Chronic Obstructive Pulmonary Disease (Bronchitis) Nursing Care Plans
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Chronic Obstructive Bronchitis is an inflammation of the bronchi (chronic obstructive bronchitis) causes increase mucus production and chronic cough. The clinical manifestations of Chronic Bronchitis continue for at least 3 months of the year for 2 consecutive years. Chronic bronchitis is also known the blue bloater. It is characterized by the following: An increase in the size and number of submucous glands in the large bronchi which causes increase mucus production An increased number of globlet cells, which also secrete mucus Impaired ciliary function, which reduces mucus clearance 1 Ineffective Airway Clearance COPD is an inflammatory response to the offending microorganism. The defense mechanisms of the lungs lose effectiveness and allow organisms to penetrate the sterile respiratory tract, as a result inflammation develops. The inflammation and increased secretions make it difficult to maintain a patent airway. Assessme nt Nursing Diagnos is Planning Nursing Inter- ventions Rationale Expected Outcome S:Æ O: The may patient manifest the ffg.: >with wheezes/ crackles upon ausculta tion on the BLF Ineffec tive airway clearan ce related to retaine d and excessi ve secreti ons and ineffec tive Short term: After 4-5 hours of nursing intervent ions the patient will demonstra te effective clearing of secretion >Establish rapport to the pt. and SO >Assess the patient condition >Monitor and record V/S >Position head >To gain trust and active participa tion >To know the condition of the pt >To have a baseline data. >To gain Short term: The patient shall have demonstr ated effectiv e clearing of secretio ns.
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Transcript of Chronic Obstructive Pulmonary Disease (Bronchitis) Nursing Care Plans
Chronic Obstructive Bronchitis is an inflammation of the bronchi (chronic obstructive bronchitis) causes increase mucus production and chronic cough. The clinical manifestations of Chronic Bronchitis continue for at least 3 months of the year for 2 consecutive years. Chronic bronchitis is also known the blue bloater. It is characterized by the following:
An increase in the size and number of submucous glands in the large bronchi which causes increase mucus production
An increased number of globlet cells, which also secrete mucus Impaired ciliary function, which reduces mucus clearance
1 Ineffective Airway Clearance
COPD is an inflammatory response to the offending microorganism. The defense mechanisms of the lungs lose effectiveness and allow organisms to penetrate the sterile respiratory tract, as a result inflammation develops. The inflammation and increased secretions make it difficult to maintain a patent airway.
Assessment
Nursing Diagnosis
PlanningNursing Inter-ventions
RationaleExpected Outcome
S:Æ O: The may patient manifest the ffg.:
>with wheezes/
crackles upon auscultation on the BLF
>with subcostal retraction
>with nasal flaring
>presence of non-productive cough
>increase
Ineffective airway clearance related to retained and excessive secretions and ineffective coughing
Short term: After 4-5 hours of nursing interventions the patient will demonstrate effective clearing of secretions.
Long term:
After 2 days of nursing interventions, the patient will maintain effective airway clearance.
>Establish rapport to the pt. and SO >Assess the patient condition
>Monitor and record V/S
>Position head midline with flexion on appropriate for age/condition
>Elevate HOB
>Observe S/Sx of infections
>Auscultate breath sounds & assess air mov’t
>To gain trust and active participation >To know the condition of the pt
>To have a baseline data.
>To gain or maintain open airway
>To decrease pressure on the diaphragm and enhancing drainage
>To identify infectious
Short term: The patient shall have demonstrated effective clearing of secretions.
Long term:
The patient shall have maintained effective airway clearance.
RR above normal range
>Instruct the patient to increase fluid intake
>Demonstrate effective coughing and deep-breathing techniques.
>Keep back dry
>Turn the patient q 2 hours
>Demonstrate chest physiotherapy, such as bronchial tapping when in cough, proper postural drainage.
>Administer bronchodilators
if prescribed.
process
>To ascertain status & note progress
>To help to liquefy secretions.
>To maximize effort
>To prevent further complications
>To prevent possible aspirations
>These techniques will prevent possible aspirations and prevent any untoward complications
>More aggressive measures to maintain airway patency.
2 Ineffective Breathing Pattern
The presence of microorganisms in the lungs causes body to increase the secretory activity of goblet cells to get rid of the invading organism but the mechanism is not enough which allows the stasis of mucus secretion leading to ineffective breathing pattern.
