Cough & dyspnea

Group A: Group B:
1- Eman Hussain Kathim 1- Abrar Mohammed Bokhamseen
2180003661 2180005582
2-Eman Abdulhadi Buhamad 2- Alhanouf Mohammed Kaabi
2180001600 2170003021
3-Buthaina Ahmed Alramadan 3- Amjad Abbas Alhanfoosh
2180000828 2180005570
4- Toqa Khaled Algumah 4- Anhar Ahmed Badawood
2180004232 2180000602

Supervised by: Mrs. Reema Alzahrani

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 Cough outline

INTRODUCTION……………………………………………………………………………… 3
-Definition of cough……………………………………………………………………………
-Definition of cough reflex………………………………………………………………….
Cough Causes……………………………………………………………………………… 4
Cough Complications…………………………………………………………………. 5
Assessment and Investigation …………………………………………………… 8
Cough Management…………………………………………………………………………….
-Non-pharma management…………………………………………………. 9
-pharma management…………………………………………………………. 10
-Nursing Care Plan………………………………………………………………. 11
References…………………………………………………..12

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 Introduction
Cough is a reflex which occur sudden and often repeat so it helps to clear the large
breathing passage. It is a protective reflex against foreign material. It may represent a
symptom of simplest diseases to fatal one as from common cold to fatal Lung
carcinoma. Cough classified into respiratory causes and non-respiratory causes. Also, it
has been classified into acute when its duration less than three weeks, and subacute
when its duration three to eight weeks, and chronic when its duration more than eight
weeks. In addition, it is also classified into dry or productive cough depending on the
presence or absence of expectoration respectively. Cough is only a symptom of some
underlying diseases and a diagnosis can be reached based on history, physical
examination, simple investigations, history taking being most important step.

Definition of cough
A rapid expulsion of air from the lungs, typically in order to clear the lung airways of
fluids, mucus, or any other material.

Definition of cough reflex

The cough reflex has two sensory (afferent) mainly via the vagus nerve and motor
(efferent) components. Pulmonary irritant receptors (cough receptors) in the epithelium
of the respiratory tract are sensitive to both mechanical and chemical motivation. The
bronchi and trachea are so sensitive to light touch that little amounts of foreign matter
or other causes of irritation begin the cough reflex. The larynx and carina are mostly
sensitive. Terminal bronchioles and even the alveoli are sensitive to chemical stimuli
such as sulfur dioxide gas or chlorine gas. Moving air usually carries with it any foreign
matter that is present in the bronchi or trachea. Stimulation of the cough receptors by
dust or other foreign particles produces a cough, which is important to remove the
foreign material from the respiratory tract before it reaches the lungs.

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 Causes of Cough
Cases of cough can range from a plebeian Cold to malignancy and pharmacists should
be capable to differentiate between a cough not resulting from a severe pathology and
one which could be the underlying symptom of a potentially critical condition. Studies
have shown that the reporting of cough is more Prevalent in females than males, maybe
Due to an increased sensitivity of cough Reflex in women.
Angiotensin-Converting-Enzyme (ACE) Inhibitor induced cough One of the most usual
causes of a dry, non-productive, persistent cough, which Could be easily observed by a
chemist, Is the one induced by angiotensin converting- Enzyme (ACE) inhibitors.
-Heart failure
Acute cough can be the presenting sign heart failure in patients who suffer
pulmonary congestion. Therefore, since cough can be a symptom of pulmonary edema
it is important to take in a high Index of suspicion of left ventricular heart Failure in
elderly patients presenting with a new or worsening cough, and refer such patients to a
specialist.
-Malignancy
Patients presenting with cough and throw risk factors for lung cancer should be
referred to a specialist. A cough may be Due to the cancer itself, the treatment, or other
co-existing disease. Malignancies which arise in other organs will often metastasize to
the lungs and therefore patients with a history of a malignancy should be referred for
specialist advice.
-Upper respiratory tract infections
Upper respiratory tract viral infections Are one of the most common movements of
Acute cough, which seems to originate from the stimulus of the cough reflex in the
Upper respiratory tract by post nasal drip, Clearing of the pharynx, or both. Five Post
infectious Cough starts with an acute Respiratory tract infection that is not complicated
by pneumonia and finally resolves without treatment. A post infectious the cough is
present for at least three weeks following an acute respiratory Infection, but not more
than eight workweeks. There are multiple pathogenic factors which may contribute to
the cause of cough and therefore therapy depend on the cough provoking factor.

