Cough Nursing Diagnosis Care Plan: A Comprehensive Guide for Healthcare Professionals

Introduction

Coughing is a prevalent symptom in healthcare, prompting millions of clinical visits annually. It’s a fundamental protective reflex of the body’s immune system, designed to clear foreign materials and irritants from the respiratory tract. However, coughs are associated with a wide range of underlying conditions, from benign to serious. The subjective nature of cough assessment and the potential for hidden etiologies emphasize the need for thorough evaluation and management. This article provides a detailed overview of cough, focusing on nursing diagnoses and care plans to effectively manage this common complaint in patients.

Nursing Diagnoses Related to Cough

Coughing, as a symptom, can lead to or be associated with several nursing diagnoses. Recognizing these diagnoses is crucial for developing a comprehensive care plan. Common nursing diagnoses related to cough include:

Ineffective Airway Clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. This is often directly related to the cough itself and its underlying cause, such as excessive mucus production in bronchitis or pneumonia.
Ineffective Breathing Pattern: Inspiration and/or expiration that does not provide adequate ventilation. Cough can disrupt normal breathing patterns, especially if it is severe or uncontrolled. Underlying conditions causing cough, like asthma or COPD exacerbations, also contribute to ineffective breathing patterns.
Impaired Gas Exchange: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane. While not always a direct consequence of cough, conditions causing cough (e.g., pneumonia, pulmonary embolism, CHF) can significantly impair gas exchange.
Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage associated with the underlying cause of cough or the act of coughing itself (e.g., chest pain from excessive coughing).
Risk for Deficient Fluid Volume: Risk of decreased intravascular, interstitial, and/or intracellular fluid. Persistent coughing, especially if accompanied by other symptoms like fever or increased respiratory rate, can lead to dehydration.
Risk for Infection: Increased risk of being invaded by pathogenic organisms. While cough is often a symptom of infection, ineffective airway clearance due to cough can increase the risk of secondary infections (e.g., pneumonia following a viral URI).
Hyperthermia: Body temperature elevated above the normal range. Infections causing cough frequently present with fever.
Risk for Imbalanced Nutrition: Less Than Body Requirements: Risk of intake of nutrients insufficient to meet metabolic needs. Persistent cough and associated symptoms can reduce appetite and make eating uncomfortable, particularly in children and the elderly.
Knowledge Deficit: Deficiency in cognitive knowledge or psychomotor skills regarding the condition, treatment, management, and prevention. Patients and families may lack understanding about cough management, medication use, and when to seek medical attention.

Causes of Cough

Classifying cough by duration is a useful approach to narrow down potential etiologies.

Acute Cough: Cough lasting less than three weeks.
Subacute Cough: Cough lasting between 3 to 8 weeks.
Chronic Cough: Cough persisting for more than 8 weeks.

Common Causes of Acute Cough

The most frequent culprits behind acute cough are:

Acute Viral Upper Respiratory Infection (URI) / Common Cold: The most common cause. Viral infections irritate the upper airways, leading to mucus production and cough.
Acute Bronchitis: Typically viral, but bacterial in about 10% of cases. Inflammation of the bronchial tubes causes cough, often with sputum production.
Acute Rhinosinusitis: Inflammation of the nasal sinuses, often viral (if <10 days) or bacterial (if >10 days). Post-nasal drip from sinus congestion irritates the throat and triggers cough.
Pertussis (Whooping Cough): A bacterial infection (Bordetella pertussis) characterized by severe coughing fits followed by a “whooping” sound during inhalation. Highly contagious and serious, especially in infants.
Acute Exacerbation of Chronic Obstructive Pulmonary Disease (COPD): Worsening of COPD symptoms, often triggered by infection or irritants, leading to increased cough and sputum production.
Asthma: Chronic inflammatory airway disease with hyperresponsiveness. Cough in asthma is due to airway inflammation, mucus production, and bronchoconstriction.
Allergic Rhinitis: Inflammation of the nasal mucosa due to allergens, causing post-nasal drip and cough.
Congestive Heart Failure (CHF): Fluid buildup in the lungs due to heart failure irritates the airways and can cause a cough, often worse when lying down.
Pneumonia: Infection of the lung tissue, can be viral or bacterial, causing cough, fever, and often sputum production.
Aspiration Syndromes: Inhalation of food, fluid, or foreign material into the airways, causing irritation and cough, potentially leading to aspiration pneumonia.
Pulmonary Embolism (PE): Blood clot in the pulmonary arteries. Cough in PE can be due to lung irritation and, sometimes, hemoptysis.

