mattisensept's version from 2017-06-03 22:23

Section 1

Question Answer
Assessment findings Barrel chest, distant breath sounds, Clubbing fingers,
COPD specific Place in tripod position, no beta blockers, no more than 2 liters O2, no suctioning
Initial symtoms Chronic cough, sputum production, exercise intolerance
Later symptoms Dyspnea & mild activity, couch with copious sputum, cyanosis, barrel chest, finger clubbing, purse lip breathing,
Diagnosis Ineffective breathing patter, ineffective airway clearance, activity intolerance, imbalanced nutrition: less than body requirements, compromised family coping, decisional conflict: smoking
Planning- outcomes Client will adapt breathing patterns to meet oxygenation needs, client will experience ease of respirations with use of positioning purse lipped breathing, client will tolerate activity levels, allowing completion of ADLS
Intervention- Ineffective airway clearance Monitor VS, assist w/ADLs, provide for rest periods between scheduled activities, teach techniques to control breathing, administer med- bronchodilators & anti-inflammatory
Intervention- Activity intolerance Assess how well client is meeting ADLS, Discuss importance of spacing periods of activity, design an exercise plan
Intervention- Imbalanced nutriton Observe and document food and calorie intake, monitor lab values, provide small frequent meals, snacks at bedside, assist client to pick foods they like
Interventions- compromised family coping Assess interactions between client and family, Assess impact, help the client and family identify strengths of coping, provide information & teaching, refer support groups
Interventions- decisional conflict: smoking Assess clients knowledge and understanding o f the choices they have and consequences, acknowledge concerns, values, beliefs, help plan a course of action, refer to counselor if necessary
How do you know the patient is getting better?Check their pulse OX, not breathing as fast
Patient has been suctioned, how do you know if it has been effective?Check their lungs

Section 2

Question Answer
BDistant breath sounds, barrel chest and clubbing fingers
RTripod position, difficulty laying flat
EPatient may only need 2 liters, may go up far if necessary, do not intubate (very long to come off of),
ARespiratory Acidosis, AIr not getting out. high levels of 02
TUsually do not require suctioning, teach pursed lip breathing
HOnly normal PPE, handwashing
ESmall frequent meals, pace activities, more nutrients, No beta blockers, meter dose inhaler,
What tells them to take their next breath?Lack of oxygen not lack of C02