1122 UNIT X / Responses to Altered Respiratory Function

techniques, preventing exacerbations, and managing pre- In addition, include the following topics when teaching for
scribed therapies. home care.
Pursed-lip and diaphragmatic breathing techniques help • Maintaining adequate fluid intake, at least 2.0 to 2.5 quarts
minimize air trapping and fatigue. Pursed-lip breathing helps of fluid daily
maintain open airways by maintaining positive pressures • Avoiding respiratory irritants, including cigarette smoke,
longer during exhalation. Teach the client to: both primary and secondary, other smoke sources, dust,
1. Inhale through the nose with the mouth closed. aerosol sprays, air pollution, and very cold dry air
2. Exhale slowly through pursed lips, as though whistling or • Preventing exposure to infection, especially upper respira-
blowing out a candle, making exhalation twice as long as tory infections
inhalation. • Importance of pneumococcal vaccine and annual influenza
immunization
Diaphragmatic or abdominal breathing helps conserve energy • Prescribed exercise program, maintaining ADLs, and bal-
by using the larger and more efficient muscles of respiration. ancing rest and exercise
Teach the client to: • Maintaining nutrient intake (e.g., eating small frequent
1. Place one hand on the abdomen, the other on the chest. meals and using nutritional supplements to provide adequate
2. Inhale, concentrating on pushing the abdominal hand out- calories)
ward while the chest hand remains still. • Ways of reducing sodium intake if prescribed
3. Exhale slowly, while the abdominal hand moves inward • Identifying early signs of an infection or exacerbation and
and the chest hand remains still. the importance of seeking medical attention for the follow-
ing: fever, increased sputum production, purulent (green or
Repeat these exercises as often as necessary until the tech- yellow) sputum, upper respiratory infection, increased
niques become incorporated into normal breathing. shortness of breath or difficulty breathing, decreased activ-
Several different coughing techniques may be useful. For ity tolerance or appetite, increased need for oxygen
controlled cough technique, teach the client to: • Prescribed medications, including purpose, proper use, and
1. Following prescribed bronchodilator treatment, inhale expected effects
deeply, and hold breath briefly. • Avoiding use of over-the-counter medications unless ap-
2. Cough twice, the first time to loosen mucus, the second to proved by the physician.
expel secretions. • Other prescribed therapies, such as use of home oxygen,
3. Inhale by sniffing to prevent mucus from moving back into percussion, postural drainage, and nebulizer treatments
deep airways. • Use, cleaning, and maintenance of any required special
4. Rest. Avoid prolonged coughing to prevent fatigue and equipment
hypoxemia. • Importance of wearing an identification band and carrying a
list of medications at all times in case of an emergency.
For huff coughing, teach the client to:
Provide referrals to home care services such as home health,
1. Inhale deeply while leaning forward. assistance with ADLs as needed, home maintenance services,
2. Exhale sharply with a “huff” sound, to help keep airways respiratory therapy and home oxygen services, and other agen-
open while mobilizing secretions. cies such as Meals-on-Wheels and senior services as indicated.

Nursing Care Plan

A Client with COPD
Anna Mercurio, known as “Happy” by all her ASSESSMENT
friends, is an 83-year-old widow who lives with Jeff Harris, RN, admits Mrs. Mercurio to the medical unit. In the
her two adult sons. Over the past 15 years, Mrs. Mercurio has be- nursing history, Mr. Harris notes that she denies ever smoking, but
come increasingly short of breath while gardening and walking, says that her husband and two sons have been smokers “for prac-
two favorite activities. She also has developed a chronic cough tically their whole lives.”She says she lived an active life before de-
that is particularly bad in the mornings. Ten years ago, her fam- veloping lung disease, but now her breathing and cough have
ily physician told her that she had emphysema. She is admitted progressed so that she now must rest after just a few minutes of
to the hospital with possible pneumonia and acute exacerba- housework or other activity. Her cough is productive of moderate
tion of COPD. to large amounts of sputum, particularly in the mornings. She
 CHAPTER 36 / Nursing Care of Clients with Lower Respiratory Disorders 1123

