Question

4/11 10:38pm

Sonia Brown
Week 5 Discussion Post-Thorax and Lungs — required

Week 5 Discussion Post -Thorax and Lungs

M.C. is a 69-year-old man who presents to the outpatient office with a hacking, raspy cough.

Subjective Data
PMH: HTN, DM
Cough is productive, bringing up green phlegm
Runny nose, sore throat
Denies fever
Sore throat pain when swallowing
No history of smoking or seasonal allergies
Complains of fatigue

Objective Data
Vital signs: T 37 P 72 R 14 BP 134/64
Lungs: + Rhonchi bilateral upper lobes, wheeze
O2 Sat = 98%
Ears = TM bulging
Nose = + erythema, yellow discharge
Throat = + erythema, – pustules
Medications: Metoprolol 12.5 mg per day, Glucophage 500 mg twice a day

Questions
1. What other questions should the nurse ask about the cough?
2. Develop a problems list from the objective and subjective data.
3. What nursing diagnoses can be derived from the problems list?
4. What should be included in the plan of care?
5. What risk factors are associated with this age group?
6. Based on the readings, what is the most likely cause of this patient’s cough?

Answer 1

1 What other questions should the nurse ask about the cough?

These questions include:

What type of cough is it? Wet or dry?

Please describe the problem that caused you to come in today?

How has this condition impacted your activities?

How often does this occur?

How long has this been occuring?

Do you have any chest pain with breathing? If so, what is the pain like, when does it occur, and what relieves it?

        Do you have a cough? If yes, What type of cough is it? Wet or dry?

what does the cough sound like, when does it occur, do you bring up any phlegm (sputum) when you cough, what does the phlegm look like? Normal sputum is thin, clear to white in color, and tasteless and odorless. Yellow-green colored sputum may indicate a bacterial infection and rust-colored sputum is characteristic of pneumonia.

Are you ever short of breath? If so, does your shortness of breath occur at rest or with activity? Ask the patient specific questions about shortness of breath that impacts daily living, such as being able to carry groceries from a car, or being able to clean floors or do laundry.

Do you have any problems breathing at night? If so, do you use pillows to help you get in a position to breathe easier?

Do you have any allergies? If yes, how does your allergy affect your breathing?

Do you smoke now or have you ever smoked? If yes, how many years did you smoke and how many packs of cigarettes did you smoke daily?

What kind of work do you do/did you do? In your work are/were you exposed to substances such as asbestos, chemicals, or cigarette smoke?

Do you have a personal or family history of asthma, tuberculosis, lung cancer, cystic fibrosis, bronchitis, emphysema, or any other lung disease?

Is the patient on any medication?

2. Develop a problems list from the objective and subjective data.

bacterial infection

Asthma

sinus infection

acute otitis

airway obstruction

Tuberculosis

lung cancer

cystic fibrosis

bronchitis

emphysema

any other lung disease

pneumonia.

3. What nursing diagnoses can be derived from the problems list?

Ineffective airway clearance R/T inflammatory process AEB increased production of secretions, cough.

Actual or potential infectious process R/T ineffective airway clearance AEB colored sputum and nasal drainage, pustules in throat, bulging TM.

Impaired swallowing R/T Sore throat pain AEB patient’s subjective data

Activity Intolerance R/T disease condition AEB fatigue

4. What should be included in the plan of care?

Steam inhalation

Salt water gaggling

Adequate rest

Nursing Interventions and Rationales

1. Auscultate breath sounds q __ h(rs).
Breath sounds are normally clear or scattered fine crackles at bases, which clear with deep breathing. The presence of coarse crackles during late inspiration indicates fluid in the airway; wheezing indicates an airway obstruction.

2. Monitor respiratory patterns, including rate, depth, and effort.
A normal respiratory rate for an adult without dyspnea is 12 to 16. With secretions in the airway, the respiratory rate will increase.

3. Monitor blood gas values and pulse oxygen saturation levels as available.
Normal blood gas values are a PO2 of 80 to 100 mm Hg and a PCO2 of 35 to 45 mm Hg. An oxygen saturation of less than 90% indicates problems with oxygenation. Hypoxemia can result from ventilation-perfusion mismatches secondary to respiratory secretions.

