometry testing, including FVC and FEV1:Measures the amount of air taken in (volume) and exhaled as a function of time (e.g., after deepest possible inhalation), which is also known as forced vital capacity (FVC).
•Total lung capacity (TLC):Maximum amount of air that lungs can hold, measured at the top of an inhalation.
•Residual volume (RV): Air remaining in the lungs after maximum exhalation
•Vital capacity (VC):Maximum amount of air that can be exhaled during a normal or slow exhalation after fullest possible inhalation. Important measurement in assessing the client’s ability to cough and protect airway.
O
THERD
IAGNOSTICS
TUDIES•Pulse oximetry:Noninvasive measure of arterial blood oxygen diffusion and saturation. Reflects oxygen saturation through measurement of the proportion of light transmitted by oxy- genated forms of hemoglobin using finger/earlobe/toe sensor.
•Chest x-ray: Evaluates organs or structures within the chest.
Abnormalities usually develop late in the disease. Hypoxemia with a PaO2<55 mm Hg or SaO2< 88% are indications for low-flow oxygen therapy (Kee, 2010). 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 secondary to hyperventilation (moderate emphysema or asthma).
Erythropoiesis is stimulated by chronic hypoxemia. Increased hemoglobin (advanced emphysema) and increased eosinophils (asthma); white blood cells (WBCs) can be elevated in severe respiratory infection.
A deficiency in AAT is a genetic trait considered to be a risk factor for the development of COPD. Decreased levels are seen in early onset emphysema in adults; increased levels are present in acute and chronic inflammatory disorders.
Performed to stage or classify the severity of disease process and to assess response to treatment (Daniels, 2012).
Used to establish baseline lung function, evaluate dyspnea, detect pulmonary disease, and monitor effects of therapies used to treat respiratory disease. Note:The spirometer is also used as an exer- cise tool for improving lung function, for example, after surgery.
Increased in obstructive lung disease Decreased in restrictive lung disease Increased in obstructive lung disease Decreased in restrictive lung disease
Normal or decreased in obstructive lung disease Decreased in restrictive lung disease
Abnormally low levels (<88%) indicate impaired gas exchange and impending respiratory failure. ABG analysis is recom- mended when SaO2<80% (Kee, 2010).
May reveal hyperinflation of lungs with increased AP diameter, flattened diaphragm, increased retrosternal air space, de- creased vascular markings/bullae (emphysema), increased bronchovascular markings (bronchitis), and normal findings during periods of remission (asthma).