Assessment
Nursing Dx
PlanningNursing Interventions
RationaleExpected Outcome
S: Reports of dyspnea O: The patient may manifest the manifest the ffg.:
> with wheezes /crackles upon auscultation on BLF
> increase RR above normal range
>presence of productive cough
>use of accessory muscle when breathing
>presence of nasal flaring and retractions
Ineffective breathing pattern related to retained mucus secretions
Short term: After 4-5 hours of nursing interventions the patient will improve breathing pattern.
Long term:
After 2 days of nursing interventions the patient will maintain a respiratory rate within normal limits.
>Establish rapport to the pt. and SO >Assess the patient condition
>Monitor and record V/S especially RR
>Provide rest periods
>Place pt in semi-fowlers position
>Increase fluid intake
>Keep patient back dry
>Change position every 2 hours
>Perform CPT
>Place a pillow when the client is sleeping
>Instruct how to splint the chest wall with a pillow for comfort during coughing and elevation of head over body as appropriate
>To gain trust and active participation >To know the condition of the pt
>To have a baseline data.
>To reduce fatigue and obtain rest
>To have a maximum lung expansion
>To liquefy secretions
>To avoid stasis of secretions and avoid further complication
>To facilitate secretion mov’t and drainage
>To loosen secretion
>To provide adequate lung expansion while
Short term: The patient shall have improved breathing pattern.
Long term:
The patient shall have maintained a respiratory rate within normal limits.
>Maintain a patent airway, suctioning of secretions may be done as ordered
>Provide respiratory support. Oxygen inhalation is provided per doctor’s order
>Administer prescribed cough suppressants and analgesics and be cautious, however, because opioids may depress respirations more than desired.
sleeping.
>To promote physiological ease of maximal inspiration
>To remove secretions that obstructs the airway
>To aid in relieving patient from dyspnea
>To promote deeper respirations and cough
3 Impaired Gas Exchange
The disruption of the mechanical defenses of cough and ciliary motility leads to colonization of the lungs and subsequent infection leading to inflammation and accumulation of secretions. Inflamed and fluid-filled alveolar sacs cannot exchange oxygen and carbon dioxide effectively.
AssessmentNursing Dx
PlanningNursing Inter-ventions
RationaleExpected Outcome
S:Æ O: The patient may manifest the ffg.:
>Appearance
Impaired gas exchange related to altered oxygen
Short term: After 4-5 hours of nursing interventions the patient
>Establish rapport to the pt. and SO >Assess the patient condition
>To gain trust and active participation
>To know the
Short term: The patient shall have improved ventilation and
of bluish extremities when in cough (cyanosis), lips
>Lethargy
>Restlessness
>Hypercapnea
>Hypoxemia
>Abnormal rate, rhythm, depth of breathing
>Diaphoresis
will improve ventilation and adequate oxygenation of tissues
Long term:
After 2 days of nursing interventions the patient will minimize or totally be free of symptoms of respiratory distress.
>Monitor and record V/S
>Monitor level of consciousness or mental status
>Assist the client into the High-Fowlers position
>Increase patient’s fluid intake
>Encourage expectoration
>Encourage frequent position changes
>Encourage adequate rest & limit activities to within client tolerance
>Promote calm/restful environments
>Administer supplemental oxygen judiciously as indicated
>Administer meds as
condition of the pt
>To have a baseline data.
>Restlessness,
anxiety,
confusion, somnolence are common manifestation of hypoxia and hypoxemia.
>The upright position allows full lung excursion and enhances air exchange
>To help liquefy secretions
>To eliminate thick, tenacious, copious secretions which contribute for the impairment of gas exchange.
>To promote drainage of secretions
>Helps limit oxygen
needs/consumption
>To correct/improve existing
adequate oxygenation of tissues
Long term:
The patient shall have minimized or totally be free of symptoms of respiratory distress.
indicated such as bronchodilators
deficiencies
>May correct or prevent worsening of hypoxia.
>To treat the underlying condition
4 Sleep Pattern Disturbance
COPD patients need a comfortable position such as the High-Fowler’s position during sleeping in order to promote lung expansion. Lying flat on bed promotes the occurrence of DOB and makes the patient uncomfortable due to the impaired alveolar ventilation which the body processes at night can’t be controlled
AssessmentNursing Dx
PlanningNursing Interventions
RationaleExpected Outcome
S:Æ O: The patient may manifest the ffg.:
>irritability
>restlessness
>lethargy
>changes in posture
>difficulty of breathing which worsens at night
Sleep pattern disturbance related to difficulty of breathing
Short term: After 4-5 hours of nursing interventions the patient will identify individually appropriate interventions to promote sleep.
