Sample Nursing Care Plan (ncp) for COPD

Chronic obstructive pulmonary disease (COPD) is one of the most common lung diseases. It generally defines the conditions which consist of regular difficulty in expelling or exhaling air from the lungs. There are two major forms of COPD: chronic bronchitis and emphysema. Chronic bronchitis consists of a long term cough with mucus. Emphysema is a gradual destruction of the lungs. Most people who have COPD have a combination of these forms because smoking is a major cause of both of them.

There are a few signs of COPD that a healthcare worker may detect although they can be seen in other diseases. Some people have COPD and have none of these signs. Common signs are :

• tachypnea, a rapid breathing rate
• wheezing sounds or crackles in the lungs heard through a stethoscope
• breathing out taking a longer time than breathing in
• enlargement of the chest, particularly the front-to-back distance (hyperaeration)
• active use of muscles in the neck to help with breathing
• breathing through pursed lips
• increased anteroposterior to lateral ratio of the chest (i.e. barrel chest).

Sample Nursing Care Plan (ncp) for COPD

NANDA Chronic Obstructive Pulmonary Disease

1. Ineffective Airway Clearance related to bronchoconstriction, increased sputum production, ineffective cough, fatigue / decreased energy and bronkopulmonal infection.

2. Ineffective Breathing Pattern related to shortness of breath, mucus, bronchoconstriction and airway irritants.

3. Impaired Gas Exchange related to ventilation perfusion inequality.

4. Activity Intolerance related to imbalance between supply with oxygen demand.

5. Imbalanced Nutrition: Less than Body Requirements related to anorexia.

6. Disturbed Sleep Pattern related to discomfort, the setting position.

7. Self-Care Deficit Bathing / Hygiene, Dressing / Grooming, Feeding, toileting related secondary fatigue due to increased respiratory effort and the insufficiency of ventilation and oxygenation.

8. Anxiety related to threat to self-concept, the threat of death, unmet needs.

9. Ineffective Individual Coping related to lack of socialization, anxiety, depression, low activity levels and inability to work.

10. Knowledge Deficit related to lack of information, do not know the source of information.


Sample Nursing Diagnosis and Nursing Intervention for COPD

Ineffective airway clearance related to the disruption of production increased secretions, retained secretions

Goal : Ventilation / oxygenation to the needs of clients.

Outcome : Maintain a patent airway and breath sounds clean

Intervention

• Review / monitor respiratory frequency, record the ratio of inspiration / expiration.
• Assess the patient to a comfortable position, such as raising the head of the bed, seat and backrest of the bed.
• Auscultation for breath sounds, record the sound of breath for example: wheezing, and rhonchi krokels.
• Note the presence disepnea, for example: complaints restlessness, anxiety, respiratory distress
• Help the abdominal breathing exercises or lip.
• Observation of the characteristic cough, for example: persistent, hacking cough, wet, auxiliary measures to improve the effectiveness of the airway.
• Increase fluid intake to 3000 ml / day according to tolerance of the heart.
• Bronchodilators, eg, β-agonists, efinefrin (adrenaline, vavonefrin), albuterol (Proventil, Ventolin), terbutaline (brethine, brethaire), isoeetrain (brokosol, bronkometer).

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Nursing Care Plan for Peritonitis Nursing Diagnosis Risk for Infection

Definition: At increased risk for being invaded by pathogenic organisms
Related Factors: See Risk Factors.

Risk Factors:

Invasive procedures; insufficient knowledge regarding avoidance of exposure to pathogens; trauma; tissue destruction and increased environmental exposure; rupture of amniotic membranes; pharmaceutical agents (e.g., immunosuppressants); malnutrition; increased environmental exposure to pathogens; immunosuppression; inadequate acquired immunity; inadequate secondary defenses (e.g., decreased hemoglobin, leukopenia, suppressed inflammatory response); inadequate primary defenses (e.g., broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids, change in pH secretions, altered peristalsis); chronic disease.

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

Immune Status
Knowledge: Infection Control
Risk Control
Risk Detection

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

Infection Control
Infection Protection

Client Outcomes

Remains free from symptoms of infection
States symptoms of infection of which to be aware
Demonstrates appropriate care of infection-prone site
Maintains white blood cell count and differential within normal limits
Demonstrates appropriate hygienic measures such as hand washing, oral care, and perineal care.

