COPD nursing care plan

Chronic obstructive pulmonary disease or COPD is marked by severe obstruction of the airway due to the inflammation of the lungs. While the most common issues that occur among patients with COPD include airway clearance and gas exchange, other symptoms can also be assessed among patients with COPD.

Two common types of COPD are emphysema and chronic bronchitis while the uncommon type is refractory asthma, which is seen among patients chronically diagnosed with asthma. All these types, however, share common manifestations such as the presence of productive cough, rapid and shallow breathing, shortness of breath, feeling of congestion and chest tightness.

Chronic Bronchitis is also known primarily as a disease affecting the upper airways and most often manifested by cough and sputum production. Patients with chronic bronchitis are given the diagnosis if they have been suffering from the condition for at least 3 months period in two consecutive years. Most of those with chronic bronchitis suffer from cyanosis, hence they are called blue bloaters

Emphysema is a term that is used to describe the destruction of the walls of the alveoli as a result of the excessive distention of the air spaces below the terminal bronchioles. As such, the disease is also considered to be affecting the lower airways of the patient. The damage results in gas exchange problems for the patient, where most of the lobular spaces become enlarged.

Patients with COPD need long-term care and respiratory rehabilitation to help ensure that they maintain an optimal level of functioning, maintain independent breathing, be free from complications and ensure that they adhere to the treatment regimen. 

In cases where patients are known to smoke, cessation of smoking is also included as a major goal of care. Management of COPD involves both pharmacologic and non-pharmacologic measures. 

Usual medications prescribed for COPD may include bronchodilators, mucolytic, anti-asthma agents and antimicrobials. Oxygen therapy may or may not be recommended depending on the severity of the disease and its symptoms.

Nurses who are caring for patients with COPD may identify one or more of the following symptoms upon assessment:

  1. Cough a primary symptom of COPD, may be productive or non-productive but the coughing persists for at least 3 months
  2. Sputum sputum is usually described as thick and viscous
  3. Dyspnea usually felt upon exertion, and is described as progressive and persistent; patients normally complain of dyspnea upon exertion
  4. Significant weight loss may be caused by anorexia and increased effort that the patient spends in respiration
  5. Barrel chest a characteristic sign; barrel chest normally occurs due to the over inflammation of the airways

Other symptoms may also be present and therefore, the nurse needs to assess these symptoms and prioritize which nursing action needs to be done first. Below are the most common nursing diagnoses for patients with COPD:

  • Ineffective airway clearance
  • Impaired gas exchange
  • Ineffective breathing patterns
  • Activity intolerance
  • Nutritional imbalance: less than body requirements
  • Activity intolerance
  • Deficient self-care
  • Risk for infection

Based on the nursing diagnoses above, it is essential that the nurse performs a thorough assessment of the patient, including the presenting signs and symptoms and corroborate these with laboratory data to come up with an accurate nursing diagnosis to guide in formulating appropriate care plans. 

It is also worth to remember that in the planning of care for patients with COPD, prevention of complications and maintenance of the optimum level of functioning is a must. Here are the four most common nursing care plans for patients with COPD.

COPD Nursing Care Plan

Impaired Gas Exchange

Impaired gas exchange related to alteration in oxygen supply to the airway due to over inflammation of the air sacs secondary to COPD evidenced by (include assessment findings related to impaired gas exchange such as, but not limited to:

  • Shortness of breath
  • Restlessness and irritability
  • Use of accessory muscles in respiration
  • Rapid, shallow breathing
  • Cyanosis of the circum-oral cavity
  • Oxygen saturation levels lower than 85%
  • ABG readings revealing respiratory acidosis

Desired Outcomes

After nursing interventions, the patient is expected to:

  • Exhibit improved gas exchange
  • Manifest improvement in ABGs and oxygen saturation
Nursing Action Rationale
Monitor the patient’s vital signs, especially noting for parameters of respiratory function such as depth, rhythm and rate.

 

This creates a baseline information for patient condition and help plan for effective care.
Auscultate lung fields, noting for presence of wheezes, crackles or other adventitious sounds. The presence of adventitious breath sounds indicate accumulation of sputum, narrowing of the airways and other complications which may necessitate immediate action.
Note for any changes in the skin color and the status of the mucus membranes, paying close attention to cyanosis. Cyanosis of the nailbeds, the skin or ear lobes may be due to hypoxemia and needs immediate attention.
Encourage the patient to perform deep breathing and coughing in an effort to expectorate sputum.

 

Note: For patients who are bed ridden or cannot expectorate sputum independently, suctioning may be recommended.

