Fluids
Low flow oxygen
Elevate hob Bronchodilators
Abg monitoring Smoking cessation
Mechanical ventilation if
needed Treatment
Diminished Pursed-lip breathing
breath sounds
Dyspnea Tripod position
Percussion is
Barrel chest
hyperresonant
Wheezing
Emphysema Health hx
Tachycardia Chronic cough & Smoking, Drug &
Wheezing Highest priority is to
mucous production ETOH use hx
promote oxygenation
Family hx
Narrow airway passages Dyspnea 2000-2500ml/day to
Interview Psychosocial hx
help thin mucus
Air trapping Bronchitis Chronic diseases
Plan
Place in Fowler, high Fowler
or orthopedic position
Medication hx Pt will adapt breathing patterns to meet
Onset & duration oxygenation demands adequately Movement &
of symptoms activity to tolerance
Educate on posture Pt will experienced ease of
changes for improved Smoking cessation respiration’s w/use of positioning Asses respiratory stats q1-2 hr or as
ventilation & pursed-lip breathing indicated (adventitious sound
Treatment
Mechanical
Assessment Pt will maintain oxygen
decrease w/improvement)
Pursed-lip breathing
ventilation if saturation levels above 90% Increase hypoxemia,
technique Increased airway
needed Monitor ABG results hypercapnia & respiratory
Pt will tolerate activity levels, obstruction (mucous)
acidosis
Elevate ho Abg monitoring allowing completion of ADLs
Assess skin turn or and
Low flow oxygen mucous membranes
Weigh daily Monitor I&O
Fluid overload can
compromise respiratory
Arrhythmia s Poor perfusion Angina
COPD Nursing Process Implement Promote airway
clearance Teach proper expectoration to
Airway prevent spread of organisms
HTN clearance,
Respiratory
Cardiac Dysfunction ineffective
therapist collab
Cardiac hypertrophy (severe cases)
Breathing Administer expectorant and
CHF pattern,
ineffective
Diagnosis bronchodilator medications
Provide supplement Helps maintain adequate blood
oxygen as ordered and tissue oxygenation
Decisional
Increasing hypoxemia
conflict: smoking
Activity intolerance Increase hypercapnia
Coping: family,
Decrease LOC
Medications Treatment compromised Promote family coping Respiratory status
SEVERE Respiratory failure
-positive inotropics deteriorates Cyanosis
-calcium blockers Assess family coping to
-antiarrhythmic help plan interventions Worsening
-diuretics Imbalanced nutrition: less airway
-nitrites than body requirements Provide info and obstruction
-antihypertensives Monitor teachings on COPD
exercise
tolerance Help family recognize s/s of COPD Promote balance nutrition
Fluid restrictions if cardiac
and exacerbating factors to help
dysfunction not medically managed
improve patient health Pt education Assess nutritional
status and diet hx
Initiate collaborative care meeting or Maintain adequate
Compression stockings to inquire on case management fluids 2-2.5 qts/day Observe/document
increase venous return food intake
Refer to support groups and Avoid respiratory irritants
pulmonary rehab programs
Low flow oxygen
Elevate hob Bronchodilators
Abg monitoring Smoking cessation
Mechanical ventilation if
needed Treatment
Diminished Pursed-lip breathing
breath sounds
Dyspnea Tripod position
Percussion is
Barrel chest
hyperresonant
Wheezing
Emphysema Health hx
Tachycardia Chronic cough & Smoking, Drug &
Wheezing Highest priority is to
mucous production ETOH use hx
promote oxygenation
Family hx
Narrow airway passages Dyspnea 2000-2500ml/day to
Interview Psychosocial hx
help thin mucus
Air trapping Bronchitis Chronic diseases
Plan
Place in Fowler, high Fowler
or orthopedic position
Medication hx Pt will adapt breathing patterns to meet
Onset & duration oxygenation demands adequately Movement &
of symptoms activity to tolerance
Educate on posture Pt will experienced ease of
changes for improved Smoking cessation respiration’s w/use of positioning Asses respiratory stats q1-2 hr or as
ventilation & pursed-lip breathing indicated (adventitious sound
Treatment
Mechanical
Assessment Pt will maintain oxygen
decrease w/improvement)
Pursed-lip breathing
ventilation if saturation levels above 90% Increase hypoxemia,
technique Increased airway
needed Monitor ABG results hypercapnia & respiratory
Pt will tolerate activity levels, obstruction (mucous)
acidosis
Elevate ho Abg monitoring allowing completion of ADLs
Assess skin turn or and
Low flow oxygen mucous membranes
Weigh daily Monitor I&O
Fluid overload can
compromise respiratory
Arrhythmia s Poor perfusion Angina
COPD Nursing Process Implement Promote airway
clearance Teach proper expectoration to
Airway prevent spread of organisms
HTN clearance,
Respiratory
Cardiac Dysfunction ineffective
therapist collab
Cardiac hypertrophy (severe cases)
Breathing Administer expectorant and
CHF pattern,
ineffective
Diagnosis bronchodilator medications
Provide supplement Helps maintain adequate blood
oxygen as ordered and tissue oxygenation
Decisional
Increasing hypoxemia
conflict: smoking
Activity intolerance Increase hypercapnia
Coping: family,
Decrease LOC
Medications Treatment compromised Promote family coping Respiratory status
SEVERE Respiratory failure
-positive inotropics deteriorates Cyanosis
-calcium blockers Assess family coping to
-antiarrhythmic help plan interventions Worsening
-diuretics Imbalanced nutrition: less airway
-nitrites than body requirements Provide info and obstruction
-antihypertensives Monitor teachings on COPD
exercise
tolerance Help family recognize s/s of COPD Promote balance nutrition
Fluid restrictions if cardiac
and exacerbating factors to help
dysfunction not medically managed
improve patient health Pt education Assess nutritional
status and diet hx
Initiate collaborative care meeting or Maintain adequate
Compression stockings to inquire on case management fluids 2-2.5 qts/day Observe/document
increase venous return food intake
Refer to support groups and Avoid respiratory irritants
pulmonary rehab programs
