Keywords: COPD, CHRONIC OBSTRUCTIVE PULMONARY DISESAES, NURSING DIAGNOSIS
Nursing Diagnosis: #1 – Insufficient airway clearance related to increase mucus production as evidenced by profuse coughing and forced breathing.
Goal: Maintain clear airway by effective coughing.
- Access lung sound at least every 4 hours.
- Monitor amount, color and consistency of sputum.
- Proper position should be provided i.e. fowler’s/semi fowler’s position to prevent aspiration of secretions.
- Provide adequate oral fluid if indicated, if not then IV fluid may be provided as per physician’s order.
- Encourage patient to cough and deep breath
- Administer expectorants and antibiotic as ordered.
- If patient is unable to cough up secretions, suction should perform as per prescription.
- Request for chest physiotherapy as per physician’s order.
- Wheezes and crackle sound may indicate excess secretions in airway.
- Thick purulent sputum indicates infection.
- Movement mobilizes secretion and helps in breath properly.
- Hydration decreases viscosity of secretion.
- Controlled coughing and deep breathe is more effective for clearing airway.
- To liquefy secretion and trigger cough reflex.
- Suction is necessary to remove secretions and clear airway.
- To mobilize secretions.
- Does lung sound indicate retained secretion?
- Does sputum indicate infection?
- Is patient mobile?
- Are secretions thin and easily expectorated?
- Does patient cough and breathe effectively?
- Are medications effective?
- Is patient feeling comfortable after suctioning?
- Is physiotherapy is well tolerated by the patient?
Nursing Diagnosis: #2- ineffective breathing patterns related to shortness of breath and airway irritation as evidenced by high respiratory rate.
Goal: Patient should maintain an effective breathing pattern i.e. respiratory rate in between 12 to 24 per minute.
- Access respiratory rate, depth and rhythm.
- Monitor blood gas and oxygen saturation value.
- Place patient in fowlers or Semi fowler’s position.
- Diaphragmatic breathing training/ deep breathing training should be given to patient.
- Administer oxygen as prescribed.
- Respiration less than 12 and more than 24 may indicate an ineffective pattern.
- An ineffective breathing pattern will not maintain oxygenation.
- This allows for maximum chest expansion.
- Breathing exercise promotes relaxation and CO2
- To maintain optimal cellular function.
- Is respiratory pattern ineffective?
- Is breathing pattern adversely affecting oxygenation?
- Is patient comfortable in this position?
- Is patient able to demonstrate an effective breathing pattern?
- Is oxygen administration restored normal breathing pattern?
Nursing Diagnosis: #3 – impaired gas exchange related to decrease ventilation or perfusion as evidenced by headache, restlessness and improving ABG.
Goal: The patient will experience improved gas exchange.
- Access lung sound, respiratory rate and effort, use of accessory muscles.
- Observe skin and mucus membrane for cyanosis.
- Access degree of dyspnea on scale of 0 to 10, 0 = no dyspnea, 10 = worst dyspnea.
- Monitor for confusion and change in mental status.
- Monitor ABG value and pulse oximetry as ordered.
- Elevate head of bed or help patient to lean on over bet table.
- Administer supplemental oxygen at ≤ 2L per minute if ordered.
- Teach patient relaxation exercise, diaphragmatic (deep) and pursed lip breathing (a breathing technique that consist of exhaling through tightly pressed lip & inhaling through the nose with closed mouth).
- Encourage patient to stop smoking.
- For severe dyspnea, ask physician about an order for intravenous morphine sulfate.
- Respiratory rate less than 12 or more than 24 or use of accessory muscles indicates distress. Diminished lung sound indicates poor air movement and impaired gas exchange.
- Cyanosis indicates poor oxygenation. Oral mucus cyanosis indicates serous hypoxia.
- The patient’s subjective report is the best measure of dyspnea.
- Change in mental status can signal impaired gas exchange.
- PaO2 < 80 mmHg, PaCO2 > 45 mmHg or SaO2 < 90 indicate impaired gas exchange.
- Upright position promotes lung expansion.
- Supplemental oxygen decreases hypoxia.
- Relaxation exercise and breathing exercise decrease perceived dyspnea and promote relaxation with increase CO2
- Smoking is damaging to lungs and respiratory function.
- Low doses of IV Morphine cause vasodilation which helps relieve pulmonary edema and anxiety.
- Are lung sounds clear and audible? Is respiratory rate 12 to 24/min?
- Are skin and mucus membrane pink?
- Is patient’s degree of dyspnea within parameters that are acceptable to patient?
- Is patient alert and oriented?
- Are values within patient’s base line value?
- Did change of position relieve some distress?
- Does oxygen provide relief from dyspnea?
- Do breathing exercises help?
- Does it have any impact on client?
- Does morphine provide relief from dyspnea?
Nursing Diagnosis: #4 – Altered nutrition less than body requirement related to reduce appetite as evidenced by poor muscle tone and lack of interest in food.
Goal: Patient should have normal body weight.
- Assess dietary habit & recent food intake.
- Auscultate bowel sound.
- Give frequent oral care & remove expectorated secretions.
