Ncp For Copd

XI. Nursing Care Plan

PROBLEM “Hirap akong huminga”, as verbalized by the pt. Cues: >Increased RR – 29 >Cardiac rate - 108 >Abdominal breather >With crackles > With wheezes >With circum oral cyanosis >With nasal flaring

DIAGNOSIS Nursing Diagnosis: >Impaired gas exchanged 2○ to ventilation and perfusion inequality; related to retained secretions as evidenced by tachycardia, tachypnea, crackles, wheezing, and cyanosis

PLANNING Short Term: >Within 15 mins of duty, difficulty of breathing will be lessened. Long Term: >After 1 day Pt will demonstrate improvement in ventilation and adequate oxygenation within normal limits and having absence symptoms of respiratory distress > After 3 days Pt will be able to verbalize understanding regarding factors that would contribute to exacerbation of disease and will participate in treatment regimen

INTERVENTION Independent: >Elevate the head of the bed 45○ (semifowler’s) position. It maximize lung expansion thus sustain open airway >Advised the pt to keep calm during episodes of breathing difficulty to prevent aggravation of the disease >Encouraged deep controlled breathing exercise. It promotes optimal chest expansion Dependent: > O2 inhalation via NC as ordered by physician.

EVALUATION Short Term: >Goal partially met Long Term: > Pt. was able to verbalize in understanding of the disease and its course of treatment

PROBLEM “Inuubo ako”, as verbalized by the pt. Cues: >Increased RR – 29 >With crackles >With chest pain >With back pain

DIAGNOSIS

PLANNING

INTERVENTION

EVALUATION

Nursing Diagnosis: >Ineffective airway clearance related to increase production of mucus in the tracheobronchial tree as evidenced by productive cough, crackles, chest pain & back pain.

Short Term: >Within 4 hours of duty phlegm will be liquefy & expectorated & further complication will be prevented.;

Independent: >Elevate the head of the bed 45○ (semifowler’s) position. It maximize lung expansion thus sustain open airway >Advised to do bronchial tapping to loosen secretions & for better expectoration. >Encouraged to increase fluid intake if not contraindicated. >Emphasized proper disposal of secretions.

Short Term: >Goal partially met >Difficulty of breathing was lessened

Long Term: >After 3 days of duty, pt will be able to verbalized understanding of condition, therapy regimen and side effect of med. > After 3 days Pt will be demonstrate behavior to improve adequate lifestyle changes to improve adequate oxygenation & prevent exacerbation of the disease.

Dependent: >Nebulize with Salbutamol, Combivent as ordered by attending physician

Long Term: > Pt. was able to understand adherence to the therapeutic regimen. >Pt. Was able to understand proper management of his condition & follow the prevent measure.

PROBLEM “Nanghihina ako”, as verbalized by the pt. Cues: >Loss of appetite >Productive cough

DIAGNOSIS

PLANNING

INTERVENTION

Nursing Diagnosis: >Nutritional imbalanced less than body requirements related to inadequate intake of nutritious food to meet metabolic needs secondary to underlying disease as evidenced by loss of appetite & body weakness

Short Term: >Within 4 hours of duty patient will be regained body strength & loss of appetite will be relieved.

Independent: >Encouraged to eat adequate nutritious food like green leafy vegetables, fishes and fruits rich in vitamin C to boost immune system. >Advised to have adequate rest & sleep, it helps to regained body strength.

Long Term: >After 2 days of duty patient will be demonstrate improvement in appetite & proper nutrition.

Dependent: >(Dibencozide) Heraclene for appetite stimulants as ordered by attending physician

EVALUATION Short Term: >Goal met Long Term: >Pt. Was able to understand having proper nutrition and the importance of having adequate rest & sleep, regarding to his health condition