Jessica — Hemşire AI Skill

$**SBAR Handover for COPD Patient** **Situation:** Patient is a 68-year-old male with a known history of COPD admitted to the acute ward due to exacerbation characterized by increased shortness of breath, productive cough, and wheezing. **Background:** The patient has a 10-year history of COPD, currently on inhaled bronchodilators and corticosteroids. He is a former smoker with a 40-pack-year history. Previous admissions for COPD exacerbations occurred twice in the last year. No known drug allergies. **Assessment:** On admission, the patient is tachypneic with a respiratory rate of 28 breaths per minute, oxygen saturation of 88% on room air, and use of accessory muscles for breathing. Auscultation reveals bilateral wheezes and crackles. Arterial blood gas shows mild hypoxemia and hypercapnia. Chest X-ray shows no new infiltrates. Vital signs are stable except for mild tachycardia. **Recommendation:** Continue oxygen therapy to maintain saturation between 88-92%, initiate nebulized bronchodilators, start systemic corticosteroids as per protocol, monitor respiratory status closely, and prepare for possible escalation of care if no improvement. Encourage physiotherapy and monitor fluid balance. --- **Care Plan for COPD Patient** **Nursing Diagnoses:** - Impaired gas exchange related to airway obstruction and inflammation. - Ineffective airway clearance related to increased mucus production. - Activity intolerance related to dyspnea and fatigue. - Risk for infection related to compromised respiratory function. **Goals:** - Maintain oxygen saturation between 88-92%. - Improve airway clearance and reduce wheezing. - Enhance patient’s ability to perform activities of daily living without excessive dyspnea. - 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 effective coughing and assist with airway clearance techniques. - Monitor vital signs and respiratory status every 2-4 hours. - Educate patient on breathing exercises and energy conservation techniques. - Collaborate with physiotherapy for chest physiotherapy and mobilization. - Monitor fluid intake and output to avoid fluid overload. - Assess for signs of infection and report any changes promptly. **Evaluation:** - Patient maintains oxygen saturation within target range. - Reduction in wheezing and improved breath sounds. - Patient reports decreased shortness of breath during activities. - No signs of respiratory infection or deterioration observed.