- Encourage a rest period of 1 hour before and after meal.
- Provide frequent and small feeding.
- Avoid gas producing food and carbonated beverages.
- Avoid very hot and very cold food.
- Weight, as indicated.
- Consult dietitian or nutritional support team to provide easily digested nutritionally balanced meals by mouth if patient can take orally.
- If not then any supplemental or tube feeding and parental nutrition must be provided.
- Respiratory distress is often anorectic because of dyspnea, sputum production and medication effect. As a result, client often admitted with some degree of malnutrition.
- Diminished or hypoactive bowel sounds may reflect decreased gastric motility and constipation related to limited fluid intake, decrease activity and hypoxia.
- Noxious tastes, smells and sights can reduce appetite and can produce nausea and vomiting with increased respiratory difficulties.
- Helps reduce fatigue in meal time and provide opportunities to increase total calorie intake.
- May help in enhance intake and easy digestion even though appetite is slow.
- Can produce abdominal distention.
- Extreme in temperature can precipitate coughing spasm.
- Useful in determining caloric needs, setting weight goal & evaluating adequacy of nutritional plan.
- Methods of feeding and caloric requirements are based on individual’s situation and specific need to provide maximum nutrients.
- Is any impact of dietary habit due to respiratory distress observed?
- Is any deviation of bowel sound detected?
- Is patient feeling better after removal of secretions?
- Is 1-hour gap before and after meal is effective?
- Does frequent and small feeding helps in food intake pattern?
- Is patient feeling good and no abdominal distention is there?
- Does it have any impact on patient’s cough reflex?
- Is patient maintaining the normal caloric need?
- Does patient take oral feeding? Does nutritional plan work?
Nursing Diagnosis: #5 – Activity intolerance related to ineffective breathing pattern as evidenced by fatigue and abnormal heart rate response to activity.
Goal: The patient will accomplish activities of daily living without dyspnea or excessive fatigue.
- Evaluate client’s response to activity. Note reports of dyspnea, increase weakness and fatigue & changes in vital signs during and after activities.
- Provide a quite environment and limit visitors during acute phase and encourage use of stress management and diversional activities.
- Explain importance of rest in treatment plan and necessity of balancing activities with rest.
- Assist client to assume comfortable position for rest and sleep.
- Assists with self-care activities as necessary.
- Establish client’s capabilities and need.
- Reduce stress and excess stimulation & promote rest.
- Minimizes exertion and helps in balancing oxygen supply and demand.
- Will help the patient to reduce exertion.
- Reduce client’s effort and maintains normal heart rate and breathing.
- Is any dyspnea and weakness identified?
- Are stress management and diversional activities helpful?
- What is the condition of the client after balanced activity and rest?
- After positioning does the patient feels good?
- What is the impact of this on client’s exertion and heart rate?
Nursing Diagnosis: #6 – Risk for infection related to the chronic disease condition.
Goal: To prevent and reduce risk and spread of secondary infection.
- Monitor vital sign, sputum color and body temperature.
- Encourage fluid intake.
- Protect patient from people with respiratory infections and limit visitors as indicated.
- Demonstrate and encourage hand washing technique.
- Change position frequently.
- Promote adequate nutritional intake.
- Investigate sudden changes and deterioration in condition such as increasing chest pain, recurring fever and changes in sputum characteristics.
- Administer antimicrobial as prescribed.
- During this period potentially, fatal complication such as hypertension and shock may develop.
- Hydration decreases viscosity of secretion.
- Effective means of reducing spread of infection.
- Best way to avoid and reduce infection.
- Improves respiratory function and releases pressure from pressure points.
- Minimizes the risk of unusual weight loss and provide adequate energy, hence improve pulmonary status.
- Helps in early detection and treatment of secondary infections.
- Reduce infectious pathogens.
- Does vital sign and sputum color indicate any complication?
- What is the consistency of secretion now?
- What is the breathing rate of the client after limiting visitors?
- Are client and family members following hand washing technique?
- Is client comfortable with changing position?
- Is client taking adequate nutrition?
- Does client feel any deterioration in health condition?
- Is patient getting antimicrobial regularly and timely?
Nursing Diagnosis: #7 – -deficient knowledge of self-care strategies related to lack of exposure as evidenced by inaccurate follow through of instruction.
Goal: Client will understand the condition, disease process and prognosis and will initiate necessary life style changes & participate in treatment program.
- Provide information in written and verbal form.
- Emphasize importance of continuing effective coughing and deep breathing exercises.
- Assist patient to identify ways to incorporate changes related to illness and its treatment into lifestyle.
- Explain importance of cessation of smoking.
- Provides patient with information that can be used for further clarification at home.
- It relieves dyspnea, increasing strength and endurance of the respiratory muscles, and optimizing the pattern of thoraco-abdominal motion.
- Patient can see that his or her life does not have to revolve around the disease.
- Smoking cessation enables loss of breath to be stabilized and reduces the frequency of coughing and expectoration.
- Is this method helpful to client and its family members?
- Does client understand the effectiveness of coughing and deep breathing exercise?
- Does this give psychological support to the client?
- Does this have any impact on client?
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