Mr. Oden, a 91-year-old patient with COPD, was admitted with an exacerbation of his condition. He has labored breathing, cyanosis, and is producing tenacious mucus. The nursing diagnosis is ineffective airway clearance related to his secretions and expiratory airflow obstruction. The plan is to assess his respiratory status regularly, encourage coughing and deep breathing, suction as needed, and ensure hydration to liquefy secretions. The goal is for Mr. Oden to maintain a patent airway and for his breathing pattern to improve with treatment.
Mr. Oden, a 91-year-old patient with COPD, was admitted with an exacerbation of his condition. He has labored breathing, cyanosis, and is producing tenacious mucus. The nursing diagnosis is ineffective airway clearance related to his secretions and expiratory airflow obstruction. The plan is to assess his respiratory status regularly, encourage coughing and deep breathing, suction as needed, and ensure hydration to liquefy secretions. The goal is for Mr. Oden to maintain a patent airway and for his breathing pattern to improve with treatment.
Original Description:
Berisi modul keperawatan bahasa inggris semester 3 dan bagus buat bahan mata ajar matkul
Mr. Oden, a 91-year-old patient with COPD, was admitted with an exacerbation of his condition. He has labored breathing, cyanosis, and is producing tenacious mucus. The nursing diagnosis is ineffective airway clearance related to his secretions and expiratory airflow obstruction. The plan is to assess his respiratory status regularly, encourage coughing and deep breathing, suction as needed, and ensure hydration to liquefy secretions. The goal is for Mr. Oden to maintain a patent airway and for his breathing pattern to improve with treatment.
Mr. Oden, a 91-year-old patient with COPD, was admitted with an exacerbation of his condition. He has labored breathing, cyanosis, and is producing tenacious mucus. The nursing diagnosis is ineffective airway clearance related to his secretions and expiratory airflow obstruction. The plan is to assess his respiratory status regularly, encourage coughing and deep breathing, suction as needed, and ensure hydration to liquefy secretions. The goal is for Mr. Oden to maintain a patent airway and for his breathing pattern to improve with treatment.
Care of the Patient with a Respiratory Disorder CHAPTER 49 1661
Nursing Care Plan 49-1 The Patient with Emphysema
Mr. Oden is a 91-year-old patient admitted with an exacerbation of chronic obstructive pulmonary disease (COPD). His respirations are 32 breaths/min and labored. He has nasal flaring, and his nailbeds are cyanotic. He has a barrel chest and digital clubbing. He states he has a productive cough and “can’t get my air.” It is noted he expectorates tenacious yellow mucus. He appears anxious during the assessment.
NURSING DIAGNOSIS Ineffective airway clearance, related to tenacious secretions and expiratory airflow obstruction
Patient Goals and Expected Outcomes Nursing Interventions Evaluation
Patient will maintain patent airway Assess lung sounds every 2 to Patient’s respiratory status remains as evidenced by decreased 4 hours. within baseline for this patient. wheezes, tachypnea, dyspnea, Encourage turning, coughing, and Patient has normal breath sounds on and arterial blood gas (ABG) deep breathing every 2 to auscultation. values within limits (for this 4 hours. Patient is able to expectorate sputum patient) Suction as needed. without difficulty. Explain all medications used in in- halation therapy and assist with treatment. Monitor effectiveness. Ensure hydration: oral intake of 2 to 3 L/day to liquefy secretions for easier expectoration.
NURSING DIAGNOSIS Ineffective breathing pattern, related to decreased lung expansion secondary to chronic airflow limitations Patient Goals and Expected Outcomes Nursing Interventions Evaluation
After treatment intervention, pa- Assess for indicators of respiratory Patient’s arterial blood gases are within tient’s breathing pattern will distress (agitation, restlessness, normal values. improve as evidenced by patient decreased level of consciousness, Patient has absence of adventitious maintaining respiratory rate and use of accessory muscles of breath sounds. within 5 breaths/min of baseline respiration). Patient is sleeping for 5 to 6 hours Patient will demonstrate relaxed Auscultate breath sounds; report a without respiratory distress. appearance decrease in breath sounds or an increase in adventitious breath sounds. Instruct patient in the use of pursed-lip breathing, which pro- vides internal stability to the airways and may prevent airway collapse during expiration. Administer bronchodilator therapy as prescribed. Monitor patient’s response to pre- scribed oxygen therapy. Be aware that high concentrations of oxygen can depress the respi- ratory drive in individuals with chronic carbon dioxide retention. Avoid use of respiratory depres- sants to ensure adequate alveolar ventilation.
Critical Thinking Questions
1. Mr. Oden turns on his call light and states that he is “unable to get my air.” The nurse notes subclavicular retractions and a respiratory rate of 36 breaths/min. His oxygen is flowing at 1 L/min via nasal cannula. What nursing interven- tions would decrease his dyspnea? 2. While the nurse is performing an assessment on Mr. Oden, he states, “I’m so tired of fighting to breathe that I wish I could just go to sleep and never wake up.” What is an appropriate response? 3. During vital signs assessment, the nurse notes that Mr. Oden’s temperature is 102° F (38.8° C), the pulse rate is 110 bpm, and the respiratory rate is 44 breaths/min. The nurse knows that Mr. Oden’s COPD places him at a high risk for:
