Tyerman: Lewis's Medical-Surgical Nursing in Canada, 5th Edition

Chapter 31: Nursing Management: Obstructive Pulmonary Diseases

Care Plans - Customizable

NCP 31-2: Nursing Care Plan: Patient With Chronic Obstructive Pulmonary Disease
(COPD)

NURSING DIAGNOSIS Ineffective breathing pattern related to body position

Expected Patient Outcomes
• Returns to baseline respiratory
function
• Demonstrates an effective rate,
rhythm, and depth of respirations
that inhibits lung expansion, fatigue, respiratory
muscle fatigue as evidenced by use of three-point
position, pursed-lip breathing, use of accessory
muscles to breathe
Nursing Interventions and Rationales
Ventilation Assistance
• Monitor respiratory and oxygenation status to
assess need for intervention.
• Auscultate breath sounds, noting areas of
decreased or absent ventilation and presence of
adventitious sounds, to obtain ongoing data on
patient’s response to therapy.
• Encourage slow, deep breathing; turning; and
coughing to promote effective breathing
techniques and secretion mobilization.
• Administer medications (e.g., bronchodilators,
inhalers) that promote airway patency and gas
exchange.
• Position to minimize respiratory efforts (i.e.,
elevate head of the bed and provide overbed
table for patient to lean on) to save energy for
breathing and promote chest expansion.

