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The cough reflex generally occurs when mechanical, chemical, thermal, inflammatory, or
psychogenic stimuli activate cough receptors. (See Reviewing the cough mechanism, page 156.)
A nonproductive cough may occur in paroxysms and can worsen by becoming more frequent.
An acute cough has a sudden onset and may be self-limiting; a cough that persists beyond 1
month is considered chronic and commonly results from cigarette smoking.
Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery,
or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which
medications the patient takes, if any, and ask about recent changes in schedule or dosages. Ask
about recent changes in his appetite, weight, exercise tolerance, or energy level and recent
exposure to irritating fumes, chemicals, or smoke.
As you're taking his history, observe the patient's general appearance and manner: Is he agitated,
restless, or lethargic; pale, diaphoretic, or flushed; anxious, confused, or nervous? Also, note
whether he's cyanotic or has clubbed fingers or peripheral edema.
Next, perform a physical examination. Start by taking the patient's vital signs. Check the depth
and rhythm of his respirations, and note if wheezing or “crowing” noises occur with breathing.
Feel the patient's skin: Is it cold or warm; clammy or dry? Check his nose and mouth for
congestion, inflammation, drainage, or signs of infection. Inspect his neck for distended jugular
veins and tracheal deviation, and palpate for masses or enlarged lymph nodes.
Examine his chest, observing its configuration and looking for abnormal chest wall motion. Do
you note any retractions or use of accessory muscles? Percuss for dullness, tympany, or flatness.
Auscultate for wheezing, crackles, rhonchi, pleural friction rubs, and decreased or absent breath
sounds. Finally, examine his abdomen for distention, tenderness, masses, or abnormal bowel
sounds.
Medical causes
Airway occlusion.Partial occlusion of the upper airway produces a sudden onset of dry,
paroxysmal coughing. The patient is gagging, wheezing, and hoarse, with stridor, tachycardia,
and decreased breath sounds.
Aortic aneurysm (thoracic).Aortic aneurysm causes a brassy cough with dyspnea, hoarseness,
wheezing, and a substernal ache in the shoulders, lower back, or abdomen. The patient may also
have facial or neck edema, jugular vein distention, dysphagia, prominent veins over his chest,
stridor and, possibly, paresthesia or neuralgia.
Asthma.Asthma attacks typically occur at night, starting with a nonproductive cough and mild
wheezing; this progresses to severe dyspnea, audible wheezing, chest tightness, and a cough that
produces thick mucus. Other signs include apprehension, rhonchi, prolonged expirations,
intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils,
tachypnea, tachycardia, diaphoresis, and flushing or cyanosis.
Bronchitis (chronic).Bronchitis starts with a nonproductive, hacking cough that later becomes
productive. Other findings include prolonged expiration, wheezing, dyspnea, accessory muscle
use, barrel chest, cyanosis, tachypnea, crackles, and scattered rhonchi. Clubbing can occur in late
stages.
Common cold.The common cold generally starts with a nonproductive, hacking cough and
progresses to some mix of sneezing, headaches, malaise, fatigue, rhinorrhea, myalgia, arthralgia,
nasal congestion, and a sore throat.
Interstitial lung disease.A patient with interstitial lung disease has a nonproductive cough and
progressive dyspnea. He may also be cyanotic and have clubbing, fine crackles, fatigue, variable
chest pain, and weight loss.
Laryngeal tumor.A mild, nonproductive cough is an early sign of a laryngeal tumor, in addition
to minor throat discomfort and hoarseness. Later, dysphagia, dyspnea, cervical
lymphadenopathy, stridor, and an earache may occur.
Laryngitis.In its acute form, laryngitis causes a nonproductive cough with localized pain
(especially when the patient is swallowing or speaking) as well as fever and malaise. His
hoarseness can range from mild to complete loss of voice.
Lung abscess.Lung abscess typically begins with a nonproductive cough, weakness, dyspnea,
and pleuritic chest pain. The patient may also exhibit diaphoresis, a fever, a headache, malaise,
fatigue, crackles, decreased breath sounds, anorexia, and weight loss. Later, his cough produces
large amounts of purulent, foul-smelling and, possibly, bloody sputum.
Pleural effusion.A nonproductive cough along with dyspnea, pleuritic chest pain, and decreased
chest motion are characteristic of pleural effusion. Other findings include a pleural friction rub,
tachycardia, tachypnea, egophony, flatness on percussion, decreased or absent breath sounds, and
decreased tactile fremitus.
With mycoplasma pneumonia, a nonproductive cough arises 2 or 3 days after the onset of
malaise, a headache, and a sore throat. The cough can be paroxysmal, causing substernal chest
pain. Fever commonly occurs, but the patient doesn't appear seriously ill.
Viral pneumonia causes a nonproductive, hacking cough and the gradual onset of malaise,
headache, anorexia, and a low-grade fever.
Tularemia.Signs and symptoms of tularemia following inhalation of the organism include the
abrupt onset of a fever, chills, a headache, generalized myalgia, a nonproductive cough, dyspnea,
pleuritic chest pain, and empyema.
Other causes
Diagnostic tests.Pulmonary function tests (PFTs) and bronchoscopy may stimulate cough
receptors and trigger coughing.
Nursing considerations
▪ A nonproductive, paroxysmal cough may induce life-threatening bronchospasm; the patient
may need a bronchodilator to relieve his bronchospasm and open his airways.
▪ Unless he has chronic obstructive pulmonary disease, you may have to give the patient an
antitussive and a sedative to suppress the cough.
▪ To relieve mucous membrane inflammation and dryness, humidify the air in the patient's room.
▪ Prepare the patient for diagnostic tests, such as X-rays, a lung scan, bronchoscopy, and PFTs.
Patient teaching
▪ Teach the patient to use a humidifier if his home is dry.
▪ Tell him to avoid using aerosols, powders, or other respiratory irritants—especially cigarettes.
▪ If the patient smokes, stress the importance of smoking cessation, and refer him to appropriate
resources, support groups, and information to help him quit smoking.
▪ Explain the importance of adequate fluids and nutrition.
▪ Explain to the patient the cause of his cough and the treatment plan.
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