COPD
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| Assessment data (subjective and objective findings relevant to THIS diagnosis) | Goals / expected outcomes | Nursing intervention | Rationale | Evaluation |
|---|---|---|---|---|
| Patient reports shortness of breath and fatigue. Observed use of accessory muscles during breathing. Decreased SpO2 levels (below 90%). Cyanosis noted on lips and nail beds. Auscultation reveals wheezing and crackles. | Patient will maintain SpO2 above 92% on room air or prescribed oxygen and demonstrate improved breathing pattern within 48 hours. | Monitor respiratory rate, depth, and effort every 2 hours. | Frequent assessment detects early signs of respiratory deterioration or improvement. | Respiratory parameters remain stable or improve, indicating effective gas exchange. |
| Position patient in high Fowler’s or semi-Fowler’s position. | Upright position facilitates lung expansion and improves ventilation. | Patient maintains improved breathing comfort and oxygen saturation. | ||
| Encourage pursed-lip breathing exercises. | Pursed-lip breathing helps slow expiration, reducing air trapping and improving oxygenation. | Patient demonstrates correct technique and reports easier breathing. | ||
| Administer supplemental oxygen as ordered and titrate to maintain target saturation. | Oxygen therapy increases oxygen availability to tissues. | Patient’s SpO2 improves to target range without signs of CO2 retention. | ||
| Assess arterial blood gases (ABGs) as ordered. | ABGs provide objective data on oxygenation and ventilation status. | ABG results guide further respiratory management. |
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