5 Nursing care plan COPD and Guide

The nursing process acts as a systematic framework to offering patient-focused care with five sequential steps. It utilizes the basic principles of critical thinking, client-centered approaches combined with evidence-based practice recommendations, and nursing intuition. The five steps are assessment, diagnosis, planning, implementation, and evaluation. The guide below delves into the process of developing a Nursing care plan COPD and gives examples of nursing care plans COPD for nursing students.

In the Nursing Diagnosis, Explain your rationale for choosing this nursing diagnosis. Include connections/relationships between the parts of the n. dx. EX: how the R/T caused the problem.

In the Client Expected Outcomes (short & long term) follow the Expected Outcome Criteria and Start with “Patient will” These goals have to be realistic, timed and measurable.

In the Nursing Interventions section of the nursing care plan COPD, Be clear on What/When or How often/start with “Nursing will”

In the Rationale section of the nursing care plan COPD (include sources) and provide a rationale for the nursing interventions in the nursing care plan COPD. The rationale section should be comprehensive and based on peer-reviewed sources within the last 5 years.

Evaluation of Expected Outcomes (include date/time). This details the patient’s response to nursing actions & progress towards achieving goals and outcomes.

Below are examples of Nursing care plan COPD. The intention of sharing the below examples is to help nursing students learn how to develop nursing care plans COPD, and should not be taken as medical advice.

Nursing Care Plan COPD
Nursing Care Plan COPD

Nursing Care Plan COPD Infection r/t chronic respiratory disease

Assessment (Supporting data)

Subjective: c/o increased cough, increased sputum Objective: Wbc increased, neutrophils high

Nursing Diagnosis (NANDA diagnostic statement)

Infection r/t chronic respiratory disease process aeb chest congestion, increased neutophil count

Goals & Expected Outcomes (Realistic, timed, measurable)

Pt will have no futher s/sx of respiratory infection after antibiotic tx aeb wbc wnl, afebrile temps, and nonmucopurulent sputum • Pt will verbalize understanding of measures to prevent infection such as adequate nutrition, activity, and immunizations.

Nursing Interventions (Strategies or actions for care)

  • Monitor for signs of infection
  • Administer abx as ordered
  • Encourage increased fluid intake of up to 2500 ml/day within cardiac or renal reserve. Fluids help minimize mucosal drying and maximize ciliary action to move secretions
  • Increase pt’s level of activity as tolerated. Helps to improve oxygenation and decrease secretion retention
  • Teach pt and family s/sx of infection, and when to report to doctor

Rationale for interventions Evaluation (Client’s response to nursing actions & progress toward achieving goals & outcomes)

Pt showed no further s/sx of infection during stay in hospital

Evaluation

Pt showed no further s/sx of infection during stay in hospital

Example 2 Nursing Care Plan COPD Impaired Swallowing

Assessment (Supporting data)

Objective: Barium esphogram found evidence of presbiesophagus and silent penetration to vocal chords

Nursing Diagnosis (NANDA diagnostic statement)

Impaired Swallowing r/t esophageal defects aeb abnormality in esophageal phase by swallow study

Goals & Expected Outcomes (Realistic, timed, measurable)

Pt will demonstrate effective swallowing without choking or coughing during meals on this student’s shift

• Pt will remain free from aspiration aeb clear lungs clear, temp WNL during hospital stay

• Pt will return demonstrate understanding of appropriate swallowing techniques after teaching session

Nursing Interventions (Strategies or actions for care)

  • Determine the client’s readiness to eat. The client needs to be alert, able to follow instructions, able to hold the head erect, and able to move the tongue in the mouth.
  • Watch for uncoordinated chewing or swallowing; coughing immediately after eating or delayed coughing, which may indicate silent aspiration; pocketing of food; wet sounding voice; sneezing when eating; delay of more than 1 second in swallowing; or a change in respiratory patterns. If any of these signs is present, put on gloves, remove all food from the oral cavity, stop feedings, and consult with a speech and language pathologist and a dysphagia team if available. These are signs of impaired swallowing and possible aspiration
  • Avoid providing liquids until the client is able to swallow effectively. Add a thickening agent to liquids to obtain a soft consistency that is similar to nectar, honey, or pudding, depending on the degree of swallowing problems. Liquids 6 can be easily aspirated; thickened liquids form a cohesive bolus that the client can swallow with increased efficiency
  • Have suction equipment available during feeding.
  • Watch for signs of aspiration and pneumonia. Auscultate lung sounds after feeding. Note new crackles or wheezing, and note elevated temperature. Notify the physician as needed. The presence of new crackles or wheezing, an elevated temperature or white blood cell count, and a change in sputum could indicate aspiration of food . It could also indicate the presence of pneumonia. Clients with dysphagia are 7 at serious risk for aspiration pneumonia
  • Watch for signs of malnutrition and dehydration. Keep a record of food intake. Malnutrition is common in dysphagic clients. A food intake record will allow the nurse, speech and language pathologist, and dietitian to determine the adequacy of nutritional intake.  