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 Complications of Cough

Variables Symptoms

Cardiovascular Arterial hypotension.

Bradyarrhythmia and tachyarrhythmias.

Dislodgement/malfunctioning of intravascular catheters.

Loss of consciousness.

Rupture of subconjunctival, nasal, and anal veins and massive

intraocular suprachoroidal hemorrhage during pars plana
vitrectomy.

Constitutional Excessive sweating, anorexia, exhaustion.

symptoms

GI Gastroesophageal reflux events.

Gastric hemorrhage following percutaneous endoscopic

gastrostomy.

Hepatic cyst rupture.

Herniations (e.g. inguinal, through abdominal wall, small bowel

through laparoscopic trocar site).

Malfunction of gastrostomy button.

Mallory-Weiss tear.

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 Splenic rupture.

Genitourinary Inversion of bladder through urethra.

Urinary incontinence.

Musculoskeletal From asymptomatic elevations of serum creatine phosphokinase

to rupture of rectus abdominus muscles.

Diaphragmatic rupture.

Rib fractures.

Sternal wound dehiscence.

Neurological Acute cervical radiculopathy.

Cerebral air embolism.

Cerebral spinal fluid rhinorrhea.

Cervical epidural hematoma associated with oral

anticoagulation.

Cough syncope.

Dizziness.

Headache.

Malfunctioning ventriculoarterial shunts.

Seizures.

Stroke due to vertebral artery dissection.

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Ophthalmologic Spontaneous compressive orbital emphysema of rhinogenic
origin.

Others are listed under ′Cardiovascular′.

Psychosocial Fear of serious disease.

Lifestyle changes.

Self-consciousness.

Quality of life Decreased.

Respiratory Exacerbation of asthma.

Herniations of the lung (e.g. intercostal and supraclavicular).

Hydrothorax in peritoneal dialysis.

Laryngeal trauma (e.g. laryngeal edema and hoarseness).

Pulmonary interstitial emphysema, with potential risk of

pneumatosis intestinalis, pneumomediastinum,
pneumoperitoneum, pneumoretroperitoneum, pneumothorax,
subcutaneous emphysema.

Tracheobronchial trauma (e.g. bronchitis and bronchial rupture).

Skin Petechiae and purpura.

Disruption of surgical wounds.

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 Assessment and Investigation

The initial assessment of the patient with chronic cough (i.e. lasting more than eight
weeks) should include a focused history and physical examination and chest radiography
in most patients.

-Clinical investigations
Some basic research should be carried out routinely, and a number of more complex
tests are often limited by availability, time and expenditure.

-Chest X-ray (CXR)

The majority of patients in specialist cough clinics have a normal CXR. However, it is
critical to review a recent radiograph, as any significant anomaly will alter the
investigation algorithm.

-Pulmonary function tests (PFTs)

If available, bronchodilator reversibility tests should be carried out in all chronic
cough patients. Serial peak expiratory flow (PEF) measurement twice over 2 weeks can
diagnose airflow obstruction with diurnal variability if not available.

-Bronchial challenge testing

Bronchial challenge testing (usually done with methacholine) can provide very useful
clinical information about chronic cough patients. Bronchial hyperreactivity in a cough
patient and normal spirometric measurements may be caused by cough variant asthma.
However, a definitive diagnosis cannot be made until the cough is treated with asthma.
Cough may persist for many weeks after an acute viral upper respiratory tract infection
and under this circumstance a positive challenge test may be diagnostically misleading
as transient airway hyper-reactivity can develop. A negative bronchial challenge off
treatment effectively excludes asthma as a diagnosis but does not eliminate a cough
that responds to steroid therapy.

