Ncp of copd
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The document outlines a nursing assessment and intervention plan for a patient with ineffective airway clearance and dyspnea. Interventions include elevating the head of the bed, minimizing environmental pollutants, encouraging cough and breathing exercises, administering prescribed medications, and providing supplemental humidification. The rationale for each intervention is aimed at improving airway clearance and respiratory function.
Ncp of copd
- 1. ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION Subjective: • Ineffective airway • After 4 hrs. Of nursing Independent: • After 4 hrs. Of nursing 1. Assist patient to 1. Elevation of the head “Nahihirapan ako clearance related to interventions, the client interventions, the client assume position of of the bed facilitates huminga” as verbalized increased production of will demonstrate comfort, e.g., elevate respiratory function by was able to demonstrate head of bed, encourage use of gravity. by the patient. secretions. behaviors to improve behaviors to improve patient to lean on airway clearance. e.g. overbed table or sit on airway clearance. e.g. the edge of the bed. Objective: cough effectively and cough effectively and • Use of accessory expectorate secretions. 2. Keep environmental 2. Precipitators of expectorate secretions. pollution to a minimum, allergic type or muscle. e.g., dust, smoke and respiratory reactions • Dyspnea feather pillows, that can trigger or according to individual exacerbate onset of Productive cough situation. acute episode. • V/S taken as follows: 3. Encourage or assist 3. Provides patient with with pursed lip some means to cope or T: 36.7 breathing exercises. control dyspnea and reduce air trapping. P: 57 R: 25 4. Administer 4. A variety of medication as medications may be Bp: 100/80 prescribed by the used to decrease mucus physician. and to improve respiration. 5. Provide supplemental 5. Humidity helps humidification like reduce viscosity of nebulizer. secretions, facilitating expectoration, and may reduce or prevent formation of thick mucus plugs in bronchioles. Patient: Diagnosis: