Question

Chief Complaint: Severe productive cough

Admitting Diagnosis: COPD

History of Present Illness

A 56-year-old man with a history of smoking rush to ER with shortness of breathandcough for several days. His symptoms began 3 days ago with runny nose. He reports a chronic morning cough productive of white sputum, which has increased over the past 2 days

Past Medical History

He has had similar episodes each time of raining season for the past 4 years. He always experiences fatigue, worsening cough, increased breathlessness and waking up in the morning with headache.

Family History

(+) Tuberculosis

(+) Hypertension

(-) Cancer

Personal and Social History

He has smoked 1 to 2 packs of cigarettes per day for 40 years and continues tosmoke. He denies hemoptysis, chills, or weight loss and has not received any relief fromover-the-countercough preparations.

Chest x-ray shows hyperinflation and right lobe pneumonia.

ABG results wasPh7.24,PO2-35 mmHg, PCO2 60mmHg, HCO3 30, O2 sat - 85%.

Spirometry with FEVI 35% predicted that does not change significantly after inhaled bronchodilators. ECG was ordered.

Physical Examination:

Took vital signs which are: BP: 130/80, T: 37.5 Celsius, PR:89, RR:30.

Examination displayed tachypnea, respiratory distress, use of accessory muscles, and intercostal retraction. Barrel chest is a common observation.

1. Create 2 nursing diagnosis with planning, intervention/rationale, evaluation based on the case scenario.

Answer 1

1. Nursing Diagnosis
Ineffective Airway Clearance

Planning
•Optimal positioning (sitting position)
•Use of pillow or hand splints when coughing.
•Use of abdominal muscles for more forceful cough.
•Use of quad and huff techniques.
•Use of incentive spirometry.

●Intervention
Assess and monitor respirations and breath sounds, noting rate and sounds (tachypnea, stridor, crackles, wheezes). Note inspiratory and expiratory ratio.

Rational
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.

●Intervention
Position head midline with flexion on appropriate for age/condition.

Rational
Gain or maintain an open airway.

●Intervention
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).

Rational
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.

Evaluation
•Patient maintains clear lung fields and remains free of signs of respiratory distress.
•Patient verbalizes understanding of oxygen and other therapeutic interventions.


2.. Nursing Diagnosis
Impaired Gas Exchange

Planning
•Plan to provide gas exchange service.
•Optimal positioning (sitting position)
•Use of pillow or hand splints when coughing.


●Intervention
Assess and record respiratory rate, depth. Note the use of accessory muscles, pursed-lip breathing, inability to speak or converse.

Rational
Useful in evaluating the degree of respiratory distress or chronicity of the disease process.

●Intervention
Monitor changes in the level of consciousness and mental status.

Rational
Restlessness, agitation, and anxiety are common manifestations of hypoxia. Worsening ABGs accompanied by confusion/ somnolence are indicative of cerebral dysfunction due to hypoxemia.

●Intervention
Monitor vital signs and cardiac rhythm.

Rational
Tachycardia, dysrhythmias, and changes in BP can reflect the effect of systemic hypoxemia on cardiac function.

Evaluation
Patient manifests resolution or absence of symptoms of respiratory distress.