Nursing Interventions Risk for Infection for Peritonitis

Independent:

1. Note the example of individual risk factors abdominal trauma, acute appendicitis, peritoneal dialysis.
Rational: Affects choice of interventions

2. Assess vital signs with frequent, noted no improvement or continuing hypotension, decreased pulse pressure, tachycardia, fever, tachypnea.
Rationale: Signs of septic shock, endotoxin circulation causes vasodilation, loss of fluid from the circulation, and low cardiac output status.

3. Note the change in mental status (eg, confusion, fainting).
Rational: Hypoxaemia, hypotension, and acidosis can cause irregularities in mental status.

4. Note the color, temperature, humidity.
Rational: Warm, redness, dry skin is an early sign of septicemia. Further manifestations include cold, pale skin moist and cyanosis as a sign of shock.

5. Monitor urine output.
Rational: Oliguria occurred as a result of reduced renal perfusion, the toxin in the circulation affects the antibiotic.

6. Maintain strict aseptic technique in the treatment of abdominal drain, wound incision / open, and the invasive side.
Rationale: Prevent the spread and limit the spread of infectious organisms / cross contamination.

7. Observations on wound drainage.
Rationale: Provides information about the status of infection.

8. Maintain sterile technique when the patient is placed catheters, and catheter care provided / or perineal hygiene routine.
Rasonal: Preventing the spread, limiting the growth of bacteria in the urinary tract.

9. Supervise / limit visitors and staff as needed. Provide insulation protection when indicated.
Rational: Reduce the risk of exposure to / add a secondary infection in patients who experienced immune pressure.


Collaboration:

1. Take for example / watch the results of serial blood, urine, wound cultures.
Rationale: Identifying microorganisms and assist in assessing the effectiveness of antimicrobial program.

2. Assist in the peritoneal aspiration, if indicated.
Rational: Guide to drain fluids and to identify infectious organisms so that appropriate antibiotics but can be given.

3. Prepare for surgical intervention when indicated
Rationale: Treatment of choice (curative) in acute peritonitis or local, for example a local abscess drainage, peritoneal exudate throw, throw rupturapendiks / gall bladder, cope with perforated ulcer, or bowel resection.

 Reference : http://careplannursing.blogspot.com/2011/12/risk-for-infection-nursing-care-plan.html

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Nursing Care Plan for Appendicitis Post Operative

Definition of Appendicitis

a. Appendicitis is a minor surgical diseases most often occur. Although appendicitis can occur at any age, but most often in young adults. Before the antibiotic era, the high mortality of this disease (Sylvia A. Price, 1994).

b. Acute appendicitis is the inflammation spreads to the surface of the parietal peritoneum the pain persists, more powerful and gain weight when moving. (Barbara C. Long, 1996)

c. Acute appendicitis is the most common cause of acute inflammation in the lower right quadrant abdominal cavity, the most common cause for emergency abdominal surgery (Brunner and Suddarth, 2001).

Clinical Manifestations of Appendicitis


a. The main complaint of appendicitis: pain. Abdominal pain lasting more than 6 hours must be taken into consideration. The pain is caused by the blockage of the appendix and its the same as the pain caused by intestinal obstruction. At first intermittent pain such as colic, because the innervation of the appendix and small intestine together. People feel when flatus or bowel movement will relieve the pain.

Manifestations of pain:

• The beginning of the pain felt in the epigastrium, or around the umbilicus.
• Incurred local pain at the Mc. Burney. This inflammation will penetrate through the serosa and serous inflammation will spread to the peritoneum local parietale.
• Any movement will cause pain, severe pain and the pain turned into a sharp and continuous.
• In the event of perforation of the pain suddenly disappeared, but only briefly and then followed by intense pain throughout the abdomen due to peritonitis.

b. Anorexia is almost always the case.
c. Vomiting is a characteristic, vomiting occurs after pain.
d. Usually constipation.
e. Frequent diarrhea especially in children, and especially on the client that the appendix is ​​located in the nearby rectum.




