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Concept Map: COPD

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Anna C

on 7 August 2013

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Transcript of Concept Map: COPD

74 year old African American
CC: SOB r/t COPD -> Acute Respiratory Failure
S/S: SOB, increasingly dyspneic past 2-3 days, steroid and O2 dependent, AFib w/ HR of 130
Medical Hx: Severe COPD on 4L O2 nasal cannula & maintenance prednisone, HTN, AFib, Pulmonary HTN, GERD, & Insomnia
Surgical Hx: None per patient
Psychosocial: Lives alone, Began smoking in her 20s and stopped in 2004
Assessments: T 97.8, RR 20, BP 96/49,
O2 94% on 4L Nasal Cannula, HR 107
1.) Nrsg Dx: Ineffective Airway Clearance r/t bronchoconstriction, increased mucus and ineffective

Interventions: Auscultate breath sounds q4h and monitor respiratory patterns, monitor blood gas values and pulse O2 saturation levels, help the pt deep breathe and perform controlled coughing, encourage the use of Incentive Spirometer and intake of fluids, encourage ambulation as tolerated w/o causing exhaustion.
Discharge Teaching: Teach the importance of not smoking as this exacerbates COPD, teach pt how to use Peak Expiratory Flow Rate meter & when to seek medical attention when reading drops, teach pt to deep breathe and cough effectively, educate pt about the significance of changes in sputum.
2.) Nrsg Dx: Impaired Gas Exchange r/t ventilation-perfusion inequality
Interventions: Monitor RR, depth, & ease of respiration & watch for use of accessory muscles and nasal flaring; monitor pt behavior and mental status; observe for cyanosis of skin, tongue, and oral mucous membranes; position pt HOB of >30 degrees.
Discharge Teaching: Teach pt how to perform pursed-lip breathing & have pt watch pulse oximeter to note improvement in O2 with breathing technique; teach p energy conservation techniques & importance of alternating rest periods w/ activity; teach importance of not smoking or being around second-hand smoke
3.) Nrsg Dx: Activity Intolerance r/t imbalance between O2 supply and demand
Interventions: Slow the pace of care to allow pt extra time for activities; assess for swaying, poor balance, weakness, & fear for falling while pt stands/walk; watch for orthostatic hypotention when mobilizing pt; evaluate medications that could cause activity intolerance.
Discharge Teaching: Instruct pt on techniques to utilize for avoiding activity intolerance such as controlled breathing techniques; teach pt techniques to decrease dizziness from postural hypotention when standing up; help pt w/ energy conservation & work simplification techniques in ADLs.
4.) Nrsg Dx: Imbalanced Nutrition-less than body requirements r/t decreased intake d/t dyspnea, unpleasant taste in mouth left by medications, increased need for calories from work of breathing
Interventions: Screen for protein-energy malnutrition using Mini Nutritional Assessment (MNA) tool; recognize that constipation is a common problem with elderly-> may avoid many types of food for fear of BM problems; coordinate with Registered Dietitian about diet and use of supplemental drinks/shakes.
Risk for injury d/t falls- place yellow fall band around pt wrist, place risk for falls sign on pt room door; inform pt to use call light for assistance
Discharge Teaching: Build on strengths of patient's food habits, likes/dislikes; recommend use of nutritional supplemental drinks such as Ensure, suggest community resources such as Meals on Wheels.
Gen Assessment: Frail, 5ft 2in, 97lbs, BMI 17.7 (Underweight)
MNA Tool: 6 points= Malnourished
Chronic Bronchitis
Attraction of inflammatory cells ->
release of elastase
Decreased alpha1-antitrypsin
Inherited alpha1-antitrypsin
Destruction of elastic fibers in lungs
Chronic exposure to irritants
triggers inflammation -> vasodilation -> congestion -> mucosal edema -> bronchospasm
chronic inflammation
increase in number & size of mucus glands -> increase production of thick mucus
bronchial walls thicken & impair airflow
lung proteases collapse walls of
bronchioles & alveolar air sacs
fewer, larger, inelastic structures
w/ little surface area
air trapped in distal structures during forced expiration (coughing) -> lungs hyperinflate
trapped air stagnates -> cannot supply needed O2 to nearby capillaries
Resp: Barrel Chest, tight breath sounds & expiratory wheezing bilaterally, RR 20, O2 94% on 4L NC, productive cough w/ bloody sputum
Productive cough with bloody sputum
Labs: Pending for sputum
collection results
Affects oxygenation and
tissue perfusion to all tissues
Resp. Acidosis
Resp. Infection
Cardiac Failure: Cor Pulmonale
Cardiac Dysrhythmias:
PO (suspension), bid
for appetite stimulation
Consult: Registered Dietitian
Consult: Speech Therapist- For Swallow Evaluation d/t intubation
Nutritional Status: Soft/Diabetic Diet
0.125 mg, PO, qDay at 1100
CV: Distant S1&S2, +1 radial and pedal pulses, cap refill 5 sec, HR 107- irregular rhythm- AFib
Assess apical pulse for 1 minute-
Hold Digoxin if <60 bpm
Neuro: A&Ox2 (person & place); eyes open-spontaneously, PERRLA; motor response-obeys commands, behavior-calm/cooperative
GI: Soft abdomen, decreased bowel sounds in all quadrants, no guarding, no BM during my visit w/ pt
Integumentary: warm & dry skin, tenting skin turgor, pink & moist oral mucosa
GU: Clear and dark yellow urine, uses bedpan for voiding
0.5mg/2mL, Inhalation, bid w/ RT
Consult: Respiratory
Therapy (RT)
40mg/0.4mL, SQ, qDay
Labs: Sodium144, Potassium 4.4,
Albumin/Total Protein needed
0.5mg/2.5mL, Inhalation,
q6h w/RT
40mg, PO, qDay at 0630
for GERD
12.5mg, PO, hs PRN
for insomnia
Consult: Social Worker for
community resources
250mg, PO, bid
for recurrent diarrhea
10mg, PO, qDay
Blood Glucose Testing: ACHS
d/t dependent steroidal medication & appetite stimulant med
results: 98 (0830), 144 (1200)
Lantus Insulin Pen
20 units, SQ, qDay
Inhalation (nebulizer),
q6h w/ RT
Inhalation (nebulizer),
bid w/ RT
10mg, PO, qDay
Patient information, CC, & S/S
Assessments: Medical & Surgical Hx, Psychosocial
Assessments: Physical
Labs: ABG- ph 7.11,
pCO2 of 122, pO2 of 120
Chest Xray: hyperexpanded lung
fields, haziness at left base
Nutritional Status
Nrsg Dx
Discharge Teaching

Clinical Manifestations
Possible Complications
Ignatavicius, D.D., & Workman, L.M. (2010). Medical surgical nursing:
Patient-centered collaborative care (6th ed.). St. Louis, Missouri:
Saunders Elsevier.
Porth, C.M. (2011). Essentials of pathophysiology (3rd ed.).
Philadelphia, PA: Lippincott Williams & Wilkins.
60mg, PO, q8h
0.9% Normal Saline
100mL/hr, IV, q10h
10mg, PO, qDay
may cause depression
May cause depression &
decreased glucose intolerance
Full transcript