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ABCDE Nursing Care Plan for COPD

COPD, or chronic obstructive pulmonary disease, is a progressive disease that makes it hard to breathe. "Progressive" means the disease gets worse over time.

COPD can cause coughing that produces large amounts of mucus (a slimy substance), wheezing, shortness of breath, chest tightness, and other symptoms.

Cigarette smoking is the leading cause of COPD. Most people who have COPDsmoke or used to smoke. Long-term exposure to other lung irritants, such as air pollution, chemical fumes, or dust, also may contribute to COPD.

COPD Nursing Care Plan



Assessment

Airway
  • Assess and maintain airway
  • Do the head tilt, chin lift if necessary
  • Use the help of the airway if necessary
  • Consider to be referring to the anesthesiologist

Breathing
  • Assess oxygen saturation using pulse oximeter
  • Do inspection arterial blood gases to assess pH, PaCO2 and PaO2
  • If the arterial pH less than 7.2, more profitable patients using non-invasive ventilation (NIV) and references must be made in accordance with local policy
  • Control of oxygen therapy to maintain oxygen saturation over 92%
  • Strictly monitoring PaCO2
  • Record the temperature
  • Make checks for signs of:
    • cyanosis
    • clubbing
    • pursed lip breathing
    • movement symmetry
    • intercostal retractions
    • tracheal deviation
  • Listen to the:
    • wheezing
    • crackles
    • decrease in airflow
    • silent chest
  • Make checks to see piston :
    • pneumothorax
    • consolidation
    • signs of heart failure
  • If there is evidence of an infection usually caused by bacterial pathogens including :
    • streptococcus pneumoniae
    • haemophilus influenzae
    • moraxella catarrhalis

Circulation
  • assess heart rate and rhythm
  • record blood pressure
  • check ECG
  • do intake output, and do a complete blood
  • pairing IV access
  • fluid restriction did

Disability
  • Assess the level of consciousness by using AVPU
  • Patients showed a decrease in consciousness needed medical help immediately and treated in ICU.

Exposure
  • If the patient is stable and health history examinations do other physical examination.

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