The Client with Alterations in Respiratory Function

CHAPTER 4


The Client with Alterations in Respiratory Function



ASTHMA


image Asthma is a disorder characterized by intermittent and reversible obstruction of the airways. This airflow obstruction is caused by bronchial hyperresponsiveness and inflammation of the airway mucous membranes. Allergens enter the airway and initiate the inflammatory cascade. Mast cells found in the basement membranes of the bronchial walls degranulate and release inflammation response mediators, which cause increased capillary permeability and vasodilation, and recruitment of eosinophils, lymphocytes, and neutrophils. The response leads to the production of thick, tenacious mucus that blocks the airways. Combined with the bronchial hyperresponsiveness and capillary vasodilation and permeability, intake of air significantly decreases, and air is trapped in the lungs below the obstruction. Chronic inflammation leads to remodeling of the bronchial walls. The bronchial walls hypertrophy, and mucus-producing cells undergo hyperplasia.


Asthma attacks are variable and unpredictable, range from mild to severe, and differ from client to client. Clinical manifestations of an asthma attack include dyspnea, wheezing, chest tightness, tachycardia, sweating, cough, tightening of neck muscles, and use of accessory muscles to breathe. The client may also have an audible wheezing or whistling on exhalation. Indications that asthma is becoming worse include an increase in the frequency and severity of asthma attacks and an increased need to use bronchodilators.


There is no clear indication why some people get asthma and others, exposed to the same conditions, do not. It is possibly due to a combination of environmental and genetic factors. Triggers for an asthma attack also vary from client to client and may include airborne allergens and air pollutants, viral respiratory infections, cold air, stress, medications (i.e., nonsteroidal anti-inflammatory drugs [NSAIDs]), exercise, gastroesophageal reflex disease, smoke, and occupational factors.


This care plan focuses on care of the adult client with asthma who is hospitalized during an exacerbation of the illness. Much of the information is applicable to clients receiving follow-up care in an extended care facility or home setting.




Nursing Diagnosis IMPAIRED RESPIRATORY FUNCTION*


Definition: Inspiration and/or expiration that does not provide adequate ventilation; inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway


Ineffective breathing pattern NDx


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Ineffective airway clearanceNDx


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Impaired Gas Exchange NDx


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Nursing Diagnosis ACTIVITY INTOLERANCE NDx


Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities


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Nursing Diagnosis DEFICIENT KNOWLEDGE NDx; INEFFECTIVE HEALTH MAINTENANCE NDx; OR INEFFECTIVE SELF-HEALTH MANAGEMENT* NDx


Definition: Absence or deficiency of cognitive information related to specific topic (lack of specific information necessary for clients/significant others) to make informed choices regarding condition/treatment/lifestyle changes; inability to identify, manage, and/or seek out help to manage health pattern of regulating and integrating into daily living a therapeutic regimen for treatment of illness and the sequelae of illness that is unsatisfactory for meeting specific health goals









CHRONIC OBSTRUCTIVE PULMONARY DISEASE


Chronic obstructive pulmonary disease (COPD) is a term used to describe a disease state characterized by the presence of airflow obstruction in the lungs. The airflow obstruction is chronic, usually progressive, and may be accompanied by airway hyperactivity. Other terms sometimes used to describe this condition are chronic obstructive lung disease (COLD) and chronic airflow limitation (CAL). Signs and symptoms usually include dyspnea, cough, and sputum production that worsen over time and during periodic exacerbations.


The two conditions that comprise COPD are chronic bronchitis and emphysema. Chronic bronchitis is characterized by a cough that persists at least 3 months of the year for 2 consecutive years and an excessive production of mucus in the bronchi due to inflammation of the bronchioles and hypertrophy and hyperplasia of the mucous glands. In contrast, emphysema is characterized by dyspnea and a mild cough. The impaired airflow that occurs with emphysema is related to loss of lung elasticity, narrowing of the terminal nonrespiratory bronchioles, and destructive changes in the walls of the alveolar and/or respiratory bronchioles. Both chronic bronchitis and emphysema are usually present in the person with COPD, although one of the two usually predominates.


Causative factors of COPD include chronic irritation of the lungs by cigarette smoke, exposure to air pollution and chemical irritants, and recurrent respiratory tract infections. In a small percentage of cases of emphysema, the destruction of lung tissue by proteolytic enzymes is a result of a genetic deficiency of alpha1-antitrypsin.


This care plan focuses on care of the adult client with COPD who is hospitalized during an acute exacerbation. Much of the information is applicable to clients receiving follow-up care in an extended care facility or home setting.



OUTCOME/DISCHARGE CRITERIA


The client will:



1. Have improved respiratory function


2. Tolerate expected level of activity


3. Have no signs and symptoms of complications


4. Identify ways to prevent or minimize further respiratory problems


5. Verbalize ways to maintain an optimal nutritional status


6. Identify ways to conserve energy and/or reduce dyspnea and fatigue


7. Demonstrate proper chest physiotherapy and use of respiratory equipment


8. Verbalize an understanding of medications ordered including rationale, food and drug interactions, side effects, methods of administering, and importance of taking as prescribed


9. Identify precautions that should be adhered to when using oxygen


10. State signs and symptoms to report to the health care provider


11. Share feelings and thoughts about the effects of COPD on lifestyle and roles


12. Identify resources that can assist with financial needs, home management, and adjustment to changes resulting from COPD


13. Verbalize an understanding of and a plan for adhering to recommended follow-up care including future appointments with health care provider and graded exercise program.



Nursing Diagnosis IMPAIRED RESPIRATORY FUNCTION*


Definition: Inability of an individual to maintain adequate ventilation of the respiratory tract and perfusion of oxygen (O2) and carbon dioxide (CO2) between the lungs and vascular system to maintain adequate tissue oxygenation


Related to:


Ineffective breathing pattern NDx


Related to:



Ineffective airway clearance NDx


Related to:



Impaired gas exchange NDx


Related to:













Nursing Diagnosis IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS NDx


Definition: Inability of the individual to maintain adequate nutrition due to increased expenditure of energy to support the work of breathing


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Nursing Diagnosis ACTIVITY INTOLERANCE NDx


Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities


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Nursing Diagnosis RISK FOR INFECTION NDx (PNEUMONIA)


Definition: At increased risk for the lungs being invaded by pathogens


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Collaborative Diagnosis RISK FOR RIGHT-SIDED HEART FAILURE


Definition: A condition where the right side of the heart is unable to pump blood efficiently


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Collaborative Diagnosis RISK FOR RESPIRATORY FAILURE


Definition: Failure of the lungs to provide adequate oxygenation to the body


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Nursing Diagnosis FEAR/ANXIETY NDx


Definition: Fear—Response to perceived threat (real or imagined) that is consciously recognized as a danger. Anxiety—Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source is often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger


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Feb 11, 2017 | Posted by in NURSING | Comments Off on The Client with Alterations in Respiratory Function

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