Subjective Objective Nursing Diagnosis Scientific Reference Planning Implementation Rationale Evaluation

“Galisud ko ug - restless Impaired gas COPD refers to That after 6 hours of independent: After 6 hours of
ginhawa”as - breathes with exchange related to several disorders nursing care -maintain a high- - to maintain airway nursing care
verbalized by the pursed lips and with alveolar-capillary that affect management my fowler’s position management my
patient. the use of accessory membrane changes movement of air in patient will be able -encouraged deep -promotes optimal patient was able to:
muscles. secondary to COPD. and out of lungs. to: breathing/coughing chest expansion and
- positioned at a The most common exercises drainage of -maintain a high
high fowlers of these disorders -participate in secretions fowler’s position
position with are Obstructive treatment regimen -encourage adequate - helps limit oxygen -have respiratory
oxygen therapy at bronchitis, within level of rest and limit needs/ consumption rate above the
2 L/ min Definition: emphysema and ability. activities to within normal range
- has cough Excess or deficit in asthma. May occur -reduce respiratory client tolerance - sleep and rest most
-respiratory rate of oxygen and/or as a result of rate from 31 to 28.. of the time
31 CPM carbon dioxide increased airway -Expectorate mucus -provide -have an oxygen
-reduced tolerance elimination at the resistance secondary secretions to clear psychological - to reduce anxiety therapy at 2 L/
of activity alveoli-capillary to bronchial airways. support, active- minute
-lethargic membrane [this may mucosal edema or listen -perform activities
-adventitious sound be an entity of its smooth muscle questions/concerns within level of
of wheezes at the own, but also may contraction. It may ability like getting
midsternal area be an end result of also be a result of -assist in giving of -to treat underlying off expectorated
- cold lower other pathology decreased elastic due medications conditions secretions with the
extremities with with an recoil, as seen in use of a tissue paper
clubbing of nails interrelatedness emphysema. -monitor vital signs -for baseline data and use of
- poor capillary between airway every 2 hours Salbutamol inhalant.
refill less than 3s. clearance and/or SOURCE: J.M.
breathing pattern Black, et.al. -keep environment -to reduce irritant
problems] Medical-Surgical clean and pollutant effect of dust and
Nursing 5th ed., page free chemical on airways
1111.
SOURCE: NANDA -Emphasize the -improves stamina
importance of and reducing the
nutrition work of breathing
 Subjective Objective Nursing Diagnosis Scientific Reference Planning Implementation Rationale Evaluation
“Galisud ko ug -weakness Activity intolerance COPD refers to That after six hours Independent: After 6 hours of
ginhawa”as -restless related to Imbalance several disorders of nursing care -take vital signs -for baseline data nursing care
verbalized by the -RR of 31 cpm between oxygen that affect management my - adjusted activities -to prevent management my
patient. -breathes with much supply and demand, movement of air in patient will be overexertion patient was able to:
exertion and with the and pain secondary and out of lungs. able to: -plan care to -to reduce fatigue or
use of accessory to COPD. The most common carefully balance weakness -have an RR of
muscles. of these disorders -participate willingly rest periods with 28 cpm from 31 cpm
- on oxygen therapy Definition: are Obstructive in necessary or activities - performed activities
at 2 L/min Insufficient bronchitis, desired activities -provide positive - helps to minimize within level of
-Functional level of physiological and emphysema and -report measurable atmosphere while frustration and activity by wiping off
IV characterized as psychological asthma. May occur increase in activity acknowledging rechannel energy expectorated
dyspnea fatigue at energy to endure or as a result of tolerance difficulty of the secretions and used
rest complete required or increased airway - be free of any situation for the Salbutamol inhalant
-with facial grimace desired daily resistance aggrevation of client -felt a little relief
due to chest pain. activities secondary to illness. -assist with - to protect client after provided with
bronchial mucosal activities and from injury comfort exercises
edema or smooth monitored client’s like deep breathing
SOURCE: NANDA muscle contraction. use of assistive and coughing
It may also be a device exercise
result of decreased -promote comfort - to enhance ability to
elastic recoil, as measures and participate in
seen in emphysema. provide relief to pain activities
-assist client in - to prevent injuries
SOURCE: J.M. learning and
Black, et.al. demonstrating
Medical-Surgical appropriate safety
Nursing 5th ed., measures
page 1111. -give client - to sustain
information that motivation
provides evidence of
daily/weekly
progress.
 Subjective Objective Nursing Diagnosis Scientific Reference Planning Implementation Rationale Evaluation
“ Maglisod ko og - restless Ineffective airway COPD refers to That after six hours Independent: After 6 hours of
ginhawa “ as - breathes with clearance as several disorders of nursing care -maintain a high- -for baseline data nursing care
verbalized by the pursed lips and with related to COPD as that affect management my fowler’s position management my
patient the use of accessory evidenced by movement of air in patient will be patient was able to:
muscles. dyspnea, cough, and and out of lungs. able to: -encourage deep -to prevent
- positioned at a presence of crackles The most common breathing/coughing overexertion -have an RR of
high fowlers of these disorders -maintain airway exercises 28 cpm from 31 cpm
position with Definition are Obstructive patency - expectorated mucus
oxygen therapy at Inability to clear bronchitis, -Expectorate -encourage -to reduce fatigue or secretions and wiped with t
2 L/ min secretions or emphysema and secretions readily adequate rest and weakness use of tissue paper
- has cough obstructions from the asthma. May occur -demonstrate limit activities to -have an oxygen
-respiratory rate of respiratory tract to as a result of behaviors to improve orwithin client therapy at 2 L/
31 CPM maintain a clear increased airway maintain clear airway tolerance minute
-reduced tolerance airway resistance -verbalize -felt a little relief
of activity secondary to understanding of -assist in -to soften secretions when provided with
-lethargic bronchial mucosal causes and administering due nebulization
-adventitious sound SOURCE: NANDA edema or smooth therapeutic medications -maintained a semi-
of wheezes at the muscle contraction. management fowler’s position
midsternal area It may also be a regimen - monitor v/s and -to ascertain status
- cold lower result of decreased breath sounds and note progress
extremities with elastic recoil, as
clubbing of nails seen in emphysema. -Encourage and -prevents or reduces fatigue
- poor capillary provide fatigue
refill less than 3s. SOURCE: J.M. opportunities for rest
Black, et.al.
Medical-Surgical Dependent:
Nursing 5th ed., - perform - to liquify thick
page 1111. nebulization mucus secretions.