There are a few signs of COPD that a healthcare worker may detect although they can be seen in other diseases. Some people have COPD and have none of these signs. Common signs are :
- tachypnea, a rapid breathing rate
- wheezing sounds or crackles in the lungs heard through a stethoscope
- breathing out taking a longer time than breathing in
- enlargement of the chest, particularly the front-to-back distance (hyperaeration)
- active use of muscles in the neck to help with breathing
- breathing through pursed lips
- increased anteroposterior to lateral ratio of the chest (i.e. barrel chest).
NANDA Chronic Obstructive Pulmonary Disease
1. Ineffective Airway Clearance related to bronchoconstriction, increased sputum production, ineffective cough, fatigue / decreased energy and bronkopulmonal infection.
2. Ineffective Breathing Pattern related to shortness of breath, mucus, bronchoconstriction and airway irritants.
3. Impaired Gas Exchange related to ventilation perfusion inequality.
4. Activity Intolerance related to imbalance between supply with oxygen demand.
5. Imbalanced Nutrition: Less than Body Requirements related to anorexia.
6. Disturbed Sleep Pattern related to discomfort, the setting position.
7. Self-Care Deficit Bathing / Hygiene, Dressing / Grooming, Feeding, toileting related secondary fatigue due to increased respiratory effort and the insufficiency of ventilation and oxygenation.
8. Anxiety related to threat to self-concept, the threat of death, unmet needs.
9. Ineffective Individual Coping related to lack of socialization, anxiety, depression, low activity levels and inability to work.
10. Knowledge Deficit related to lack of information, do not know the source of information.
Sample Nursing Diagnosis and Nursing Intervention for COPD
Ineffective airway clearance related to the disruption of production increased secretions, retained secretions
Goal : Ventilation / oxygenation to the needs of clients.
Outcome : Maintain a patent airway and breath sounds clean
- Review / monitor respiratory frequency, record the ratio of inspiration / expiration.
- Assess the patient to a comfortable position, such as raising the head of the bed, seat and backrest of the bed.
- Auscultation for breath sounds, record the sound of breath for example: wheezing, and rhonchi krokels.
- Note the presence disepnea, for example: complaints restlessness, anxiety, respiratory distress
- Help the abdominal breathing exercises or lip.
- Observation of the characteristic cough, for example: persistent, hacking cough, wet, auxiliary measures to improve the effectiveness of the airway.
- Increase fluid intake to 3000 ml / day according to tolerance of the heart.
- Bronchodilators, eg, β-agonists, efinefrin (adrenaline, vavonefrin), albuterol (Proventil, Ventolin), terbutaline (brethine, brethaire), isoeetrain (brokosol, bronkometer).