Orthopnea

Orthopnea: Excerpt from Nursing: Interpreting Signs and Symptoms

Orthopnea—difficulty breathing in the supine position—is a common symptom of cardiopulmonary disorders that produce dyspnea. It's usually a subtle symptom; the patient may complain that he can't catch his breath when lying down, or he may mention that he sleeps most comfortably in a reclining chair or propped up by pillows. Derived from this complaint is the common classification of two- or three-pillow orthopnea.

Orthopnea presumably results from increased hydrostatic pressure in the pulmonary vasculature related to gravitational effects in the supine position. It may be aggravated by obesity or pregnancy, which restricts diaphragmatic excursion. Sitting in an upright position relieves orthopnea by placing much of the pulmonary vasculature above the left atrium, which reduces mean hydrostatic pressure, and by enhancing diaphragmatic excursion, which increases inspiratory volume.

History and physical examination

Begin by asking about a history of cardiopulmonary disorders, such as myocardial infarction, rheumatic heart disease, valvular disease, asthma, emphysema, or chronic bronchitis. Does the patient smoke? If so, how much? Explore associated symptoms, noting especially complaints of coughing, nocturnal or exertional dyspnea, fatigue, weakness, loss of appetite, or chest pain. Does the patient use alcohol or have a history of heavy alcohol use?

When examining the patient, check for other signs of increased respiratory effort, such as accessory muscle use, shallow respirations, and tachypnea. Also note barrel chest. Inspect the patient's skin for pallor or cyanosis and the fingers for clubbing. Observe and palpate for edema, and check for jugular vein distention. Auscultate the lungs for crackles, rhonchi, or wheezing. Also auscultate the heart. Monitor the patient's oxygen saturation.

Medical causes

Chronic obstructive pulmonary disease (COPD).COPD typically produces orthopnea and other dyspneic complaints, accompanied by accessory muscle use, tachypnea, tachycardia, and paradoxical pulse. Auscultation may reveal diminished breath sounds, rhonchi, crackles, and wheezing. The patient may also exhibit a dry or productive cough with copious sputum. Other features include anorexia, weight loss, and edema. Barrel chest, cyanosis, and clubbing are usually late signs.

Left-sided heart failure.Orthopnea occurs late in left-sided heart failure. If heart failure is acute, orthopnea may begin suddenly; if chronic, it may become constant. The earliest symptom of this disorder is progressively severe dyspnea. Other common early symptoms include Cheyne-Stokes respirations, paroxysmal nocturnal dyspnea, fatigue, weakness, and cough that may occasionally produce clear or blood-tinged sputum. Tachycardia, tachypnea, and crackles may also occur.

Other late findings include cyanosis, clubbing, a ventricular gallop, and hemoptysis. Left-sided heart failure may also lead to signs of shock, such as hypotension, a thready pulse, and cold, clammy skin.

Mediastinal tumor.Orthopnea is an early sign of a mediastinal tumor, resulting from pressure of the tumor against the trachea, bronchus, or lung when the patient lies down. However, he may be asymptomatic until the tumor enlarges. Then it produces retrosternal chest pain, a dry cough, hoarseness, dysphagia, stertorous respirations, palpitations, and cyanosis. Examination reveals suprasternal retractions on inspiration, bulging of the chest wall, tracheal deviation, dilated jugular and superficial chest veins, and face, neck, and arm edema.

Nursing considerations

▪ To relieve orthopnea, place the patient in semi-Fowler's or high Fowler's position.

▪ Alternatively, have the patient lean over a bedside table with his chest forward.

▪ Administer oxygen via nasal cannula, if indicated.

▪ Administer a diuretic, if needed.

▪ For the patient with left-sided heart failure, give angiotensin-converting enzyme inhibitors, unless contraindicated.

▪ Monitor intake and output.

▪ Prepare the patient for diagnostic testing, such as an electrocardiogram, chest X-ray, pulmonary function tests, and arterial blood gas analysis.

▪ Assist with insertion of a central venous catheter or pulmonary artery catheter to measure central venous pressure and pulmonary artery wedge pressure and cardiac output, respectively.

Patient teaching

▪ Explains signs and symptoms that require prompt medical attention.

▪ Discuss any dietary and fluid restrictions.

▪ Reinforce the need to monitor weight daily.

▪ Explain diagnostic tests, diagnosis, and treatment plan.

Book Source Details

• Book Title: Nursing: Interpreting Signs and Symptoms
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Nursing: Interpreting Signs and Symptoms Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-668-7

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