Jessica — Perawat 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 previous hospital admissions for exacerbations. Smoker for 40 years, quit 2 years ago. On home oxygen therapy 2L/min at night. Medications include salbutamol inhaler, tiotropium, and prednisone during exacerbations. **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. ABG shows mild respiratory acidosis with hypoxemia. Patient is alert but anxious and using accessory muscles to breathe. **Recommendation:** Continue oxygen therapy to maintain SpO2 between 88-92%. Start nebulized bronchodilators every 4 hours and oral corticosteroids as per protocol. Monitor vital signs and ABGs regularly. Encourage effective coughing and sputum clearance. Assess for signs of infection and consider antibiotics. Plan for physiotherapy and smoking cessation support. Review in 4 hours or sooner if deterioration occurs. --- **Care Plan for COPD Patient** **Nursing Diagnosis:** Impaired gas exchange related to airway inflammation and mucus production. **Goals:** - Maintain adequate oxygenation (SpO2 88-92%). - Reduce work of breathing and respiratory distress. - Prevent infection and promote airway clearance. - Educate patient on disease management and smoking cessation. **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 effective coughing techniques to clear secretions. - Monitor vital signs, respiratory status, and ABG results regularly. - Administer antibiotics if infection is confirmed or suspected. - Provide emotional support and education about COPD management, medication adherence, and smoking cessation. - Collaborate with physiotherapy for pulmonary rehabilitation. **Evaluation:** - Patient maintains SpO2 within target range. - Respiratory rate decreases to normal limits. - Patient demonstrates effective coughing and sputum clearance. - No signs of worsening infection or respiratory failure. - Patient verbalizes understanding of COPD management and smoking cessation importance.