Nursing Care Plan for Appendicitis Post Operative, as follows:

1. Assessment of post-operative data

The data on the client might get appendicitis authors include:
a. The identity of the client

• Name, tribe / nation, age, education, employment, income, address and Registration number.

b. Medical history

• History of the main complaints: Client: There is usually nausea, vomiting, rapid pulse, pain in the operated area.
• Incidence of complaints:Quarter of an hour after surgery.
• Nature of complaints: Since becoming aware of the client to feel the pain that persisted in the operated area.
• Another complaint came: Clients feel nausea, vomiting, and headache / dizziness.

c. Past medical history

• Lower right abdominal pain.

d. Physical examination

• The general situation: Client appears ill.
• Circulation: It may indicate respiratory bradycardia.
• Respiration: It may seem tachipnea clients because there is a sense of nausea and vomiting.
• Abdomen: abdominal distension may be tenderness in the area of ​​incision.
• Extremities: There may be cyanosis.

e. Patterns of daily life

• Nutrition: There is a sense of nausea and vomiting, the client can not eat, maybe a bad skin turgor.
• Elimination :Bowel movements: The client has not / does not defecate, may not flatus. Urinating: There may be disorders of urination
• Hygiene: Regional visible incision closed operations (wound was sterile).
• Convenience: Clients seem grimace.

f. Psychological data

• Clients seem restless.

NANDA Appendicitis

1. Risk for Infection

2. Acute pain

3. Risk for Fluid Volume

4. Anxiety

5. Knowledge Deficit

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Nursing Care Plan for Deficient Knowledge

Knowledge, deficient regarding condition, treatment program, self-care, and discharge needs related to lack of exposure and information, misinterpretation of information and unfamiliarity with information resources.

Deficient Knowledge Definition: Absence or deficiency of cognitive information related to a specific topic
Defining Characteristics: Verbalization of the problem; inaccurate follow-through of instruction; inaccurate performance of test; inappropriate or exaggerated behaviors (e.g., hysterical, hostile, agitated, apathetic)

Related Factors:

• Lack of exposure
• lack of recall
• information misinterpretation
• cognitive limitation
• lack of interest in learning
• unfamiliarity with information resources

Nursing Interventions Nursing Care Plan for Deficient Knowledge

1. Assess ability to learn or perform desired health-related care.
Rational : Cognitive impairments need to be identified so an appropriate teaching plan can be designed.

2. Determine client’s learning style especially if client had learned and retained new information in the past.
Rational: Some persons may prefer written over visual materials, or they may prefer group versus individual instruction. Matching the learner’s preferred style with the educational method facilitates success in mastery of knowledge.

3. Assess motivation and willingness of client.
Rational : Some clients are ready to learn soon after they are diagnosed.

4. Instruct client/ family in disease process, progression, what to expect, and answer all questions honestly.
Rational : Promotes optimal learning environment when client show willingness to learn. Family members may assist with helping the client to make informed choices regarding the treatment. Anxiety or large volumes of instruction may impede comprehension and limit learning.

5. Explain purpose of activity restrictions and need for balance between activity/rest.
Rational : Rest reduces oxygen and nutrient needs of compromised tissues and decreases risk of fragmentation of thrombosis. Balancing rest with activity prevents exhaustion and further impairment of cellular perfusion.

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Family Nursing Diagnosis - Nursing Care Plan for Tuberculosis

Nursing Diagnosis that may arise in families with tuberculosis disease are:

a. Nutrition less than body requirements related to anorexia
b. Risk for Infection related to the secret is out
c. Ineffective airway clearance related to the accumulation of excessive secretions.
d. Disruption of gas exchange related to the decreased oxygen supply

In formulating nursing diagnoses in the family need to be a priority issue and a matter of priority criteria.

Priority issues

Things that need to be considered in the priority issues are as follows:
a. Not possible, the problems of health and nursing are found in the family can be addressed simultaneously.
b. Need to consider the problems that can threaten the lives of families like the problem of disease.
c. Need to consider the response and attention to family nursing care to be provided.
d. Family involvement in solving problems they face.
e. Family resources that can support problem solving health / family nursing.
f. Family and cultural knowledge.

Criteria for priority problems

Some of the criteria in priority setting problems:
1. Nature of the problem, are grouped into: health threats, is ill or unwell and crisis situations.

