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ASSESSMENT DIAGNOSIS BACKGROUND
KNOWLEDGE
GOALS AND
OBJECTIVE
NURSING
INTERVENTIONS AND
RATIONALE
EVALUATION
Objective: Vital Signs:
● RR: 28 cpm
● TEMP: 38
● O2SAT: 95% with
2 LPM nasal prongs Physical Assessment :
● (+)Use of
accessory muscles
● Crico-sternal
distance of 2 fingers
● Generalized
bronchial sounds with early inspiratory complication s
Anteroposteri or to transverse chest diameter
● (+) dyspnea
at rest
● (+) swollen
ankles
IMPAIRED GAS
EXCHANGE related to alveolar destruction, air trapping, and ventilation perfusion mismatch. Impaired Gas Exchange is an excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane (NANDA 15TH EDITION) In COPD, impaired gas exchange is diagnosed through arterial blood gas (ABG) analysis, which typically shows hypoxemia (low oxygen levels) and hypercapnia (elevated carbon dioxide levels), alongside symptoms like shortness of breath and chronic cough NOC: Respiratory Status: Gas Exchange GOAL: At the end of nursing interventions, the patient will demonstrate improved gas exchange, as evidenced by normal respiratory effort, oxygen saturation maintained within acceptable with client condition on prescribed oxygen therapy, and reduced dyspnea at rest and with mild exertion. SHORT TERM OBJECTIVE: At the end of 24 hours of nursing intervention, the patient will:
m a i n t a i n o x y g e n s a t u r a t i o n w i t h i n a c c e p t a b l e w i t h t h e c l i e n t w i t h s u p p l e m e NIC: Respiratory Monitoring Short term Independent: Position the patient in a high Fowler’s or tripod position. Maximizes lung expansion and reduces the effort required for breathing. Teach and After 24 hours of nursing intervention, the client was able to: GOAL MET:
Maintain oxygen saturation within the acceptable range fwith supplemental oxygen as prescribed, as evidenced by pulse oximetry readings.
Verbalize decreased shortness of breath and report relief from dyspnea , demonstrating improved comfort and reduced respiratory distress.
Demonstrate
● ntermittent
cough for the past 3 years Diagnostic:
Hyperinflate d chest n t a l o x y g e n a s p r e s c r i b e d.
- verbalize decreased shortness of breath and report relief from dyspnea.
- Demonstrate effective coughing techniques to clear airway secretions, reducing the presence of coarse crackles or bronchial sounds.
- exhibit decreased use of accessory muscles during breathing, as observed in physical assessment.
- The patient will maintain a respiratory rate within 20– 24 breaths per minute with less effort. demonstrate pursed- lip breathing: Instruct the patient to inhale deeply through the nose for 4 seconds, hold for 7 seconds, and exhale slowly through pursed lips for 4 seconds. Helps slow respiratory rate, prevent air trapping, and improve gas exchange. Monitor SpO₂ levels every 2 – 4 hours. Ensures adequate oxygenation and allows early detection of worsening hypoxia. Assess for signs of worsening hypoxia (e.g., restlessness, confusion, cyanosis). Early identification and intervention prevent severe respiratory distress or failure. Assist with energy conservation strategies, such as resting between activities and avoiding unnecessary exertion. Reduces oxygen demand and prevents fatigue, which can worsen dyspnea. Encourage fluid intake (2-3L/day) (if not contraindicated). Helps thin respiratory effective coughing techniques , successfully clearing airway secretions, as evidenced by reduced presence of coarse crackles or bronchial sounds upon auscultation.
- Exhibit decreased use of accessory muscles during breathing , indicating improved respiratory efficiency and reduced work of breathing.
- Maintain a respiratory rate within 20–24 breaths per minute with less effort, showing improved ventilation and oxygenation.
Administer prescribed medications (Prednisone, Salbutamol 200 mcg PRN) as ordered. Reduces airway inflammation and bronchodilation to improve airflow. Administer bronchodilators using a metered-dose inhaler (MDI) as prescribed. Monitor response to bronchodilators (e.g., Salbutamol) and assess for side effects (e.g., tachycardia, tremors). Ensures medication effectiveness and prevents complications. Regularly auscultate lung sounds to assess the effectiveness of secretion clearance and response to treatment. Identifies changes in airway status, such as crackles or wheezing.
LONG TERM
OBJECTIVES:
Within 3 - 5 days before discharge, the patient will:
- The patient will demonstrate improved activity tolerance, being able to perform mild activities (e.g., sitting up, walking short distances) with minimal dyspnea.
- The patient will verbalize understanding of COPD management, including medication adherence, oxygen therapy, and breathing exercises.
- The patient will have reduced respiratory distress, with decreased frequency and severity of Long term Independent: 1. Educate on early signs of exacerbation (e.g., increased breathlessness, persistent cough, wheezing) and when to seek medical attention. Early recognition of worsening symptoms allows timely intervention and prevents hospitalizations. 2. Teach proper use of Metered - Dose inhalers Shake the inhaler well (5- 10 seconds) to mix the medication. Exhale completely to empty the lungs before inhalation. Hold the inhaler upright, placing the mouthpiece 1-2 inches from the mouth. Press down on the canister while inhaling deeply and slowly through the mouth for 3-5 seconds. Hold the breath for 10 seconds, allowing the medication to reach deep into the lungs. Exhale slowly through pursed lips. Wait 30 - 60 seconds before taking another puff if needed. Rinse the mouth after using corticosteroid inhalers (e.g., fluticasone) to prevent oral thrush. Correct medication administration improves lung function and prevents After 3-5 Days Before Discharge, the Patient Was Able To: GOAL MET: 1. Demonstrat improved activity tolerance , performing mild activities (e.g., sitting up, walking short distances) with minimal dyspnea. 2. Verbalize understanding of COPD management , including medication adherence, oxygen therapy, and breathing exercises. 3. Experienced reduced respiratory distress , with decreased frequency and severity of exacerbations. 4. Identified and avoided potential respiratory irritants (e.g., smoking, pollutants) and demonstrated lifestyle modifications for better lung health.
Reducing exposure to occupational irritants helps prevent worsening lung function.
7. Educate on environmental modifications (e.g., using air purifiers, avoiding allergens, wearing masks in polluted areas). Reducing exposure to indoor and outdoor pollutants minimizes airway irritation. 8. Recommend smoking cessation to prevent compounding lung damage. Smoking worsens lung function and increases COPD progression and exacerbation risk.
