Alisha - COPD care plan PDF

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COPD care plan...

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Actual Patient Initials: _AZ__________, Rm#______ Age: __75___ M/F, Allergies: Penicillin_________, Date of care: _4/5/2020__________ Primary Dx: Chronic obstructive pulmonary disease (COPD) Co-morbidities and PMH: Heart failure, hypertension, Cerebrovascular accident, residual right sided hemiplegia, and Benign prostatic hypertrophy How do the co-morbidities and PMH impact the primary dx’s? Heart failure impact COPD because a damage heart cannot pump blood as effectively to and from your lungs out to your body, while hypertension cause respiratory problems because not enough oxygen is reaching the lungs. Cerebrovascular and residual right sided hemiplegia causes a lung infection. Actual/Potential Complications: Risk for falls, risk for lung infection, pain increase blood pressure

Student Name:

Patient Initials:___________, Rm#______ Age: _____ M/F, Allergies:____________, Date of care:___________ Priority #2: Skin & Tissue Integrity______________________________

Priority #1: _Oxygenation_____________________________ Assessment: CV: HR and heart sounds, BP, cap refill, pulses, EKG, JVD, edema. RESP: Resp rate/rhythm, lung sounds, O2Sat, cough, sputum, chest shape/symmetry Objective:  COPD (Pre-OP)  Heart failure (Pre-Op)  Hypertension (Pre-Op)  HR 95 regular (Post-Op)  BP 140/90 (Post-Op)  RR 30/min (Post-Op)  O2 sat 88% when on room air (Post-Op)  Patient on O2 at 2L/min via NC with sats of 92% (Post-Op)  Noted he desaturates with minimal exertion (Post-Op)  Trachea Midline (Post-Op)  Feet cool to the touch and pale (Post-Op)  No JVD noted at 45 degrees sitting in bed (Post-Op)  Chest expansion symmetrical (Post-Op)  Radial pulses 1+/4 and regular (Post-Op)  Noted expiratory wheezing bilaterally over mid to lower lung fields (Post-Op)  S1 S2 without murmur or gallop noted (Post-Op)  Apical 95/min and regular (Post-Op)  Noted fingers nail clubbing on hands (Post-Op)  Capillary refill noted 3 bilaterally on feet (Post-Op)  Significant air trapping (Post-Op)  Bilateral atelectasis in bases (Post-Op)  Cardiomegaly with increased AP diameter (Post-Op)  No acute consolidation noted (Post-Op)  Noted decreased hair on legs bilaterally (Post-Op) Subjective:  Complains of shortness of breath (Post-Op)  Patient states, “I can barely walk across the room without getting winded”  He states, “I often feel dizzy and have to sit down when I stand up quickly because I feel like I am going to faint” (Post-Op) Meds:  Albuterol  Metoprolol  Oxygen 2L/min via nasal cannula  Lasix Labs:  WBC 17,000 X10E6/uL  Hemoglobin 8.5 g/dL (Low)  Hct 55% (High)  Albumin 2.2mg/dl (Low) Ordered Medical Treatments:  Chest X-rays

Assessment: Skin color, temp, texture, turgor, Braden score, scars, tattoos Objective:  Temp 100.4 orally (Post-Op)  He is thin (Post-Op)  Frail appearing male (Post-Op)  Skin pale (Post-Op)  Slightly diaphoretic (Post-Op)  Scalp is dry and flakey (Post-Op)  Noted cracking of skin around the corners of the mouth (Post-Op)  Noted tenting skin turgor over clavicle bilaterally (Post-Op)  Braden scale is 14 (Post-Op)  Tongue with fissures (Post-Op)  Tongue protrudes midline (Post-Op)  Noted 6cm non-blanchable skin redness over coccyx (Post-Op)  Feet cool to the touch and pale (Post-Op) Meds: N/A Labs: N/A Ordered Medical Treatments: N/A NANDA/Nursing Diagnosis:  Impaired Skin integrity r/t pressure over bony prominence AEB patient has 6cm non-blanchable skin redness over coccyx. NOC: Expected Outcomes:  Long-term outcome/goal (by discharge)  Short term outcome/goal (by the end of your shift) NIC: Interventions (A/D/M/T) with rationales for Levels I, II & LPN: 1. 2. 3. 4. 5. Actual Outcomes: 1. 2. 3. 4. 5. Evaluation:

NANDA/Nursing Diagnosis:  Ineffective Airway Clearance r/t smoking AEB patient has COPD, expiratory wheezing bilaterally over mid to lower lung fields and respiratory rate of 30. NOC:  Ventilation Expected Outcomes:  By discharge, the patient will be able to maintain clear, open airways.  By the end of the shift, the patient will be able to perform the huff cough technique effectively. NIC: Airway management Interventions (A/D/M/T) with rationales for Levels I, II & LPN: 1. Auscultate breath sounds every 1 to 4 hours (IA) Rationale: “In severe exacerbations of chronic obstructive pulmonary disease (COPD), lung sounds may be diminished or distant with air trapping (Bickley & Szilahyi, 2017)”. 2.Administer oxygen as ordered (CD) Rationale: “Administer humidified oxygen through appropriate device aim for an oxygen saturation level of 90% or above (Bickley & Szilahyi, 2017)”. 3.Teach the client how to use the technique called the huff cough (IT) Rationale: “This technique prevents the glottis from closing during the cough and is effective in clearing secretions (Bickley & Szilahyi, 2017)”. 4. Administer medications such as bronchodilators as ordered (CD) Rationale: “Pharmacologic therapy in COPD is used to reduce symptoms, reduce the frequency and severity of exacerbation, and improve health strategies and exercise tolerance (Bickley & Szilahyi, 2017)”. 5.Monitor respiratory patterns, including rate, depth, and effort (IA) Rationale: “A normal respiratory rate for an adult without dyspnea is 12 to 16 breaths per min. With secretions in the airway it will increase (Bickley & Szilahyi, 2017)”. Actual Outcomes: 1. Patient will explain methods useful to enhance secretion removal 2. Patient will be able to identify and avoid certain factors that prevent effective airway clearance 3. Administering bronchodilators medication reduce symptoms of COPD 4. Patient know how to perform the technique called huff cough correctly 5.Patient will be able to show effective coughing and clear breath sounds Evaluation: Patient long term and short-term goal was met due to patient breathing normally and able to maintain a clear and open airway.

Student Name:

Actual Patient Initials: _AZ__________, Rm#______ Age: __75___ M/F, Allergies: Penicillin_________, Date of care: _4/5/2020__________ Priority #3: __Fluid Balance ____________________________ Assessment: Intake/ output, edema, turgor, JVD Objective:  No JVD noted at 45 degrees sitting in bed (Post-Op)  Noted tenting skin turgor over clavicle bilaterally (Post-Op)  Urine output: 100mls since he arrived over 6 hours ago (Post-Op)  He drank two 120ml juices with breakfast (Post-Op)  He drank 6 ounces of coffee for breakfast (Post-Op)  He drank 4 ounces of soda with his lunch (Post-Op) Meds: 

Lasix

Labs:    

Sodium Level: 148 mmol/L (high) Potassium: 3.0 mmol/L (Low) Serum Osmolality 310 mOsm/kg (High) Creatinine 2.0 mg/dL(High)

Priority #4: __Elimination____________________________ Assessment: BM and descriptors, Urine and descriptors, Bowel sounds, last BM, urine color, frequency Objective: Abdomen is soft and slightly distended with hypoactive bowel sounds noted  in all 4 quadrants (Post-Op)  Urine is dark concentrated amber with sediment (Post-Op)  Benign Prostatic hypertrophy (Pre-Op) Subjective:  Patient says, “I have been having trouble moving my bowels, I think the last time was 3 days ago and it was very hard and dark, almost black in color”  Patient says” I have difficulty starting my stream and occasionally have accidents” (Post-Op) Meds: 

Lasix

Labs:  

Ordered Medical Treatments: N/A

BUN 30mg/Dl (High) Urinalysis-reveals positive nitrates, a few WBCs, and 1+ Protein