2. Possible problems can be changed, is the likelihood of success to reduce the problem or prevent a problem when it's done nursing and medical interventions.
Factors that may affect the problem of TB can be changed are:
a. Knowledge and action for the problem of tuberculosis.
b. Family resources, such as finance, personnel, facilities and infrastructure.
c. Care resources, including the knowledge and skills in handling the problem of tuberculosis.
d. Community resources, can be in the form of facilities, organization.

3. Potential problems of tuberculosis, to prevent, is the nature and severity of problems that will arise and TB can be reduced or prevented through nursing and health measures.
Things that need to be considered in view of the potential problem of prevention of tuberculosis are:
a. Severity / difficulty of the problem, this is related to severity of disease or tuberculosis that showed the prognosis and severity of tuberculosis suffered by family members.
b. Action has been and is being run, is an act to prevent and treat tuberculosis in order to improve the health status of the family.
c. The duration of the problem, severity of problems associated with tuberculosis in the family and the potential problems to be prevented.
d. The existence of high-risk groups within the family or a group of highly sensitive adds to the potential to prevent problems.

4. Prominence of the tuberculosis problem, is how families see and assess the tuberculosis problem in terms of severity and urgency to be addressed through nursing and medical interventions.

Nursing Care Plan for Tuberculosis

Tuberculosis Nursing Care Plan includes general and specific objectives based on problems that come with the criteria and standards that refer to the cause. Furthermore formulate action-oriented nursing criteria and standards.

There are several levels of objectives in the planning of nursing according to Friedman (1998: 64). Short-term goals that are measurable, immediate and specific. And long-term goal which is the final level of the broad purposes stated expected by nurses and families to be reached.

The purpose of nursing care in a family with tuberculosis:

A. Short term goals include:
Once the information is given to the families of tuberculosis, the family is able to recognize the problem of tuberculosis, is able to take decisions and be able to care for family members suffering from tuberculosis.

Evaluation criteria:
a. Verbal response, the family is able to mention the understanding, the signs and symptoms, causes, treatment and prevention of transmission of tuberculosis.
b. Effective response, the family able to care for family members suffering from tuberculosis.
c. Psychomotor response, the family is able to modify the environment for people with tuberculosis.

Evaluation standards:
Definition, signs and symptoms, causes, prevention of tuberculosis, prevention of transmission and ways of treatment of tuberculosis.

2. Long-term goals
Problem of TB in the family can be resolved / reduced after nursing actions.

Intervention phase begins with the completion of treatment planning. Like the opinion of Friedman (1998: 67). During the implementation of nursing interventions, new data is continuously flowing into. Because this information (the response from the client, the situation changes, etc.) were collected, nurses need to be quite flexible and can adapt to review the family situation by making modifications to the plan without a plan. In choosing nursing actions depending on the nature of the problem and the resources available for solving.

Nursing Interventions - TB Nursing Care Plan are as follows:

1. Instruct patient to cough / sneeze and remove the tissue and avoid spitting in any place.
2. Urge families to provide nutritious food.
3. Weight control periodically
4. Encourage the patient to eat little but often with a high-carbohydrate diet and high protein.
5. Encourage the patient to take medication regularly.

Implementation - Nursing Care Plan for Tuberculosis

Implementation of nursing actions on the family, based on the nursing plan has been prepared.
Things that need to be considered in the implementation of nursing actions against families with tuberculosis are:

a. Family of resources (financial)
Resources (financial) that are expected to adequately support the healing process to family members suffering from tuberculosis

b. Levels of family education
Family education level may affect the family in identifying problems kemampuam tuberculosis and making decisions about appropriate actions against family members suffering from tuberculosis.

c. Customs applicable
Customs prevailing effect on the ability of families in caring for family members suffering from tuberculosis

d. Response and acceptance of family
Response and acceptance of family is very influential in healing as families are able to provide motivation.

e. Facilities and infrastructure that exist in the family
In the presence of both facilities and infrastructure that will allow families to the family in providing care and treatment to family members suffering from tuberculosis.

