Nursing Assessment COPD (Chronic Obstructive Pulmonary Disease)
- The Identity of the Client
Name, place and date of birth, age, sex, the responsible include: name, address, relationship with the client.
- Perception of Health and Health Maintenance.
Review the status of a medical history of having experienced the client, what efforts and where clients get medical help, then what makes the client’s health status declined.
- Metabolic Nutrition
Ask the client about the type, frequency, and amount of food and drink clients in a day. Assess excessive or decreased appetite, nausea, vomiting or a review of the intravenous therapy, use of enteric tube, measuring weight, height measurement.
Review of rekuensi, characteristics, difficulties / problems and also the use of assistive devices such as catheters, also measuring intake and output.
Elimination process, review the frequency, characteristics, difficulties / problems defecation and also the use of tools / interventions in defecation.
- Activity and Exercise
Assess the ability of activities both before illness or condition now and also the use of assistive devices such as canes, wheel chairs and others. Ask the client about the use of leisure time. Are there any complaints on your breathing, such as the beating heart, chest pain, weak body.
- Sleep and Rest
Ask the client’s daily sleep habits. How to sleep atmosphere client whether light or dark. Often wake up during sleep caused by pain, itching, urination, difficulty and others.
- Cognitive Perception
Ask the client whether to use vision aids, hearing. Is there any client trouble remembering things, how clients cope with discomfort: pain. Is there a perception of sensory disturbances such as blurred vision, hearing impaired. Assess the level of orientation to time place and person.
- Perception and Self-Concept
Assess the behavior of the self, whether the client has experienced despair / frustration / stress, and how according to clients about themselves.
- Role Relationships
What is the role of clients in the community and family, how client relationships in the community, family and coworkers. Assess whether there is disruption and disturbance of verbal communication in interactions with family members and others.
- Sexual Production
Ask the client about the use of contraception and the problems that arise. How many children of clients and client’s marital status.
- Coping Mechanisms and Tolerance to Stress.
Assess the factors that make the client angry, where clients exchange opinions and coping mechanisms that are used for this. Assess client’s current situation against conformity, expression, denial / rejection of self.
- Belief System
Assess whether the client worship, clients follow a religion? Assess whether there are values on which clients embrace religion contrary to health.
Nursing Diagnosis Nursing Care Plan for COPD
- Ineffective Airway Clearance related to bronchoconstriction, increased sputum production, ineffective cough, fatigue / decreased energy and bronkopulmonal infection.
- Ineffective Breathing Pattern related to shortness of breath, mucus, bronchoconstriction and airway irritants.
- Impaired Gas Exchange related to ventilation perfusion inequality.
- Activity Intolerance related to imbalance between supply with oxygen demand.
- Imbalanced Nutrition: Less than Body Requirements related to anorexia.
- Disturbed Sleep Pattern related to discomfort, the setting position.
- Self-Care Deficit Bathing / Hygiene, Dressing / Grooming, Feeding, toileting related secondary fatigue due to increased respiratory effort and the insufficiency of ventilation and oxygenation.
- Anxiety related to threat to self-concept, the threat of death, unmet needs.
- Ineffective Individual Coping related to lack of socialization, anxiety, depression, low activity levels and inability to work.
- Knowledge Deficit related to lack of information, do not know the source of information.
Nursing Intervention Nursing Care Plan for Chronic Obstructive Pulmonary Disease (COPD)
Nursing Diagnosis for COPD
Ineffective Airway Clearance related to bronchoconstriction, Increased sputum production, ineffective cough, fatigue / decreased energy and bronkopulmonal infection.
Achieving client airway clearance
Nursing Intervention for COPD
- Give the patient 6 to 8 glasses of fluid per day unless there is Cor pulmonale.
- Teach and give the use of diaphragmatic breathing and coughing techniques.
- Assist in the provision of a nebulizer action, measured dose inhalers.
- Perform postural drainage with percussion and vibration in the morning and at night as required.
- Instruct patient to avoid irritants such as cigarette smoke, aerosols, temperature extremes, and smoke.
- Teach about the early signs of infection should be reported to your doctor immediately: increased sputum, change in color of sputum, sputum viscosity, increased shortness of breath, chest tightness, fatigue.
- Give antibiotics as required.
- Give encouragement to patients to immunize against influenzae and Streptococcus pneumoniae.
Nursing Diagnosis for COPD
Ineffective Breathing Pattern related to shortness of breath, mucus, bronchoconstriction and airway Irritants.
Improvement of breathing patterns
Nursing Intervention for COPD
- Teach client diaphragmatic breathing exercises and breathing lips sealed.
- Give encouragement to intersperse activity with periods of rest. Let the patient make decisions about treatment based on patient tolerance level.
- Give encouragement to use the muscles of breathing exercises if required.