Джессіка — медсестра AI Skill

$**SBAR Handover for a COPD Patient on an Acute Ward** **Situation:** Patient is a 68-year-old male with a known history of chronic obstructive pulmonary disease (COPD) admitted with an acute exacerbation. Currently experiencing increased shortness of breath, productive cough with green sputum, and mild hypoxia. **Background:** Patient has a 40-pack-year smoking history, diagnosed with COPD 10 years ago. Previous admissions for exacerbations approximately twice a year. On home oxygen therapy at 2 L/min and uses inhalers (salbutamol and tiotropium). No known drug allergies. Comorbidities include hypertension and type 2 diabetes. **Assessment:** On admission, respiratory rate 28 breaths/min, oxygen saturation 88% on room air, improved to 92% on 2 L/min oxygen. Auscultation reveals bilateral wheezes and crackles. Arterial blood gas shows mild respiratory acidosis. Chest X-ray shows hyperinflation without consolidation. Patient is alert but visibly distressed due to breathlessness. **Recommendation:** Continue oxygen therapy to maintain saturation between 88-92%. Initiate nebulized bronchodilators and systemic corticosteroids as per protocol. Monitor vital signs and oxygen saturation closely. Encourage effective coughing and sputum clearance. Assess for signs of infection and consider antibiotics. Plan for physiotherapy input and smoking cessation support. Review after 24 hours for response to treatment and consider escalation if no improvement. --- **Care Plan for COPD Patient on Acute Ward** **Problem:** Acute exacerbation of COPD with hypoxia and increased sputum production. **Goals:** - Improve oxygenation and maintain saturation between 88-92%. - Reduce breathlessness and improve ventilation. - Clear airway secretions effectively. - Prevent complications such as respiratory failure or infection. - Support smoking cessation and optimize long-term management. **Interventions:** - Administer oxygen therapy titrated to target saturation. - Provide nebulized bronchodilators (e.g., salbutamol, ipratropium) as prescribed. - Administer systemic corticosteroids (e.g., prednisolone) as per guidelines. - Monitor vital signs, respiratory status, and ABGs regularly. - Encourage effective coughing techniques and assist with sputum clearance. - Initiate antibiotic therapy if bacterial infection is suspected. - Collaborate with physiotherapy for chest physiotherapy and mobilization. - Educate patient on smoking cessation and provide resources/support. - Review medication adherence and inhaler technique. - Plan for discharge with follow-up in respiratory clinic and pulmonary rehabilitation referral. **Evaluation:** - Monitor improvement in oxygen saturation and respiratory rate. - Assess reduction in dyspnea and sputum production. - Evaluate patient’s ability to clear secretions and mobilize. - Review response to medications and adjust treatment as needed. - Confirm patient understanding of disease management and smoking cessation plan.