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Nursing Assessment for Appendicitis (NCP for Appendicitis)

Assessment according to Wong (2003), Doenges (1999), Catzel (1995), Betz (2002), among others:

A. Interview

• Get a thorough medical history, especially regarding:
• The main complaint: the client will get a pain around the epigastrium radiating to the lower right abdomen. Complaints arising under the right abdominal pain may be a few hours later after the pain in the center or in the epigastrium felt in some time ago. Nature of the complaints of persistent pain is felt, may be lost or there is pain in a long time. Complaints which usually accompanies a client complaining of nausea and vomiting, loss of heat.
• Past medical history: usually associated with health problems the client is now asked of the parents.
• Diet, eating foods low in fiber.
• Elimination habits.

2. Physical examination

• General condition: the client looks sick mild / moderate / severe.
• Circulation: tachycardia.
• Respiratory: Tachypnea, shallow breathing.
• Activity / rest: Malaise.
• Elimination: Constipation in early onset, sometimes diarrhea.
• Abdominal distension, tenderness / pain off, stiffness, decreased or absent bowel sounds.
• Pain / comfort, epigastric and abdominal pain around the umbilicus, the increased severe and localized to the point Mc. Burney, an increase of walking, sneezing, coughing or breathing deeply. Pain in the lower right quadrant because the position of the right leg extension / seated upright position.
• Fever over 38 0C.
• Psychological data seem anxious clients.
• There are changes in pulse rate and breathing.
• Weight as an indicator to determine the drug.

3. Examination Support

• Signs of peritonitis, lower right quadrant. Line drawings of air fluid level in the cecum or ileum.
• Erythrocyte sedimentation rate (ESR) is increased in the state of appendicitis infiltrates.
• Routine urinalysis is important to see what there is infection in the kidney.
• The increase of leukocytes, Neutrophilia, without eosinophils.
• Appendix on barium enema is not filled.
• Ultrasound: fekalit non-calcified, non-perforated appendix, appendix abscess.

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Anemia - Ineffective Tissue Perfusion Nursing Diagnosis and Interventions

Nursing Diagnosis for Anemia: Ineffective Tissue Perfusion related to the decrease in the cellular components required for the delivery of oxygen / nutrients to the cells.

Objectives: increased tissue perfusion.

Expected outcomes are: - indicates inadequate perfusion, such as stable vital signs.

Ineffective Tissue Perfusion Nursing Interventions for Anemia

Independent

1. Monitor vital signs assess capillary refill, color of skin / mucous membranes, nail beds.
Rational: provides information about the degree / adequacy of tissue perfusion and help determine the need for intervention.

2. Elevate head of bed as tolerated.
Rational: increase lung expansion and maximize oxygenation for cellular needs. Note: if there is hypotension contraindicated.

3. Monitor respiratory effort; auscultation of breath sounds adventisius note sounds.
Rational: dyspnea, gurgling menununjukkan heart problems due to strain the old heart / cardiac output increased compensation.

4. Investigate complaints of chest pain / palpitations.
Rational: influence cellular network myocardial ischemia / infarction risk potential.

5. Avoid using a bottle warmer or hot water bottle. Measure the temperature of bath water with a thermometer.
Rational: termoreseptor superficial dermal tissue due to disruption of oxygen.

Collaboration

1. Keep an eye on the results of laboratory examination. Give a complete red blood cell / blood product packed as indicated.
Rational: identify deficiencies and needs treatment / response to therapy.

2. Provide supplemental oxygen as indicated.
Rational: to maximize the transport of oxygen to the tissues.

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NANDA Pneumonia and Nursing Interventions

Nursing Care Plan for Pneumonia
Nursing Diagnosis for Pneumonia 

Nursing Interventions for Pneumonia

Pneumonia is an illness that affects one or both lungs and that used to be one of the main causes of death 2 centuries ago. It is caused by microorganisms that attack the tissue from the lungs, causing it to inflammate and leading to a severe condition if the infection is not treated in time.

Viral pneumonia is very common form of pneumonia affecting children, teenagers and the elderly. It can sometimes be mistaken for either the flu or a cold. Viral pneumonia presents the following symptoms: inflammation of the throat, productive or non-productive cough, a swelling in the lymph nodes, chest discomfort during breathing, mild to severe headache and a generalized feeling of fatigue. The cough may or may not produce varying amounts of mucus. You may also experience a mild fever and chills.

