Display progressive weight gain toward goal as appropriate.
Demonstrate behaviors and lifestyle changes to regain and maintain appropriate weight.
NOC
ACTIONS/INTERVENTIONS RATIONALE
Nutrition Therapy Independent
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.
Collaborative
Consult dietitian or nutritional support team to provide easily digested, nutritionally balanced meals by mouth, supple- mental or tube feedings, and parenteral nutrition. (Refer to CP: Total Nutritional Support: Parenteral/Enteral Feeding.) Review serum albumin or prealbumin, transferrin, amino acid
profile, iron, nitrogen balance studies, glucose, liver func- tion studies, and electrolyte laboratory values as ordered.
Administer supplemental oxygen during meals, as indicated.
NIC
Client in acute respiratory distress is often anorectic because of dyspnea, sputum production, and medication effects. In ad- dition, 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 emphy- sema are often thin, with wasted musculature.
Diminished or hypoactive bowel sounds may reflect decreased gastric motility and constipation (common complication) re- lated to limited fluid intake, poor food choices, decreased activity, and hypoxemia.
Noxious tastes, smells, and sights are prime deterrents to ap- petite and can produce nausea and vomiting with increased respiratory difficulty.
Helps reduce fatigue during mealtime, and provides opportu- nity 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.
Method of feeding and caloric requirements are based on indi- vidual situation and specific needs to provide maximal nu- trients with minimal client effort and energy expenditure.
Determines deficits and monitors effectiveness of nutritional therapy.
Decreases dyspnea and increases energy for eating, enhancing intake.
N U R S I N G D I A G N O S I S : ineffective Self-Health Management
May Be Related To
Deficient knowledge; complexity of therapeutic regimen Economic difficulties
Perceived benefits/seriousness Possibly Evidenced By
Reports difficulty with prescribed regimen
Failure to include treatment regimens in daily living Failure to take action to reduce risk factors
CHAPTER 5RESPIRATORY—COPD AND ASTHMA
N U R S I N G D I A G N O S I S : ineffective Self-Health Management
(continued)Desired Outcomes/Evaluation Criteria—Client Will
Self-Management: Chronic Obstructive Pulmonary Disease/Asthma Management 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.
NOC
ACTIONS/INTERVENTIONS RATIONALE
Teaching: Disease Process Asthma Management Independent
Explain and reinforce explanations of individual disease process, including factors that lead to exacerbation episodes.
Review possible disease course as appropriate.
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 clean- ing the inhaler.
Devise system for recording prescribed intermittent drug and inhaler usage.
Discuss use of herbals, especially when client is on multiple respiratory medications.
Recommend avoidance of sedative anti-anxiety agents unless specifically prescribed and approved by physician treating respiratory condition.
Instruct asthmatic client/parent in use of peak flow meter (PMF) as appropriate.
Encourage client to monitor own status with use of CAT score (evaluates cough, mucus production, chest tightness, ability to rest, activity limitations, confidence and energy levels with a numeric value) and to relay the information to health- care providers.
Recommend client/parent keep a daily or periodic diary of asthma symptoms as indicated.
Discuss self-management plan:
Avoidance of triggers and ways to control these factors in and around the home and school/work setting.
NIC NIC
Understanding decreases anxiety and can lead to improved participation in treatment plan.
For children with asthma, symptoms may disappear during their teen years but may return in adulthood.
Frequently, these clients are simultaneously on several respira- tory drugs that have similar side effects and potential drug interactions. It is important that the client understands the difference between nuisance side effects (medication con- tinued) and untoward or adverse side effects (medication possibly discontinued or dosage changed).
Proper administration of drug enhances delivery and effective- ness. Note: When administering MDI, client begins inhala- tion and then presses canister. If MDI is used with a spacer, canister is pressed first then client takes two breaths.
Reduces risk of improper use or overdosage of prn (as neces- sary) medications, especially during acute exacerbations, when cognition may be impaired.
Many interactions can occur between herbals and medications used to treat respiratory disorders. Although most herbals do not have dangerous side effects, effects can be danger- ous or lethal if combined with other substances or when taken in larger doses. Herbs, such as ephedra, should be used only in very small doses and for a short time. Echi- nacea can alter the actions of a variety of drugs and is not recommended for persons with HIV infection, multiple scle- rosis (MS), and other autoimmune disorders.
Although client may be nervous and feel the need for seda- tives, these can depress respiratory drive and protective cough mechanisms. Note: These drugs may be used pro- phylactically when client is unable to avoid situations known to increase stress and trigger respiratory response.
Peak flow level can drop before client exhibits any signs and symptoms of asthma after the “first time” the client is ex- posed to a trigger. Regular use of the peak flow meter may reduce the severity of the attack because of earlier interven- tion. However, trying to learn to use the PFM during an at- tack may not be possible.
This self-administered questionnaire helps the client monitor own respiratory status and changes that may be indicative of improvement or need for prompt medical evaluation.
Helpful in determining effectiveness of treatment plan and need for adjustment as child ages. Note: Symptoms at night are an indication of nocturnal asthma or poor control even if condition appears stable during the day (Sawicki, 2012).
Avoiding triggers, such as known allergens, environmental fac- tors, such as excessively dry air, wind, temperature extremes, pollen, chemical products and fumes, tobacco smoke,
(continues on page 128)
ACTIONS/INTERVENTIONS
(continued)RATIONALE
(continued)Use of asthma symptom zones, as appropriate.
Review of breathing exercises, coughing effectively, and general conditioning exercises.