Subacute and Chronic Cough

Subacute Cough: Commonly post-infectious cough, resulting from persistent airway inflammation after a URI.
Chronic Cough: More complex, often requiring specialist referral. Common causes include:
- Upper Airway Cough Syndrome (UACS) / Post-Nasal Drip Syndrome: Chronic post-nasal drip irritating the airways.
- Gastroesophageal Reflux Disease (GERD): Stomach acid refluxing into the esophagus and potentially the airways, causing irritation and cough, often worse at night.
- Non-asthmatic Eosinophilic Bronchitis (NAEB): Airway inflammation with eosinophils, causing cough without typical asthma symptoms.
- Chronic Bronchitis: Chronic cough with sputum production for at least 3 months per year for 2 consecutive years.
- Post-infectious Cough: Prolonged cough after a respiratory infection due to airway hyperresponsiveness.
- Cough Variant Asthma: Asthma presenting primarily with cough, without wheezing.
- ACE Inhibitor-Induced Cough: A common side effect of ACE inhibitor medications.
- Malignancy (Lung Cancer): Tumors in the airways can cause cough, sometimes with hemoptysis.
- Interstitial Lung Diseases (ILDs): Group of lung disorders causing scarring and fibrosis, leading to chronic cough.
- Obstructive Sleep Apnea (OSA): Airway obstruction during sleep can trigger cough reflexes.
- Chronic Sinusitis: Prolonged sinus inflammation with purulent discharge, causing post-nasal drip and cough.
- Psychosomatic Cough: Coughing habit without an underlying physical cause (diagnosis of exclusion).

Risk Factors for Cough

Cough is a highly prevalent symptom, and its occurrence is influenced by various factors. Smoking is a significant risk factor, with prevalence rates of cough being higher in smokers (5% to 40%). Other risk factors depend on the specific underlying etiology of the cough.

Assessment of Cough

A thorough assessment is crucial for identifying the cause of cough and developing an appropriate care plan. Key components of cough assessment include:

Detailed History:
- Duration of cough: Acute, subacute, or chronic.
- Characteristics of cough: Dry or productive, frequency, timing (day/night), triggers (exercise, cold air, allergens), aggravating and relieving factors.
- Sputum production: Color, consistency, amount.
- Associated symptoms: Fever, shortness of breath, chest pain, hemoptysis, post-nasal drip, heartburn, weight loss, fatigue, night sweats.
- Smoking history: Current or past smoker, pack-years.
- Medication history: ACE inhibitors, other medications.
- Occupation and environmental exposures: Dust, fumes, allergens.
- Past medical history: Asthma, COPD, CHF, GERD, allergies, sinusitis, etc.
Physical Examination:
- General appearance: Signs of respiratory distress, cyanosis.
- Vital signs: Temperature, heart rate, respiratory rate, blood pressure, oxygen saturation.
- Respiratory exam: Lung sounds (wheezing, crackles, rhonchi), breathing effort, chest wall movement.
- ENT exam: Nasal discharge, sinus tenderness, throat examination for post-nasal drip or irritation.
- Cardiovascular exam: Heart sounds, edema, signs of CHF.

Evaluation and Diagnostic Tests

For acute and subacute coughs without red flags, symptomatic treatment may be sufficient. However, persistent or severe coughs, or those with concerning symptoms, warrant further investigation.

