Question

i need nursing care plan for COPD with 2 goal and 6 intevention and 2 evaluation all suppose to be evidnace based with rational

Answer 1

Nursing care plan :-

1. Nursing Diagnosis :-

Ineffective Airway Clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.

May be related to :-

Bronchospasm

Increased production of secretions; retained secretions; thick, viscous secretions

Allergic airways

Hyperplasia of bronchial walls

Decreased energy/fatigue

Possibly evidenced by :-

Statement of difficulty breathing

Changes in depth/rate of respirations, use of accessory muscles

Abnormal breath sounds, e.g., wheezes, rhonchi, crackles

Cough (persistent), with/without sputum production

Desired Outcomes:-

Maintain airway patency with breath sounds clear/clearing.

Demonstrate behaviors to improve airway clearance, e.g., cough effectively and expectorate secretions.

Nursing Interventions and Rationale :-

Assess and monitor respirations and breath sounds, noting rate and sounds (tachypnea, stridor, crackles, wheezes). Note inspiratory and expiratory ratio. Tachypnea is usually present to some degree and may be pronounced on admission or during stress or concurrent acute infectious process. Respirations may be shallow and rapid, with prolonged expiration in comparison to inspiration.

Auscultate breath sounds. Note adventitious breath sounds (wheezes, crackles, rhonchi). Some degree of bronchospasm is present with obstructions in the airway and may or may not be manifested in adventitious breath sounds such as scattered, moist crackles (bronchitis); faint sounds, with expiratory wheezes (emphysema); or absent breath sounds (severe asthma).

Note presence and degree of dyspnea as for reports of “air hunger,” restlessness, anxiety, respiratory distress, use of accessory muscles. Use 0–10 scale or American Thoracic Society’s “Grade of Breathlessness Scale” to rate breathing difficulty. Ascertain precipitating factors when possible. Differentiate acute episode from exacerbation of chronic dyspnea. Respiratory dysfunction is variable depending on the underlying process such as infection, allergic reaction, and the stage of chronicity in a patient with established COPD. Note: Using a 0–10 scale to rate dyspnea aids in quantifying and tracking changes in respiratory distress. Rapid onset of acute dyspnea may reflect pulmonary embolus.

Observe sign and symptoms of infections. Identify the occurrence of an infectious process.

Monitor and graph serial ABGs, pulse oximetry, chest x-ray. Establishes a baseline for monitoring progression or regression of disease process complications.

Therapeutic Interventions :-

Position head midline with flexion on appropriate for age/condition.Gain or maintain an open airway.

Assist the patient to assume a position of comfort (elevate the head of the bed, have patient lean on an overbed table or sit on edge of the bed).Elevation of the head of the bed facilitates respiratory function by use of gravity; however, patient in severe distress will seek the position that most eases breathing. Supporting arms and legs with table, pillows, and so on helps reduce muscle fatigue and can aid chest expansion.

Keep environmental pollution to a minimum such as dust, smoke, and feather pillows, according to the individual situation.Precipitators of an allergic type of respiratory reactions that can trigger or exacerbate the onset of an acute episode.

Encourage abdominal or pursed-lip breathing exercises.Provides patient with some means to cope with or control dyspnea and reduce air-trapping.

Observe characteristics of cough (persistent, hacking, moist). Assist with measures to improve the effectiveness of cough effort.Cough can be persistent but ineffective, especially if the patient is elderly, acutely ill, or debilitated. Coughing is most effective in an upright or in a head-down position after chest percussion.

Increase fluid intake to 3000 mL per day within cardiac tolerance. Provide warm or tepid liquids. Recommend the intake of fluids between, instead of during, meals. Hydration helps decrease the viscosity of secretions, facilitating expectoration. Using warm liquids may decrease bronchospasm. Fluids during meals can increase gastric distension and pressure on the diaphragm.

Demonstrate effective coughing and deep-breathing techniques. Helps maximize ventilation.

Assist the patient to turn every 2 hours. If ambulatory, allow patient to ambulate as tolerated. Movement aids in mobilizing secretions to facilitate clearing of airways.

Suction secretions as needed. Suctioning clear secretions that obstruct the airway therefore improves oxygenation.