NANDA Pneumonia

1. Impaired Gas Exchange

2. Ineffective Breathing Pattern

3. Risk for Infection related

4. Ineffective airway clearance

5. Activity Intolerance


Nursng Interventions - Impaired Gas Exchange for Pneumonia:

- Assess the frequency / depth and ease of breathing
Rational: the manifestation of respiratory distress depends on the indication of the degree of lung involvement and general health status.

- Observe the color of skin, mucous membranes and nails. Note the presence of peripheral cyanosis (nail) or central cyanosis.
Rational: nails showed cyanosis vasoconstriction body's response to fever / chills, but cyanosis on the ears, mucous membranes and skin around the mouth indicate systemic hypoxemia.

- Assess mental status.
Rational: nervous irritability, confusion and somnolence may indicate cerebral hypoxia or decreased oxygen.

- Elevate the head and thrust frequently change position, breathe deeply and cough effectively.
Rationale: This action increases the maximum inspiration, increased spending secretions to improve ventilation ineffective.

- Collaboration
Give oxygen therapy correctly.
Rational: to maintain PaO2 above 60 mmHg. Oxygenation provided with a method that provides precise delivery.

Nursing Interventions - Ineffective Breathing Pattern for Pneumonia :

    Assess the frequency, depth of breathing and chest expansion
    Auscultation of breath sounds
    Elevate the head and help change the position
    Observation of cough pattern and character of secretions
    Encourage / help the patient breathe deeply and cough effectively exercise
    Give additional oxygen
    Watch the Blood Gas Analysis


Nursing Interventions - Ineffective Airway Clearance for Pneumonia :

- Assess the frequency / depth of breathing and chest movement
Rational: tachypnea, shallow breathing and chest movement was symmetrical often occurs because of discomfort.

- Auscultation of lung area, record the time there's an area of ​​decreased airflow and breath sounds
Rational: decrease in blood flow occurred in the area of ​​consolidation with fluid.

- Teach effective cough techniques
Rational: cough is a natural airway clearance mechanisms for maintaining a patent airway.

- Sucking as indicated
Rational: stimulate coughing or clearing the airway of mechanical noise on the factors that are not able to perform effectively because of a cough or a decreased level of consciousness.

- Give fluids at least
Rational: liquid (especially warm) mobilizing and removing secretions.

- Collaboration with physicians for drug delivery as indicated: mukolitik, ex.
Rational: a tool to reduce bronchial spasms with mobilization of secretions, analgesic given to improve the cough by decreasing the discomfort but should be used carefully, because it can reduce cough effort / suppress breathing.
 
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10 Nanda Nursing Diagnosis for Anemia

Nursing Diagnosis for Anemia

Anemia is a decrease in number of red blood cells (RBCs) or less than the normal quantity of hemoglobin in the blood. However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin deficiency.

Causes of Anemia

Except for the acute form, anemia is a result of systemic toxemia and acidosis-a condition of poisons, toxins and accumulated waste products floating in the blood - and lymph-streams, and of enervation or lowered nerve-tone. There is either an accumulation of these injurious substances due to failure of eliminative organs to handle a normal amount of such products, or they are produced in such considerable quantities that even normal organs, eliminating a normal amount or more than a normal amount of eliminations can not remove them rapidly enough. They have the effect of poisoning the organs that make the blood cells, which produce a deficient amount of blood cells or altered blood cells.
The signs and symptoms of this disease are:
1. Paleness
2. Headache
3. Irritability
Symptoms of more severe iron deficiency anaemia include:
1. Dyspnea
2. Rapid heartbeat
3. Brittle hair and nails

Clinical Manifestations of Anemia

Clinical symptoms that appear to reflect impaired function of the various systems in the body including decreased physical performance, neurological (nerve) which is manifested in changes in behavior, anorexia (loss emaciated), and abnormal cognitive development in children. Growth abnormalities often occur, epithelial dysfunction, and reduced gastric acidity.

Anemia can cause fatigue, weakness, lack of energy and the head was floating. If the anemia gets worse, can lead to stroke or heart attack (Sjaifoellah, 1998).

