PATIENT

CARE PLAN

Patient Information:
75-year-old female. History of COPD, chronic respiratory failure. Admitted for AMS, weakness, general
fatigue and trouble breathing.


Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as evidenced by (AEB).

Problem #1 Impaired gas exchange r/t alveoli destruction secondary to respiratory failure.
Desired Outcome: Patient will maintain o2 saturation no less than 91.
Nursing Interventions.
Client Response to Intervention
1.
1.
Nursing staff will auscultate for breath sounds Q2H
During lung assessment, patients exhalation
noting any areas of diminished breath sounds or
was very weak, noted slightly diminished
decreased airflow. Nursing staff will educate patient and exhalation on all lung fields. Believed to hear
demonstrate correct breathing measurements in regards wheezing on the anterior portion of lung
to the importance of trying to inhale and exhale fully to
fields.
promote better gas exchange.
Patient did comment that she finds her self
not breathing as well or evenly when she
slouches in bed. I talked with her and went
over a few ways to help her maintain a better
posture with using pillows or positioning
devices. Patient agreed that it could help her
breathing patterns.
2.
2.
Nursing staff will monitor level of consciousness and
Patients was alert to stimuli and able to hold
mental status changes. If mental status becomes altered full conversations throughout shift. She was
nursing staff will promptly check oxygen saturation and alert and orientated x4. Patient stated she
report finding physician.
was feeling much better- her strength was
coming back
3.
3.
Nursing staff will palpate for fremitus once per shift.
Palpations were clear for fremitus. Noted and
Nursing staff will note any decrease in fremitus that
assessed in chart.
could suggest air trapping, air sacks in the lungs or
possible fluid retention.
Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed):
Patient O2 stats remained above 91 during shift. Patients level of consciousness and mental status was
alert and orientated times 4 during shift.

Problem #2 Increased fall risk r/t spells of dizziness AEB impaired gas exchange secondary to COPD
Desired Outcome: Patient will remain free of any falls.
Nursing Interventions
Client Response to Intervention
1.
1.
Nursing staff will perform environmental assessment
Patients room was clustered with her things
once per shift to ensure patients environmental area is
around the bottom of the bed. Helped patient
clear of any fall risk or tripping hazards.
move them into the closest and explained how
it could potentially cause her to fall or trip her
when trying to get out of bed. Patient was
compliant and verbalized that she
understood.

2.
Nursing staff will assess and obtain orthostatic blood
pressures on patient twice per shift. Nursing staff will
promptly report any hypotension to physician. Nursing
staff will educate patient on the importance of reporting
any signs or symptoms of dizziness upon standing or
changing positions. Patient will verbalize back
understanding to ensure coherency.
3.
Nursing staff will educate patient on the importance of
complying with continuous 02 to reduce the risk of
decreased oxygen causing spells of dizziness. Patient
should be able to verbalize back the understanding and
importance of complying with continuous 02. Nursing
staff will also evaluate patients oxygen cords to ensure
there is no fall risk or tripping hazards during ADLs.

2.
Patient reported no signs or symptoms of
dizziness in position changing or movements.
Patient reported she was tired of all the vital
signs being taken; she would let us know
when she feels ill.

3.
Patient is compliant with care and agrees with
the importance of keeping her o2 in place.
Patient needed further education on the
hazards of her o2 cords. I talked with patient
and showed her if she rolls the cord up neatly
and keeps it at bedside she will be less likely
to trip over it during ADLs. As well, a kink in
the line is less likely to occur. Patient seemed
to understand and agree.
Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed):
Patients gait has improved since being admitted. As too, her O2 levels, consciousness and ability to stand
and ambulate on her own.


Problem #3 Chronic pain r/t muscle spasms of back and neck AEB facial grimacing, shouting out Im in
pain and sessions of tearfulness.
Desired Outcome: Patients pain will remain at a tolerable level on a scale 0-10.
Nursing Interventions
Client Response to Intervention
1.
1.
Nursing staff will talk with patient to find a tolerable
Patients tolerable level for pain on a scale 0level of pain to maintain an acceptable baseline. Nursing 10 was 3. Patient was educated on how the
staff will assess patients pain level using a scale 0-10
scale used. 0 being with no pain and 10 being
Q2H
unbearable and can not go on.
2.
2.
Nursing staff will use other ways of pain management as Patient did not want to use ice packs but did
tolerated by patient. Such as; cryotherapies, positioning like to use pillows to support her neck and
aids or devices, deep breathing exercise and reposition
back. Patient sat in chair for dinner and
the patient frequently as tolerated.
reported that moving from chair to bed did
help her lower back feel better for a short
time.
3.
3.
Nursing staff will collaborate with patients family for
The patient had family (2 daughters) in and
distraction tools or ideas that could help aid pain or
out of the room all throughout the day. The
make patient more comfortable.
daughters seemed to be very close to their

mother and provided a very solid support
system. Talked with daughters and their
mother seems to like TV, and just to have
someone around. They did mention their
mother is very HOH and loves to talk but often
feels like no one talks to her due to inability to
hear well.
Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed):

The patient was very painful at times. I noticed when her anxiety would start to rise her pain coincided.
Keeping her pain level minimal also was beneficial to her breathing patterns which are a large relation to
her O2 levels.