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Submitted by:
Renalyn A. Tupas
Submitted to:
Mrs. Gloria Jamindan




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College of ursing

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A. . 
71 years old

  
Dr.Samora/ DrTrimanes 
May 21, 2010


  
Difficulty of breathing

    
COPD in acute exacerbation

   

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neffective airway clearance 

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related to copious bronchial At the end of 2 hours of nursing At the end of 2
Secretions secondary to chronic intervention the patient will be { Remind patient to drink { Hydration helps decrease the hours, the patient:
Obstructive pulmonary disease as able to : fluids per cardiac tolerance. viscosity of secretions { ffectively expectorated
evidenced by presence of { have the ability to effectively Provide warm or hot drinks facilitating expectoration. secretions.
productive cough. cough up secretions instead of cold fluids { Maintained airway patency
{ demonstrate behaviors to { Assist the patient in { Demonstrated improved\
improve or maintain clear coughing, huffing, and { Deep breathing and oxygen exchange as
airway breathing efforts to make diaphragmatic breathing evidenced by reduction of
{ demonstrate improved them more productive allow for greater lung breath sounds and noiseless
oxygen exchange, reduction expansion and ventilation as respirations
with breath sounds and well as a more effective { erbalized understanding of
respirations noiseless { Assist with cupping and cough cause & therapeutic
{ verbalize understanding of clapping activities q4h while { Cupping and clapping loosen management regimen
cause & therapeutic awake. Teach the family secretions and assist 
management regimen these procedures. expectoration.  

{ Assist the patient with Objectives were not met.
clearing secretions from { Teaching the family allows
mouth or nose by: them to participate in care
-Providing tissues under supervision and
 

 promotes continuation of the
At the end of 16 hours of nursing   
 procedure after discharge.
intervention, 
the patient will be able to: { Administer medications such
{ maintain airway free of as antibiotics as ordered.
secretions oting effectiveness and side { This aids the patient in
{ show evidence of clear lung effect. recovering from the disease
sound and eupnea ÷ zithromax process and eliminate signs
{ demonstrate absence of and symptoms
congestion with breathing
{ Demonstrate behaviors to
maintain clear airway.
 Ô
MÔîñ
cñÔ
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RS
TY OF
O
O
PH
MA ducation etwork
College of ursing

Ô
  
A. . 
71 years old

  
Dr.Samora/Trimanes 
May 21, 2010


  
Difficulty of breathing

    
COPD in acute exacerbation

   

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mpaired Gas xchange related 

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 Short and long term goals were
to alveolar capillary membrane y the end of 4 hours of nursing { Maintain oxygen { This provides for adequate fully met as evidenced by:
changes secondary to chronic interventions, the client and her administration device as tissue oxygenation. Hypoxia { A decrease in the RR and
obstructive pulmonary disease as folks ordered, attempting to stimulates the drive to PR of the client after
evidenced by: must be able to: maintain O2 saturation at 2.5 breathe in the chronic CO2 interventions.
shallow breathing, productive { erbalize understanding of PM.Avoid high container patient. { An increase in the oxygen
cough and oxygen inhalation at causative factors and concentration of O2 in saturation of the client.
2.5 liters per minute. appropriate interventions patients with COPD unless { Client already has alert.
{ Participate in treatment ordered.
regimen within level of { Position the patient with { This prevents the abdominal
ability proper body alignment for contents from crowding the
{ Demonstrate an optimal respiratory excursion lungs and preventing their
improvement in ventilation (if tolerated, head of bed at full expansion.
and adequate gas exchange. 45°.)

 

 { Position patient to facilitate { Àhen the patient is
y the end of 16 hours, patient ventilation perfusion positioned on the side, the
must maintain optimal gas matching when a side-lying good side down.
exchange as evidenced by arterial position is used.
blood gases and oxygen { Pace activities and schedule { ven simple activities during
 saturation within the patient¶s rest periods to prevent bed rest can cause fatigue
usual range. fatigue. Assist with ADs. and increase O2 demand,
{ Change position every 2 resulting in dyspnea.
hours. { This facilitates secretion
{ ncourage deep breathing. movement and drainage.
{ This reducesalveolar
collapse


 Ô
MÔîñ
cñÔ
ë
RS
TY OF
O
O
PH
MA ducation etwork
College of ursing

Ô
  
A. . 
71 years old

  
Dr.Samora/ DrTrimanes 
May 21, 2010


  
Difficulty of breathing

    
COPD in acute exacerbation

  


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Acute chest pain related to 
 M

 
 At the end of 30
reduced coronary blood flow At the end of 30 minutes the { Assist the patient to a { A semi-fowler¶s is usually minutes of nursing
resulting to myocardial ischemia patient comfortable position. most comfortable. interventions, patient
as evidenced by: will be able to: Maintain bed rest, at least was able to
{ sighing with no intent to { Report that pain/discomfort during periods of pain. experience relief from
move unless absolutely is alleviated or controlled, as { Provide comfort measures, { Restricted activity reduces pain as evidenced by
necessary evidenced by a decrease in quiet environment and calm oxygen demands of the heart. a decrease in the Pain
{ very slow movement with pain rating the scale. activities Techniques are used to bring Scale Rate: 2/5, with 5
facial grimace { Display a relaxed appearance about a state of physical and as the most painful
{ shortness of breath upon pain and be able to sleep/rest mental awareness and - Short term goal was
onset with facial grimace and comfortably and engage in tranquillity. The goal of these fully met 02/10/10
sighing desired activities she can techniques is to reduce At the end of 8 hours
tolerate. tension, subsequently, of nursing
{ Demonstrates ability to cope { ncourage use of relaxation reducing pain. interventions patient
with partially relieved pain. techniques, such as focused { This heightens one¶s was able to
(e.g., deep breathing breathing and imagery. concentration upon demonstrate use of
exercises and position nonpainful stimuli to relaxation skills to
 changes) decrease one¶s awareness help alleviate pain.
{ Demonstrate use of { liminate additional and experience of pain. ong term goal was
relaxation skills and
diversional activities as
indicated for individual
situation and verbalize
nonpharmacologic methods
that provide relief.
stressors or sources of
discomfort when possible.
{ Patient may experience an Fully met.
exaggeration in pain or a
decreased ability\ to tolerate
painful stimuli if
environmental, intrapsychic,
intrapersonal factors are
{ Provide rest periods to further stressing him.
 

 facilitate comfort, sleep and { Patient¶s experience of pain
At the end of four days, client relaxation. may become exaggerated
will due to fatigue.
remain free from pain as 
 

evidenced by no reports of pain, { Administers analgesics as { Analgesics are given to
and normal vital signs ordered alleviate pain
÷ zantac

Renalyn A. TupasMrs.Gloria Jamindang

  
S 3 ± G   M