Nursing Diagnosis of Cough: A Comprehensive Guide for Effective Patient Care

Introduction

Cough, a prevalent symptom in healthcare, prompts millions of clinical visits annually and often necessitates specialist referral. This innate reflex is a critical component of the body’s defense, safeguarding against irritants and pathogens. Coughing is associated with a diverse range of clinical conditions and underlying causes. Notably, the subjective nature of cough evaluation, due to the absence of objective measurement tools, underscores the complexity of its assessment. Given the potential for serious underlying conditions, the significant impact on patient quality of life, and the lack of objective diagnostic measures, a thorough evaluation and appropriate management of cough is paramount until a benign cause is identified. This article aims to provide a comprehensive guide to nursing diagnoses related to cough, enhancing nurses’ ability to deliver effective patient care.

Nursing Diagnoses Related to Cough

Nurses play a pivotal role in assessing and managing patients experiencing cough. Several nursing diagnoses may be pertinent depending on the etiology and patient presentation. These include:

• Ineffective Airway Clearance: This diagnosis is relevant when a patient is unable to clear secretions or obstructions from the respiratory tract to maintain airway patency. Cough, in this context, may be weak or ineffective in expelling mucus.
• Ineffective Breathing Pattern: This diagnosis applies when the patient’s respiratory rate, depth, or rhythm is altered and does not provide adequate ventilation. Cough may be a symptom of an underlying breathing pattern issue, or the cough itself may disrupt normal breathing patterns.
• Impaired Gas Exchange: This diagnosis is considered when the patient experiences a deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane. Cough, especially when associated with underlying respiratory or cardiac conditions, can contribute to or indicate impaired gas exchange.
• Acute Pain: Persistent or forceful coughing can lead to musculoskeletal pain, particularly in the chest or abdominal muscles. This diagnosis addresses the patient’s discomfort associated with the physical act of coughing.
• Deficient Knowledge: Patients may lack understanding regarding the cause of their cough, appropriate management strategies, or when to seek medical attention. This diagnosis highlights the need for patient education.
• Hyperthermia: Cough associated with infectious processes can lead to an elevation in body temperature. This diagnosis addresses the physiological response to illness.
• Risk for Infection: While cough is often a symptom of infection, it can also be a risk factor for secondary infections, especially in patients with ineffective airway clearance or underlying respiratory conditions.
• Risk for Deficient Fluid Volume: Persistent coughing, especially when accompanied by fever and increased respiratory rate, can contribute to dehydration. This diagnosis addresses the potential for fluid imbalance.
• Risk for Imbalanced Nutrition: Less Than Body Requirements: Severe or persistent cough can interfere with a patient’s ability to eat and maintain adequate nutritional intake, particularly if associated with fatigue or nausea.

Understanding the Causes of Cough

Classifying cough by duration is a common approach in clinical practice. This categorization helps guide diagnostic and management strategies.

Acute Cough

An acute cough is defined as a cough lasting less than three weeks. In adults, the most frequent causes are:

• Acute Viral Upper Respiratory Infection (URI), or the Common Cold: Viral URIs are the most common cause of acute cough. Inflammation of the upper airways, including the nasal passages and throat, triggers mucus production and irritation, leading to cough.
• Acute Bronchitis: Typically viral in origin, acute bronchitis involves inflammation of the bronchi. Cough is a hallmark symptom, often accompanied by sputum production. While usually viral, bacterial infections account for about 10% of cases.
• Acute Rhinosinusitis: Inflammation of the paranasal sinus lining, often viral if lasting less than 10 days, can also be bacterial if prolonged. Increased mucus production and post-nasal drip irritate the airways, inducing cough.
• Pertussis (Whooping Cough): This bacterial infection, caused by Bordetella pertussis, is characterized by severe paroxysmal coughing episodes followed by a “whooping” sound during inhalation. The infection progresses through stages: catarrhal (cold-like symptoms), paroxysmal (intense coughing fits, post-tussive vomiting), and convalescent (chronic cough). Pertussis remains a serious illness, especially for infants.
• Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): Patients with COPD, encompassing chronic bronchitis and emphysema, experience airflow limitation and lung damage. Acute exacerbations are characterized by worsened respiratory symptoms, including increased cough, sputum production, and shortness of breath due to airway inflammation and mucus accumulation.
• Allergic Rhinitis: Inflammation of the nasal mucosa due to allergens leads to increased mucus secretion and post-nasal drip. This post-nasal drip irritates the airways and triggers a cough reflex.
• Asthma: This chronic inflammatory airway disease involves hyperresponsiveness to stimuli, leading to airway obstruction and bronchial hyperreactivity. Cough in asthma is often due to increased mucus, airway narrowing, and bronchial irritation.
• Congestive Heart Failure (CHF): Reduced cardiac output in CHF leads to fluid congestion in the pulmonary vasculature. Pulmonary edema irritates the lungs and stimulates a cough, often described as dry and hacking.
• Pneumonia: Infection of the lung parenchyma can be viral or bacterial. Both types cause airway inflammation and irritation, leading to cough. Bacterial pneumonia often presents with purulent sputum.
• Aspiration Syndromes: When food or fluids are misdirected into the airway instead of the esophagus, aspiration occurs. This can cause immediate irritation and cough, and potentially lead to aspiration pneumonia.
• Pulmonary Embolism (PE): A blood clot in the pulmonary arteries obstructs blood flow, leading to lung congestion and irritation. Cough in PE can be a symptom, alongside shortness of breath and chest pain.

Subacute Cough

Subacute cough, lasting between 3 to 8 weeks, is frequently post-infectious. It often results from persistent irritation of cough receptors in the airways due to ongoing inflammation after a viral URI. Both acute and subacute coughs are typically self-limiting and managed with supportive care.

Chronic Cough

A chronic cough persists for more than 8 weeks and often necessitates specialist referral for thorough evaluation. Potential causes are diverse and include:

• Upper Airway Cough Syndrome (UACS), formerly Post-Nasal Drip Syndrome: This is the most common cause of chronic cough. Persistent post-nasal drip from various rhinitis conditions (allergic, non-allergic, infectious) irritates the upper airways, triggering chronic cough.
• Gastroesophageal Reflux Disease (GERD): Stomach acid refluxing into the esophagus, pharynx, and larynx can irritate laryngeal receptors and cause microaspiration. This can lead to a chronic cough, often worse at night when lying down.
• Non-Asthmatic Eosinophilic Bronchitis (NAEB): This condition involves airway inflammation with eosinophils but without typical asthma characteristics. Increased inflammatory cytokines irritate the airways and cause cough.
• Chronic Bronchitis: Defined as a cough with sputum production for at least 3 months per year for two consecutive years. Excessive mucus secretion and airway inflammation are key factors. Chronic bronchitis predisposes to bacterial infections, further exacerbating cough.
• Post-Infectious Cough: Increased cough receptor sensitivity and bronchial hyperresponsiveness can persist after a respiratory infection, leading to a prolonged cough even after the infection has resolved.
• Cough Variant Asthma (CVA): In CVA, cough is the predominant symptom rather than wheezing. Inflammation primarily affects proximal airways where cough receptors are concentrated, leading to cough triggered by exercise, cold air, or URIs.
• Malignancy: Lung tumors can cause cough through airway obstruction, mucus accumulation, secondary infections, and direct irritation of cough receptors. Some tumors may also secrete substances that stimulate cough.
• Interstitial Lung Diseases (ILDs): This group of disorders causes lung tissue scarring and stiffening due to chronic exposure to irritants (e.g., asbestos, dust) or autoimmune diseases. Lung damage and inflammation in ILDs can lead to chronic cough.
• Obstructive Sleep Apnea (OSA): Airway obstruction during sleep in OSA triggers reflexive coughing and gasping to reopen the airway.
• Chronic Sinusitis: Prolonged sinus inflammation and purulent discharge, often due to bacterial infections, can cause persistent post-nasal drip and chronic cough.
• Psychosomatic Cough: This diagnosis is rare and considered only after excluding all other organic causes. It involves coughing as a habitual or psychologically-driven behavior.

Risk Factors for Cough

Cough is a highly prevalent symptom, with smoking being a significant risk factor, increasing prevalence rates from 5% to 40%. Specific etiologies of cough may have varied predispositions based on demographics and other factors.

Nursing Assessment of Cough

A comprehensive patient history and physical examination are crucial for evaluating cough. Cough is a symptom, and patients often seek care for its secondary effects. Key components of nursing assessment include:

• Detailed History:
  • Duration of cough: Acute, subacute, or chronic.
  • Smoking history: Current or past smoking.
  • Use of ACE inhibitors: A common medication side effect.
  • Weight loss: May indicate underlying serious illness.
  • Occupation: Exposure to occupational irritants.
  • Diurnal variation: Worse at night (GERD, asthma) or day (psychogenic).
  • Relieving and Aggravating factors: Activities, positions, or substances that affect cough.
  • Productive vs. Nonproductive cough: Presence and characteristics of sputum (color, consistency, odor).
  • Associated hemoptysis: Coughing up blood, a serious symptom.
  • Associated fever: Suggests infection.
  • Associated shortness of breath: Indicates respiratory compromise.
  • Preceding upper respiratory infection: Suggests viral or post-infectious cough.
  • Other medical conditions: Asthma, COPD, CHF, GERD, allergies, etc.
• Physical Examination:
  • General appearance: Signs of respiratory distress, level of consciousness.
  • Vital signs: Temperature, heart rate, respiratory rate, blood pressure, oxygen saturation.
  • Respiratory system: Lung auscultation for wheezes, crackles, rhonchi, diminished breath sounds. Assess breathing effort, chest wall movement, and use of accessory muscles.
  • Cardiovascular system: Heart sounds, edema, signs of heart failure.
  • ENT examination: Nasal discharge, sinus tenderness, throat examination for post-nasal drip, redness, or lesions.
  • Musculoskeletal exam: Chest wall tenderness.

Associated symptoms that may accompany cough and warrant assessment include malaise, fatigue, insomnia, lifestyle changes, musculoskeletal chest pain, hoarseness, excessive sweating, urinary incontinence, syncope, cardiac arrhythmias, headache, subconjunctival hemorrhage, inguinal hernia, and/or gastroesophageal reflux. The patient’s specific complaints guide the focus of the physical exam and diagnostic workup.

Evaluation and Diagnostic Measures

Acute and subacute coughs typically do not require extensive diagnostic testing unless there are red flags suggesting serious pathology. Symptomatic treatment is usually sufficient. A chest X-ray may be indicated for severe cough or in patients appearing acutely ill.

Chronic cough often warrants diagnostic evaluation, including:

• Chest X-ray: To rule out pneumonia, lung masses, or other structural abnormalities.
• Pulmonary Function Testing (PFTs): To assess for asthma, COPD, or other obstructive or restrictive lung diseases.
• Referral to Pulmonologist: For complex cases, persistent cough without clear etiology, or abnormal chest X-ray or PFTs.
• Bronchoscopy: Direct visualization of airways to evaluate vocal cords, trachea, and bronchi for masses, lesions, or inflammation. Biopsy or bronchoalveolar lavage may be performed for microbiological and cytological analysis.
• Echocardiogram: To assess cardiac function, especially if CHF is suspected.
• CT Scan of the Chest: For detailed anatomical evaluation of the lungs and mediastinum.
• Gastroesophageal Studies: Speech and swallow evaluation, esophagogastroduodenoscopy (EGD), or esophageal pH monitoring to assess for GERD or aspiration.
• Sleep Study: Polysomnography to diagnose obstructive sleep apnea if nocturnal cough is prominent and OSA is suspected.
• Laryngeal Exam with Electromyography: For suspected neurogenic cough, to assess vocal cord paresis.