This action helps establish independence on the part of the patient and helps maintain his optimal functioning. Patients who feel that they are being considered as important part of their care are more likely to cooperate with interventions directed to them.
Administer oxygen therapy as prescribed. Providing humidified oxygen helps relieve the patient from the strain of having to catch his breath to take in more are, improves oxygenation and gas exchange, and helps reduce dryness of the lung fields.
Place the patient in a semi-sitting position, if he/she is conscious. For unconscious or weak patients, elevate the head of the bed and place support to prevent falling. Placing the patient on a semi-sitting position helps to allow maximal expansion of the lungs and the diaphragm, improving air intake and gas exchange.
Encourage pursed-lip breathing, focusing on doubling the time for the patient to exhale as compared to inhalation. Pursed lip breathing helps the patient regulate gas exchange and improve overall tissue perfusion.
Arrange for collaborative care, especially after discharge. Refer the patient to a physiotherapist. Arranging for a physiotherapist helps ensure continuity of care and maintenance of the patient’s optimal level of functioning.
Provide diversionary activities to help manage pain such as guided imagery, use of music, meditation. Allows the patient to focus his attention other than the pain. These activities may also help enhance his mood and response to other measures.

Activity Intolerance

Activity intolerance related to imbalance between oxygen supply and oxygen demands of the tissues as evidenced by  (include assessment findings related to the identified nursing problem such as, but not limited to:

  • Shortness of breath
  • Feeling of being tired
  • Complaints of weakness
  • Fatigue
  • Verbalization of an overwhelming lack of energy

Desired Outcomes

After nursing interventions, the patient is expected to demonstrate:

  • Increased activity tolerance
  • Active participation in performance of his activities of daily living
Nursing Action Rationale
Assess the patient’s activity tolerance prior to diagnosis, noting for his perceived limitation due to the diagnosis.

 

This creates a baseline information for patient condition and help plan for effective care.
Encourage patient to perform self-care task within the level of tolerance, pausing when breathlessness sets in. This helps maintain independent self-care and makes the patient feel in control of his situation.
Add progressive activities and exercises in the care plan of the patient, gradually increasing activity levels within tolerance. Prepares the patient for more complicated tasks but prevents fatigue and tiredness because resistance to activity is gradually increased.
Alternate periods of activity and rest. Decreases oxygen demands of the patient, allows him to rest and regain strength and prepare to take on additional activities.
Administer oxygen therapy as prescribed. Providing humidified oxygen helps relieve the patient from the strain of having to catch his breath to take in more are, improves oxygenation and gas exchange, and helps reduce dryness of the lung fields.
Arrange for collaborative care, especially after discharge. Refer the patient to a physiotherapist. Arranging for a physiotherapist helps ensure continuity of care and maintenance of the patient’s optimal level of functioning.
Provide diversionary activities to help manage pain such as guided imagery, use of music, meditation. Allows the patient to focus his attention other than the pain. These activities may also help enhance his mood and response to other measures.

Nutritional Imbalance: Less than body requirements

Nutritional imbalance: less than body requirements related to decreased intake of food and other nutrients due to presence of dyspnea and fatigue secondary to diagnosis of COPD as evidenced by  (include assessment findings related to the identified nursing problem such as, but not limited to:

  • Complaints of dyspnea
  • Loss of weight (indicate how many pounds/kilograms weight loss)
  • Decrease in appetite
  • Muscle tone changes
  • BMI below ideal for height and weight

Desired Outcomes

After nursing interventions, the patient is expected to demonstrate:

  • Knowledge on healthier eating patterns
  • Increased intake of foods and other nutrients
  • Manifest with weight/BMI within the ideal range
Nursing Action Rationale
Weigh the patient and conduct anthropometric measurements. Plot these information on a weight chart/.

 

This creates a baseline information for patient condition and help plan for effective care.
Discuss with the patient the goals of care (long-term vs. short-term such as increase in appetite vs increase in body weight). Allowing the patient to have a clear and more realistic picture of his care plan encourages active participation in the care, thereby increasing the success of the plan of care.
Allow the patient to verbalize his thoughts and feelings related to his food and nutritional intake, noting for potential misconceptions about how food affects his condition. Allowing the patient to verbalize his thoughts to the nurse helps in establishing trust, provides the nurse with useful information helpful in planning care and gives an avenue to correct misconceptions that may be present.
Help the patient to select appropriate food choices necessary to maintain high caloric diet. Ensure that these choices would still be possible even on an outpatient setting. Patients with COPD have a higher caloric requirement to supply the body’s need for energy to help the respiratory muscles in breathing. The presence of high caloric diet would not only help provide much needed energy for the body, it can also help increase body weight within the  targeted range.
Remind the patient about the need to avoid gas-forming foods such as onions, cabbages, and carbonated beverages. These foods may cause abdominal distention, thereby hindering the optimal expansion of the diaphragm. When the diaphragm is not able to expand well, dyspnea may worsen.
Arrange for collaborative care, especially after discharge. Refer the patient to a dietitian. Referring the patient to a dietitian after discharge would help ensure continuity of care and that the patient’s target weight would be achieved and maintained.

