Chronic bronchitis is a long-term condition wherein the lower airways become inflamed. It is characterized by the excessive secretion of mucus, hypertrophy of mucous glands, and recurring infection, progressing to narrowing and obstruction of airflow. The condition is primarily defined as a productive cough, which lasts for 3 months for at least 2 consecutive years. Individuals with chronic bronchitis have chronic obstructive pulmonary disease (COPD), which is a group of diseases that cause air flow blockage in the lungs, and make it difficult for the patient to breathe.
The patient will maintain a respiratory rate within normal limits.
Nursing interventions
INTERVENTION
RATIONALE
Place patient in semi-fowler’s position
To have a maximum lung expansion
Increase fluid intake as applicable
To liquefy secretions
Keep patient back dry
To avoid stasis of secretions and avoid further complication
Change position every 2 hours
To facilitate secretion mov’t and drainage
Perform CPT
To loosen secretion
Place a pillow when the client is sleeping
To provide adequate lung expansion while sleeping.
Instruct how to splint the chest wall with a pillow for comfort during coughing and elevation of head over body as appropriate
To promote physiological ease of maximal inspiration
Maintain a patent airway, suctioning of secretions may be done as ordered
To remove secretions that obstructs the airway
Provide respiratory support. Oxygen inhalation is provided per doctor’s order
To aid in relieving patient from dyspnea
Administer prescribed cough suppressants and analgesics and be cautious, however, because opioids may depress respirations more than desired.
To promote deeper respirations and cough
Impaired Gas Exchange RT Altered Oxygen Balance
Assessment
Appearance of bluish extremities when in cough (cyanosis), lips
Lethargy
Restlessness
Hypercapnia
Hypoxemia
Abnormal rate, rhythm, depth of breathing
Diaphoresis
Outcomes
The patient will improve ventilation and adequate oxygenation of tissues
The patient will minimize or totally be free of symptoms of respiratory distress.
Nursing interventions
INTERVENTION
RATIONALE
Monitor level of consciousness or mental status
Restlessness,anxiety, confusion, and somnolence are common manifestations of hypoxia and hypoxemia.
Assist the client into the High-Fowler’s position
The upright position allows full lung excursion and enhances air exchange
Increase patient’s fluid intake
To help liquefy secretions
Encourage expectoration
To eliminate thick, tenacious, copious secretions which contribute to the impairment of gas exchange.
Encourage frequent position changes
To promote drainage of secretions
Encourage adequate rest & limit activities to within client tolerance
Helps limit oxygen needs/consumption
Promote calm/restful environments
To correct/improve existing deficiencies
Administer supplemental oxygen judiciously as indicated
May correct or prevent worsening of hypoxia.
Administer meds as indicated such as bronchodilators
To treat the underlying condition
Sleep Pattern Disturbance RT Difficulty of Breathing
Assessment
Irritability
Restlessness
Lethargy
Changes in posture
Difficulty of breathing which worsens at night
Outcomes
The patient will identify individually appropriate interventions to promote sleep.
The patient will be able to report improvements in sleep/rest pattern.
Nursing interventions
INTERVENTION
RATIONALE
Monitor level of consciousness or mental status
Restlessness, anxiety,confusion, and somnolence are common manifestations of hypoxia and hypoxemia.
Promote comfort measures such as back rub and change in position as necessary
To provide non pharmacologic management
Observe provision of emotional support
Lack of knowledge and problems, relationships may create tension. Interfering with sleep routines based on adult schedules may not meet a child’s needs.
Provide quiet environment
To promote an environment conducive to sleep.
Increase patient’s fluid intake
To help liquefy secretions
Encourage expectoration
To eliminate thick, tenacious, copious secretions which contribute for the DOB
Limit the fluid intake in evening if nocturia is a problem
To reduce need for nighttime elimination
Obtain feedback from SO regarding usual bedtime, rituals/routines
To determine usual sleep patterns & provide comparative baseline
Provide safety for patient sleep time safety
To promote comfort/safety
Recommend mid morning nap if one required
Napping especially in the afternoon can disrupt normal sleep pattern
Administer pain medication as ordered
To relieve discomfort and take maximum advantage of sedative effect
Risk for Spread of Infection
Assessment
Body temperature above normal range
Dehydration
Increase WBC count
Presence of increase mucus production
Outcomes
The patient will identify interventions to prevent and/or reduce the risk of infection
The patient will minimize or totally be free from the risk of infection.
Nursing interventions
INTERVENTION
RATIONALE
Review importance of breathing exercises, effective cough, frequent position changes, and adequate fluid intake
These activities promote mobilization and expectoration of secretions to reduce the risk of developing pulmonary infection.
Turn the patient q 2 hours
To liquefy secretions
Stress the importance of handwashing to SO’s
Handwashing is the primary defense against the spread of infection
Teach the SO’s how to care for and clean respiratory equipment
Water in respiratory equipment is a common source of bacterial growth
Teach the SO’s the manifestations of pulmonary infections (change in color of sputum, fever, chills) , self-care and when to call the physician
Early recognition of manifestations can lead to a rapid diagnosis.
Recommend rinsing mouth with water
To prevent risk of oral candidiasis.