Chest X-ray: To rule out pneumonia, lung masses, or other lung pathologies, especially in chronic cough or suspected lower respiratory tract infection.
Pulmonary Function Tests (PFTs): To assess lung function, particularly in chronic cough, suspected asthma, or COPD. Spirometry can help identify obstructive or restrictive patterns.
Sputum Culture and Sensitivity: If productive cough with purulent sputum, to identify bacterial pathogens and guide antibiotic therapy.
Bronchoscopy: For persistent cough, hemoptysis, or suspected airway lesions. Allows direct visualization of the airways, biopsy, and bronchoalveolar lavage (BAL) for cytology and microbiology.
Echocardiogram: If CHF is suspected as the cause of cough.
CT Scan of the Chest: More detailed anatomical imaging, useful for evaluating lung masses, interstitial lung disease, or pulmonary embolism.
Gastroesophageal Studies: For suspected GERD-related cough. May include esophageal pH monitoring, endoscopy (EGD), and speech and swallow evaluations.
Sleep Study (Polysomnography): If obstructive sleep apnea is suspected as a cause of nocturnal cough.
Allergy Testing: If allergic rhinitis is suspected.

Medical Management of Cough

Medical management focuses on treating the underlying cause and providing symptomatic relief.

Acute Cough

Symptomatic Relief:
- Over-the-counter (OTC) cough and cold medications: While evidence for efficacy is limited, some patients find relief with decongestants, antihistamines, and cough suppressants. However, guidelines generally discourage routine use for acute cough due to common cold.
- Cough Suppressants (Antitussives): Like dextromethorphan, to reduce cough frequency, particularly for dry, bothersome cough. Use cautiously as cough is a protective reflex.
- Expectorants: Like guaifenesin, to help loosen mucus and make coughs more productive, though evidence of effectiveness is also limited.
- Pain relievers: Acetaminophen or ibuprofen for fever and pain.
- Hydration: Encourage fluid intake to thin mucus.
- Rest: Promote recovery.
Antibiotics: Generally not indicated for acute viral coughs. Consider antibiotics for suspected bacterial infections (e.g., bacterial bronchitis, pneumonia, bacterial sinusitis, pertussis). Antibiotic choice should be guided by suspected pathogen and local resistance patterns. For bacterial sinusitis, amoxicillin-clavulanate is often first-line. Alternatives include clindamycin, cefuroxime, cefprozil, clarithromycin, levofloxacin, moxifloxacin, gatifloxacin.
Bronchodilators: Inhaled beta-agonists (e.g., albuterol) and anticholinergics (e.g., ipratropium) may be used for symptomatic relief of cough associated with bronchospasm (e.g., asthma exacerbation, COPD exacerbation).

Chronic Cough

Treat Underlying Cause: The primary goal.
- UACS/Post-Nasal Drip: Intranasal corticosteroids, antihistamines, decongestants, saline nasal rinses.
- GERD: Lifestyle modifications (elevate head of bed, avoid late meals, trigger foods like chocolate, caffeine, alcohol), proton pump inhibitors (PPIs) at maximal doses.
- Asthma/Cough Variant Asthma: Inhaled corticosteroids (ICS), long-acting beta-agonists (LABA), leukotriene modifiers.
- NAEB: Inhaled corticosteroids.
- ACE Inhibitor-Induced Cough: Discontinue ACE inhibitor and switch to an angiotensin receptor blocker (ARB).
- Chronic Bronchitis/COPD: Smoking cessation, bronchodilators, inhaled corticosteroids, pulmonary rehabilitation, oxygen therapy if indicated.
- Interstitial Lung Disease: Management depends on specific ILD, may include antifibrotic medications, immunosuppressants, oxygen therapy, pulmonary rehabilitation.
- Neurogenic Cough: Neuromodulators like gabapentin, pregabalin, amitriptyline, tramadol.