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 Cough Management

-Non-pharma Management
People can manage their coughs at home by taking over-the-counter medicine
and cough lozenges, removing possibility allergens, or Exposure to a steam bath
1. Staying Hydrated
An upper respiratory tract infection such as a cold or flu causes postnasal drip.
further secretions trickle down the back of patient throat, irritating it and
sometimes causing a cough, drinking fluids helps to thin out the mucus in
postnasal drip and helps to keep mucous membranes moist. This is especially
helpful in winter when houses tend to be dry, another cause of a cough.
2. cough drop and Hot Drinks
Patient can try a menthol cough drop, it numbs the back of the throat, and that
will tend to reduce the cough reflex. Also, drinking warm tea with honey can help
in soothe the throat.
3. Steamy Showers, and Use a Humidifier
A hot shower helps a cough by loosening secretions in the nose. A steamy
strategy can help ease coughs not only from colds but also from allergies.
Humidifiers may also help. In a dry home, nasal secretions (snot) can become
dried out and uncomfortable, putting moisture in the air can help patient to
cough, but it is important to not overdo it.
4. Remove Irritants from the Air
Perfumes and scented bathroom sprays may seem good. But for some people,
they can cause chronic sinus irritation, producing extra mucus that leads to a
chronic cough, should Take careful by avoiding such scented products.
The worst irritant in the air is, smoke. nearly all smokers eventually develop
“smoker’s cough." Everyone around the smoker might suffer from some airway
irritation. The best solution is Smokers need to stop smoking. a chronic cough can
be a sign of emphysema or lung cancer in smokers.

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Pharma Management

1- Cough suppressants and expectorants

If patient coughing so much that their chest hurts and they are getting a bad night’s
sleep, consider a cough suppressant, for example, dextromethorphan, but recommends
using cough suppressants only at night.
When patient has a cough that is thick with phlegm, they can take a cough expectorant
such as guaifenesin. Expectorants thin out the mucus so patient can very easily cough it
up.

2- Plenty of OTC
“OTC” products are sold “over the counter,” that means they don’t need a
prescription. Some focus on one symptom, such as congestion or a cough.
Antihistamines block a chemical which makes nose fill up and run. Studies detect
antihistamines don't improve cold symptoms much on their own. But they might work
better when combined with a decongestant. Some antihistamines can help patient
drowsier than others, so awareness is important of the side effects.
Dextromethorphan can affect drugs which treat depression. In addition, some
combination cold, and cough medicines contain decongestants, which can raise patient
blood pressure. So, it shouldn’t be given to Hypertension or heart disease patients.

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Nursing Care Plan

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 References

1. Morice AH, McGarvey L, Pavord I. 2006. BTS guidelines. Recommendations for

the management of cough in adults
2. RS Irwin, Diagnosis and management of cough: ACCP evidence-based clinical
practice guidelines. 2006. American College of Chest Physicians.
3. Morice AH, Fontana GA, Belvisi MG, et al. ERS guidelines on the assessment of
cough. European respiratory Journal 2007
Ainslie G. 2006. Assessment of cough journal. Cape Town. CME. P.88
4. gNursingCrib.com Nursing Care Plan Cough. (2011, May 15). Retrieved January
29, 2019
5. Blasio FD, Virchow JC, Polverino M, Zanas A, Behrakis PK, Kilinç G, et.al. Cough
management: a practical approach Cough. 2011
6. Definition of Cough. (2016, January 13). Retrieved January 17, 2019, from
https://www.medicinenet.com/script/main/art.asp?articlekey=2852
7. DerSarkissian C. 2018. What Are “OTC” Cough and Cold Medicines?.
https://www.webmd.com/cold-and-flu/otc-cold-medicines#1