Demonstrate chest physiotherapy, such as bronchial tapping when in cough, proper postural drainage.These techniques will prevent possible aspirations and prevent any untoward complications.

Administer bronchodilators if prescribed.More aggressive measures to maintain airway patency.

2. Nursing Diagnosis :-

Impaired Gas Exchange: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

May be related to :-

Altered oxygen supply (obstruction of airways by secretions, bronchospasm; air-trapping)

Alveoli destruction

Alveolar-capillary membrane changes

Possibly evidenced by :-

Dyspnea

Abnormal breathing

Confusion, restlessness

Inability to move secretions

Abnormal ABG values (hypoxia and hypercapnia)

Changes in vital signs

Reduced tolerance for activity

Desired Outcomes:-

Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within patient’s normal range and be free of symptoms of respiratory distress.

Participate in treatment regimen within the level of ability/situation.

Nursing Interventions and Rationale

Assess and record respiratory rate, depth. Note the use of accessory muscles, pursed-lip breathing, inability to speak or converse. Useful in evaluating the degree of respiratory distress or chronicity of the disease process.

Assess and routinely monitor skin and mucous membrane color. Cyanosis may be peripheral (noted in nail beds) or central (noted around lips/or earlobes). Duskiness and central cyanosis indicate advanced hypoxemia.

Monitor changes in the level of consciousness and mental status.Restlessness, agitation, and anxiety are common manifestations of hypoxia. Worsening ABGs accompanied by confusion/ somnolence are indicative of cerebral dysfunction due to hypoxemia.

Monitor vital signs and cardiac rhythm. Tachycardia, dysrhythmias, and changes in BP can reflect the effect of systemic hypoxemia on cardiac function.

Auscultate breath sounds, noting areas of decreased airflow and adventitious sounds. Breath sounds may be faint because of decreased airflow or areas of consolidation. Presence of wheezes may indicate bronchospasm or retained secretions. Scattered moist crackles may indicate interstitial fluid or cardiac decompensation.

Palpate for fremitus. A decrease of vibratory tremors suggests fluid collection or air-trapping.

Monitor O2 saturation and titrate oxygen to maintain Sp02 between 88% to 92%. Pulse oximetry reading of 87% below may indicate the need for oxygen administration while a pulse oximetry reading of 92% or higher may require oxygen titration.

Monitor arterial blood gasses values as ordered. As the patient’s condition progresses, Pa02 usually decreases. For patient’s with chronic carbon dioxide retention may have chronically compensated respiratory acidosis with a low normal pH and a PaCo2 higher than 50 mm Hg.

Therapeutic Intervention :-

Encourage expectoration of sputum; suction when needed. Thick, tenacious, copious secretions are a major source of impaired gas exchange in small airways. Deep suctioning may be required when the cough is ineffective for expectoration of secretions.

Elevate the head of the bed, assist the patient to assume a position to ease work of breathing. Include periods of time in a prone position as tolerated. Encourage deep-slow or pursed-lip breathing as individually needed or tolerated .Oxygen delivery may be improved by upright position and breathing exercises to decrease airway collapse, dyspnea, and work of breathing. Use of prone position to increase Pao2.

Evaluate the level of activity tolerance. Provide a calm, quiet environment. Limit patient’s activity or encourage bed or chair rest during the acute phase. Have patient resume activity gradually and increase as individually tolerated. During severe, acute or refractory respiratory distress, the patient may be totally unable to perform basic self-care activities because of hypoxemia and dyspnea. Rest interspersed with care activities remains an important part of the treatment regimen. An exercise program is aimed at increasing endurance and strength without causing severe dyspnea and can enhance a sense of well-being.

Evaluate sleep patterns,note reports of difficulties and whether patient feels well rested. Provide quiet environment, group care or monitoring activities to allow periods of uninterrupted sleep; limit stimulants such as caffeine; encourage position of comfort.Multiple external stimuli and the presence of dyspnea may prevent relaxation and inhibit sleep.

Provide humidified oxygen as ordered. Administering humidified oxygen prevents drying out the airways, decrease convective moisture losses, and improves compliance.

Administer noninvasive positive pressure ventilation (NIPPV) as ordered. The use of noninvasive positive pressure ventilation can decrease PacO2, increase blood pH, and minimize symptoms of severe dyspnea during the first 4 hours of the treatment.