Administer antimicrobials such as cefuroxime as indicated.
Given prophylactically to reduce any possible complications
Nursing Notes
Causes/ Risk Factors
The primary cause of chronic bronchitis is smoking or exposure to some type of respiratory irritant. Established risk factors include a history of smoking, occupational exposures, air pollution,reduced lung function, and heredity. Children of parents who smoke are at higher risk for pulmonary infections that may lead to bronchitis.
Pathophysiology
Assessment
Signs and symptoms of chronic bronchitis (insidious onset):
Productive cough lasting at least 3 months during a year for 2 successive years.
Thick, gelatinous sputum (greater amounts produced during superimposed infections).
Dyspnea and wheezing as disease progresses.
Diagnostic Evaluation
Pulmonary function tests, to demonstrate airflow obstruction-reduced forced expiratory volume in 1 second (FEV1), FEV1 to forced vital capacity ratio; increased residual volume to total lung capacity (TLC) ration, possibly increased TLC.
Chest X-rays to detect hyperinflation, flattened diaphragm, increased retrosternal space, decreased vascular markings, possible bullae (all in late stages).
Arterial blood gases, to detect decreased arterial oxygen pressure (PaO2), pH, and increased arterial carbon dioxide pressure (Paco2).
Sputum smears and cultures to identify pathogens.
Primary Nursing Diagnosis
Impaired gas exchange related to obstructed airways
Therapeutic Intervention / Medical Management
Smoking cessation to stop the progression and preserve lung capacity.
Low-flow oxygen to correct severe hypoxemia in a controlled manner and minimize carbon dioxide retention.
Home oxygen therapy, especially at night to prevent turnal oxygen desaturation.
Pulmonary rehabilitation to reduce symptoms that limit activity.
Chest physical therapy, including postural drainage and breathing retraining.
Lung transplant in severe cases of alpha1-antitrypsin deficiency.
Pharmacologic Intervention
Bronchodilators to reduce dyspnea and control bronchospasm delivered by metered-dose inhaler, other handheld devices, or nebulization.
Inhaled corticosteroids may be useful for some with severe airflow limitation and frequent exacerbations.
Corticosteroids by mouth or I.V. in acute exacerbations.
Antimicrobials to control secondary bacterial infections in the bronchial tree, thus clearing the airways.
Alpha1-antitrypsin replacement delivered by I.V. infusion.
Nursing Intervention
Monitor for adverse effects of bronchodilators-tremulousness, tachycardia, cardiac arrhythmias, central nervous system stimulation, hypertension.
Monitor oxygen saturation at rest and with activity.
Eliminate all pulmonary irritants, particularly cigarette smoke. Smoking cessation usually reduces pulmonary irritation, sputum production, and cough. Keep the patient’s room as dust-free as possible.
Use postural drainage positions to help clear secretions responsible for airway obstruction.
Teach controlled coughing.
Encourage high levels of fluid intake (8 to 10 glasses; 2 to 2.5 L daily) within the level of cardiac reserve.
Give inhalations of nebulized saline to humidify bronchial trees and liquefy sputum. Add moisture (humidifier, vaporizer) to indoor air.
Avoid dairy products if these increase sputum production.
Encourage the patient to assume a comfortable position to decrease dyspnea.
Use pursed lip breathing at intervals and during periods of dyspnea to control rate and depth of respiration and improve respiratory muscle coordination.
Discuss and demonstrate relaxation exercises to reduce stress, tension, and anxiety.
Encourage frequent small meals if the patient is dyspneic; a small increase in abdominal contents may press on diaphragm and impede breathing.
Offer liquid nutritional supplements to improve caloric intake and counteract weight loss.
Avoid foods producing abdominal discomfort.
Encourage use of portable oxygen system for ambulation for patients with hypoxemia and marked disability.
Encourage the patient in energy conservation techniques.
Documentation Guidelines
Respiratory status of the patient: Respiratory rate, breath sounds, use of oxygen, color of nail beds and lips; note any respiratory distress
Response to activity: Degree of shortness of breath with any exertion,degree of fatigue
Comfort, body temperature
Response to medications, oxygen,and breathing treatments
Need for assistance with activities of daily living
Response to diet and increased caloric intake, daily weights
Discharge and Home Healthcare Guidelines
Medications.
Be sure that the patient understands all medications, including the dosage, route, action, and adverse effects. Patients on aminophylline should have blood levels drawn as ordered by the physician. Before being discharged from the hospital, the patient should demonstrate the proper use of metered-dose inhalers.
Complications.
Instruct patients to notify their primary healthcare provider of any change in the color or consistency of their secretions. Green-colored secretions may indicate the presence of a respiratory infection. Patients should also report consistent, prolonged periods of dyspnea that are unrelieved by medications.
Follow-up.
Consider that patients with severe disease may need assistance with activities of daily living after discharge. Note any referrals to social services. Send patients home with a diet, provided by the dietitian and reinforced by the nurse, which provides a high-caloric intake. Encourage the patient to cover the face with a scarf if he or she goes out-of-doors in the winter. If the patient continues to smoke,provide the name of a smoking cessation program or a support group. Encourage the patient to avoid irritants in the air.
