NURSING CARE PLAN COPD (COMPLETED) GRADED A; PT PRESENTED AT ED WITH C/O SOB AND DYPSNEA

NURSING CARE PLAN COPD (COMPLETED) GRADED A; PT PRESENTED AT ED WITH C/O SOB AND DYPSNEA

Assessment (Supporting data)

Nursing Diagnosis (NANDA diagnostic statement)

Goals & Expected Outcomes (Realistic, timed, measurable)

Nursing Interventions (Strategies or actions for care) Rationale for interventions

Evaluation

(Client’s response to nursing actions & progress toward achieving

goals & outcomes)

Subjective:

Pt presented at ED with C/O SOB and dypsnea

Objective:

Pt was hypoxemic at admission; spoke in short sentences; used acc. muscles when breathing

Ineffective airway clearance r/t secretions in bronchi and obstructed airway aeb

hypoxemia and dypsnea

· Pt will maintain a patent airway at all times

· Pt will demonstrate improved ventilation and adequate oxygenation within normal parameters for her as evidenced by blood gas levels before d/c

· Pt will maintain clear lung fields and remain free of signs of respiratory distress throughout hospital stay

· Pt will Demonstrate effective coughing techniques after teaching session

✓ Monitor resp. rate, depth, and effort, use of accessory muscles, nasal flaring, and abnml breathing patterns.

↑ respiratory rate, use of accessory muscles, nasal flaring, and abdominal breathing may indicate hypoxia.

✓ Auscultate breath sounds Q1- 2 °. Presence of crackles, wheezes may signify airway obstruction, leading to or exacerbating existing hypoxia.

✓ Observe sputum, noting color, odor, and volume. Normal sputum is clear or gray and minimal; abnormal sputum is green, yellow, or bloody; malodorous; and often copious.

Pt’s airway remained open

Pt’s lungs remained free of new onset wheezes

Pt demo’d effective coughing techniques for student nurse