Here is  11 Nanda Nursing Diagnosis for Anemia

1. Activity Intolerance
2. Impaired oral mucous membrane
3. Imbalanced Nutrition: Less than Body Requirements
4. Constipation/Diarrhea
5. Risk for Infection
6. Risk for deficient fluid volume
7. Deficient Knowledge regarding condition, prognosis, treatment, self-care, prevention of crisis, and discharge needs,
8. Fatigue
9. Fear
10. Ineffective coping

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Nanda Nursing Care Plan

NURSHING MANAGEMENT OF COPD

COPD (Chronic Obstructive Pulmonary Disease) is one of the most common lung diseases. It generally defines the conditions which consist of regular difficulty in expelling or exhaling air from the lungs.

The most common symptoms of COPD are a cough with mucus, shortness of breath (dyspnoea) which gets more severe with any mild activity, fatigue, frequently respiratory infections such as colds and influenza, and wheezing. The symptoms of COPD usually develop slowly.

There are two major forms of COPD: chronic bronchitis and emphysema. Chronic bronchitis consists of a long term cough with mucus. Emphysema is a gradual destruction of the lungs. Most people who have COPD have a combination of these forms because smoking is a major cause of both of them.

Some severe symptoms may require hospital treatment. People should seek medical attention if they are having a hard time catching their breath or taking, see their lips or fingernails turning blue or gray (which is a sign of low COPD oxygen in their blood), are not mentally alert, or have a very rapid heartbeat. It is also important to seek medical attention when the treatment that has been recommended for a person's symptoms is no longer working.

Nursing Management of COPD

Nursing management of COPD begins with the assessment, the following

The assessment includes information about the symptoms last and previous disease manifestations. Here are some guidelines to get data question the health history of the disease process:

1. How long the patient has trouble breathing?
2. Does the activity increase of dyspnea?
3. How much restriction of patients to tolerate the activity?
4. When patients complain of the fatigue and shortness of breath?
5. Are eating and sleeping habits are affected?
6. History of smoking?
7. Drugs used every day?
8. Drugs used in acute attacks?
9. What is known about the condition of the patient and his disease?

Additional data collected through observation and examination as follows:

1. Patient's pulse rate and breathing?
2. Is the same breath without effort?
3. Is there a contraction of abdominal muscles during inspiration?
4. Is there any use of accessory respiratory muscles during breathing?
5. Barrel chest?
6. Does seem cyanosis?
7. Is there a cough?
8. Are there any peripheral edema?
9. Are the neck veins look bigger?
10. What is the color, amount and consistency of sputum of patients?
11. What is the status of patients sensorium?
12. Is there an increase in stupor? Anxiety?
13. Palpation:
    • Reduction in the development of breast palpation?
    • Is there a decreased tactile fremitus?
14. Percussion:
    • Are there any hyper-resonance on percussion?
    • The diaphragm moves just a little?
15. Auscultation:
    • Is there a loud wheezing sound?
    • Is there a sound ronkhi?
    • Nomal or decreased vocal fremitus?

The purpose of nursing management of COPD are:

1. Touch ups the ability of people with the symptoms not only in the acute phase, but also the chronic phase.
2. Improve the ability of patients in performing daily activities.
3. Reducing the rate of progression of disease if the disease can be detected early.

Nursing management of COPD in the elderly are as follows:

1. Eliminate the etiologic factors / precipitation, for example, immediately stop smoking, avoid air pollution.
2. Cleaning bronchial secretions, with the help of a variety of ways.
3. Eradicate the infection with antimicrobial. If there is no antimicrobial infection need not be given. Provision should be appropriate antimicrobials according to the germs that cause infections according to the results of sensitivity testing or empirical treatment.
4. Overcome bronchospasm with bronchodilator drugs. The use of corticosteroids to resolve the inflammatory process (bronchospasm) remains controversial.
5. Symptomatic treatment.
6. Treatment of the complications that arise.
7. Oxygen treatment, for those who need. Oxygen should be administered with a slow flow of 1-2 liters / minute.

Rehabilitation actions that include:

1. Physiotherapy, mainly aims to help the bronchial secret spending.
2. Breathing exercises, to train the patient in order to make the most effective breathing.
3. Exercise with weights given sport, in order to restore physical fitness.
4. Vocational guidance, the work done against the patient can re-do their previous occupation.

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