Diagnostic Studies

Chest x-ray: May reveal hyperinflation of lungs, flattened diaphragm, increased

retrosternal air space, decreased vascular markings/bullae (emphysema),
increased bronchovascular markings (bronchitis), normal findings during periods
of remission (asthma).

Pulmonary function tests: Done to determine cause of dyspnea, whether

functional abnormality is obstructive or restrictive, to estimate degree of
dysfunction and to evaluate effects of therapy, e.g., bronchodilators. Exercise
pulmonary function studies may also be done to evaluate activity tolerance in
those with known pulmonary impairment/progression of disease.

The forced expiratory volume over 1 second (FEV1): Reduced FEV1 not only is the
standard way of assessing the clinical course and degree of reversibility in
response to therapy, but also is an important predictor of prognosis.

Total lung capacity (TLC), functional residual capacity (FRC), and residual
volume (RV): May be increased, indicating air-trapping. In obstructive lung
disease, the RV will make up the greater portion of the TLC.

Arterial blood gases (ABGs): Determines degree and severity of disease

process, e.g., most often Pao2is decreased, and Paco2 is normal or increased in
chronic bronchitis and emphysema, but is often decreased in asthma; pH normal
or acidotic, mild respiratory alkalosis secondary to hyperventilation (moderate
emphysema or asthma).

DL CO test: Assesses diffusion in lungs. Carbon monoxide is used to measure

gas diffusion across the alveocapillary membrane. Because carbon monoxide
combines with hemoglobin 200 times more easily than oxygen, it easily affects the
alveoli and small airways where gas exchange occurs. Emphysema is the only
obstructive disease that causes diffusion dysfunction.

Bronchogram: Can show cylindrical dilation of bronchi on inspiration; bronchial

collapse on forced expiration (emphysema); enlarged mucous ducts (bronchitis).

Lung scan: Perfusion/ventilation studies may be done to differentiate between

the various pulmonary diseases. COPD is characterized by a mismatch of
perfusion and ventilation (i.e., areas of abnormal ventilation in area of perfusion
defect).

Complete blood count (CBC) and differential: Increased hemoglobin

(advanced emphysema), increased eosinophils (asthma).

Blood chemistry: alpha1-antitrypsin is measured to verify deficiency and

diagnosis of primary emphysema.

Sputum culture: Determines presence of infection, identifies pathogen.

Cytologic examination: Rules out underlying malignancy or allergic disorder.

Electrocardiogram (ECG): Right axis deviation, peaked P waves (severe

asthma); atrial dysrhythmias (bronchitis), tall, peaked P waves in leads II, III, AVF
(bronchitis, emphysema); vertical QRS axis (emphysema).

Exercise ECG, stress test: Helps in assessing degree of pulmonary dysfunction,

evaluating effectiveness of bronchodilator therapy, planning/evaluating exercise
program.

Nursing Priorities
1. Maintain airway patency.
2. Assist with measures to facilitate gas exchange.
3. Enhance nutritional intake.
4. Prevent complications, slow progression of condition.
5. Provide information about disease process/prognosis and treatment regimen.
Discharge Goals
1. Ventilation/oxygenation adequate to meet self-care needs.
2. Nutritional intake meeting caloric needs.
3. Infection treated/prevented.
4. Disease process/prognosis and therapeutic regimen understood.

1. Ineffective Airway Clearance

Nursing Diagnosis

Ineffective Airway Clearance

May be related to

Bronchospasm

Increased production of secretions; retained secretions; thick, viscous secretions

Allergic airways

Hyperplasia of bronchial walls

Decreased energy/fatigue

Possibly evidenced by

Statement of difficulty breathing

Changes in depth/rate of respirations, use of accessory muscles

Abnormal breath sounds, e.g., wheezes, rhonchi, crackles

Cough (persistent), with/without sputum production

Desired Outcomes

Maintain airway patency with breath sounds clear/clearing.

Demonstrate behaviors to improve airway clearance, e.g., cough effectively and

expectorate secretions.
Nursing Interventions

Rationale
Some degree of bronchospasm is present
with obstructions in airway and may or may

Auscultate breath sounds. Note adventitious

breath sounds (wheezes, crackles, rhonchi).

not be manifested in adventitious breath

sounds such as scattered, moist crackles
(bronchitis); faint sounds, with expiratory
wheezes (emphysema); or absent breath
sounds (severe asthma).

Assess and monitor respirations and breath

Tachypnea is usually present to some

sounds, noting rate and sounds (tachypnea,

degree and may be pronounced on

Nursing Interventions

Rationale
admission or during stress or concurrent

stridor, crackles, wheezes). Note inspiratory

acute infectious process. Respirations may

and expiratory ratio.

be shallow and rapid, with prolonged

expiration in comparison to inspiration.

Note presence and degree of dyspnea as for

Respiratory dysfunction is variable

reports of air hunger, restlessness, anxiety,

depending on the underlying process such

respiratory distress, use of accessory

as infection, allergic reaction, and the stage

muscles. Use 010 scale or American

of chronicity in a patient with established

Thoracic Societys Grade of Breathlessness

COPD. Note: Using a 010 scale to rate

Scale to rate breathing difficulty. Ascertain

dyspnea aids in quantifying and tracking

precipitating factors when possible.

changes in respiratory distress. Rapid onset

Differentiate acute episode from

of acute dyspnea may reflect pulmonary

exacerbation of chronic dyspnea.

embolus.
Elevation of the head of the bed facilitates
respiratory function by use of gravity;

Assist patient to assume position of comfort

however, patient in severe distress will seek

(elevate head of bed, have patient lean on

the position that most eases breathing.

overbed table or sit on edge of bed).