Nursing Management and Cough Nursing Care Plan

Nursing care plays a vital role in managing patients with cough. A comprehensive cough nursing care plan should address symptom relief, patient education, and monitoring for complications.

Nursing Interventions for Cough

Promote Effective Coughing Techniques:
- Directed Cough: Teach the patient to take slow, deep breaths, hold briefly, and then cough forcefully using abdominal muscles. This helps mobilize and expel secretions.
- Huff Cough: For patients with weak coughs or COPD. Instruct the patient to say “huff” during exhalation, which helps move mucus without causing airway collapse.
Maintain Hydration: Encourage oral fluid intake (water, warm liquids) to thin secretions and ease expectoration.
Positioning:
- Elevate Head of Bed: Especially for patients with GERD, CHF, or post-nasal drip, to reduce reflux and promote drainage.
- Frequent Repositioning: Every 2 hours for bedridden patients to prevent secretion pooling and promote lung expansion. Ambulation should be encouraged as tolerated.
Soothe Throat Irritation:
- Warm Liquids: Warm tea, broth, or water with honey and lemon can soothe the throat.
- Gargling: Warm saline gargles can relieve throat irritation.
- Lozenges/Cough Drops: Soothing effect, may contain menthol or honey.
Humidification:
- Humidifier/Cool Mist Vaporizer: Increase humidity in the air to moisten airways and loosen secretions. Clean humidifier regularly to prevent mold growth.
- Steam Inhalation: Warm showers or steam from a bowl of hot water (with caution to avoid burns) can help loosen secretions.
Chest Physiotherapy (CPT): For patients with significant mucus production or difficulty clearing secretions (e.g., cystic fibrosis, bronchiectasis). Includes postural drainage, chest percussion, and vibration.
Saline Nasal Rinses: For patients with post-nasal drip or sinusitis, to clear nasal passages and reduce irritation.
Oral Care: Frequent oral hygiene (every 4 hours) to prevent oral dryness and promote comfort.
Menthol Rubs: OTC menthol-containing chest rubs may provide a soothing sensation and temporary relief.
Patient Education:
- Cough Etiology and Management: Explain the cause of their cough and the treatment plan.
- Medication Education: Explain the purpose, dosage, frequency, and side effects of prescribed medications.
- Self-Care Measures: Hydration, rest, humidification, avoiding irritants (smoke, allergens).
- When to Seek Medical Attention: Warn patients about worsening symptoms (shortness of breath, high fever, hemoptysis, chest pain, change in consciousness).
- Smoking Cessation: If applicable, provide resources and support for smoking cessation.

Sample Cough Nursing Care Plan

Patient Problem: Ineffective Airway Clearance related to excessive mucus production secondary to acute bronchitis, as evidenced by productive cough, rhonchi on auscultation, and patient report of difficulty expectorating sputum.

Nursing Goal: Patient will maintain effective airway clearance as evidenced by clear breath sounds, effective cough, and expectoration of secretions without difficulty by discharge.

Nursing Interventions:

Assess respiratory status every 4 hours and PRN, including respiratory rate, depth, oxygen saturation, breath sounds, and cough characteristics.
Encourage and teach effective coughing techniques (directed cough, huff cough) every 2 hours while awake.
Maintain hydration: Encourage oral fluid intake of at least 2 liters per day, unless contraindicated.
Position patient in semi-Fowler’s or high-Fowler’s position to facilitate lung expansion and drainage of secretions.
Administer prescribed medications as ordered (e.g., expectorant, bronchodilator). Evaluate and document patient response to medications.
Provide humidification via humidifier or encourage warm showers/steam inhalation.
Perform chest physiotherapy if ordered and indicated, considering patient tolerance.
Teach patient about the importance of:
- Continuing coughing exercises at home.
- Maintaining adequate hydration.
- Avoiding smoking and respiratory irritants.
- Recognizing signs and symptoms of worsening respiratory infection and when to seek medical attention.

