Nursing Care Plan Notes

Clinically Relevant Assessment Data

• 68 yo M (MRN: 459-812-39, IHI: 8003608166670914) admitted 24/05/2024 at 09:30 AEST with IECOPD. C/O severe SOB and productive cough with thick purulent sputum. Hx of GOLD Stage III COPD, 40-pack-year smoker. O/E: RR 28 bpm, SpO2 86 % on RA, HR 108 bpm, BP 145/88 mmHg, Temp 37.8 °C. Bilateral expiratory wheezes and coarse crackles at bases. Accessory muscle use noted. CXR shows hyperinflation and RLL infiltrate.
• Pt appears restless, diaphoretic, and hypervigilant. Verbalises fear of suffocation ("I feel like I can't catch my breath and might die"). Tremors noted in hands, inability to focus on admission education.

Nursing Diagnosis #1

• The actual problem: Ineffective Airway Clearance (NANDA Code: 00031)

Related Factors

• Bronchospasm, increased production of thick tracheobronchial secretions, and RLL respiratory tract infection secondary to IECOPD.

Defining Characteristics

• Dyspnoea at rest, RR 28 bpm, SpO2 86 % on RA, bilateral expiratory wheezes, coarse basilar crackles, accessory muscle use, and productive cough with thick purulent sputum.

Overall Goal

• Pt will maintain a patent airway and demonstrate improved gas exchange throughout the hospital stay.

Expected Outcomes

• Pt will achieve and maintain SpO2 between 88 % and 92 % within 4 hours of intervention.
• RR will decrease to 16–20 bpm with reduced accessory muscle use within 12 hours.
• Pt will effectively expectorate secretions using the huff coughing technique within 24 hours.

Nursing Interventions

• Position pt in high Fowler's position.
• Administer controlled O2 via Venturi mask at 28 % FiO2 to target SpO2 88–92 %.
• Administer salbutamol (Ventolin®) 5 mg NEB Q4H and ipratropium bromide (Atrovent®) 500 mcg NEB QID.
• Administer prednisolone (Panafcortelone®) 40 mg PO daily and amoxicillin 500 mg PO TID.
• Instruct and assist with pursed-lip breathing and huff coughing techniques Q2H while awake.
• Encourage oral fluid intake up to 2,000 mL/day.

Rationale

• High Fowler's position maximises diaphragmatic excursion and lung expansion.
• Controlled O2 corrects hypoxaemia while preventing hypercapnic respiratory failure in COPD.
• Short-acting bronchodilators relax bronchial smooth muscle to relieve bronchospasm; systemic corticosteroids reduce airway inflammation; antibiotics treat underlying bacterial infection.
• Pursed-lip breathing prevents small airway collapse during expiration; huff coughing mobilises central secretions with less energy expenditure.
• Adequate hydration decreases sputum viscosity, facilitating easier expectoration.

Evaluation

• Goal partially met at 15:30 AEST. SpO2 stabilised at 90 % on 28 % FiO2. RR remains elevated at 24 bpm. Cough remains productive of thick sputum; moderate wheezing persists on auscultation.

Revision (if goal was not met)

• Refer to chest physiotherapy for airway clearance adjuncts (e.g., PEP therapy). Increase nebulised salbutamol frequency to Q2H PRN and monitor ABGs if respiratory acidosis is suspected.

Nursing Diagnosis #2

• The actual problem: Anxiety (NANDA Code: 00146)

Related Factors

• Acute dyspnoea, perceived threat of death (fear of suffocation), and hospitalisation.

Defining Characteristics

• Verbalisation of fear ("feel like I might die"), restlessness, diaphoresis, hand tremors, tachycardia (HR 108 bpm), and narrowed perceptual field.

Overall Goal

• Pt will experience a reduction in anxiety and demonstrate effective coping mechanisms during acute dyspnoeic episodes.

Expected Outcomes

• Pt will report anxiety level decreased from 8/10 to ≤ 3/10 on a subjective rating scale within 2 hours.
• HR will return to baseline (< 100 bpm) and physical signs of restlessness will subside within 4 hours.
• Pt will independently utilise paced breathing when feeling breathless within 24 hours.

Nursing Interventions

• Remain with the pt during acute dyspnoeic episodes, maintaining a calm and reassuring demeanour.
• Maintain a quiet environment by limiting unnecessary stimuli.
• Coach the pt through slow, paced pursed-lip breathing step-by-step.
• Provide concise, simple explanations before performing any clinical procedures.

Rationale

• Therapeutic presence provides security and reduces panic associated with breathlessness.
• Decreasing environmental stimuli prevents sensory overload, which can escalate anxiety.
• Focusing on controlled breathing redirects cognitive attention, improves ventilation, and stimulates the parasympathetic nervous system.
• Clear communication reduces fear of the unknown without overwhelming a hypoxic patient.

Evaluation

• Goal met at 13:30 AEST. Pt reports anxiety at 2/10. HR decreased to 92 bpm. Pt appears visibly more relaxed, resting comfortably in bed, and actively using pursed-lip breathing during mild exertion.

Revision (if goal was not met)

• Continue current plan of care. No modifications required at this time; monitor for recurrence of acute anxiety during night shift.