The Patient’s Problems
This patient has both long-lasting obstructive and bronchitis along with (severe) exacerbation, as well as recurrent emphysema and hypertension. The client’s principal focus is a persistent obstructive pulmonary disease (COPD) caused by her pre-existing complications of obstructive chronic bronchitis and emphysema. She had intense breathing problems, hypertension, and tachycardia due to her chronic condition (Nici & ZuWallack, 2018). The woman was discovered to be suffering from an acute exacerbation of COPD.
Patient’s Vitals, Lab Reports, Assessment, and Subjective Information Results
The findings include breathing difficulties, exhaustion, weakness, depression, scapular pain, hypertension, tachycardia, edema in the abdominal area, and chest x-ray consistent with phase 3 chronic obstructive pulmonary disorder. Other results include elevated fever, coughing regularly, hypoxemia (low sao2 thresholds), wheezing along with coarse sounds, high blood sugar, hypercapnia (high paco2 concentrations), and distress urinary incontinence (low PH levels).
Patient’s vitals, Lab reports, Assessment, and Objective Information Results
The finding indicated that the patient had an enlarged chest, a sign of COPD (barrel chest). During normal breathing, wheezing occurs, inducing the patient to take longer to exhale completely. Communication problems were also recorded since the patient had body weakness wheezing with coarse noises, high blood sugar, and urinary incontinence that is distressing (low PH levels) also made his body weak.
Patient Goal and Three SMART Outcomes
The aim is to increase the sick person’s oxygen levels when relaxing and conducting tasks and assist the patient in preventing recurrences at home. The three outcome requirements are enhanced airway clearing (specific), increased resistance to exercise (measurable), and client education on healthier functioning with COPD until discharged (timely).
Nursing Interventions and Achievements
According to Nici & ZuWallack (2018), nursing interventions in this scenario will include:
- Auscultate breathing sounds
- Note adventitious breath resonances (wheezing, crackling, rhonchi)
- Assessing and monitoring breathing rate.
- Noting the ratio of inspiratory versus expiratory.
- Noting the presence or degree of dyspnea (reportage of air deprivation), agitation, nervousness, breathing distress,
- Utilization of accessory muscles
- Monitoring of graph serial ABGs (arterial blood gases), pulse oximetry, and the -ray for the chest.
- Assisting the patient with repositioning.
- Supporting the client with self-care undertakings
- Providing the patient with supplementary oxygen and increasing its levels during activities
- Evaluating the client’s responsiveness to activities
- Noting reports of dyspnea augmented weakness and alterations in the patient’s vital signs during and after activities
- Administering the prescribed medications as specified.
Medications for the Problem
- Inhalant Solution (Albuterol 0.21 MG/ML) – the inhaler is used in rescuing or providing a fast respite for severe exacerbation from the client’s COPD
- 24 hours orally administering of Nifedipine 30 MG Extended Release Tablet – this is used in reducing the sick person’s blood pressure
- 60 tiotropium 0.0025 MG/ACTUAT Metered Dose Inhaler – this is used to prevent breathing difficulties, wheezing sounds, and crackling signs instigated by COPD. This prescription is used as a prevention measure in reducing acute exacerbation, though it should not be used during the occurrence.
- Oral administering of Omeprazole 40 MG Delayed-Release Capsule – this is used in inhibiting low acidity levels in PH.
Patient Care Orders, Patient’s Support, and Schedule
- Pulse Ox is prescribed to help the patient breathe easily, raise oxygenation, and reduce CO2 levels.
- An incentive spirometer is a diagnostic tool that assists patients in improving the operation of their lungs.
- Turning, coughing, and deep breathing help remove mucus from the lungs, which aids prevent infections.
- Before the client’s release, health education must continue providing her with awareness for successful treatment, correct drug usage, and ways of coping with COPD at home.
- Support with 1:1 assistance is directed to help the client while she is active due to her risk of falls.
- A current weight schedule is used to keep track of the sufferer’s weight to provide sufficient nutrition.
- Track water intake and discharge to ensure the individual is hydrated and has an average urine level.
|Oxygenation Therapy||As ordered||Intervals of two hours|
|Turn/cough/deep breath||Q2H||Intervals of two hours|
|Incentive Spirometer||Q1H||Interval of one hour|
|Sustenance with 1:1 assist||Every Day||Interval of one day|
|Patient Awareness||As Directed||Once|
|Monitoring of Fluid||TID||Intervals of 8 hours|
Assessing the vital signs, laboratory tests, diagnostic testing, a clinical investigation, and a client interview may be needed to reconsider the patient’s progress to decide if the treatment plan is working or whether instructions and treatments can be modified.
Nici, L., & ZuWallack, R. (2018). Integrated care in chronic obstructive pulmonary disease and rehabilitation. COPD: Journal of Chronic Obstructive Pulmonary Disease, 15(3), 223-230. Web.