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Care Plans - Customizable
NURSING DIAGNOSIS
Expected Patient Outcomes
• Has normal breath sounds for the
patient
• Demonstrates effective coughing
• Reports decreased dyspnea
• Maintains clear airway
NURSING DIAGNOSIS
Expected Patient Outcomes
• Has PaCO2 of 35–45 mm Hg or
usual compensated baseline
value
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31-2
• Monitor for respiratory muscle fatigue to detect a
need for ventilatory assistance.
• Initiate a program of respiratory muscle strength
and/or endurance training to establish effective
breathing patterns and techniques.
Ineffective airway clearance related to excessive
mucus, retained secretions as evidenced by ineffective
cough, absence of cough, diminished breath sounds
Nursing Interventions and Rationales
• Facilitate deep breathing by sitting the patient
up to maximize the use of the diaphragm and to
prolong the expiratory phase.
• Ensure adequate hydration (oral intake
approximately 2–3 L/day, humidified ambient
air) to liquefy secretions for easier
expectoration.
• Teach effective cough techniques to minimize
the extent of airway collapse and to enhance
airway clearance.
• Assist with inhaled bronchodilator
administration to facilitate clearance of
retained secretions.
Impaired gas exchange (related to alveolar
hypoventilation, as evidenced by headache on
awakening, PaCO2 ≥ 45 mm Hg and abnormal for
patient’s baseline, PaO2 <60 mm Hg, or SaO2 <90% at
rest)
Nursing Interventions and Rationales
• Monitor respiratory and oxygenation status to
assess the need for intervention.
• Teach pursed-lip breathing to prolong the
Care Plans - Customizable
• Experiences return of PaO2 to
normal range for patient
• Reports improved mental status
• Reports decreased dyspnea
• Performs ADLs
NURSING DIAGNOSIS
Expected Patient Outcomes
• Maintains body weight within
normal range for sex, height, and
age
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31-3
expiratory phase and slow the respiratory rate.
• Assist the patient to assume a position of
comfort (e.g., tripod position, elevated back
rest, support of upper extremities to fix shoulder
girdle) to maximize respiratory excursion.
• Administer and teach the appropriate use of
bronchodilators to open the airways.
• Teach signs, symptoms, and consequences of
hypercapnia (e.g., confusion, somnolence,
headache, irritability, decrease in mental acuity,
increase in respiration, facial flush, diaphoresis)
to recognize the problem early and initiate
treatment.
• Teach avoidance of central nervous system
depressants because they further depress
respirations.
• Administer O2 if appropriate, to increase SaO2
saturation.
• Select O2 supply systems and devices (e.g.,
nasal cannula, mask) that are appropriate for the
patient’s ADLs (rest, sleep, exercise) to
minimize the effect on preferred lifestyle.
Imbalanced nutrition: less than body requirements
related to insufficient dietary intake, inability to ingest
food (decreased energy level, shortness of breath,
gastric distention) as evidenced by food intake less
than recommended daily allowance
Nursing Interventions and Rationales
• Monitor caloric intake, weight, and serum
albumin and protein levels to determine
adequacy of intake.
Care Plans - Customizable
• Has normal serum protein and
albumin levels
NURSING DIAGNOSIS
Expected Patient Outcomes
• Sleeps at least 5 hr over a 24-hr
period
• Reports improved sleep pattern
• Reports feeling rejuvenated on
awakening
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31-4
• Provide menu suggestions for high-protein,
high-calorie foods to ensure maintenance of
weight.
• Give patient high-protein, high-calorie liquid
supplements if necessary to provide adequate
calories and protein to prevent weight loss and
muscle wasting.
• Plan periods of rest before and after food intake
to assist with controlling fatigue and to
compensate for blood flow diversion to the
gastro-intestinal tract for digestion.
• Refer to agency for financial and nutritional
assistance as necessary (e.g., Meals-On-Wheels,
home care) to ensure nutritional adequacy after
discharge.
• Discuss the benefit of five to six small meals
throughout the day because this reduces
bloating.
Disturbed sleep pattern related to nonrestorative sleep
pattern (dyspnea, orthopnea, paroxysmal nocturnal
dyspnea) as evidenced by unintentional awakening,
feeling unrested
Nursing Interventions and Rationales
• Identify usual sleep habits and elicit reasons for
difficulty sleeping to provide baseline data.
• Monitor the patient’s sleep pattern, and note
physical circumstances (e.g., that causes fear or
anxiety) that interrupt sleep to initiate
appropriate interventions.
• Observe for signs and symptoms of sleep apnea
Care Plans - Customizable
NURSING DIAGNOSIS
Expected Patient Outcomes
• Uses behaviours that minimize
the risk of infection.
• Experiences fewer or no
respiratory infections.
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31-5
such as frequent awakenings at night, excessive
daytime sleepiness, or a partner that complains
of the patient’s snoring or gasping for air to
initiate appropriate diagnostic tests and
interventions.
• Identify patient-specific methods of relaxation,
and teach patient relaxation methods to foster
sleep.
• Encourage exercise and activity during daylight
hours to ensure improved sleep at night.
• Provide the patient with activity that promotes
wakefulness to limit daytime sleep.
• Instruct the patient in arranging surroundings
(e.g., clothing, temperature, position, noise
level) to produce an environment conducive to
sleep.
• Teach the patient to avoid alcoholic beverages,
caffeine products, or other stimulants before
bedtime to reduce interference with sleep.
Risk for infection as evidenced by insufficient
knowledge to avoid exposure to pathogens, smoking,
malnutrition, stasis of body fluid (increased secretions)
Nursing Interventions and Rationales
• Monitor for systemic and localized signs and
symptoms of infection to determine whether an
infection is present.
• Teach the patient to assess indicators of
infection: changes in sputum colour, quantity,
odour, and viscosity; an increase in cough and
dyspnea; the experience of fever, chills,
Care Plans - Customizable 31-6

diaphoresis, or excessive fatigue; an increase in

respiratory rate; and abnormal breath sounds
(gurgles, wheezing) to determine whether an
infection is present.
• Teach the patient to use good handwashing and
hygiene techniques and to avoid contact (when
possible) with people with respiratory
infections to minimize sources of infection.
• Encourage the patient to obtain vaccination for
influenza and pneumococcal pneumonia to
decrease the occurrence or severity of influenza
or pneumonia.
• Teach proper care and cleaning of home
respiratory equipment to eliminate this source
of infection.
• Instruct the patient to seek medical attention for
manifestations of early infection to initiate
treatment promptly.
• Teach the patient to follow the plan of care for
managing exacerbations (e.g., increase fluid
intake, initiate antibiotics and oral
corticosteroid) to initiate appropriate self-care
promptly.

ADLs, activities of daily living; PaCO2, partial pressure of arterial carbon dioxide; PaO2, partial
pressure of arterial oxygen; SaO2, arterial oxygen saturation.

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