جيسيكا — ممرضة Skill AI

$**SBAR Handover for COPD Patient** **Situation:** Patient is a 68-year-old male admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD). Currently experiencing increased shortness of breath, productive cough with green sputum, and mild hypoxia. **Background:** Known history of COPD diagnosed 5 years ago, with frequent exacerbations requiring hospital admissions. Smoker for 40 years, quit 2 years ago. On home oxygen therapy at 2 L/min. Medications include inhaled corticosteroids, long-acting beta-agonists, and short-acting bronchodilators as needed. **Assessment:** Vital signs: RR 28/min, SpO2 88% on room air, HR 110 bpm, BP 135/85 mmHg, Temp 37.8°C. Auscultation reveals wheezing and crackles bilaterally. Arterial blood gas shows mild respiratory acidosis. Chest X-ray indicates hyperinflation without consolidation. **Recommendation:** Continue oxygen therapy to maintain SpO2 between 88-92%. Administer nebulized bronchodilators every 4 hours and corticosteroids as prescribed. Monitor respiratory status closely, encourage effective coughing and sputum clearance. Assess for signs of infection and consider antibiotics. Plan for physiotherapy referral and smoking cessation support. Review in 4 hours or sooner if deterioration occurs. --- **Care Plan for COPD Patient** **Nursing Diagnoses:** - Impaired gas exchange related to airway obstruction and inflammation. - Ineffective airway clearance related to increased sputum production. - Activity intolerance related to dyspnea and fatigue. - Risk for infection related to compromised respiratory function. **Goals:** - Maintain adequate oxygenation with SpO2 ≥ 88%. - Promote effective airway clearance. - Improve activity tolerance. - Prevent complications such as respiratory failure or infection. **Interventions:** - Administer prescribed oxygen therapy and monitor saturation continuously. - Provide nebulized bronchodilators and corticosteroids as ordered. - Encourage deep breathing exercises and use of incentive spirometer. - Assist with airway clearance techniques, including suctioning if necessary. - Monitor vital signs and respiratory status regularly. - Educate patient on smoking cessation and medication adherence. - Collaborate with physiotherapy for mobilization and respiratory exercises. - Monitor for signs of infection and administer antibiotics as prescribed. **Evaluation:** - Patient maintains SpO2 within target range. - Demonstrates effective coughing and sputum clearance. - Reports decreased shortness of breath during activities. - Shows no signs of respiratory infection or deterioration.