COPD Nursing Concept Map

85 y-o-F
COPD
4'-11"
119 ibs.
BMI 24.3
Dx: Impaired gas exchange r/t
altered oxygen supply
(obstruction of airways by
secrections, bronchospasm: air-
trapping) as evidenced by
dyspnea, confusion, inability to
move signs, and reduced
tolerance for activity.
Goal: Improve ventilation and
oxygenation of tissues by use of
oxygen therapy before
discharge.
Goal met: patient received
oxygen per nasal cannula
throughout hospital stay and
will be receiving home oxygen
therapy.
Dx: Ineffective airway
clearance r/t increased
production of secretions as
evidenced by persistent cought
with sputum production.
Goal:Maintaing airway patency
with breath sounds
clear/clearing throughout stay
and before discharge.
Goal met:patient's airway
remained patent throughout
hospital stay.
Interventions:
1. Auscultate breath sounds. Note
adventitious breath sounds
(wheezes, crackles, rkonchi).
2. Note presence and degree of
dyspnea as for restlessness, anxiety,
respiratory muscles.
3. Assist parient to assume postition
of comfort (elevate head of bed,
have patient lean on overbed table
or sit on edge of bed.
Goal: Identify interventions to
prevent/reduce risk of
infection before discharge.
Goal met: patient indentified
ways to prevent and reduce
risk of infection as well as
stayed free of infection during
hospital stay.
Dx: Risk for infection r/t
inadequate primary defenses
(decreased ciliary action, Stasis
of secretions), inadequate
acquired immunity (tissue
destruction, increased
environmental exposure),"
chronic disease process, and
malnutrition as evidenced by
COPD diagnosis.
Allergies:
-Codeine
-Corticosteroids
-demerol (Meperidine)
-morphine
-talwin compound
Interventions:
1. Monitor temperature.
2. Review importance of
breathing exercises,
effective cough, frequent
position changes, and
adequate fluid intake,
3. Observe color,
character, odor of
sputum.
4. Demonstrate and assist
patient in disposal of
tissues and sputum.
Stress proper
handwashing (nurse and
patient), and use gloves
when handing or
disposing of tissues,
sputum containers.
5. Encourage balance
between activity and rest.
6. Discuss need for
adequate nutritional
intake.
7. Administer
antimicrobials as needed.
Interventions:
1. Encourage deep-slow pr pursed-lip breathing as individually
needed or tolerated.
2. Assess and routinely monitor skin and mucous membrance color.
3. Encourage expectoration of sputum; suction when indicated
4. Monitor level of consciousness and mental statue. Investigete
changes.
Pertinent information:
-Chest X-Ray on 10/10 showed
mild progressive bibasilar
infiltrates or atelectasis
-Patient is NPO at this time and
is not reveiving any IV fluids
-Patient had a fall proior to admit
and her main complaints in the
ER were abdominal pain, N/V,
and constipation
-Patient has a history of COPD,
sleep apanea, thyroid disease,
stroke, seizures, dementia,
pneumonia, hypertension, heart
attack, GERD, depression,
anxiety, CHF, chronic back pain,
CAD, and asthmaght
with sputum production.
Medications:
-albuterol-ipratropium (Duo-Neb) 3mL
4x/day nebulizer
-aspirin tablet 325mg PO daily with
meal
-atorvastatin (Lipitor) tablet 10mg PO
nightly
-carvedilol (Coreg) tablet 10mg PO
nightly
-Docusate sodium (colace) capsule
25mg PO 2x/day
-fluoxetine (Prozac) capsule 20mg PO
daily
-levothyroxine (Synthroid) tablet
175mcg PO daily early AM
-tiotropium bromide (Spiriva
Respimat) inhalation solution 2 puff
daily AM
Vitals:
-0748
Temp - 98.3
pulse -79
Resp - 23
BP - 207/129
O2 sat-95%
pain - 0
Reported to
increased B/P and
respirations to
primary nurse
Labs:
CBC 10/10/18 1244
WBC _ 8.8
RBC - 3.38
Hgb - 9.7
Hct - 29.2
Platelets -216
BMP 10/10/18 1308
Sodium -4.6
chloride -104
Tatal co2 - 23
Anion gap -
Calcum - 8.9
Glucose - 112
BUN - 5
Creatinine - 0.46
Magnesium - 0.9
15