“I can’t… I can’t breathe.”

Objective

exacerbation of chronic obstructive pulmonary disease (COPD) due to left lower lobe pneumonia

three-day history of increasingly productive cough, difficulty breathing and fever

medical history includes

COPD,

osteoarthritis,

gastroesophageal reflux disease (GERD) and

atrial fibrillation (Afib)

alert oriented X3

Nasal cannula 2L/min

SPO2 85%

Resp 26

HR 79

BP 138/87

Temp 36.9

Ineffective breathing pattern related to COPD diagnosis as evidenced by productive cough, difficulty breathing and fever.

Goals:

short-term goal.

The patient will be given teaching on how to properly take inhalers and medications as well as the importance of a healthy lifestyle and smoking cessation when it comes with COPD. She will receive this teaching 2 days prior to discharge date, in the meantime medication education will be reinforced each time medication is administered.

long-term goal.

Further exacerbation will be prevented by monitoring closely the vitals signs, especially SPO2 and respiratory rate. Making sure SPO2 stays between 88-92. In this way she will not experience any COPD exacerbation within 5 months after discharge date.

Nursing Interventions

1.     Educate patient on impact of smoking.

2.     Develop breathing exercises for client.

3.     Monitor vital signs.

4.     Educate on how to properly take medications.

5.     Encourage healthy lifestyle.

Rationale

–        Cigarette smoking is a major cause of COPD.

–        Will help strengthen breathing muscles and assist in getting m ore oxygen as well as breathing with less effort.

–        This will allow to quickly notice any decline in health.

–        After discussing the important of a healthy lifestyle and smoking cessation, encourage patient to apply changes to life. For example by setting a plan.

Goal 1 – NOT MET – discharge date has not been set yet and therefore goal cannot yet be considered met.

Goal 2 – NOT MET – not enough time has passed to consider this goal has met