Evaluation:

Goal Met: Patient exhibits clear breath sounds, effective cough, expectorates secretions easily, and demonstrates understanding of home care instructions.
Goal Partially Met: Patient shows improvement in airway clearance, but still experiences some difficulty with cough or secretion expectoration. Continue interventions and reassess.
Goal Not Met: Patient continues to have ineffective airway clearance, persistent cough, and difficulty expectorating secretions. Re-evaluate care plan and consider further medical interventions.

When to Seek Help for Cough

Patients should be instructed to seek immediate medical attention if they experience any of the following:

Shortness of breath or difficulty breathing
Wheezing
Chest pain or tightness
Hemoptysis (coughing up blood)
High fever (over 102°F or 39°C)
Cyanosis (bluish discoloration of lips or skin)
Change in level of consciousness or confusion
Persistent cough that worsens or does not improve after several weeks
Cough accompanied by unexplained weight loss or night sweats
Inability to sleep due to excessive coughing or vomiting from coughing

Monitoring Cough

Nurses should monitor patients with cough regularly, including:

Vital signs: Temperature, heart rate, respiratory rate, blood pressure, oxygen saturation.
Respiratory status: Breath sounds, cough characteristics, sputum production, breathing effort.
Hydration status: Skin turgor, mucous membrane moisture, urine output.
Symptom relief: Assess effectiveness of interventions and medications.

Coordination of Care

Managing cough, especially chronic cough, often requires a multidisciplinary approach. Collaboration between primary care providers, nurse practitioners, internists, pulmonologists, and ENT specialists is essential to determine the underlying cause and develop an effective treatment plan. Avoid empirical use of antitussives without identifying the etiology.

Health Teaching and Health Promotion for Cough

Humidifier use: Especially for coughs related to colds, to moisten airways.
OTC cough remedies: Use as directed for symptom relief, but not as a substitute for addressing the underlying cause.
Cough drops/lozenges: For soothing throat irritation.
Smoking cessation: Crucial for smokers with cough to improve respiratory health.
Allergy avoidance: For patients with allergic rhinitis, identify and avoid allergens.
Acid reflux management: Lifestyle modifications and medications for GERD-related cough.

Risk Management for Cough

Smoking cessation: The most important risk management strategy for cough.
Vaccination: Influenza and pneumococcal vaccines to prevent respiratory infections that can cause cough.
Infection control: Good hand hygiene and avoiding contact with sick individuals to reduce the risk of respiratory infections.
Environmental control: Minimize exposure to dust, fumes, allergens, and irritants.

Discharge Planning for Cough

Provide patients with clear discharge instructions, including:

Emergency instructions: When to call 911 or seek immediate medical attention (shortness of breath, chest pain, cyanosis, confusion).
Medication instructions: Dosage, frequency, duration, and side effects of prescribed medications.
Symptom management strategies: Hydration, rest, humidification, cough techniques, OTC remedies.
Follow-up appointments: Schedule follow-up with primary care provider or specialist as needed.
Lifestyle modifications: Smoking cessation, GERD management, allergy avoidance.

Pearls and Other Important Considerations

Antibiotics for typical cough: Use judiciously, only if bacterial infection is suspected and symptomatic treatment fails, especially with purulent nasal discharge, maxillary toothache, or abnormal sinus transillumination.
Bacterial sinusitis: Can follow viral rhinitis or rhinosinusitis.
Bacterial bronchitis: Consider antibiotics for acute COPD exacerbations with worsening shortness of breath or wheezing.
Pertussis: Cough and vomiting may be suggestive. Antibiotics reduce infectivity but may not shorten the paroxysmal phase.
Elderly patients: May present with atypical cough symptoms. Consider pneumonia, CHF, asthma, and aspiration.
GERD-related cough: Heartburn may be absent in up to 75% of patients. GERD cough requires both reflux and cough propensity.

Review Questions (To be developed – based on content for knowledge assessment)

References

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