Nursing Care Plan

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Showing posts with label COPD. Show all posts
Showing posts with label COPD. Show all posts

Nursing Care Plan for COPD

Nursing Care Plan for COPD
Nursing Assessment for COPD

Chronic obstructive pulmonary disease (COPD), also known as chronic obstructive lung disease (COLD), chronic obstructive airway disease (COAD), chronic airflow limitation (CAL) and chronic obstructive respiratory disease (CORD), is the co-occurrence of chronic bronchitis and emphysema, a pair of commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs, causing shortness of breath. In clinical practice, COPD is defined by its characteristically low airflow on lung function tests. In contrast to asthma, this limitation is poorly reversible and usually gets progressively worse over time. In England, an estimated 842,100 of 50 million people have a diagnosis of COPD; thus, approximately 1 person in 59 is diagnosed with COPD at some point in their lives.
wikipedia

Nursing Care Plan for COPD : Nursing Assessment for COPD

The assessment includes information about past symptoms and manifestations of the disease earlier. Here are some guidance questions to obtain data on the health history of the disease process:
  1. How long patients have difficulty breathing?
  2. Does the activity increase dyspnea?
  3. How much restriction on the patient's activity tolerance?
  4. When do patients complain most tired and shortness of breath?
  5. Is eating and sleeping habits are affected?
  6. History of smoking?
  7. Drugs that are used every day?
  8. Drugs used in acute attacks?
  9. What patients know about the condition and the disease?
Additional data collected through observation and examination as follows:
  1. Pulse rate and respiratory patients?
  2. Is the same breathing without effort?
  3. Is there a contraction of abdominal muscles during inspiration?
  4. Is there any use of accessory respiratory muscles during breathing?
  5. Barrel chest?
  6. Do look cyanotic?
  7. Is there a cough?
  8. Is there peripheral edema?
  9. Are the neck veins look bigger?
  10. What color, number and consistency of sputum of patients?
  11. How, the sensor status of patients?
  12. Is there an increase stupor? Anxiety?
Source : http://nursing-assessment.blogspot.com/2011/05/nursing-assessment-for-copd.html


Nursing Care Plan for COPD : Nursing Diagnosis for COPD

1. Ineffective Airway Clearance related to bronchoconstriction, increased sputum production, ineffective cough, fatigue / decreased energy and bronkopulmonal infection.

2. Ineffective Breathing Pattern related to shortness of breath, mucus, bronchoconstriction and airway irritants.

3. Impaired Gas Exchange related to ventilation perfusion inequality.

4. Activity Intolerance related to imbalance between supply with oxygen demand.

5. Imbalanced Nutrition: Less than Body Requirements related to anorexia.

6. Disturbed Sleep Pattern related to discomfort, the setting position.

7. Self-Care Deficit Bathing / Hygiene, Dressing / Grooming, Feeding, toileting related secondary fatigue due to increased respiratory effort and the insufficiency of ventilation and oxygenation.

8. Anxiety related to threat to self-concept, the threat of death, unmet needs.

9. Ineffective Individual Coping related to lack of socialization, anxiety, depression, low activity levels and inability to work.

10. Knowledge Deficit related to lack of information, do not know the source of information.

Source : http://nandanursingdiagnosis.blogspot.com/2011/05/nursing-diagnosis-for-copd.html

COPD - Acute Pain Nursing Interventions

Nursing Care Plan for COPD - Nursing Interventions for Acute Pain

Acute pain related to the process of inflammation in the lining of the lungs

Goal: The pain is reduced / lost.

Expected outcomes are:
  • Clients say the pain is reduced / lost.
  • Relaxed facial expression.

Nursing Interventions - Acute Pain for COPD

1. Determine the characteristics of pain, for example; sharp, consistent, stabbed. Investigate changes in character / intensity of pain / location.
Rational: Chest pain is usually present in some degree of pneumonia, complications can arise such as pericarditis and endocarditis.

2. Monitor vital signs.
Rationale: Changes in heart rate or blood pressure showed that patients experience pain, especially when other reasons for changes in vital signs.

3. Provide comfort measures, for example: back massage, change of position, quiet music / conversation, relaxation / breathing exercises.
Rational: The act of non-analgesics administered with a gentle touch to relieve discomfort and increase the effects of analgesic therapy.

4. Offer a clean mouth often.
Rational: mouth breathing and oxygen therapy may irritate and dry the mucous memberan, potential public inconvenience.

5. Advise and assist the patient in the technique of chest compressions during episodes of coughing.
Rational: A tool to control chest discomfort while increasing the effectiveness of cough effort.

6. Give analgesic and antitussive according to indications.
Rational: This drug can be used to suppress non-productive cough / proximal or reduce excessive mucus, improve comfort / rest common.

COPD - Acute Pain Nursing Interventions
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