COPD Basic Nursing Assessment
1. Activity / rest
symptoms:
a. Exhaustion, fatigue.
b. The inability to perform daily activities because of difficulty breathing.
c. Inability to sleep, need to sleep in a higher body position.
d. Dyspnea at rest or in response to activity or exercise.
Signs:
a. Fatigue.
b. Restlessness, insomnia.
c. General fatigue or loss of muscle mass.
2. Circulation
symptoms:
a. Swelling of the lower extremities.
Signs:
a. The increase in blood pressure.
b. Increased heart rate or severe tachycardia, dysrhythmias.
c. Distended neck veins.
d. Edema not associated with heart disease.
e. Faint heart sounds.
3. Ego Integrity
symptoms:
a. Increased risk factors
b. Changes in lifestyle
Signs:
a. Anxiety, fear, sensitive excitatory.
4. Food and fluids
Symptoms:
a. Nausea or vomiting.
b. Anorexia.
c. Weight loss.
Signs:
a. Poor skin turgor.
b. Edema.
c. Sweating.
d. Decrease in muscle mass.
5. Hygiene
Symptoms:
a. Decreased ability or increased need for activity.
Signs:
a. Poor hygiene,
body odor.
6. Breathing
Symptoms:
a. Shortness of breath, feeling depressed in the chest.
b. Cough with sputum production settled every day.
c. A history of recurrent pneumonia.
d. Family factors and heredity.
e. The use of oxygen at night or continuously.
Signs:
a. Fast or slow breathing, expiratory elongated with snoring.
b. The use of accessory muscles of breathing.
c. Faint breath sounds with expiratory wheezing.
d. Percussion hipersonor.
e. Difficulty speaking.
f. Color pale, and cyanotic lips and nail beds.
g. There clubbing (clupping finger).
7. Security
Symptoms:
a. A history of allergic reactions, sensitive to environmental factors.
b. The presence or recurrence of infection.
Signs:
a. Redness or sweating.
8. Seuality
Symptoms: Decreased libido.
9. Social Interaction
Symptoms:
a. Dependency relationship.
b. Lack of support systems.
c. Failure to support people nearby.
d. A long illness.
Signs:
a. Physical mobility limitations.
b. Negligence relationships with other family members.
10. Extension or learning
Symptoms:
a. Respiratory drug abuse.
b. Difficulty stopping smoking.
c. The use of alcohol on a regular basis.
