Disorders of the Respiratory System

CHAPTER 13

LEARNING OUTCOMES

Upon completion of this chapter, the nurse will:

1. Summarize the different disorders of the respiratory system

2. Examine approaches to assess different disorders of the respiratory system

3. Determine approaches that can be used for more than one respiratory disorder

RESPIRATORY DISORDERS

The respiratory disorders can be divided into those that affect the upper respiratory or lower respiratory tracts. The major disorders of the upper respiratory tract include:

Common cold

Influenza

Sinusitis

Pharyngitis

Laryngeal cancer

Sleep apnea

And the major disorders of the lower respiratory tract are:

Asthma

Bronchitis

Pneumonia

Emphysema

Chronic obstructive lung/pulmonary disease (COLD/COPD)

Tuberculosis

Lung cancer

Assessing the patient/client with these respiratory disorders may be challenging mainly because the client could be experiencing shortness of breath. Although open-ended questions are encouraged during the telephonic assessment, closed-ended questions might be easier for the client to answer. Carefully listen to the client’s breathing and speech pattern when beginning a call to a client with a known respiratory disorder. If the client is having difficulty in breathing and talking, change the questions to closed-ended or consider rescheduling the call to when the client’s breathing has stabilized or improved.

ASSESSING UPPER RESPIRATORY CONDITIONS

Health Problem	Question
Common cold	Are you experiencing nasal stuffiness, sneezing, watery eyes, and a scratchy throat?
	How would you describe what you are experiencing?
	What have you been doing to treat the symptoms?
	Has the treatment been effective?
Influenza	Are you experiencing body aches/pains, tiredness, nasal stuffiness, and a raspy cough?
	Did you receive a flu vaccination this season?
	How long have you been feeling this way?
	What are you doing to help with the symptoms?
Sinusitis	How long has your voice sounded nasal?
	Has this ever happened to you before?
	Are you feeling any fullness of pressure along your forehead or alongside your nose and cheekbones?
	Does your head feel full when you lean forward?
	What are you doing to help with the symptoms?
Pharyngitis	How long has your voice sounded hoarse or raspy?
	Is your throat sore?
	Are you able to drink fluids?
	Have you taken your temperature? If so, what was your last temperature?
	What are you doing to help with the symptoms?
Laryngeal cancer	(For telephonic care, the client with a history of laryngeal cancer will most likely use a device to assist with verbal communication. The sound of the device is very distinctive and sounds mechanical. Talking with these clients is not tiring or painful but ask if the client feels up to carrying on a conversation before proceeding.) It sounds like you are using something to help you talk. Can you tell me what you are using and why?
	When were you diagnosed with laryngeal cancer?
	Are you still undergoing treatment?
	Are you experiencing any other symptoms because of it?
Sleep apnea	Have you ever had a test where you slept in a laboratory overnight and your breathing was measured?
	Have you ever been told that you stop breathing while you are asleep?
	Do you use a machine at home to keep your airway open when you sleep?
	Do you place the device in your nose or your mouth?
	Do you use the device every night?
	Are you having any difficulty or issues with using the device?

ASSESSING LOWER RESPIRATORY CONDITIONS

It is likely that clients with a lower respiratory condition will be enrolled in a disease management program. Even so, it is important for you to assess the client’s current status and if any new manifestations are occurring. Keep in mind that the client may be short of breath or fatigued. The episodes of telephonic care may be shorter but more frequently conducted. Consider the following techniques when assessing a client with any of these lower respiratory conditions:

