Jessica — Sykepleier 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 10 years ago, with frequent exacerbations requiring hospital admissions. Smoker for 40 years, quit 2 years ago. On home oxygen therapy 2L/min at night. Current 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. Arterial blood gas shows mild respiratory acidosis with partial compensation. Chest X-ray shows hyperinflation, no consolidation. Patient is alert but anxious and using accessory muscles to breathe. **Recommendation:** Continue oxygen therapy to maintain SpO2 between 88-92%. Administer nebulized bronchodilators every 4 hours and as needed. Start oral corticosteroids as per protocol. Monitor respiratory status closely, including ABGs and vital signs every 4 hours. Encourage effective coughing and sputum clearance. Prepare for possible escalation to non-invasive ventilation if no improvement. Provide patient education on smoking cessation and inhaler technique. --- **Care Plan for COPD Patient on Acute Ward** **Nursing Diagnoses:** - Impaired gas exchange related to airway obstruction and inflammation. - Ineffective airway clearance related to increased sputum production. - Anxiety related to dyspnea and hospitalization. - Risk for infection related to compromised respiratory function. **Goals:** - Maintain adequate oxygenation (SpO2 88-92%). - Clear airway secretions effectively. - Reduce anxiety and promote comfort. - Prevent complications such as respiratory failure or secondary infections. **Interventions:** - Administer prescribed oxygen therapy and monitor saturation continuously. - Provide nebulized bronchodilators and corticosteroids as ordered. - Assist with airway clearance techniques: encourage coughing, suction if necessary, and position patient to optimize breathing. - Monitor vital signs and respiratory status regularly, including ABGs. - Educate patient on breathing exercises and inhaler use. - Provide emotional support and reassurance to reduce anxiety. - Maintain infection control measures and monitor for signs of infection. **Evaluation:** - Patient maintains SpO2 within target range. - Sputum production decreases and airway clearance improves. - Patient reports reduced shortness of breath and anxiety. - No signs of respiratory deterioration or secondary infection observed.