Ordered Medical Treatments: N/A NANDA/Nursing Diagnosis:  Deficient Fluid volume r/t insufficient fluid intake AEB patient has tenting skin NANDA/Nursing Diagnosis: turgor over clavicle bilaterally.  Impaired urinary elimination r/t multiple causality AEB patient stays, “I have difficulty starting my stream and occasionally have accidents”. NOC: Expected Outcomes:  Long-term outcome/goal (by discharge)  Short term outcome/goal (by the end of your shift) NIC: Interventions (A/D/M/T) with rationales for Levels I, II & LPN: 1. 2. 3. 4. 5. Actual Outcomes: 1. 2. 3. 4. 5. Evaluation:

NOC: Expected Outcomes:  Long-term outcome/goal (by discharge)  Short term outcome/goal (by the end of your shift) NIC: Interventions (A/D/M/T) with rationales for Levels I, II & LPN: 1. 2. 3. 4. 5. Actual Outcomes: 1. 2. 3. 4. 5. Evaluation:

Student Name:

Patient Initials:___________, Rm#______ Age: _____ M/F, Allergies:____________, Date of care:___________ Priority #5: __Sleep/Pain/Rest___________________________

Priority #6: _Neurosensory_____________________________

Assessment: Pain scale, descriptors, sleep pattern and hours Assessment: Orientation, LOC, Hearing, vision, sensory loss, GCS Objective: N/A Objective: A&O X4 (Post-Op) Subjective:   Patient admits to having “cramping pain in lower legs when I walk that goes  PERRLA (Post-Op)  He wears glasses (Post-Op) away after I sit and rest” (Post-Op)  Ears noted to have excessive cerumen bilaterally and patient often asks the  Patient complains of pain in lower extremities bilaterally 3/10 (Post-Op) nurse “could you repeat that”. (Post-Op)  Residual right sided hemiplegia (Pre-Op) Meds: Subjective:  Acetylsalicylic Acid  Patients says, “they don’t work as well as they used to, I haven’t seen the eye doctor in a few years” He is referring to his glasses (Post-Op) Labs: N/A  Patient states, “I often feel dizzy and have to sit down when I stand up quickly because I feel like I am going to faint”. (Post-Op) Ordered Medical Treatments: N/A  Patient states, “food doesn’t taste good to me” (Post-Op) NANDA/Nursing Diagnosis:  Impaired walking r/t pain AEB patient states, “cramping pain in lower legs when I walk that goes away after I sit and rest”. NOC: Expected Outcomes:  Long-term outcome/goal (by discharge)  Short term outcome/goal (by the end of your shift)

Meds: N/A Labs: N/A Ordered Medical Treatments: NANDA/Nursing Diagnosis:  Hearing loss r/t buildup of cerumen in ear canal AEB ear noted to have excessive cerumen bilaterally and patient often asks the nurse “could you repeat that”.

NIC: Interventions (D/M/T) with rationales for Levels I, II & LPN: 1. 2. 3. 4. 5.

NOC: Expected Outcomes:  Long-term outcome/goal (by discharge)  Short term outcome/goal (by the end of your shift) NIC:

Actual Outcomes: 1. 2. 3. 4. 5.

Interventions (D/M/T) with rationales for Levels I, II & LPN: 1. 2. 3. 4. 5.

Evaluation: Actual Outcomes: 1. 2. 3. 4. 5. Evaluation:

Student Name:

Actual Patient Initials: _AZ__________, Rm#______ Age: __75___ M/F, Allergies: Penicillin_________, Date of care: _4/5/2020__________ Priority #8: ______Mobility________________________