Health Problem	Question
Asthma	When were you diagnosed with asthma?
	What do you avoid so that you don’t experience an asthma attack? (document as triggers)
	When was your most recent asthma attack?
	How often do you have acute attacks?
	Describe what happens to you when you have an asthma attack. Does your chest become tight? Do you start to wheeze or make noises when you breathe? Do you become short of breath?
	Have you ever been hospitalized because of your asthma?
	Do you have a peak flow meter at home?
	Do you use the peak flow meter? If so, what was your last “color”? (Peak flow meter readings are estimated according to traffic signal colors: Green indicates asthma is under control; yellow means asthma is somewhat controlled; red means the client needs immediate medical attention.)
	What medications do you take to control the asthma?
	Do you take any of these medications as an inhaler? Is the inhaler meter-dosed or dry powder?
	How often do you use a rescue bronchodilator inhaler during the day?
	How often do you see your doctor or health care provider for the asthma?
Bronchitis	How often do you experience episodes of bronchitis?
	Are you coughing up phlegm? What color is the phlegm?
	Are you experiencing any pain when you cough? Where is the pain located?
	What causes the bronchitis to occur? Smoking? Environmental irritants?
	What do you do to reduce the symptoms of bronchitis?
	What medications are you prescribed for the bronchitis?
	How often do you see your doctor or health care provider for the bronchitis?
Pneumonia	Did your doctor or health care provider tell you what type of pneumonia you have?
	How often do you experience episodes of pneumonia?
	Have you received the pneumonia vaccination? When did you receive it?
	What are your current symptoms? Cough? Phlegm production and color? Chest pain with coughing? Fatigue/sleepiness?
	What medication have you been prescribed for the pneumonia? Has the medication been helping?
	What else have you been doing to help with the pneumonia? Increasing oral fluids? Getting more rest? Not smoking/avoiding cigarette smoke?
Emphysema/COPD	When were you diagnosed with emphysema/COPD?
	Did you or are you currently smoking cigarettes? When did you start smoking cigarettes? How many packs of cigarettes do you smoke each day? Have you tried to stop smoking cigarettes? Are you interested in smoking cessation information?
	What symptoms do you experience on a daily basis? Cough? Phlegm production? Color, consistency, and amount? Pain with coughing? Shortness of breath?
	What is your activity level right now? Do you become short of breath when walking short distances? Are you able to complete your own basic care such as bathing, dressing, and going to the bathroom? Are you able to shop and prepare your own meals? How many times do you need to stop, sit, and catch your breath when engaging in activities?
	Do you wear oxygen? (portable oxygen concentrator) Do you wear it continuously? Do you have an oxygen concentrator in the home? What is the setting for your oxygen (liters per minute)? Do you use a face mask or the prongs in the nose (nasal cannula)?
	How often do you develop or experience lung infections?
	What is your current weight? Have you lost/gained weight over the last few months?
	How would you rate your appetite (poor, fair, or good)? Has your appetite changed over the last few months? Do you experience shortness of breath when eating?
	How much fluid do you drink each day? Have you been instructed to increase/decrease fluid intake by your doctor or health care provider?
	What medication have you been prescribed for the emphysema/COPD? Has your breathing improved with the medication?
	What else have you been doing to help with your breathing?
	Have you been instructed in any coughing techniques to help clear your lungs? Pursed lip breathing? Diaphragmatic breathing? Huff coughing?
	How often do you see your doctor/health care provider for your breathing?
Tuberculosis	When were you diagnosed with tuberculosis?
	What were your symptoms? Cough with bloody phlegm? Weight loss? Fatigue? Night sweating?
	What testing did you have done? Skin test? Chest x-ray? Sputum samples?
	What medication have you been prescribed? Are you taking the medication as prescribed? Why or why not?
	Are you experiencing any “odd” effects from the medication? Change in urine/feces/tears/sweat color? (Rifampin can change body fluids to orange-red in color) Tingling of the hands or feet? (Isoniazid would be prescribed to prevent this) Changes in seeing colors in your vision? (Ethambutol can affect red-green color discrimination and visual acuity) Changes in hearing? (Streptomycin is ototoxic and affects hearing)
	How long have you been told that you need to take this medication?
	How are you feeling right now? Improved appetite? Weight gain? Less night sweats? Reduced coughing? Color of phlegm improved?
	How often do you see your doctor/health care provider? When is your next appointment? When was your last sputum sample?
Lung cancer	A patient with a diagnosis of lung cancer might be enrolled in another disease management program. It is rare for a disease management program to be created for an oncological health problem. General questions appropriate for this health problem are as follows:
	When were you diagnosed with the lung cancer?
	What treatment have you or are you receiving for the problem? Chemotherapy? Radiation? Surgery?
	How are you feeling right now?
	Are you experiencing any shortness of breath?
	Are you experiencing any effects from the treatment? Poor appetite? Weight loss? Mouth sores? Fatigue/sleepiness?
	How often do you have a treatment?
	How long will you be getting treatments?
	Are you able to: Perform self-care? Bathing, toileting, dressing? Shop and prepare meals for yourself?
	Are you wearing or using oxygen? Is it continuous or only when you feel short of breath? Do you have a portable oxygen container to use when you go out of doors? Do you have an oxygen concentrator in the home? Do you use a face mask or nasal prongs for the oxygen?
	Are you experiencing any pain? Where is the pain? How would you rate the pain on a scale from 1 to 10 with 1 being no or minimal pain to 10 being the worst possible pain? What helps with the pain? How often do you take pain medication if prescribed?
	What other medications have you been prescribed for your lung cancer?
	When is your next doctor/health care provider appointment?

