ATI COPD Care plan PDF

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COPD Pathophysiology: Damage to the airways and tiny air sacs in the lungs. Peripheral airway inflammation and narrowing of the airway. Patient: Hector P. Gomez (68 yr. Male)

NANDA diagnosis: Ineffective Airway Clearance related to bronchospasm as evidenced by a low Hgb (9.3 d/dL) Monitor/ Reassess: Monitor respirations Monitor/ Reassess: Monitor Breath sounds Monitor/ Reassess: Monitor ABGs and other breath sounds Do/Action: Auscultate breath sounds Do/Action: Position the patient to sit upright Do/Action: Suction secretions as needed Teach: Deep breathing exercises Teach: Teach how to splint with a pillow Teach: How to use bronchodilators if prescribed

NANDA diagnosis: Ineffective Breathing Pattern related to retained secretions as evidenced by a productive cough, greenish-yellow tenacious sputum. Monitor/ Reassess: Assess patient’s respiratory status every 2-4 hours as indicated Monitor/ Reassess: Monitor breath sounds Monitor/ Reassess: Monitor patient’s oxygen level Do/Action: Suctions secretions if necessary Do/Action: Auscultate breath sounds Do/Action: Get a sputum sample Teach: Teach patient how to splint with a pillow Teach: Teach patient how to properly take their medication Teach: Teach patient how to get the phlegm out of throat

NANDA diagnosis: Impaired Gas Exchange related to altered oxygen supply as evidenced by diminished lung sounds at the bases and upper lobes with inspiratory. Monitor/ Reassess: Assess Respiratory Rate Monitor/ Reassess: Monitor skin and mucous membrane color Monitor/ Reassess: Monitor level of consciousness and mental status Do/Action: Auscultate breath sounds Do/Action: Palpate for fremitus Do/Action: Note any change in ABG or lab values Teach: Teach expectoration of sputum Teach: Teach the proper way of sitting Teach: Teach patient how to take medication

Medication: Albuterol It is a bronchodilator Pharmacological Action: Binds to beta2 adrenergic receptors in airway smooth muscle leading to activation of adenyl cyclase and increased level of cyclic. Therapeutic Use: Bronchodilation Complications: nervousness, restlessness, headache, insomnia, chest pain, palpitation, angina, arrhythmias, hypertension, nausea, vomiting, hyperglycemia, tremor. Medication Administration: Oral Inhalation, tablets, extended-release tablets, oral syrup, metered doses aerosol. Contraindications: adrenergic amines, cardiac disease, hypertension, hyperthyroidism, diabetes, glaucoma, seizure disorders Nursing Interventions: administer oral route with food, shake inhaler well take as directed. Interactions: concurrent use with other adrenergic agents will have a high adrenergic side effect. Use with caffeine- containing herbs, potassium-losing diuretics. Client education: take as directed, discard after 200 puffs, prime with 4 sprays Evaluations: prevention or relief of bronchospasm.

Medication: Prednisone It is an anti-inflammatory Pharmacological Action: Suppresses inflammation and the normal immune response. Has numerous intense metabolic effects. Suppresses adrenal function at chronic doses of 5 mg/day. Therapeutic Uses: Suppression of inflammation and modification of the normal immune response. Complications: Depression, euphona, headache, high ICP, personality changes, hypertension, peptic ulcerations. Medication Administration: Given PO max is 80 mg/day initial is 2 mg/kg/day given in 1-3 divided doses.

Contraindications/Precautions: active untreated infections, alcohol, lactation, chronic treatment, chronic use will result in decrease in growth. Nursing Interventions: Assess involved systems before and periodically during therapy, assess for signs of adrenal insuffiency before and periodically during therapy. Interactions: Additive hypokalemia, loop diuretics, Hypokalemia, oral hypoglycemic agents Client Education: Instruct correct technique for med administration, may mask symptoms of interaction Evaluation of Medication Effectiveness: decrease in presenting symptoms with minimal systemic side effects. Medication: Ceftriaxone It is anti-infective Pharmacological Action: binds to the bacterial cell wall membrane, causing cell death Therapeutic Use: Bactericidal action against susceptible bacteria Complications: seizures, diarrhea, cholelithiasis, gallbladder sludging, pancreatitis, rash, urticaria, acute renal failure, urolithiasis, bleeding, hemolytic anemia. Medication Administration: Intramuscular intravenous powder for injection, premixed containers Contraindications/ Precautions: Hypersensitivity to cephalosporin, serious hypersensitivity to penicillin’s, hyperbilirubinemia neonates, pregnancy and lactation. Nursing Interventions: Assess for infection obtain a history and obtain specimens Interactions: should not be administered concomitantly with any calcium- containing solutions. May increase risk of bleeding with warfarin. Client Education: Advise patient to report any signs of superinfection, lose or foul-smelling stools. Evaluation of Medication Effectiveness: Resolution of the signs and symptoms of infection. Length of time for compete resolution depends on the organism and sit of infection. Decreased incidence ofinfection when used for prophylaxi

3 Nursing Diagnoses in NANDA form-to address the client who has an acute exacerbation of COPD o 9 interventions for each nursing diagnoses • 3 things to monitor/reassess • 3 things to do/actions for patient • 3 things to teach the client  ATI template: Medications (at least 3) including dosage, indications, side effects, labs to monitor and patient teaching...