Supporting arms and legs with table, pillows,

and so on helps reduce muscle fatigue and
can aid chest expansion.

Keep environmental pollution to a

Precipitators of allergic type of respiratory

minimum such as dust, smoke, and feather

reactions that can trigger or exacerbate

pillows, according to individual situation.

onset of acute episode.

Encourage abdominal or pursed-lip

breathing exercises.

Provides patient with some means to cope

with or control dyspnea and reduce airtrapping.
Cough can be persistent but ineffective,

Observe characteristics of cough (persistent,

especially if patient is elderly, acutely ill, or

hacking, moist). Assist with measures to

debilitated. Coughing is most effective in an

improve effectiveness of cough effort.

upright or in a head-down position after

chest percussion.

Increase fluid intake to 3000 mL per day

Hydration helps decrease the viscosity of

Nursing Interventions
within cardiac tolerance. Provide warm or
tepid liquids. Recommend intake of fluids
between, instead of during, meals.

Rationale
secretions, facilitating expectoration. Using
warm liquids may decrease bronchospasm.
Fluids during meals can increase gastric
distension and pressure on the diaphragm.
Establishes baseline for monitoring
progression or regression of disease
process an complications. Note: Pulse
oximetry readings detect changes in

Monitor and graph serial ABGs, pulse

saturation as they are happening, helping to

oximetry, chest x-ray.

identify trends before patient is symptomatic.

However, studies have shown that the
accuracy of pulse oximetry may be
questioned if patient has severe peripheral
vasoconstriction.

2. Impaired Gas Exchange

Nursing Diagnosis

Impaired Gas Exchange

May be related to

Altered oxygen supply (obstruction of airways by secretions, bronchospasm; airtrapping)

Alveoli destruction

Alveolar-capillary membrane changes

Possibly evidenced by

Dyspnea

Abnormal breathing

Confusion, restlessness

Inability to move secretions

Abnormal ABG values (hypoxia and hypercapnia)

Changes in vital signs

Reduced tolerance for activity

Desired Outcomes

Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs

within patients normal range and be free of symptoms of respiratory distress.

Participate in treatment regimen within level of ability/situation.

Nursing Interventions

Rationale

Assess and record respiratory rate, depth.

Useful in evaluating the degree of

Note use of accessory muscles, pursed-lip

respiratory distress or chronicity of the

breathing, inability to speak or converse.

disease process.

Elevate head of bed, assist patient to

assume position to ease work of breathing.
Include periods of time in prone position as
tolerated. Encourage deep-slow or pursedlip breathing as individually needed or
tolerated.

Oxygen delivery may be improved by upright

position and breathing exercises to decrease
airway collapse, dyspnea, and work of
breathing. Note: Recent research supports
use of prone position to increase Pao2.
Cyanosis may be peripheral (noted in

Assess and routinely monitor skin and

nailbeds) or central (noted around lips/or

mucous membrane color.

earlobes). Duskiness and central cyanosis

indicate advanced hypoxemia.
Thick, tenacious, copious secretions are a

Encourage expectoration of sputum; suction

when indicated.

major source of impaired gas exchange in

small airways. Deep suctioning may be
required when cough is ineffective for
expectoration of secretions.
Breath sounds may be faint because of
decreased airflow or areas of consolidation.

Auscultate breath sounds, noting areas of

Presence of wheezes may indicate

decreased airflow and adventitious sounds.

bronchospasm or retained secretions.

Scattered moist crackles may indicate
interstitial fluid or cardiac decompensation.

Palpate for fremitus.

Decrease of vibratory tremors suggests fluid

collection or air-trapping.

Nursing Interventions

Rationale
Restlessness and anxiety are common

Monitor level of consciousness and mental

status. Investigate changes.

manifestations of hypoxia. Worsening ABGs

accompanied by confusion/ somnolence are
indicative of cerebral dysfunction due to
hypoxemia.
During severe, acute or refractory
respiratory distress, patient may be totally

Evaluate level of activity tolerance. Provide

unable to perform basic self-care activities

calm, quiet environment. Limit patients

because of hypoxemia and dyspnea. Rest

activity or encourage bed or chair rest during

interspersed with care activities remains an

acute phase. Have patient resume activity

important part of treatment regimen. An

gradually and increase as individually

exercise program is aimed at increasing

tolerated.

endurance and strength without causing

severe dyspnea and can enhance sense of
well-being.

Evaluate sleep patterns, note reports of

difficulties and whether patient feels well
rested. Provide quiet environment, group
care or monitoring activities to allow periods
of uninterrupted sleep; limit stimulants such

Multiple external stimuli and presence of

dyspnea may prevent relaxation and inhibit
sleep.

as caffeine; encourage position of comfort.

Tachycardia, dysrhythmias, and changes in
Monitor vital signs and cardiac rhythm.

BP can reflect effect of systemic hypoxemia

on cardiac function.