Medical Management and Nursing Implications

Most acute cough cases are managed empirically with symptomatic relief.

• Over-the-Counter (OTC) Cough and Cold Medications: While many combination antihistamine-decongestants have limited proven efficacy over placebo, cough suppressants and expectorants may provide some relief.
  • Cough Suppressants (Antitussives): Dextromethorphan is a common suppressant, acting to blunt the cough reflex. Nurses should educate patients that suppressing cough may not always be beneficial, as coughing is a protective mechanism.
  • Expectorants: Guaifenesin is a common expectorant, intended to thin mucus and facilitate expectoration. Hydration is equally important in thinning secretions.
• Antibiotics: Antibiotics are generally not indicated for acute cough unless bacterial infection is suspected (e.g., bacterial pneumonia, acute bacterial sinusitis, pertussis). Sputum culture may be needed to guide antibiotic therapy. For chronic infectious upper respiratory etiologies, prolonged antibiotic courses (3-6 weeks) may be necessary.
• Bronchodilators: Inhaled albuterol or ipratropium bromide may be used to relieve cough associated with bronchospasm, as in asthma or COPD exacerbations. Nurses administer these medications and monitor for side effects like tachycardia and tremors.
• Discontinuation of ACE Inhibitors: If cough is suspected to be ACE inhibitor-induced, the medication should be discontinued and an alternative antihypertensive prescribed. Nurses should monitor blood pressure and educate patients about medication changes.
• Management of Underlying Conditions: Chronic cough management focuses on treating the underlying cause. This may include inhaled corticosteroids and anticholinergics for reactive airway disease, optimized cardiac management for CHF, and aggressive GERD treatment (lifestyle modifications, proton pump inhibitors). Nurses play a key role in patient education about these management strategies and monitoring treatment effectiveness.
• Neurogenic Cough Management: Tramadol, amitriptyline, or gabapentin may be used for chronic neurogenic cough. Nurses should educate patients about potential side effects and monitor for therapeutic response.

Nursing Management of Cough

Nurses implement various interventions to promote patient comfort and recovery from cough:

• Education on Effective Coughing Techniques: Teach patients how to perform “controlled coughing” using abdominal muscles to generate a more forceful and productive cough.
• Hydration: Encourage increased fluid intake to thin secretions and promote expectoration.
• Ambulation and Repositioning: Encourage frequent ambulation and repositioning (every 2 hours) to mobilize secretions and prevent stasis.
• Elevate Head of Bed: Elevating the head of the bed, especially at night, can help reduce post-nasal drip and GERD-related cough.
• Warm Liquids and Gargles: Suggest warm liquids and saline gargles to soothe throat irritation.
• Lozenges and Cough Drops: Recommend using cough drops or lozenges to soothe the throat and suppress cough reflex.
• Steam Inhalation and Humidifiers: Recommend warm showers, steam inhalation, or cool-mist humidifiers to moisten airways and loosen secretions.
• Topical Menthol Rubs: Advise applying OTC menthol rubs to the chest and back for symptomatic relief.
• Chest Physiotherapy: In specific cases, chest physiotherapy techniques may be used to help mobilize secretions, particularly in patients with impaired airway clearance.
• Sterile Saline Nasal Rinses: Recommend nasal saline rinses to clear nasal passages and reduce post-nasal drip.
• Frequent Oral Care: Provide frequent oral care (every 4 hours) to maintain oral hygiene and comfort, especially if cough is productive.