Importance of regular oral care and dental hygiene.
Importance of avoiding people with active respiratory infections. Emphasize need for routine influenza and pneumococcal vaccinations.
Discuss and encourage family to form a detailed rescue plan for an acute asthmatic episode, including how to iden- tify signs of an acute attack, how to use and monitor effects of rescue medications, and how, when and where to obtain emergent care.
Recommend client wear medical identification device at all times.
Review the harmful effects of smoking, and strongly advise cessation of smoking by client and SO. Provide information on QUITLINES, support groups, nicotine substitutes, and other resources that aid in smoking cessation.
Provide information about benefits of regular exercise while addressing individual activity limitations.
Encourage preventive therapy for strenuous play or sports.
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.
Review oxygen requirements and dosage for client who is discharged on supplemental oxygen. Discuss safe use of oxygen and refer to supplier as indicated.
Instruct client and SO in use of NIPPV as appropriate. Problem- solve possible side effects, and identify adverse signs and symptoms such as increased dyspnea, fatigue, daytime drowsiness, or headaches on awakening.
aerosol sprays, are important in the self-management of asthma and in the prevention of acute exacerbations.
Zones may be divided into green (peak expiratory flow rate [PEFR] 80% to 100% and no breathing difficulty), yellow (PEFR 50% to 80% of baseline and some difficulty breathing, with wheezing and coughing) indicating need for a short- term change or increase in medication, and red (PEFR less than 50% baseline and does not respond to inhaled bron- chodilators), which should be evaluated by care provider (Sawicki, 2012).
Pursed-lip and abdominal or diaphragmatic breathing exer- cises strengthen muscles of respiration, help minimize col- lapse of small airways, and provide the individual with means to control dyspnea. General paced conditioning exer- cises, carried out regularly and perhaps timed with activity soon after taking medication or breathing treatments, can increase activity tolerance, muscle strength, and sense of well-being and quality of life.
Decreases bacterial growth in the mouth, which can lead to pulmonary infections.
Decreases exposure to and incidence of acquired acute upper respiratory infections (URIs). Note: Studies have shown that in high-risk groups, such as persons with COPD, influenza vaccination alone was associated with a 52% reduction in the risk of hospitalization for pneumonia and a 70% reduc- tion in the risk for death (Nichol, 1999).
Child (if of age to self-manage) and/or caregiver must have the knowledge and capability of helping child in emergent asthma attack, including medications to use and contact numbers to obtain rapid assistance. Relief medications in- clude short-acting bronchodilators, systemic corticos- teroids, and ipratropium (Atrovent) to bring about relaxation of bronchi (Sawicki, 2012; Sharma, 2013).
Provides important information regarding condition, allergies, treatment, emergency contact and provider information dur- ing emergencies (Sawicki, 2012).
Cessation of smoking may slow or halt progression of COPD.
Even when client wants to stop smoking, support groups and medical monitoring may be needed. Note: Research studies suggest that sidestream or secondhand smoke can be as detrimental as actually smoking (Simon, 2011).
Having this knowledge can enable client and SO to make in- formed choices and decisions to reduce client’s dyspnea, maximize functional level, perform most desired activities, and prevent complications. This may include alternating ac- tivities with rest periods to prevent fatigue, conserving en- ergy during activities by pulling instead of pushing articles, sitting instead of standing while performing tasks, using pursed-lip breathing, side-lying position, and possible need for supplemental oxygen during sexual activity.
Use of a reliever inhaler 10 to 15 minutes before engaging in activities and repeating medication after 2 hours of continu- ous exercise or conclusion of activity as well as warm-up exercises and appropriate cool-down activities can prevent asthma symptoms.
Monitoring disease process allows for alterations in therapeu- tic regimen to meet changing needs and may help prevent complications. It is recommended that children with asthma see their primary provider every 1 to 6 months, as the choice of medications varies depending on age of child (Sawicki, 2012).
Reduces risk of misuse—too little or too much—and resultant complications. Promotes environmental and physical safety.
NIPPV may be used at night and periodically during day to de- crease CO2level, improve quality of sleep, and enhance functional level during the day. Signs of increasing CO2 level indicate need for more aggressive therapy.
CHAPTER 5RESPIRATORY—PNEUMONIA
ACTIONS/INTERVENTIONS
(continued)RATIONALE
(continued)Provide information and encourage participation in support groups sponsored by the American Lung Association and public health department.
Refer for evaluation of home care if indicated. Provide a de- tailed plan of care and baseline physical assessment to home-care nurse as needed on discharge from acute care.
Assist client and SO in making arrangements for access to emergency assistance, such as a buddy system for getting help quickly, special phone numbers, and “panic button.”
Facilitate discussion about healthcare directives and end-of-life wishes as indicated.
These clients and their SOs may experience anxiety, depres- sion, and other reactions as they deal with a chronic disease that has an impact on their desired lifestyle. Support groups may be desired or needed to provide assistance, emotional support, and respite care.
Provides for continuity of care. May help reduce frequency of hospitalization.
Client with chronic respiratory condition should have access to prompt assistance when needed. This is both necessary and psychologically comforting for self-management.
Although many clients have an interest in discussing living wills, their wishes may be unspoken. In client with severe pulmonary disease, it is helpful to discuss preferences re- garding aggressive treatment, home care only, hospitaliza- tion for comfort care, and full life support. It is useful also to discuss the goals of care, such as functional independence or continuation of life support in an extended care nursing facility.
b.Distribution
i.CAP commonly caused by S. pneumoniae, Chlamydia