Nursing Care Plan

A Client with COPD (continued)
developed increasing shortness of breath and sputum 2 days ago; • Increase fluid intake to at least 2500 mL
this morning, she could not complete her morning activities with- per day and provide bedside humidifier.
out resting, so she contacted her doctor. • Elevate head of bed to at least 30 degrees at all times.
On physical examination, Mr. Harris notes the following: skin • Teach “huff” coughing technique.
very warm and dry, color dusky. Pauses frequently while speaking • Administer medications as ordered; providing ipratropium in-
to breathe. Respiratory rate 36, fairly shallow; coughs frequently, haler before beclomethasone inhaler. Provide mouth care after
producing large amounts of thick, tenacious green sputum. Other inhalers.
vital signs: P 115 and irregular, BP 186/60,T 102.4°F (39°C). Appears • Contact respiratory therapy for percussion and postural
very thin; weight 96 lb (43.6 kg), height 63 inches (160 cm). drainage following inhaler treatments.
Anteroposterior:lateral chest diameter approximately 1:1; moder- • Provide for uninterrupted rest periods following treatments
ate kyphosis noted. Chest hyperresonant to percussion. and procedures.
Auscultation reveals distant breath sounds with scattered • Meet with Mrs. Mercurio and her sons to develop a postdis-
wheezes and rhonchi throughout lung fields. Chest X-ray shows charge care plan.
flattening of diaphragm, slight cardiac enlargement, prominent • Refer to home health department for nursing follow-up.
vascular and bronchial markings, and patchy infiltrates. Initial lab- • Refer to social services for possible assistance with home
oratory work reveals moderate erythrocytosis, leukocytosis, and maintenance.
low serum albumin. Arterial blood gas results: pH 7.19; PO2 54
mmHg; PCO2 59 mmHg; HCO3 30 mg/dL, and O2 saturation 88%. EVALUATION
Admitting orders include sputum specimen for culture; intra- After the first day in the hospital, Mrs. Mercurio’s condition begins
venous penicillin G, 2 million units every 4 hours; ipratropium bro- to improve slowly. On discharge 6 days later, she is able to provide
mide (Atrovent) inhaler, two puffs every 6 hours; beclomethasone self-care with less fatigue and dyspnea. She is using oxygen at
diproprionate (Vanceril) inhaler, two puffs every 6 hours; bed rest night only,admitting that it is just for security.Although a few scat-
with bathroom privileges; oxygen per nasal cannula at 2 L contin- tered wheezes and rhonchi are still present in her lungs, Mrs.
uously; and regular diet. Mercurio’s sputum is thinner, white, and easily expectorated. She
will continue taking oral penicillin V for an additional 10 days at
DIAGNOSES home. She will also continue using the Atrovent and Vanceril in-
Mr. Harris develops the following nursing diagnoses for Mrs. halers as prescribed at home. Although Mrs. Mercurio’s sons admit
Mercurio. they will probably never be able to quit smoking, they have
• Ineffective airway clearance related to pneumonia and COPD agreed to smoke only in the garage or outside. A home health
• Impaired gas exchange related to acute and chronic lung nurse will initially evaluate Mrs. Mercurio’s progress three times
disease weekly. Arrangements have been made for a housekeeper to
• Risk for impaired spontaneous ventilation related to loss of come twice a week for cleaning and laundry. Mrs. Mercurio is glad
hypoxemic respiratory drive and respiratory muscle fatigue to be returning home and grateful for the arrangements that have
• Impaired home maintenance related to activity intolerance been made.

EXPECTED OUTCOMES Critical Thinking in the Nursing Process

The expected outcomes specify that Mrs. Mercurio will: 1. Mrs. Mercurio has never been a smoker but had long-term ex-
• Expectorate secretions effectively. posure to secondhand smoke. How does secondhand smoke
• Return to level of pulmonary function prior to acute exacerba- contribute to lung diseases in adults and children?
tion. 2. Mr. Harris’s nursing care plan included the nursing diagnosis,
• Demonstrate improved arterial blood gas and oxygen satura- Risk for impaired spontaneous ventilation related to loss of hy-
tion values. poxemic respiratory drive and respiratory muscle fatigue.
• Maintain spontaneous respirations without excess fatigue. Identify the normal physiologic events that stimulate breath-
• Verbalize willingness to allow sons or a housekeeper to assist ing, and describe how these differ for the client with chronic
with daily household tasks. hypoxemia and hypercapnia.
3. The client with an acute exacerbation of COPD is at risk for res-
PLANNING AND IMPLEMENTATION
piratory failure. What changes in Mrs. Mercurio’s assessment
Mr. Harris plans and implements the following interventions while
findings could indicate this complication?
Mrs. Mercurio is hospitalized.
4. Develop a nursing care plan for Mrs. Mercurio for the nursing
• Assess respiratory status and level of consciousness every 1 to
diagnosis, Deficient diversional activities related to inability to
2 hours until stable, then at least every 4 hours.
continue preferred activities.
• Closely monitor response to oxygen therapy, including skin
color, oxygen saturation, sputum consistency, and respiratory See Critical Thinking in the Nursing Process in Appendix C.
drive.