Nursing Concept Map – Claudia Guardado
Acute COPD exacerbation
Pathophysiology = RT Nursing Diagnosis
Risk for Developing
Chronic obstructive pulmonary - Ineffective airway clearance
- Risk for infection related to malnutrition
disease is a chronic inflammatory - Risk for fall related to weakness related to retained secretions in the
lung disease that causes obstructed lungs as evidence by excessive
airflow from the lungs. Its typically a sputum, ineffective cough,
long -term exposure to irritating alteration in respiratory pattern and
gases or particulate matter such as rate secondary to (medical
smoking. diagnosis).
Disease Process - Impaired gas exchange related to
Diagnostics Medication obstruction of airways by secretions
- Chest X-ray - Cefuroxime as evidence by decrease in SPO2,
- ECG - Ipratropium & albuterol labored breathing, and diaphoresis.
- Sputum culture & nebulization - Ineffective health management
sensitivity - Lisinopril related to difficulty managing
- Blood cultures - Prednisone complex treatment regimen as
- Lorazepam evidence by ineffective choices in
- Acetaminophen daily living for meeting health
meeting health goal.
Signs & Symptoms Nursing Interventions
- Shortness of breath Education - Assess the patency of the oxygen tubing
- Wheezing - Instruct the client to take medication as prescribed and to ensure adequate oxygen flow
- Chest tightness use inhalers properly. This would be included in the clients - Educate/encourage clients to use pursed-
- Chronic cough that may produce discharge papers with instructions step by step. lip breathing to slow expirations and rate
mucus that may be clear, white, - Instruct the client to quit smoking and community and depth of respirations
yellow, or green. resources that assist in the process of smoking cessation. - Monitor changes in respiratory rate,
- Frequent respiratory infections - Educate the client with the signs and symptoms of COPD depth, effort, and position and notify HCP if
- Lack of energy exacerbation such as yellow, green, bloody, or smelly interventions fail.
- Swelling in ankles, feet or legs. mucus; fever or chills; shortness of breath, trouble - Administer antipyretics for
breathing; tightness in the chest; lightheadedness or thermoregulation of fever.
dizziness.
Acute COPD exacerbation
Pathophysiology = RT Nursing Diagnosis
Risk for Developing
Chronic obstructive pulmonary - Ineffective airway clearance
- Risk for infection related to malnutrition
disease is a chronic inflammatory - Risk for fall related to weakness related to retained secretions in the
lung disease that causes obstructed lungs as evidence by excessive
airflow from the lungs. Its typically a sputum, ineffective cough,
long -term exposure to irritating alteration in respiratory pattern and
gases or particulate matter such as rate secondary to (medical
smoking. diagnosis).
Disease Process - Impaired gas exchange related to
Diagnostics Medication obstruction of airways by secretions
- Chest X-ray - Cefuroxime as evidence by decrease in SPO2,
- ECG - Ipratropium & albuterol labored breathing, and diaphoresis.
- Sputum culture & nebulization - Ineffective health management
sensitivity - Lisinopril related to difficulty managing
- Blood cultures - Prednisone complex treatment regimen as
- Lorazepam evidence by ineffective choices in
- Acetaminophen daily living for meeting health
meeting health goal.
Signs & Symptoms Nursing Interventions
- Shortness of breath Education - Assess the patency of the oxygen tubing
- Wheezing - Instruct the client to take medication as prescribed and to ensure adequate oxygen flow
- Chest tightness use inhalers properly. This would be included in the clients - Educate/encourage clients to use pursed-
- Chronic cough that may produce discharge papers with instructions step by step. lip breathing to slow expirations and rate
mucus that may be clear, white, - Instruct the client to quit smoking and community and depth of respirations
yellow, or green. resources that assist in the process of smoking cessation. - Monitor changes in respiratory rate,
- Frequent respiratory infections - Educate the client with the signs and symptoms of COPD depth, effort, and position and notify HCP if
- Lack of energy exacerbation such as yellow, green, bloody, or smelly interventions fail.
- Swelling in ankles, feet or legs. mucus; fever or chills; shortness of breath, trouble - Administer antipyretics for
breathing; tightness in the chest; lightheadedness or thermoregulation of fever.
dizziness.
