Listen to lung sounds and take note of any abnormal breath sounds like rales, wheezing, coarse sounds or no lung sounds at all. This will tell you if there is obstruction or secretions in the airways. Assess respiratory rate and depth, cyanosis or color changes of the skin, secretions for infections, hydration status through weight and ability to do activities of daily living. Also check oxygen saturation levels to ensure adequate oxygenation of the blood.
Gather all the information from your assessments. Write down nursing diagnoses based on the information you collected. Nursing diagnoses for COPD include impaired gas exchange, imbalanced nutrition; less than body requirements, risk for infection and deficient knowledge. Ensure that your nursing diagnoses are backed by supporting evidence as indicated by your assessments.
Create a plan that includes expected outcomes and nursing interventions based on your nursing diagnoses for the COPD patient. Nursing interventions for COPD include; administration of medication like albuterol, anti-cholinergic and corticosteroids. These help to create a more patent airway. Teach the COPD client how to cough out secretions effectively and pursed lip breathing to enable more effective expiration without causing the air sacs to collapse. Place the patient in a high fowlers position to enable better breathing and reduce the work of breathing. Evaluate your patient periodically to make sure the goals you have set are being reached and they are not, reassess your patient and reapply the nursing process.