UNIT FOUR
576
Clinical Skills and Care
Nursing Care Plan for a Patient With COPD and Pneumonia—cont'd
Nursing Diagnosis: Impaired gas exchange related to chronic lung changes as evidenced by dyspnea and decreased oxygen saturation Expected Outcome: Patient will be able to ambulate to bathroom without dyspnea before discharge. Patient will maintain oxygen saturation of 92% or above before discharge. Interventions Evaluations
Day 1: Oxygen maintained as ordered. SaO 2 still low at 90%. Mild restlessness, but no other signs of hypoxia. Lips and mucous membranes dusky. Day 2: Lung sounds improving. SaO 2 now at 91%. No signs or symptoms of hypoxia. Nailbeds less dusky. Day 3: Oxygen continued as ordered. SaO 2 at 92%, which is very good for his situation. Cough more effective and lung sounds clearer. Nailbeds and mucous membranes remain slightly dusky.
Maintain supplemental oxygen as ordered at 2 L per nasal cannula. Assess pulse oximetry every 4 hours to determine effective oxygenation. Assess the patient for signs and symptoms of hypoxia, including confusion, restlessness, and irritability. Assess color and circulation by evaluating the nailbeds, lips, and mucous membranes every 2 hours.
Nursing Diagnosis: Decreased activity tolerance related to imbalance between oxygen supply and demand as evidenced by dyspnea with exertion Expected Outcome: Patient will be able to participate in ADLs with minimal dyspnea by discharge. Patient will verbalize ways to conserve energy when performing ADLs at home before discharge. Interventions Evaluations
Day 1: Refused bed bath due to shortness of breath. Allowed nurse to sponge off perineal area and armpits only. Day 2: Able to tolerate full bed bath with assistance. Became short of breath after washing arms and face. Took a 10-minute break, then able to assist by washing own perineal area. Day 3: Able to ambulate to bathroom. Had to rest on chair once at the sink. Waited for him to regain energy, then assisted with sponge bath at sink. Verbalizes plans to try chair in shower at home and using a terrycloth robe instead of drying after shower.
Assist the patient with conservation-of-energy techniques: • Decrease activities that require use of accessory muscles. Use a bench or chair in the shower; use a terrycloth robe instead of drying after a shower when home. • Take frequent rest breaks during activities. Do not rush the patient; plan for extra time when assisting with ADLs.
Skill 28.1 Obtaining a Sputum Specimen
Assessment Steps 1. Verify the health-care provider’s order for the sputum specimen. 2. Determine the frequency and type of cough the patient is experiencing. If it is frequent and productive, you may be able to get the specimen at any time. If not, plan to obtain the specimen in the early morning when the most sputum is available for expectoration. 3. Determine the patient’s pain level and medicate if necessary. The patient may be unable to give good cough effort if they are in pain.
Planning Step 1. Gather needed equipment and supplies: a sterile sputum specimen container with a lid and clean gloves. If obtaining a suctioned specimen, you will need a sterile suction catheter kit and a sputum trap that attaches to the suction tubing. You will also need a preprinted label for the specimen container, a biohazard specimen bag for transport, and protective eyewear. Implementation Steps 1. Follow the Initial Implementation Steps located on the inside front cover.
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