Pathophysiology: Pathophysiology:, Exams of Nursing

Download Pathophysiology: Pathophysiology: and more Exams Nursing in PDF only on Docsity! NUP 353 - CLINICAL CARE PLAN Pathophysiology: COPD stands for chronic obstructive pulmonary disorder. What leads to this is things like smoking, secondhand smoke, and other inhaled pollutants, which causes destruction of the air sacs in your lungs called alveoli and your airways leading down to your lungs. This makes it difficult for your body to get oxygen to the rest of your body, and can make it very difficult to breathe. Patient situation and background: HG is a 68 y/o Latino M admitted to the hospital today for c/o pneumonia. His daughter found him unresponsive at home. Daughter stated HG has hx of COPD and since his wife died recently, ETOH abuse. PMHX (past medical history): COPD Final DX: Pneumonia w COPD exacerbation Revised: 01/27/2021 (kkp) Complete the following table: ASSESSMENT DATA: SUBJECTIVE & OBJECTIVE NURSING DIAGNOSIS OUTCOME CRITERIA NURSING INTERVENTIONS EVALUATION Subjective: - Recently retired - Recently widowed - Possible ETOH abuse Subjective: - Hx of COPD - Productive cough - Diminished sounds at lung bases - BP: 150/49 1. Impaired gas exchange related to COPD and pneumonia 1a. Pt. ABGs will return to baseline within two days A1. Nurse will titrate O2 levels as needed. (Balanced O2 supply and demand, pg. , Harding et al., 1544 2020) A2. Nurse will encourage incentive spirometer use. (Postoperative Care, pg. 335, Harding et al., 2020) A3. Nurse will administer a1 . Pts breathing returned to within normal/acceptable range. NUP 353 - CLINICAL CARE PLAN Revised: 01/27/2021 (kkp) - T: 99.2 - HR: 100 - SaO 2: 91% - RR: 36 1b. Pt lung sounds will return to baseline by end of shift medications as ordered. (COPD Drug Therapy, pg. 566 2020), Harding et al., A4 . Nurse will elevate pt head of bed to a comfortable level. Postoperative Care, ( pg. 335, Harding et al., 2020) A5 . Nurse will encourage frequent turning to promote chest expansion. (Postoperative Care, pg. 335, Harding et al., 2020) B1 . Nurse will titrate O2 levels as needed (Balanced O2 supply and demand, pg. 1544, Harding et al., 2020) B2 . Nurse will encourage incentive spirometer use. (Postoperative Care, pg. 335, Harding et al., 2020) B3 . Nurse will administer medications as ordered. (COPD Drug Therapy, pg. 566, Harding et al., 2020) 1b. Pts ABGs returned to normal levels. NUP 353 - CLINICAL CARE PLAN Revised: 01/27/2021 (kkp) 2. Ineffective airway clearance related to increased secretions and abnormal auscultation sounds a2 . Pt will have decrease in adventitious lung sounds by end of shift C5 . Nurse will encourage frequent turning to promote chest expansion. (Postoperative Care, pg. 335, Harding et al., 2020) A1. Nurse will administer and titrate oxygen as needed (Balanced O2 supply and demand, pg. 1544, Harding et al., 2020) A2. Nurse will encourage incentive spirometer use. Postoperative Care, pg. ( 335, Harding et al., 2020) A3. Pt will cough and deep breathe. (Postoperative Care, pg. 335, Harding et al., 2020) A4. Nurse will administer nebulizer treatment as ordered & needed (COPD Care, pg. 567, Harding et al., 2020) A5. The nurse will encourage smoking a.2 Pts adventitious lung sounds decreased significantly by end of shift. NUP 353 - CLINICAL CARE PLAN Revised: 01/27/2021 (kkp) 2c. Pt will identify possible complications and know when to seek medical attention. C1 . The nurse will provide education on colors of sputum. (COPD Care, pg. , Harding et al., 2020)567 C2 . Pt will properly and effectively use incentive spirometer 10x per 1-2 hrs. Postoperative Care, pg. ( 335, Harding et al., 2020) C3 . Nurse will administer nebulizer treatment as ordered & needed. COPD ( Care, pg. 567, Harding et al., 2020) C4 . Nurse will provide education on deep breathing. Postoperative ( Care, pg. 335, Harding et al., 2020) C5 . The nurse will encourage smoking cessation. COPD Care, pg. 2020)566, Harding et al., 2c. Pt was open to discussing smoking cessation with social worker. 3. Risk for depression related to COPD as evidence by activity intolerance and ineffective coping 4. Ineffective Coping . Imbalanced Nutrition5 3a. Pt will verbalize three coping mechanisms by end of shift. A1 . The nurse will provide list of effective coping mechanisms. (COPD Considerations, pg. 574- 575 2020), Harding et al., A2 . The nurse will help facilitate communication with friends, family, and support systems. (COPD Considerations, pg. 575, Harding et al., 2020) A3 . The nurse will help pt get in contact with social worker/case manager. (COPD Considerations, pg. , Harding et al., 2020)575 A4 . The nurse will help pt get in touch with support groups. (COPD Considerations, pg. 575, Harding et al., 2020) A5 . The nurse will encourage smoking cessation. COPD Care, pg. 2020)566, Harding et al., a3 . Pt is able to verbalize three healthy coping mechanisms. 3b. Pt will experience increase activity tolerance in at least one activity by end of stay. 3c. Pt will identify three support systems/resources by B1. The nurse will encourage smoking cessation. COPD Care, pg. 566, Harding et al., 2020) B2. Th nurse will encourage incentive spirometer use. (Postoperative Care, pg. 335, Harding et al., 2020) B3. The nurse will adm nister medications. COPD Drug Therapy, pg. 566, Harding et al., 2020) B4. The nurse will encourage deep breathing and forceful coughing. (Postoperative Care, pg. 335, Harding et al., 2020) B5. The nurse will administer nebulizer treatment, O2, and humidification prn. (COPD Care, pg. 567, Harding et al., 2020) C1 . RN will provide list of effective coping mechanisms. (COPD b3 . Pt met with social worker/case manager and to set up follow up meetings once discharged. NUP 353 - CLINICAL CARE PLAN Revised: 01/27/2021 (kkp) end of shift. Considerations, pg. 574- 575, Harding et al., 2020) C2 . The nurse will help facilitate communication with friends, family, and support systems. COPD Considerations, pg. ( 2020)575, Harding et al., C3 . The nurse will help pt get in contact with social worker/case manager. (COPD Considerations, pg. 575, Harding et al., 2020) C4 . The nurse will help pt get in touch with support groups. (COPD Considerations, pg. 575, Harding et al., 2020) C5 . The nurse will encourage smoking cessation. COPD Care, pg. 566, Harding et al., 2020) 3c. Pt was interested about smoking cessation options.