Nursing diagnoses, outcomes and interventions for patient with pneumonia and exacerbated COPD - a case study

Introduction: Pneumonia and Chronic Obstructive Pulmonary Disease (COPD) are prevalent and impactful respiratory diseases, often leading to hospitalization. These conditions pose a challenge to nurses. A systematic approach is essential for the care of these patients, ensuring the promotion and recovery of health and the prevention of exacerbations. Objective: To describe the nursing diagnoses, outcomes and interventions in a patient with pneumonia and COPD and exacerbated hospitalized in a medical clinic unit. Methods: This is a case study, carried out during clinical teaching in a medical clinic unit in a hospital in the interior of São Paulo, in May 2023. The research was carried out in three stages. First: collection and analysis of the data obtained. Second: identification of nursing diagnoses according to NANDA-I and the third: description of nursing outcomes and interventions according to the Nursing Outcomes Classification (NOC) and the Nursing Interventions Classification (NIC). CEP opinion: 2.599.089. Results: It was possible to elaborate the nursing diagnoses: impaired gas exchange, ineffective breathing pattern and decreased activity tolerance. The nursing outcomes were identified: Respiratory Status: Gas Exchange and Activity Tolerance and the nursing interventions: Respiratory Physiotherapy; Monitor respiratory and cardiac status; oxygen therapy; respiratory monitoring of frequency, rhythm, depth, effort and oxygen saturation. Conclusion: The NANDA-I, NOC and NIC taxonomies are essential tools in the systematization of nursing care, enabling comprehensive care for patients with pneumonia and exacerbated COPD, capable of promoting recovery and preventing complications.