Question

Develop a tentative plan of care for a client who has COPD. Include three nursing diagnoses to be addressed for the client who has an acute exacerbation of COPD, with one nursing diagnosis related to discharge planning.

Answer 1

Nursing diagnosis

1.Impaired Gas Exchange

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Quantity and viscosity of sputum can obstruct the airway and impair pulmonary ventilation and gas exchange.

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	Rationale
Nursing Assessment
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.

2. Ineffective Breathing Pattern

Shortness of breath and ineffective breathing patterns are caused by ineffective respiratory mechanics of the chest wall and lung resulting from air trapping, ineffective diaphragmatic movement, airway obstruction, the metabolic cost of breathing, and stress.

Nursing Diagnosis

Ineffective Breathing Pattern: Inspiration and/or expiration that does not provide adequate ventilation

In this nursing care plan guide are seven (7) nursing diagnosis for Chronic Obstructive Pulmonary Disease (COPD). Get to know the nursing interventions, goals and outcomes, assessment tips, and related factors for COPD.

What is Chronic Obstructive Pulmonary Disease (COPD)?

Chronic Obstructive Pulmonary Disease (COPD) is defined as “a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fuina, or airway destruction.

The term COPD mainly involves two related diseases — chronic bronchitis and emphysema. Although asthma also involves airway inflammation and periodic narrowing of the airway lumina (hyperreactivity), the condition is the result of an individual response to a wide variety of stimuli/triggers and is therefore episodic in nature with fluctuations/exacerbations of symptoms. COPD is also called chronic obstructive lung disease (COLD).

Asthma: Also known as chronic reactive airway disease, asthma is characterized by reversible inflammation and constriction of bronchial smooth muscle, hypersecretion of mucus, and edema. Precipitating factors include allergens, emotional upheaval, cold w

Nursing Care Plans

Nursing care planning for patients with COPD involves the introduction of a treatment regimen to relieve symptoms and prevent complications. Most patients with COPD receive outpatient treatment, the nurse should develop a teaching plan to help them comply with the therapy and understand the nature of this chronic disease.

Here are seven (7) nursing care plans (NCP) and nursing diagnosis (NDx) for Chronic Obstructive Pulmonary Disease (COPD):

1. Ineffective Airway Clearance
2. Impaired Gas Exchange
3. Ineffective Breathing Pattern
4. Imbalanced Nutrition: Less Than Body Requirements
5. Risk for Infection
6. Deficient Knowledge
7. Activity Intolerance
8. Other Possible Nursing Diagnosis

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3. Ineffective Breathing Pattern

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Shortness of breath and ineffective breathing patterns are caused by ineffective respiratory mechanics of the chest wall and lung resulting from air trapping, ineffective diaphragmatic movement, airway obstruction, the metabolic cost of breathing, and stress.

Nursing Diagnosis

Ineffective Breathing Pattern: Inspiration and/or expiration that does not provide adequate ventilation.

May be related to

• Retained Secretions
• Ineffective inspiration and expiration occurring with chronic airflow constraints

Possibly evidenced by

• Wheezes/crackles on auscultation on both lung fields
• Subcostal retraction
• Nasal flaring
• Presence of non-productive cough
• Increase RR above the normal range

Desired outcomes

• Improvement of breathing pattern.
• Maintain a respiratory rate within normal limits.

Nursing Interventions	Rationale
Nursing Assessment
Assess patient’s respiratory status every 2 to 4 hours as indicated and notify any abnormal findings.	Manifestation of respiratory distress include shortness of breath, tachypnea, changes in mental status and the use of accessory muscles.
Auscultate breath sounds every 2 to 4 hours as indicated.	Decreased breath sounds, crackles, wheezes, and rhonchi can be observed and must be reported promptly for immediatement treatment.
Therapeutic Intervention
Place a pillow when the client is sleeping.	Provides adequate lung expansion while sleeping.
Instruct how to splint the chest wall with a pillow for comfort during coughing and elevation of head over the body as appropriate.	Promotes physiological ease of maximal inspiration.
Maintain a patent airway, suctioning of secretions may be done as ordered.	Remove secretions that obstructs the airway.
Provide respiratory support. Oxygen inhalation is given as ordered.	Aid in relieving the patient from dyspnea.
Administer the following medications as prescribed:
Oral corticosteroids such as beclomethasone (Qvar), budesonide (Pulmicort), fluticasone (Flovent), mometasone (Asmanex)	Cuts down recovery time, enhance lung function, and arterial hypoxemia, and minimize length of hospital stay.
Inhaled corticosteroids such as budesonide (Pulmicort Flexhaler), mometasone (Asmanex Twisthaler), beclomethasone (Qvar RediHaler), fluticasone (Flovent HFA)	These medications is given for patient with Forced expiratory volume in 1 second (FEV1) at less than 30% whose history of exacerbations are poorly managed by the use of long-acting bronchodilators.
Long-acting bronchodilators such as salmeterol, perforomist (formoterol), bambuterol, indacaterol	Decreases hyperinflation, lessen bronchial obstruction and enhances lung emptying.
Combination of inhaled corticosteroids and bronchodilator such as Symbicort (budesonide combined with formoterol fumarate), Advair (fluticasone combined with salmeterol, Breo TM (fluticasone furoate combined with vilanterol trifenatate)	This combination of medications are known to be more effective than any single treatment in decreasing episodes of exacerbations and provides overall improvement of lung function. One disadvantage of its use is the increased prone to pneumonia.