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 Dyspnea outline

INTRODUCTION………………………………………………………………………… 14
-Definition of dyspnea…………………………………………………………………………….
Signs and symptoms…………………………………………………………………… 15
Dyspnea Causes…………………………………………………………………………… 16
Assessment and investigation ………………………………………………… 17
Management and treatment…………………………………………………….. 18
-Non-pharmacologic management…………………………………………………..
- pharmacologic management …………………………………………………………..
-Nursing Care Plan……………………………………………………………….. 211

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 Introduction

A healthy person breathes in and out up to 20 times a minute. That's mean 30,000
breaths a day. A vigorous workout or the common cold might throw a kink in that
pattern from time to time, but generally it should never feel short of breath.

Dyspnea it's shortness of breath can be a sign of health problems, there is many
causes of dyspnea but often related to heart or lung disease, also you may experience
temporary dyspnea after an intense workout.

There are different ways of treatment, but it's depending of the cause will talk about
it in details. Moreover, there is chronic and acute dyspnea, symptoms and causes of
them should be known and to differentiate between them. And nurses have a significant
role in dyspnea assessment and the care plan which will be mentioned.

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Signs and Symptoms of Dyspnea

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 Causes of Dyspnea

Variables Symptoms
Cardiovascular Heart failure

Congenital heart
anomalies
Superior vena cava
syndrome
Neuromuscular Amyotrophic lateral
sclerosis
Muscular dystrophy

Multiple sclerosis

Myasthenia gravis

deconditioning

Miscellaneous Hypervolemia

Anemia

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Pulmonary Asthma

Chronic obstructive
pulmonary diseases
Adult respiratory
distress syndrome
Cystic fibrosis

Interstitial lung disease

Lung cancer, metastatic

Pneumonia

Pneumothorax

Pleural effusion

Pulmonary arterial
hypertension
Pulmonary embolism

Radiation pneumonitis

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 Assessment & Investigation of Dyspnea

to evaluate and manage dyspnea, assessment is important part especially in

cardiopulmonary diseases. Dyspnea is a sensation so it could be as result from different
sources. Also, the severity of dyspnea differs from patient to another, so, it’s better to
measure dyspnea correctly and any other signs that leads to disease should be noticed
to give better treatment. However, the focus in this part will be on how to assess and
investigate dyspnea patient to achieve better measurement to dyspnea.
Historically, searching for the primary problem which lead to show dyspnea is
significant, in most cases it will be either in lung or heart or neuromuscular abnormality
which usually can be known by physical assessment and diagnostic test to achieve
correct diagnosis so it leads to the correction of disorder which will reduce the intensity
of dyspnea and increase patient comfort. Also, Physical assessment include symptom
intensity and interference with activities by using pain scale, skin color, temperature,
cough, abdominal girth, edema presence, auscultation of lung sounds, sputum quantity
and its character, and fluid balance assessment.

Diagnostic tests should be taken as chest x-ray to show if there is heart or lung
problem, lung volume measurement by spirometry, measurement of gas diffusion to
know if there is decrease in in diffusing capacity which is associate with abnormalities
occur in exercise and commonly found in patient with interstitial lung disease which
may result in hypoxia and lead to dyspnea. Also, oxygen test to measure oxygen in
patient blood, and Electrocardiography to measure patient heart electrical impulses and
it show if blood flow to the heart efficiently. All of these tests help better to assess and
investigate dyspnea and its cause.

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 Management and Treatment
The treatment will depend on the results of the tests and what's causing the shortness
of breath. example, if someone have asthma, they will get an inhaler to use when have a
flare. And the smoker should stop smoking, because it's bad for breathing, lungs and over
all the health. The life style should change depend in the cause. Treating dyspnea usually
means treating its underlying cause and there is two type of treatment pharmacology and
nonpharmacologic.