When to Seek Medical Help

Nurses must educate patients and caregivers about when to seek immediate medical attention. Urgent symptoms include:

• Changes in level of consciousness
• Cyanosis or pallor (bluish or pale skin)
• Hemoptysis (coughing up blood)
• Symptoms of hypoxia (severe shortness of breath, confusion)
• Wheezing or difficulty breathing
• Chest pain or tightness
• Irregular or rapid heartbeat

Patients unable to sleep due to excessive coughing or experiencing vomiting from coughing should also be advised to contact their healthcare provider.

Nursing Monitoring

Nurses routinely monitor vital signs, including pulse oximetry, as per protocol. Hydration status, assessed by skin turgor and mucous membrane assessment, should also be monitored. Respiratory assessment, including breath sounds and cough characteristics, should be ongoing.

Coordination of Care

Cough can have diverse etiologies, ranging from benign to serious conditions like malignancy or severe infections. A multidisciplinary approach is essential for persistent cough. Collaboration between primary care providers, nurse practitioners, internists, pulmonologists, and ENT specialists is crucial. Empirical prescribing of antitussives without identifying the underlying cause should be avoided. A thorough history is vital, and referral to specialists is recommended for prolonged cough or cough accompanied by concerning symptoms.

Health Teaching and Health Promotion

Nurses provide essential health teaching to empower patients in managing cough:

• Humidifier Use: For coughs related to colds, using a humidifier in the bedroom can provide relief.
• OTC Cough Medications: Educate patients on the appropriate use and limitations of OTC cough medicines, cough drops, or hard candies.
• Smoking Cessation: Strongly advise smokers to quit smoking.
• Allergy Avoidance: For patients with allergies, advise avoidance of known allergens (pollen, dust, animals, mold).
• Acid Reflux Management: For patients with acid reflux, provide education on lifestyle modifications and prescribed medications to reduce symptoms.

Risk Management

Smoking cessation is a critical risk management strategy for cough and respiratory health.

Discharge Planning

Discharge instructions should include:

• Emergency Instructions (Call 911): Provide clear instructions to seek immediate emergency care for shortness of breath, wheezing, trouble breathing, chest tightness/pain, cyanosis, irregular heartbeat, difficulty talking, or confusion.
• Cough Symptom Management: Reinforce home care measures for cough symptom management, including hydration, rest, head elevation, warm liquids, steam inhalation, saline rinses, and oral care.
• Medication Instructions: Provide detailed instructions on any prescribed medications, including dosage, frequency, duration, and potential side effects.
• Follow-up Appointments: Ensure patients understand follow-up appointment schedules.

Pearls and Other Issues

• Antibiotic Use in Acute Cough: Reserve antibiotics for cases of acute cough with suspected bacterial sinusitis or bronchitis, indicated by purulent nasal discharge, maxillary toothache, abnormal sinus transillumination, or discolored nasal discharge, and when symptomatic therapy fails.
• Bacterial Sinusitis: Consider bacterial sinusitis when viral rhinosinusitis symptoms worsen or persist beyond 10 days.
• Bacterial Bronchitis: Consider bacterial bronchitis and antibiotics in COPD exacerbations with worsening shortness of breath or wheezing.
• Pertussis and Vomiting: Cough followed by vomiting is highly suggestive of pertussis. Antibiotics for pertussis primarily reduce infectivity, not the duration of the paroxysmal cough phase.
• Cough in Elderly: In older adults, typical cough symptoms may be subtle. Consider pneumonia, CHF, asthma, and aspiration in the differential diagnosis.
• GERD and Cough: Heartburn is not always present in GERD-induced cough. GERD-related cough is more likely in patients with unexplained chronic cough and a propensity to cough.

Review Questions

(Note: Review questions are not included as per instructions)

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Disclosure: Sandeep Sharma declares no relevant financial relationships with ineligible companies.

Disclosure: Muhammad Hashmi declares no relevant financial relationships with ineligible companies.

Disclosure: Mohamed Alhajjaj declares no relevant financial relationships with ineligible companies.

Disclosure: Jessica Knizel declares no relevant financial relationships with ineligible companies.