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Documentation and Evaluation in Chronic Illness Care
Documentation and Evaluation in Chronic Illness Care ( 4 Questions)
A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which finding should the nurse document as an expected outcome of the client's plan of care?
The goal of care for a client with COPD is to maintain adequate oxygenation and prevent complications. An oxygen saturation of 95% on room air indicates that the client is receiving enough oxygen without supplemental oxygen therapy.
This is an abnormal finding, as a normal respiratory rate for an adult is 12 to 20 breaths per minute. A respiratory rate of 28 breaths per minute indicates tachypnea, which may be a sign of respiratory distress or hypoxemia in a client with COPD.
This is an abnormal finding, as a normal chest shape is elliptical, with a transverse diameter that is twice the anteroposterior diameter. A barrel-shaped chest, where the chest appears rounded and enlarged, is a result of chronic hyperinflation of the lungs due to COPD. It is not an expected outcome of the client's plan of care.
This is an abnormal finding, as normal fingernails have a 160-degree angle between the nail and the nail bed. Clubbing of the fingers, where the angle increases to 180 degrees or more and the nail bed becomes soft and spongy, is a sign of chronic hypoxia due to COPD or other lung diseases. It is not an expected outcome of the client's plan of care.
The goal of care for a client with COPD is to maintain adequate oxygenation and prevent complications. An oxygen saturation of 95% on room air indicates that the client is receiving enough oxygen without supplemental oxygen therapy.
Incorrect options:
B) Respiratory rate of 28 breaths per minute - This is an abnormal finding, as a normal respiratory rate for an adult is 12 to 20 breaths per minute. A respiratory rate of 28 breaths per minute indicates tachypnea, which may be a sign of respiratory distress or hypoxemia in a client with COPD.
C) Barrel-shaped chest on inspection - This is an abnormal finding, as a normal chest shape is elliptical, with a transverse diameter that is twice the anteroposterior diameter. A barrel-shaped chest, where the chest appears rounded and enlarged, is a result of chronic hyperinflation of the lungs due to COPD. It is not an expected outcome of the client's plan of care.
D) Clubbing of the fingers on palpation - This is an abnormal finding, as normal fingernails have a 160-degree angle between the nail and the nail bed. Clubbing of the fingers, where the angle increases to 180 degrees or more and the nail bed becomes soft and spongy, is a sign of chronic hypoxia due to COPD or other lung diseases. It is not an expected outcome of the client's plan of care.