Ineffective Airway Clearance

Ineffective airway clearance related to (choose one of the following factors: spasms of the airway due to an allergic response, presence of secretions on the airway, increased production of thick sputum, hyperplasia of the bronchial walls) secondary to diagnosis of COPD  as evidenced by (include assessment findings related to the identified nursing problem such as, but not limited to:

  • Patient complaints of difficulty in respirations
  • Complaints of inability to expectorate sputum effectively
  • Presence of adventitious breath sounds (rales, crackles or wheezing)
  • Changes in respiratory pattern
  • In worse cases: changes in level of consciousness
  • Irritability and restlessness

Desired Outcomes

After nursing interventions, the patient is expected to demonstrate:

  • Enhanced airway patency
  • Demonstrate measures to help clear airways
Nursing Action Rationale
Monitor the patient’s vital signs, especially noting for parameters of respiratory function such as depth, rhythm and rate.

 

This creates a baseline information for patient condition and help plan for effective care.
Auscultate lung fields, noting for presence of wheezes, crackles or other adventitious sounds. The presence of adventitious breath sounds indicate accumulation of sputum, narrowing of the airways and other complications which may necessitate immediate action.
Monitor the severity of complaints of dyspnea, identifying whether the patient uses accessory muscles to help in respirations and what factors cause dyspnea.

 

Patients with asthma may experience dyspnea when triggered by a certain stimulus. Knowing how severe episodes of dyspnea and what causes them helps the murse in planning better care.
Administer oxygen therapy if needed.

 

Note: This is usually done for patients with moderate to severe airway clearance problem. Always check with the physician’s orders for the flow rate and equipment to use.

Providing humidified oxygen helps relieve the patient from the strain of having to catch his breath to take in more are, improves oxygenation and gas exchange, and helps reduce dryness of the lung fields.
Place the patient in a semi-sitting position, if he is conscious. Some patients may feel more comfortable leaning on a table to ease difficulty of breathing. Provide a pillow for comfort. Placing the patient on a semi-sitting position helps to allow maximal expansion of the lungs and the diaphragm, improving air intake and gas exchange.
Encourage pursed-lip breathing, focusing on doubling the time for the patient to exhale as compared to inhalation. Pursed lip breathing helps the patient regulate gas exchange and improve overall tissue perfusion.
Ensure that the environment is free from dust, pollen and other allergens which may trigger bronchospasm. These substances trigger an allergic response to some patients and may further exacerbate the current symptoms.
Increase fluid intake to 3 liters daily if not contraindicated. Ensure that these liquids are provided tepid or in room temperature and given in between meals. Warm, room temperature or tepid liquids prevent further bronchospasm from occurring, allowing improved airway clearance. Providing fluids in between meals also help reduce aspiration and relieves pressure on the diaphragm.
Encourage the patient to turn in bed once every 2 hours or to ambulate several times daily. Movement aids in mobilizing secretions, helping the patient to expectorate them or to eliminate them via the GI tract.
Involve significant others in instructing patient about how to perform chest physiotherapy and postural drainage. Ask them to demonstrate the steps after the health education. Chest physiotherapy helps loosen secretions, allowing it to be expectorated easier. Demonstrating the proper way to the patient and his significant others and asking them to return-demonstrate ensures that they understand the instructions well.
Perform suctioning when necessary. This procedure is done among patients who have thick sputum that are difficult to expectorate in other ways. Suctioning helps clear the airway of these secretions and improves airway patency.

References

  1. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis.
  2. Carpenito, L. (2016). Handbook of Nursing Diagnosis (15th ed.).
  3. Herdman, T., & Kamitsuru, S. (2018). NANDA International, Inc. nursing diagnoses (11th ed.).
  4. Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Harding, M.M. (2017). Medical-
  5. Surgical Nursing: Assessment and Management of Clinical Problems (10th ed.). St. Louis: Elsevier.
  6. McCance, K.L. & Huether, S.E. (2017). Understanding Pathophysiology: The Biologic Basis for Disease in Adults and Children (6th ed.). St. Louis: Elsevier/Mosby.

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