-Pharmacology Management

1- Pulmonary rehabilitation
is one of the important components of the management of patients with chronic lung
disease, the beneficial effects of pulmonary rehabilitation are a reduction in exertional
dyspnea during exercise and improved exercise tolerance, as well as decreases feeling of
dyspnea with activity. The main component of pulmonary rehabilitation responsible for
these improvements is exercise, but it is less clear whether mechanisms leading to
improvement in dyspnea are mainly due to improvements in conditioning, in pacing of
activities, desensitization to respiratory sensations or affective distress, or all these effects
together.
2-Heliox
Heliox a result of their decreased density, helium-containing gas mixtures decrease
the resistance to airflow, which may decrease the work of breathing, decrease the severity
of hyperinflation, increase exercise capacity, and decrease dyspnea in patients with
obstructive lung disease.
3-Oxygen
Supplemental oxygen increase death in chronically hypoxemic patients with COPD,
there are conflicting data about its ability to relieve breathlessness. The beneficial effect
of oxygen could be related to changes in chemoreceptor stimulation, resulting changes in
breathing pattern and stimulation of receptors related to gas flow through the upper
airway. Oxygen therapy is useful for patients with advanced heart or lung disease, those
who are hypoxemic at rest or with minimal activity.
4-Nebulized furosemide
Nebulized furosemide has been investigated as a new pharmacologic approach to t
treatment of dyspnea. they decrease breathlessness induced in normal people and Opioids
have been the most studied factor in treatment of dyspnea Short-term administration
reduces breathlessness in patients with a different of conditions

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-Nonpharmacologic
there is many small studies have shown that chest wall vibration reduces dyspnea in
patients with COPD, but there is no available device until now for delivering chest wall
vibration. Other things, increased respiratory muscle effort, related with high ventilatory
demand relative to respiratory muscle capacity, could contribute to dyspnea in many
patients with chronic respiratory disease. By reducing the effort on the respiratory
muscles, noninvasive ventilation (NIV) can reduce dyspnea. moreover, diet and exercise
If you obese and a poor fitness level are the cause of dyspnea you should be
experiencing, eat healthier diet and exercise more. If it’s been a long time or you have a
medical condition that reduce your activity level, contact with your doctor about how to
begin a safe exercise routine.

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Nursing Care Plan of Dyspneic patients
To manage dyspnea, the first aim is to treat the cause of dyspnea because it is a
symptom can occur from different causes such as heart failure, low blood pressure,
pneumonia, pulmonary embolism, carbon monoxide poisoning, cancer and anxiety. So,
some examples of nursing care plan to the most common causes of dyspnea will be
mentioned.
First, asthma, it is a chronic lung disease of the airways usually identified by bronchial
hyper reactivity, mucosal edema and production of mucus. This disease leads to several
symptoms as dyspnea, wheezing, cough, tachypnea, and other symptoms.

Second, heart failure, it is when heart unable to pump enough blood to meet what
tissue need of oxygen. It is characterized by rapid and irregular beats, dyspnea,
weakness, swelling in legs, and others.

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 Third, anemia, it is when hemoglobin is lower than the normal and then red blood
cells numbers will diminished, so, the amount of oxygen in body tissue will decrease.
Also, it could be characterized by several symptom as dyspnea, chest pain, weakness,
Jaundice and other symptoms.

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 References:

1. S. Smeltzer and B. Bare. (2003). Brunner and Suddarth's Textbook of Medical-

Surgical Nursing, 10th Edition. Philadelphia. Lippincott, Williams & Wilkins
2. Limmer, D., O'Keefe, M. and Dickinson, E. (2012). Emergency care.
12th ed. Boston: Brady.
3. "Dyspnea." American Journal of Respiratory and Critical Care
Medicine, 159(1), pp. 321–340
4. Campbell, M. L. (2017). dyspnea. Critical Care Nursing Clinics of
North America, 29(4), 461-470. doi:10.1016/j.cnc.2017.08.006
5. Pisani L, Nicholas S. Hill, Angela Maria Grazia Pacilli, Massimiliano
Polastri, Stefano Nava. (2018) Management of Dyspnea in the
Terminally Ill. Chest 154:4, 925-934.

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