COPD nursing diagnosis

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So a little background on my patient. He came in through the E.D. SOB, 3L NC O2 as 90% they gave him a breathing treatment his O2 went to 100%. He has a history of COPD and has been intubated several times in the passed. He was put on Bipap but his LOC decreased and they decided to intubate. When I had him he was in the ICU, intubated, ABGs were all out of whack, as to be expected. His O2 sat was running from 93-100 he still has wheezes and decreased breath sounds. Many of the Nursing diagnosis that I have found are for COPD patients that are not currently on mechanical ventilation. Right now I am trying to figure out 3 top diagnosis and then prioritizing them. I have- Ineffective airway clearance r/t expiratory airflow obstruction, bronchoconstriction AEB wheezing, difficulty breathing, impaired gas exchange r/t ventilation perfusion inequality AEB abnormal ABG values, reduced tolerance for activity, risk for infection: risk factors: inadequate primary defenses, chronic disease process, malnutrition. He had a chest x-ray and there was no pneumonia just overinflation and presence of chronic lung disease. Do you guys have any advice on better nursing diagnosis/ better prioritization?

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Specializes in Complex pedi to LTC/SA & now a manager.
So a little background on my patient. He came in through the E.D. SOB, 3L NC O2 as 90% they gave him a breathing treatment his O2 went to 100%. He has a history of COPD and has been intubated several times in the passed. He was put on Bipap but his LOC decreased and they decided to intubate. When I had him he was in the ICU, intubated, ABGs were all out of whack, as to be expected. His O2 sat was running from 93-100 he still has wheezes and decreased breath sounds. Many of the Nursing diagnosis that I have found are for COPD patients that are not currently on mechanical ventilation. Right now I am trying to figure out 3 top diagnosis and then prioritizing them. I have- Ineffective airway clearance r/t expiratory airflow obstruction, bronchoconstriction AEB wheezing, difficulty breathing, impaired gas exchange r/t ventilation perfusion inequality AEB abnormal ABG values, reduced tolerance for activity, risk for infection: risk factors: inadequate primary defenses, chronic disease process, malnutrition. He had a chest x-ray and there was no pneumonia just overinflation and presence of chronic lung disease. Do you guys have any advice on better nursing diagnosis/ better prioritization?

Terminology is close, airway always first. Terminology must match the defining characteristics and related factors defined by NANDA-I current edition

- Ineffective airway clearance r/t airway spasm, chronic obstructive pulmonary disease, retained secretions AEB adventitious breath sounds, diminished breath sounds, restlessness, dyspnea, changes in respiratory rate & rhythm, cyanosis

impaired gas exchange r/t ventilation perfusion imbalance AEB abnormal ABG values, abnormal breathing, abnormal skin color, dyspnea, hypoxia, hypoxemia, hypercapnia, restlessness, dyspnea

risk for infection: risk factors: inadequate primary defenses (decrease in ciliary action, change in pH of secretions) inadequate secondary defenses: malnutrition

You could always add risk for impaired skin integrity. The ineffective breathing pattern is what resulted in BiPAP& intubation.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Many of the Nursing diagnosis that I have found are for COPD patients that are not currently on mechanical ventilation
You should not be finding the nursing diagnosis fit then trying to retro fit the patient into what you think "sounded right". Care plans are all about the assessment...of the patient. You assess the patient and determine what they NEED...putting what they NEED NOW first.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics.

  1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
  2. Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
  3. Planning (write measurable goals/outcomes and nursing interventions)
  4. Implementation (initiate the care plan)
  5. Evaluation (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at).

The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis. Another member GrnTea say this best......

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

"Related to" means "caused by," not something else.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Now you prioritize according to what will kill the patient first....remember you ABC's. Think about Maslows Hierarchy of needs.

When I had him he was in the ICU, intubated, ABGs were all out of whack, as to be expected. His O2 sat was running from 93-100 he still has wheezes and decreased breath sounds
Tell me your assessment...what were the patients ABG's? Are there any co-morbidities? Were the secretions? What were the vent settings? Was the patient sedated? Were they on any DVT prophylaxis? Did they have an art line? Foley? Multi-lumen? Peripheral line? Are they awake? Alert?

Tell me about the patient.....

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He had decreased breath sound and wheezing. He had the barrel chest. As for the ABGs his latest was a pH of 7.41 PCO2 67 121 bicarb 42.5. He has HTN, afib, CAD, he had an MI in 06, hypercapnia. He had been in the ICU five times in the past six months every time he had been intubated. He was on DVT prophylaxis, he did have a foley, he was on propofol he had 2 PICC lines. If you would talk to him he could respond to you knew where he was and who he was.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
He had decreased breath sound and wheezing. He had the barrel chest. As for the ABGs his latest was a pH of 7.41 PCO2 67 121 bicarb 42.5. He has HTN, afib, CAD, he had an MI in 06, hypercapnia. He had been in the ICU five times in the past six months every time he had been intubated. He was on DVT prophylaxis, he did have a foley, he was on propofol he had 2 PICC lines. If you would talk to him he could respond to you knew where he was and who he was.
Ok looking at this....what do you think he might need?
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Sorry I was replying on my phone the last time. His vent settings: Peep- 5.0 I:E- 1:2.7 FiO2- 30% VT- 550 RR-12 and he was on assist control. The doctors were contemplating on placing a trach because he had been intubated so many times in the past. We were letting his lungs rest. He was on fentayl, vanco, normal saline and propofol drips. Our goal was to get him back to his baseline ABGs which was what I would consider a somewhat controlled resp. acidosis. I chose ineffective airway clearance because he still had the wheezing and decreased breath sounds, I went with impaired gas exchange because of his abnormal ABGs. While I was there his O2 sats never dropped below 93%. I had a hard time choosing a third diagnosis for this patient. I went with risk for infection because he had decreased ciliary action and stasis of secretions and he was a little malnutritioned. I didn't chose ineffective breathing pattern because he was on the vent which was giving him at least 12 respirations per minute.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
He was on DVT prophylaxis, he did have a foley, he was on propofol he had 2 PICC lines.
risk of infection is ok....but not because of the
decreased ciliary action and stasis of secretions
I would think the foley and multiple lines would pose more of a threat. How abut risk of bleeding due to the DVT prophylaxis? How is his skin? any breakdown?
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Yeah, that makes sense. His skin was fine, no breakdown. He had just been admitted the evening before. He was in end-stage COPD so I could go towards powerlessness r/t progressive nature of disease? I feel like my prof. would say he wouldn't be at risk for infection because we were performing peri care Q8H. Thanks for your help, I appreciate it!

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Specializes in Complex pedi to LTC/SA & now a manager.

Risk for infection intervention is meticulous pericare. Having a foley, central line, intubated are all risk for infection

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So, how would you put that into a nursing diagnosis? The presence of a foley, 2 PICC lines, intubated?

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Specializes in Complex pedi to LTC/SA & now a manager.

Risk for infection d/t inadequate secondary defenses: invasive procedures (Foley catheter, intubation with mechanical ventilation, PICC lines x2)

Are there parenteral steroids being given? Then you can add immunosuppression from steroids

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