NURSING CARE PLAN
ASSESSMENT
Subjective: “Nahihirapan ako huminga” as verbalized by the patient. Objective: • Use of accessory muscle. Dyspnea Productive cough V/S taken as follows: T: 36.7 P: 57 R: 25 Bp: 100/80 •
DIAGNOSIS
Ineffective airway clearance related to increased production of secretions. •
INFERENCE
Chronic obstructive pulmonary disease (COPD) is a disease characterized by airflow limitation that is not fully reversible. Air flow limitation is usually progressive and associated with an inflammatory response in the lungs stimulated by irritants. Common cause of COPD is cigarette smoking, air pollution, allergens and infections that may also act as irritants. •
PLANNING
INTERVENTION
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RATIONALE
Elevation of the head of the bed facilitates respiratory function by use of gravity.
EVALUATION
• After 4 hrs. Of nursing intervention s, the client was able to demonstrate behaviors to improve airway clearance. e.g. cough effectively and expectorate secretions.
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Independent: • Assist patient After 4 hrs. to assume Of nursing position of interventions, comfort, e.g., the client will elevate head demonstrate behaviors to of bed, encourage improve airway patient to lean on overbed clearance. e.g. cough table or sit on the edge of effectively and the bed. expectorate • Keep secretions. environmental pollution to a minimum, e.g., dust, smoke and feather pillows, according to individual situation • Encourage or assist with pursed lip breathing exercises. • Observe characteristics of cough like persistent or hacking or moist. Assist with measures to improve effectiveness o cough effort.
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Precipitators of allergic type or respiratory reactions that can trigger or exacerbate onset of acute episode.
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Provides patient with some means to cope or control dyspnea and reduce air trapping. Coughing is most effective in an upright position or head down position after chest percussion.
Dependent: • Administer medication as prescribed by the physician. •
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Provide supplemental humidification like nebulizer.
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A variety of medications may be used to decrease mucus and to improve respiration. Humidity helps reduce viscosity of secretions, facilitating expectoration, and may reduce or prevent formation of thick mucus plugs in bronchioles.