4. Position client to optimize respiration (e.g., head of bed elevated 45 degrees and repositioned at least every 2 hours).
An upright position allows for maximal air exchange and lung expansion; lying flat causes abdominal organs to shift toward the chest, which crowds the lungs and makes it more difficult to breathe. Studies have shown that in mechanically ventilated clients receiving enteral feedings, there is a decreased incidence of nosocomial pneumonia if the client is positioned at a 45-degree semirecumbent position as opposed to a supine position

5. If the client has unilateral lung disease, alternate a semi-Fowler's position with a lateral position (with a 10- to 15-degree elevation and "good lung down") for 60 to 90 minutes. This method is contraindicated for a client with a pulmonary abscess or hemorrhage or with interstitial emphysema.
Gravity and hydrostatic pressure allow the dependent lung to become better ventilated and perfused, which increases oxygenation

6. Help client to deep breathe and perform controlled coughing. Have client inhale deeply, hold breath for several seconds, and cough two to three times with mouth open while tightening the upper abdominal muscles.
This technique can help increase sputum clearance and decrease cough spasms (Celli, 1998). Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective.

7. If the client has COPD, consider helping the client use the "huff cough." The client does a series of coughs while saying the word "huff."
This technique prevents the glottis from closing during the cough and is effective in clearing secretions in the centra airways

8. Encourage client to use incentive spirometer.
The incentive spirometer is an effective tool that can help prevent atelectasis and retention of bronchial secretions

9. Assist with clearing secretions from pharynx by offering tissues and gentle suction of the oral pharynx if necessary. Do not do nasotracheal suctioning.
It is preferable for the client to cough up secretions. In the debilitated client, gentle suctioning of the posterior pharynx may stimulate coughing and help remove secretions; nasotracheal suctioning is dangerous because the nurse is unable to hyperoxygenate before, during, and after to maintain adequate oxygenation .

10. Observe sputum, noting color, odor, and volume.
Normal sputum is clear or gray and minimal; abnormal sputum is green, yellow, or bloody; malodorous; and often copious.

11. When suctioning an endotracheal tube or tracheostomy tube for a client on a ventilator, do the following:

Hyperoxygenate before, between, and after endotracheal suction sessions. Nursing research has demonstrated that the client should be hyperoxygenated during suctioning .

Use a closed, in-line suction system. The closed, in-line suction system is associated with a decrease in nosocomial pneumonia (Deppe et al, 1990; Johnson et al, 1994; Mathews, Mathews, 2000), reduced suction-induced hypoxemia, and fewer physiological disturbances (including decreased development of dysrhythmia) and often saves money.

Avoid saline instillation during suctioning. Saline instillation before suctioning has an adverse effect on oxygen saturation.

12. Document results of coughing and suctioning, particularly client tolerance and secretion characteristics such as color, odor, and volume.

13. Provide oral care every 4 hours.
Oral care freshens the mouth after respiratory secretions have been expectorated. Research is promising on the use of chlorhexidine oral rinses after oral care to reduce bacteria, and possibly reduce the incidence of nosocomial pneumonia.

14. Encourage activity and ambulation as tolerated. If unable to ambulate client, turn client from side to side at least every 2 hours.
Body movement helps mobilize secretions. The supine position and immobility have been shown to predispose postoperative clients to pneumonia (Brooks-Brunn, 1995). See interventions for Impaired gas exchange for further information on positioning a respiratory client.

15. Encourage increased fluid intake of up to 3000 ml/day within cardiac or renal reserve.
Fluids help minimize mucosal drying and maximize ciliary action to move secretions . Some clients cannot tolerate increased fluids because of underlying disease.

16. Administer oxygen as ordered.
Oxygen has been shown to correct hypoxemia, which can be caused by retained respiratory secretions.

17. Administer medications such as bronchodilators or inhaled steroids as ordered. Watch for side effects such as tachycardia or anxiety with bronchodilators, inflamed pharynx with inhaled steroids.
Bronchodilators decrease airway resistance secondary to bronchoconstriction.

18. Provide postural drainage, percussion, and vibration as ordered.
Chest physical therapy helps mobilize bronchial secretions; it should be used only when prescribed because it can cause harm if client has underlying conditions such as cardiac disease or increased intracranial pressure .

19. Refer for physical therapy or respiratory therapy for further treatment.

Geriatric

1. Encourage ambulation as tolerated without causing exhaustion.
Immobility is often harmful to the elderly because it decreases ventilation and increases stasis of secretions, leading to atelectasis or pneumonia .

2. Actively encourage the elderly to deep breathe and cough.
Cough reflexes are blunted and coughing is decreased in the elderly (Sparrow, Weiss, 1988).

3. Ensure adequate hydration within cardiac and renal reserves.
The elderly are prone to dehydration and therefore more viscous secretions because they frequently use diuretics or laxatives and forget to drink adequate amounts of water .

Home Care Interventions

1. Assess home environment for factors that exacerbate airway clearance problems (e.g., presence of allergens, lack of adequate humidity in air, stressful family relationships).

