11 Nursing care plans for COPD | Nursing diagnosis And the rationale

Intervention

Perform a comprehensive respiratory assessment including airway patency e rate rhythm and depth of breathing chest and traumatic excursion auscultation of breath sound.

Rationale

A major goal of airway management is to establish and maintain adequate alveolar ventilation. Auscultation of breath sound Meditech evidence of secretion accumulation, airway obstruction and atelectasis.

Intervention

Monitor quality quantity colour and consistency of sputum.

Rationale

Baseline data enable changes in sputum production and characteristics to be identified infection other than pulmonary insult main please quantity of sputum production

Intervention

Assist in semi fowler’s position

Rationale

It allows for the best possible lungs expansion.

Intervention

Perform pharyngeal and tracheobronchial suctioning as needed.

Rationale

Suctioning is not without risk of toxaemia atelectasis infection; it should be performed only as indicated.

Intervention 

Instruct patients in the use of incentive spirometry.

Rationale

Increase vital capacity and helps to evenly match ventilation with perfusion.

Intervention

Assess respiratory function like rate rhythm and pattern of breathing.

Rationale

Reflect work of breathing increase work of breathing increased oxygen consumption and result in hypercapnia physical fatigue.

Intervention

Assess the symmetry of the chest wall and diaphragmatic excursion.

Rationale

Effective ventilation required a synchronous moment of the chest wall diaphragm and abdominal wall. Rapid cell respiration moves dead space, significantly reducing alveolar ventilation. Asymmetry respiratory excursion underlying pathology for example pneumothorax and atelectasis.

Intervention

Teach about Pursed lip breathing

Rationale

Increases expiratory airway resistance which functions to keep Airways open longer to allow airflow and to reduce trapping.

Intervention

Avoid lying flat ( supine)

Rationale

Causes of abdominal contents to shift towards chest cavity limiting diaphragmatic  excursion May predispose to atelectasis 

Intervention

Perform neurologic examination including mental status deep tendon reflexes complaint of headache dizziness nervousness restlessness.

Rationale

Hypercapnia may be predisposed to carbon dioxide necrosis with depression of the central respiratory centre. Hypoxia may predispose to Central tissue hypoxia.

Intervention

Avoid sedatives narcotics  hypnotics tranquillizers 

Rationale

It may be depressed Central respiratory centre predisposing to alveolar hypoventilation with hypercapnia.

Intervention

Administer prescribed oxygen concentration

Rationale

Alveolar hypoventilation and VQ mismatch respond favourably to low flow supplemental oxygen therapy.

Intervention

Monitor arterial blood gases at regular intervals

Rationale 

Reflect effectiveness of lungs in gas exchange.

Intervention

Continuous cardiac monitoring

Rationale

Cardiac Tissue hypoxia May predispose to dysrhythmias.

Intervention

Continuous hemodynamic monitoring

Rationale 

Offers significant data regarding cardiopulmonary function. Mechanical ventilation with positive pressure increases the pressure inside the thorax, which impedes return to the heart. Decreased venous return reduces cardiac output.

Intervention

Monitor regularly heart sounds loudness and intensity splitting extra heart sounds like S3 or S4.

Rationale

Loud pulmonary sound or splitting is commonly seen in cor pulmonale. It is related to pulmonary hypertension due to a long-standing hypoxic state.

Intervention

Give fluid replacement therapy as prescribed

Rationale

Adequate fluid replacement therapy is essential to maintain blood volume and keep pulmonary secretion moist and easily mobilized.

Intervention 

Monitor hydration status, daily weight, intake and output, urine specific gravity.

Rationale

Long-standing pulmonary disease with pulmonary hypertension predisposes to right heart failure.

Intervention

Assess ongoing neurologic function like mental status level of consciousness behaviour appropriate.

Rationale

Compromised hemodynamics and hypoxemia predisposed to cerebral hypoxia with altered cerebral function.

Intervention

Maintain a quiet relaxed milieu.

Rationale

Minimise fear and anxiety which increases oxygen consumption and demand.

Intervention

Establish a routine for turning and repositioning.

Rationale

Exercise maintains muscle tone and prevents muscle atrophy.

Intervention

Assist with a range of motion exercises to extremities.

Rationale

Exercise stimulates circulation and prevents stasis.

Intervention

Provide special skincare to the back and joints and all other pressure points.

Rationale

To maintain circulation to all areas these patients frequently have a compromised body defence system and are at high risk of infection.

Intervention

Daily weight intake and output vital signs.

Rationale

Patients receiving mechanical ventilation with humidified gas therapy are at risk to increase total body water.

Impaired nutrition less than body requirement

Intervention

Arrange a consultation with a nutritionist and collaborate to perform nutrition assessment, general state of health, baseline body weight, nutritional history, likes, dislikes, meal preparation, eating habits, cultural-religious consideration.

Rationale

Adequate nutritional intake is necessary to meet metabolic requirements for two rivers acute respiratory failure.

Intervention

Avoid large glucose loads to meet caloric needs 

Rationale

There is an obligate increase in carbon dioxide with increased glucose intake fat emulsion may be used to provide calories.

Intervention

Avoid Hypophosphatemia

Rationale

Reduced phosphate levels are associated with decreased energy level respiratory muscle weakness and increased risk of infection.

Intervention

Amino High amino acids loading.

Rationale 

It may increase oxygen consumption.

Intervention

Administer Oxygen therapy continuously as prescribed concentration.

Rationale

Patients with long-standing c o p d with chronic hypercapnia and consequent acidemia the kidney respond by reabsorbing bicarbonate. This buffers the excess hydrogen ion associated with hypercapnia and stabilizes the pH.

Intervention

Deep breathing exercises

Rationale

The use of positive pressure ventilation predisposes to atrophy of the respiratory musculature which can present problems for weaning.

Intervention

Involve patient family in decision making for example scheduling of exercise activities.

Rationale

The nature of chronic illness requires the cooperation of all family members if exacerbation is to be prevented.

Intervention 

Assess knowledge regarding COPD

Rationale

Chronic lungs disease is a family disease impacting every member to some degree.

Intervention

Verbal is fear and concern for patient and family

Rationale 

If the patient and family are to realise optimal function within the limitation of disease all family members should be involved in educating and carrying out the process.

Intervention

Verbalizing intentions to make necessary lifestyle adjustments.

Rationale

Help them to recognise and to express their feelings regarding disruption in their lifestyle.