Long term:
After 2 days of nursing interventions, the patient will be able to report improvements in sleep/rest pattern.
>Establish rapport to the pt. and SO >Assess the patient condition
>Monitor and record V/S
>Monitor level of consciousness or mental status
>Promote comfort measures such as back rub and change in position as necessary
>Observe
>To gain trust and active participation >To know the condition of the pt
>To have a baseline data
>Restlessness, anxiety,
confusion, somnolence are common manifestation of hypoxia and hypoxemia.
>To provide non pharmagcologic management
Short term: The patient shall have identified individually appropriate interventions to promote sleep
Long term:
The patient shall have reported improvements in pt.’s sleep/rest
provision of emotional support
>Provide quiet environment.
>Increase patient’s fluid intake
>Encourage expectoration
>Limit the fluid intake in evening if nocturia is a problem
>Obtain feedback from SO regarding usual bedtime, rituals/routines
>Provide safety for patient sleep time safety
>Recommend midmorning nap if one required
>Administer pain medication as ordered.
>Lack of knowledge and problems, relationships may create tension. Interfering with sleep routines based on adult schedules may not meet child’s needs.
>To promote an environment conducive to sleep.
>To help liquefy secretions
>To eliminate thick, tenacious, copious secretions which contribute for the DOB
>To reduce need for nighttime elimination
>To determine usual sleep patterns & provide comparative baseline
>To promote
comfort/safety
>Napping esp. in the afternoon can disrupt normal sleep pattern
>To relieve discomfort and take maximum advantage of sedative effect
5 Risk for Spread of Infection
Once the bacteria, virus, or fungus enter the lungs, they usually settle in the air sacs of the lung where they rapidly grow in number. This area of the lung then becomes filled with fluid and pus as the body attempts to fight the infection. Disruption of the mechanical defenses of cough and ciliary motility leads to colonization of the lungs and subsequent infection
AssessmentNursing Dx
PlanningNursing Interventions
RationaleExpected Outcome
S:Æ O: The patient may manifest:
>Body temperature above normal range
>dehydration
>increase WBC count
>presence of increase mucus production
Risk for spread of infection related to stasis of secretions and decreased ciliary action.
Short term: After 4-5 hours of nursing interventions the patient will identify interventions to prevent and/or reduce the risk of infection
Long term:
After 2 days of nursing interventions the patient will have minimize or totally be free from the
>Establish rapport to the pt. and SO >Assess the patient condition
>Monitor & record V/S
>Review importance of breathing exercises, effective cough, frequent position changes, and adequate fluid
>To gain trust and active participation >To know the condition of the pt
>To have a baseline data and fever may be present because of infection and/or dehydration
>These activities promote mobilization and expectoration
Short term: The shall have identified interventions to prevent and/or reduce the risk of infection
Long term:
The patient shall have minimized or totally be free from the risk of infection.
risk of infection.
intake
>Turn the patient q 2 hours
>Encourage increase fluid intake
>Stress the importance of handwashing to SO’s
>Teach the SO’s how to care for and clean respiratory equipment
>Teach the SO’s the manifestations of pulmonary infections (change in color of sputum, fever, chills) , self-care and when to call the physician
>Recommend rinsing mouth with water
>Administer antimicrobial such as cefuroxime as indicated.
of secretions to reduce the risk of developing pulmonary infection.
>To facilitate secretion mov’t and drainage
>To liquefy secretions
>Handwashing is the primary defense against the spread of infection
>Water in respiratory equipment is a common source of bacterial growth
>Early recognition of manifestations can lead to a rapid diagnosis.
>To prevent risk of oral candidiasis.
>Given prophylactically to reduce any possible complications
Other nursing diagnoses:
6 High risk for suffocation 7 High risk for aspiration 8 Anxiety RT acute breathing difficulties 9 Activity Intolerance RT inadequate oxygenation 10 Imbalanced Nutrition: Less than body requirements RT reduced appetite and dyspnea
(for empysema)
Once the bacteria, virus, or fungus enter the lungs, they usually settle in the air sacs of the lung where they rapidly grow in number. This area of the lung then becomes filled with fluid and pus as the body attempts to fight the infection. Disruption of the mechanical defenses of cough and ciliary motility leads to colonization of the lungs and subsequent infection