Rationale for interventions Evaluation (Client’s response to nursing actions & progress toward achieving goals & outcomes)

  • Pt did not choke or cough during meals
  • Pt temp remained WNL during hospital stay
  • Pt was able to demo. appropriate swallowing techniques after teaching session; may need reinforcing before d/c

Nursing Care Plan Ineffective airway clearance

Assessment (Supporting data)

Nursing Care Plan COPD
Nursing Care Plan COPD

Subjective: Pt presented at ED with C/O SOB and dypsnea

Objective: Pt was hypoxemic at admission; spoke in short sentences; used acc. muscles when breathing

Nursing Diagnosis (NANDA diagnostic statement)

Ineffective airway clearance r/t secretions in bronchi and obstructed airway aeb hypoxemia and dypsnea

Goals & Expected Outcomes (Realistic, timed, measurable)

  • Pt will maintain a patent airway at all times
  • Pt will demonstrate improved ventilation and adequate oxygenation within normal parameters for her as evidenced by blood gas levels before d/c
  • Pt will maintain clear lung fields and remain free of signs of respiratory distress throughout hospital stay Pt will Demonstrate effective coughing techniques after teaching session

Nursing Interventions (Strategies or actions for care)

  • Monitor resp. rate, depth, and effort, use of accessory muscles, nasal flaring, and abnml breathing patterns.
    • respiratory rate, use of accessory muscles, nasal flaring, and abdominal breathing may indicate hypoxia.
  • Auscultate breath sounds Q1- 2 °. Presence of crackles, wheezes may signify airway obstruction, leading to or exacerbating existing hypoxia.
  • Observe sputum, noting color, odor, and volume. Normal sputum is clear or gray and minimal; abnormal sputum is green, yellow, or bloody; malodorous; and often copious. Pt’s airway remained open Pt’s lungs remained free of new onset wheezes Pt demo’d effective coughing techniques for student nurse 1
  • Monitor pt’s behavior and mental status for onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. Changes in behavior and mental status can be early signs of impaired gas exchange
  • Monitor oxygen sats continuously with pulse ox. Note blood gas results as available. An oxygen saturation of less than 90% or a partial pressure of oxygen of less than 80 mm Hg (normal: 80 to 100 mm Hg) indicates significant oxygenation problems
  • Observe for cyanosis of the skin; especially note color of the tongue and oral mucous membranes.
  • If acutely dyspneic, consider having pt 2 lean forward over a bedside table, if tolerated. Leaning forward can help decrease dyspnea, possibly because gastric pressure allows better contraction of the diaphragm).
  • Help pt deep breathe and perform controlled coughing. Have pt inhale deeply, hold the breath for several seconds, and cough two or three times with the mouth open while tightening the upper abdominal muscles as tolerated. This technique can help increase sputum clearance and decrease cough spasms. Teach pt to use the forced expiratory technique, the “huff cough.” This technique prevents the glottis from closing during the cough and is effective in clearing 3 secretions in the central airways
  • Administer humidified oxygen through an appropriate device (per the physician’s order); watch for onset of hypoventilation aeb
    • somnolence after initiating or increasing O2 tx. Pts with chronic lung disease may need a hypoxic drive to breathe and may hypoventilate during O2 tx
  • Encourage increased fluid intake of up to 2500 ml/day within cardiac or renal reserve. Fluids help minimize mucosal drying and maximize ciliary action to move secretions.  

Rationale for interventions Evaluation (Client’s response to nursing actions & progress toward achieving goals & outcomes)

  • Pt’s airway remained open
  • Pt’s lungs remained free of new onset wheezes
  • Pt demo’d effective coughing techniques for student nurse

Nursing care plan COPD inefective airway clearance

Assessment

Subjective: is verbalized by the patient.

Objective: • Use of accessory muscle. • Dyspnea • Productive cough • V/S taken as follows: T: 36.7 P: 57 R: 25 Bp: 100/80

Nursing Diagnosis

Ineffective airway clearance related to increased production of secretions.

Inference/ Interventions • Chronic obstructive pulmonary disease (COPD) is a disease characterized by airflow limitation that is not fully reversible. Air flow limitation is usually progressive and associated with an inflammatory response in the lungs stimulated by irritants. Common cause of COPD is cigarette smoking, air pollution, allergens and infections that may also act as irritants. •

Planning

After 4 hrs. Of nursing interventions, the client will demonstrate behaviors to improve airway clearance. e.g. cough effectively and expectorate secretions.

Nursing Interventions

Independent:

• Assist patient to assume position of comfort, e.g., elevate head of bed, encourage patient to lean on overbed table or sit on the edge of the bed.

• Keep environmental pollution to a minimum, e.g., dust, smoke and feather pillows, according to individual situation

• Encourage or assist with pursed lip breathing exercises.

• Observe characteristics of cough like persistent or hacking or moist. Assist with measures to improve effectiveness of cough effort.

Dependent:

• Administer medication as prescribed by the physician.

• Provide supplemental humidification like nebulizer.

Rationale

• Elevation of the head of the bed facilitates respiratory function by use of gravity.

• Precipitators of allergic type or respiratory reactions that can trigger or exacerbate onset of acute episode.

• Provides patient with some means to cope or control dyspnea and reduce air trapping.

• Coughing is most effective in an upright position or head down position after chest percussion.

• A variety of medications may be used to decrease mucus and to improve respiration.

• Humidity helps reduce viscosity of secretions, facilitating expectoration, and may reduce or prevent formation of thick mucus plugs in bronchioles.

Evaluation

After 4 hrs. Of nursing interventions, the client was able to demonstrate behaviors to improve airway clearance. e.g. cough effectively and expectorate secretions.

Example 5 Nursing Care Plan COPD Ineffective Airway Clearance

Nursing Care Plan COPD
Nursing Care Plan COPD/order
 
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