Priority #7: __Nutrition____________________________

Assessment: Weight/BMI, diet, percent consumed, preferences, tolerances, swallowing/ Assessment: Ambulation, assistive devices, fall risk score, ROM, strength, gait, activity, therapy gag reflex issues Objective: Objective:   Weight 115 lbs. (Post-Op) BP 140/90 RR 30/min with the use of accessory muscles and tripoding (Post Height 6ft 2 inch (Post-Op) Op)  Uvula rises midline when the patient says “ahh” (Post-Op)  EOMs are intact (Post-Op)  He ate 50% of his breakfast (Post-Op)  Hand grips are unequal and 2+(Post-Op)  He ate 75% of his lunch (Post-Op)  Using accessory muscles (Post-Op)  Diet: Low Sodium diet  Braden score 14 (Post-Op)  Motor: Right upper extremity 3/5 (Post-Op) Subjective:  Recently lost 10lbs over last 45 days (Post Op)  Motor: Left upper extremity 5/5 (Post-Op)  States he wears dentures but “since I lost weight, they don’t really fit, and  Motor: Right lower extremity 4/5 (Post-Op)  Motor: Left lower extremity is 5/5 (Post-Op) food doesn’t taste good to me anyways (Post-Op)  Patient’s gait is unsteady (Post-Op)  Morse fall scale is 46 (Post-Op) Meds: N/A  Residual right sided hemiplegia (Pre-Op) Subjective: Labs:  He states, “I often feel dizzy and have to sit down when I stand up quickly  Albumin 2.2 mg/dL (low) because I feel like I am going to faint”  Sodium 148 mmol/L (High) Ordered Medical Treatments:

Meds: N/A

Labs: N/A NANDA/Nursing Diagnosis:  Frail elderly syndrome r/t malnutrition AEB patient BMI is underweight, which Ordered Medical Treatments: N/A was calculated from his weight and height and recently lost 10lbs over last 45 days. NANDA/Nursing Diagnosis: 

Risk for falls r/t difficulty with gait AEB patient’s gait is unsteady.

NOC:

NOC:

Expected Outcomes:  Long-term outcome/goal (by discharge)  Short term outcome/goal (by the end of your shift)

Expected Outcomes:  Long-term outcome/goal (by discharge)  Short term outcome/goal (by the end of your shift)

NIC:

NIC:

Interventions (D/M/T) with rationales for Levels I, II & LPN: 1. 2. 3. 4. 5.

Interventions (D/M/T) with rationales for Levels I, II & LPN: 1. 2. 3. 4. 5.

Actual Outcomes: 1. 2. 3. 4. 5.

Actual Outcomes: 1. 2. 3. 4. 5.

Evaluation:

Evaluation:

Student Name:

Patient Initials:___________, Rm#______ Age: _____ M/F, Allergies:____________, Date of care:___________ Priority #10: ___Self Expression___________________________

Priority #9: _Wellness_____________________________

Assessment: Should include religion, education, sexuality, self-esteem, support system/ Assessment: Should include comments on tobacco use, alcohol/drug use, exercise, immunizations, employment, housing/living situation, social environment, martial status family role, affect, speech/communication issues Objective: Objective:   40 pk/year smoking history-quit 5 years ago Speech is clear (Post-Op)  Full code status Subjective:  He admits to feeling “depressed” since his wife’s diagnosis last year (PostSubjective: Op)  Patient states, “I really need to get home to take care of my wife and dog, we  They used to attend the local Baptist church regularly but, have not been have nobody else (Post-Op) able to attend for the past year (Post-Op)  Marital status: Married  He lives in a mobile home with 3 steps to front door with his wife who is  Patient states, “I really need to get home to take care of my wife and dog, under hospice care for terminal cancer (Post-Op) we have nobody else (Post-Op)  Complain of fatigue (Post-Op)  He admits to feeling “depressed” since his wife’s diagnosis last year (Post- Meds: N/A Op) Labs: N/A Meds: N/A

Ordered Medical Treatments: N/A

Labs: N/A

NANDA/Nursing Diagnosis:  Risk for Loneliness r/t social isolation AEB patient states, “I really need to get home to take care of my wife and dog, we have nobody else”.

Ordered Medical Treatments: N/A NANDA/Nursing Diagnosis:  Fatigue r/t depression AEB patient admits to feeling depressed since his wife was diagnosis last year with cancer. NOC: Expected Outcomes:  Long-term outcome/goal (by discharge)  Short term outcome/goal (by the end of your shift) NIC: Interventions (D/M/T) with rationales for Levels I, II & LPN: 1. 2. 3. 4. 5. Actual Outcomes: 1. 2. 3. 4. 5.

NOC: Expected Outcomes:  Long-term outcome/goal (by discharge)  Short term outcome/goal (by the end of your shift) NIC: Interventions (D/M/T) with rationales for Levels I, II & LPN: 1. 2. 3. 4. 5. Actual Outcomes: 1. 2. 3. 4. 5. Evaluation:

Evaluation:

Student Name:...