Nursing Diagnosis for COPD : Chronic Pain related to inflammation of the lining of the lungs.
Goal: Pain is reduced until it disappears.
Outcomes:
- Clients say the pain is reduced / lost.
- Relaxed facial expression.
Intervention:
1. Determine the characteristics of pain, miasalnya; sharp, consistent, stabbed, explore the changing character / intensity of pain / location.
Rational:
Chest pain is usually there within a few degrees of pneumonia, complications can arise such as pericarditis and endocarditis.
2. Monitor vital signs.
Rational:
Changes in heart rate or BP indicates that the patient is experiencing pain, especially when other reasons for changes in vital signs.
3. Provide comfortable action, for example; back massage, change of positions, calm music / conversation, relaxation / breathing exercises.
Rational:
Non-analgesic action is given with a gentle touch can eliminate the discomfort and magnify the effects of analgesic therapy.
4. Offer cleaning the mouth, with often.
Rational:
Mouth breathing and oxygen therapy can irritate and dry the mucous memberan, potential general discomfort.
5. Advise and assist the patient in the chest pressing techniques during coughing episodes.
Rational:
Tool for controlling chest discomfort while enhancing the effectiveness of cough effort.
6. Provide analgesic and antitussive as indicated.
Rational:
Drugs like this can be used to suppress non-productive cough / excessive mucosa proximal or decrease, increase comfort / general break. (Doenges, 1999. Thing 171).
Nursing Diagnosis for COPD : Impaired Gas Exchange related to bronchial constriction.
Goal: Maintain the oxygen level is adequate for the purposes of the body.
Outcomes:
- Without oxygen therapy, SaO2 95% dank lien ti and experiencing shortness of breath.
- Vital signs within normal limits.
- There are no signs of cyanosis.
Intervention:
1. Assess frequency, depth of breathing, note the use of accessory muscles, mouth breathing, inability to speak / talk.
Rationale: Useful in the evaluation of the degree of respiratory distress and chronic disease processes.
2. Assess regularly the skin and mucous membrane color.
Rational:
Possible peripheral cyanosis (seen in the nail) or central (seen around the lips or ears). Grayish, and the diagnosis of central indicate the severity of hypoxemia.
3. Elevate head of bed, help patients make choosing easier position for breathing. Push slowly breathing in or breathing lips in accordance with the needs / individual tolerance.
Rational:
Oxygen delivery can be improved with a high seating position and breathing exercises to lower airway collapse, dyspnea and breath work.
4. Encourage issued sputum, suction if indicated.
Rational:
Thick and viscous secretions lot; The main source of disruption of gas exchange in the small airway, and suction needed when coughing ineffective.
5. Auscultation of breath sounds, note areas of decreased air flow and / or additional noise.
Rational:
Breath sounds may be dim due to a decrease in airflow or consolidation area. Indicate bronchospasm wheeze / ter-discharge immunity. Spread wet crackles showed fluid in the interstitial / cardiac decompensation.
6. Monitor vital signs and cardiac rhythm.
Rational:
Tachycardia, disiretmia and changes in blood pressure may indicate the effect of systemic hypoxemia on cardiac function.
7. Provide supplemental oxygen in accordance with the indications of the results of the GDA and patient tolerance.
Rational:
Can fix / prevent worsening hypoxia. Note; chronic emphysema, regulate breathing patients ditentikan by CO2 levels and may be issued with excessive increase in PaO 2. (Doenges, 1999. Thing 158).