2. Limit client exposure to persons with upper respiratory infections.

3. Provide/teach percussion and postural drainage per physician orders. Teach adaptive breathing techniques.
Adaptive breathing, percussion, and postural drainage loosen secretions and allow more effective oxygenation.

4. Determine client compliance with medical regimen.

5. Teach client when and how to use inhalant or nebulizer treatments at home.

6. Teach client/family importance of maintaining regimen and having prn drugs easily accessible at all times.
Success in avoiding emergency or institutional care may rest solely on medication compliance or availability.

7. Identify an emergency plan, including criteria for use.
Ineffective airway clearance can be life threatening.

8. Refer for home health aide services for assist with ADLs.
Clients with decreased oxygenation and copious respiratory secretions are often unable to maintain energy for ADLs.

9. Assess family for role changes and coping skills. Refer to medical social services as necessary.
Clients with decreased oxygenation are unable to maintain role activities and therefore experience frustration and anger, which may pose a threat to family integrity.

10. Provide family with support for care of a client with a chronic or terminal illness.
Severe compromise to respiratory function creates fear in clients and caregivers. Fear inhibits effective coping.

Client/Family Teaching

1. Teach importance of not smoking. Be aggressive in approach, ask to set a date for smoking cessation, and recommend nicotine replacement therapy (nicotine patch or gum). Refer to smoking cessation programs, and encourage clients who relapse to keep trying to quit.
All health care clinicians should be aggressive in helping smokers quit .

2. Teach client how to use a flutter clearance device if ordered, which vibrates to loosen mucus and gives positive pressure to keep airways open.
This device has been shown to effectively decrease mucous viscosity and elasticity (App et al, 1998), increase amount of sputum expectorated (Langenderfer, 1998; Bellone et al, 2000), and increase peak expiratory flow rate .

3. Teach client how to use peak expiratory flow rate (PEFR) meter if ordered and when to seek medical attention if PEFR reading drops. Also teach how to use metered dose inhalers and self-administer inhaled corticosteroids following precautions to decrease side effects .

4. Teach client how to deep breathe and cough effectively. Teach how to use the ELTGOL method-an airway clearance method that uses lateral posture and diferent lung volumes to control expiratory flow of air to avoid airway compression.
Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective. The ELTGOL method was shown to be more effective in secretion removal in chronic bronchitis than postural drainage .

5. Teach client/family to identify and avoid specific factors that exacerbate ineffective airway clearance, including known allergens and especially smoking (if relevant) or exposure to second-hand smoke.

6. Educate client and family about the significance of changes in sputum characteristics, including color, character, amount, and odor.
With this knowledge the client and family can identify early the signs of infection and seek treatment before acute illness occurs.

7. Teach client/family need to take antibiotics until prescription has run out.
Taking the entire course of antibiotics helps to eradicate bacterial infection, which decreases lingering, chronic infection.

5. What risk factors are associated with this age group?

Age related risk

Vulnerable group

Immune compromised

6. Based on the readings, what is the most likely cause of this patient’s cough?

These are common causes of acute cough – lasting less than two months:

Upper respiratory tract infections: Infections of the nose and throat are the most common cause of coughing related to illness. They are usually associated with fevers, sore throat and runny nose. They are almost always caused by viruses, and include the common cold, viral laryngitis and influenza.

Hay fever (or allergic rhinitis): A common allergic condition that mimics the symptoms of a common cold. It is usually associated with dry cough, sneezing and runny nose.

Inhalation of irritants: Acute exposure to some fumes and vapors can cause inflammation of the throat and airway and cause cough.

Lower respiratory tract infections: These are more serious viral and bacterial infections that usually cause a deep, lingering cough and fever. They can affect the airways (bronchitis) or go further into the lungs (pneumonia).

Pulmonary embolism: This is a potentially life-threatening condition where a blood clot travels, usually from the legs, to the lungs causing sudden shortness of breath and sometimes a dry cough.

Lung collapse (or pneumothorax): This is caused by the deflation of the lung. It can be spontaneous or due to chest trauma. Signs of a collapsed lung include sudden chest pain, dry cough and shortness of breath.

Heart failure: A weak or diseased heart can cause buildup of fluid in the lung, causing cough and worsening shortness of breath.

Post-nasal drip: This condition shows up as a dry cough caused by the chronic dripping of mucus from the back of the nose to the throat. Usually this occurs after a recent infection or continuous exposure to an allergy trigger.

Gastro-esophageal reflux (GERD): This digestive disorder occurs when stomach acid frequently backs up into the esophagus, causing heartburn. When the acid rises into the throat it can also cause a dry cough.