VB

Patient Prep
Follow guidelines on p. 65 of clinical packet

Medical Diagnosis: COPD (Chronic Obstructive Pulmonary Disease): Is a preventable and treatable
disease characterized by persistent airflow limitation that is slowly progressive. COPD is often associated
with an enhanced chronic inflammatory response of the airways and lungs to noxious particles or gases,
primarily caused by cigarette smoking. COPD exacerbations and other coexisting illnesses contribute to
the overall severity of the disease. S/x chronic internment cough, without presence of mucus, Dyspnea on
exertion, c/o heaviness in chest, c/o not being able to take a deep breath, gasping for air.
Emphysema: An abnormal permanent enlargement of the airspaces distal to the terminal bronchioles,
accompanied by destruction of their walls and without obvious fibrosis. Only about 10% of patients with
COPD have pure emphysema.

Nursing assessments required for this pt.: (oxygen, elimination, S&S, etc...)
Asses ABGs frequently comparing to baseline
Assess Lung sounds (Wheezing, rhonchi, crackles, diminished or bronchial breath sounds, Decreased
chest excursion, Hyperresonant or dull chest sounds on percussion)
Asses medications used (O2 use, and duration, Bronchodilators, Corticosteroids, ATBs, Anticholinergics,
and any OTC medications)
Asses Respiratory status (Cyanosis, Rapid, shallow breathing, use of accessory muscles for breathing,
pursed lip)
Asses nutritional status (weight loss/gain, Anorexia)
Asses cognitive status (Headaches, chest or ABD soreness)
Asses past health history (pack/years, including passive smoking, willing ness to stop, and family hx of
respiratory diseases)
Asses ability to perform ADLs (Increasing dyspnea/ sputum, may create fatigue)
Assess Elimination issues (Constipation, bloating, gas, Ascites)
Asses Sleep patterns (Insomnia; type of positioning, dyspnea)

Asses coping/stress tolerance (Anxiety, depression)

Nursing interventions specific to this pt.:
Assess ABGs per Md orders
Asses lung sounds Q 4hrs and PRN
Asses Vital signs/ Spo2 Q4hrs and PRN
Administer Alupent nebulizer PRN
Administer Soulumedrol 125mg IV Q6hrs
Administer Servent DPI Q12hrs
Asses/ obtain CBC/ CRX
Administer O2 via NC at 1-2L/min
Encourage IS Q2hrs
Encourage fluids Qshift
Encourage C&DB Q 2hrs and PRN
Elevate HOB at 30-45 degrees

Rationale: (why are you providing these interventions for this pt? What problems are listed on the
assessment sheet?)
These interventions are extremely important to this particular patient, because many of these interventions
are clues that can lead us into a bigger issue that could be occurring in patient. If ABGs and SPo2 are off
it could indicate Hypoxia. Obtaining chest x-rays and CBC can see if another cause could be the cause of
the patients recent hospitalization (like pneumonia). Coughing and deep breathing are important to clear
airway of any excess mucus that could be building up in lungs. IS is important in keeping lungs inflated.
HOB elevation insures that patient will be in better position for ease of breathing. Encouraging the
increase in fluids helps mobilize secretions that could be building up in lungs (the nebulizer helps with
this as well). Administering the Servent is important to promote opening of the bronchi, as it works as a
bronchodilator. Solumedrol is a corticosteroid and works to decrease bodys immune response such as
swelling and pain.
Medications (action, classification, rationale for use, side effects, nursing
implications/responsibilities)
Serevent: Action; Relaxes bronchospasm, and increases ciliary motility, thus facilitating expectoration of
pulmonary secretions. Classifications; Bronchodilator, smooth muscle relaxant Rational for use;
Maintenance therapy for asthma or bronchospasm associated with COPD. Prevention of exercise induced

bronchospasm. S/E; dizziness, H/A, tremor, palpitations, sinus tachycardia Nursing implications;
Monitor cardiovascular status (Tachycardia), Monitor lab tests, periodic LFTs, withhold the drug and
notify prescriber if bronchospasms occur after administration of medication.
Solumedrol Action; Has an anti-inflammatory and immunosuppressive properties Classification;
Corticosteroid, glucocorticoid Rational for use; An ant inflammatory agent used in the management of
acute and chronic inflammatory diseases S/E; Headache, insomnia, confusion, N/V, poor wound healing
Nursing implications; Monitor diabetics for loss of glycemic controls, monitor serum potassium and
report s/sx of hypokalemia, Monitor lab tests, Esp. CBC, serum electrolytes, and kidney function.
Alupent Action; Relaxes muscles in the airways to improve breathing Classification; Bronchodilator
Rational for use; It helps open up the airways in your lungs to make it easier to breathe. This medicine is
used to treat and to prevent bronchospasm. S/E; Tachycardia, dizziness, diarrhea, chills, cough, chest
pain. Nursing implications; monitor respiratory status. Auscultate lungs before and after inhalation

to determine efficacy of drug in decreasing airway resistance. Monitor cardiac status. Report
tachycardia and hypotension.

Potential complications that may occur with this pt.: (considering their age, dx, surgery)
Ineffective breathing pattern
Ineffective airway clearance
Impaired gas exchange

Health teaching specific to this pt.:

H/T importance of quitting smoking
H/T importance of using medications as ordered
H/T importance of home oxygen and use
H/T Importance of rest and sleep
H/T pursed lip breathing/ huff cough
H/T correct use of inhalers/ nebulizer
H/T healthy nutrition

References; Gulanick/ Myers- Nursing Care Plans 8th edition, Lewis, Dirksen, Heitkemper, BucherMedical- Surgical Nursing 9th Edition. Wilson, Shannon, Shields -Pearson- Nurses Drug Guide 2015