SUGGESTIONS FOR RESPIRATORY DISORDERS

Clients may be hesitant to admit of a chronic health problem. This could be due to the fear of losing health insurance coverage or having this information shared with an employer. Ensure the client that all information collected is confidential and not reported back to the health plan or employer.

Clients may be frustrated with having a respiratory problem and sound annoyed with the questioning. Keep in mind that the client may be short of breath. Do not keep the client on the telephone for extended periods of time. Structure more assessment questions to have yes/no answers (closed-ended). Offer the client guidance, encouragement, and support.

Clients may have a chronic cough caused by smoking. Oftentimes the client would have already been counselled about smoking cessation and may not want to hear anything more about it. The only way to know how the client will respond is to ask. If the client becomes angry, do not insist on smoking cessation at this time. If the client acknowledges that smoking is contributing/causing the health problem, proceed with discussing options for smoking cessation. There is no major potion for smoking cessation. Most individuals who have successfully stopped smoking tried a variety of techniques and cessation aides such as nicotine patches or chewing gum and support groups. The client may be encouraged to discuss smoking cessation actions with the doctor/health care provider who may prescribe medication to assist in the process.

Clients may have a diagnosis of chronic lung disease and use oxygen periodically in the home. During the course of a conversation, you may learn that the client continues to smoke cigarettes. Be sure to emphasize that smoking should not be done in the home with an oxygen concentrator. Emphasize that this is a fire hazard. Follow up in a few days with another telephone call to reinforce the information about oxygen safety.

Clients being treated for lung cancer may convey depression about the diagnosis and prognosis. Realize that these conversations and episodes of care provide the client with opportunities to discuss thoughts, feelings, and reactions to treatment. Do not approach these calls as being futile because the client is terminally ill. Provide as much emotional and caring support as possible.

Clients may have limited financial resources and be unable to afford medications prescribed for asthma. Take the time to explain or reinforce actions to reduce the risk of asthma attacks. Brainstorm ways for the client to be able to find resources to pay for the needed medication. Suggest that the client discuss the financial hardship with the doctor/health care provider who may be able to prescribe a less costly medication or have access to pharmaceutical representatives who could have coupons or samples that can be shared with the client.

Clients with tuberculosis may admit to stopping their medication because of adverse effects. Gently remind the client that the health problem is treatable and is not chronic. Ask if the adverse effects have been discussed with the doctor/health care provider. The medications may need to be altered or changed, which would reduce or eliminate the adverse effects while continuing to treat the infection.