PLU School of Nursing Care Plan Form

STUDENT NAME: John Smith DATE: 10/18/19 WEEK #: 6

Patient Age/Decade: 70 Gender: M Medical/Admitting Diagnosis: Lung mass, COPD

Assessment Data Nursing Diagnosis Expected Interventions Evaluation Statement

(Subjective and Objective- (NANDA- includes related Outcomes/Goals (In order of priority list a (Evaluation of each goal.
Include all relevant to and as evidenced by in (Minimum of one short- minimum of 5 nursing Was the goal met,
assessment and statement) term goal and one long- interventions. One must partially met or unmet?
diagnostic data) term goal. Goal statement address teaching while Must include as evidenced
must be specific, realistic, the others should address by to support evaluation
measurable, and with a assessment and actions) of goal)
timeframe) Must include rationale
for each intervention and
site source

Subjective: Impaired gas exchange r/t Short Term- Short- Short term- Goal met
 Decreased energy COPD AEB Client will maintain O2 sat Assessment- Monitor the Client maintained O2 sat
 Fatigue  Use of 5L O2 with between 88%-92% by the patient’s respirations and of 96% by end of shift AEB
 Weakness O2 sat of 92% end of shift on 10/17/19 regularly assess breath  92% O2 sat
 SOB with activity  Dyspnea on sounds to be able to  Use of 5L O2 by
exertion and Long Term- determine baseline and nasal Canal
Objective: resting tachypnea By the time of discharge the effectiveness of  Respiratory rate
 168/63; HR 84; RR  Chest X ray with the client will verbalize treatment. of 18 and regular
36; SPO2 92% 5L evidence of COPD understanding of oxygen without dyspnea
NC.  Expiratory administration including Rationale- Monitoring
 Non-productive wheezing s/sx of hypoxia, changes in client’s Long Term- Goal met
cough demonstrate applying respiratory status are key Client demonstrated
 Increased oxygen delivery devices to providing prompt understanding of oxygen
breathing effort and safety. interventions in order to administration AEB
with movement. reduce complications  Verbalized how
 Baseline of 3L O2 (Ignatavicius, Workman, oxygen is safely
with O2. Current Rebar, 2018, p.578). administered by
5L sat of 92%. NC at home.
Action- Administer O2  Use of effective
and titrate oxygen to cough to clear
airways

N340 Care Plan JKushner 02/03/2019


STUDENT NAME: John Smith
Patient Age/Decade: 70
 Chest X ray with
evidence of COPD
and lung mass
 ABG CO2 92
 Breath sounds:
expiratory
wheezing
N340 Care Plan JKushner 02/03/2019
PLU School of Nursing Care Plan Form
DATE: 10/18/19 WEEK #: 6
Gender: M Medical/Admitting Diagnosis: Lung mass, COPD
main O2 sat between 88%  Knowledge and
to 92% use of pursed lip
breathing
Rationale- All hypoxic  Demonstrated use
patients, even patients of portable pulse
with COPD and oximetry with
hypercarbia should verbalizing plan to
receive oxygen therapy at increase oxygen
appropriate rate in order as needed when
to decrease hypoxia and levels drop below
bring spO2 levels up to 88%.
88%-92% (Ignatavicius,
Workman, Rebar, 2018,
p.578).
Education- Demonstrate
effective coughing and
deep breathing
techniques
Rationale- Coughing
effectively can improve
gas exchange by helping
increase airflow in the
larger airways
(Ignatavicius, Workman,
Rebar, 2018, p.578).
Long-
Assessment- Auscultate
breath sounds
 PLU School of Nursing Care Plan Form
STUDENT NAME: John Smith DATE: 10/18/19 WEEK #: 6

Patient Age/Decade: 70 Gender: M Medical/Admitting Diagnosis: Lung mass, COPD

Rationale- By auscultating
the clients breath sounds
the nurse can determine if
an obstruction or changes
in breath sounds have
occurred. If the nurse
notices a change it can
alert them to administer
an intervention because
airway maintenance is the
most important focus to
improve gas exchange
(Ignatavicius, Workman,
Rebar, 2018, p. 574).

Action- Administered
Steroids and
Bronchodilators as
prescribed

Rationale- Steroids and

corticosteroids are good
for long term control,
while bronchodilators are
useful for rescue therapy
(Ignatavicius, Workman,
Rebar, 2018, p.579).

Education- Encourage
abdominal or pursed lip
breathing exercises during

N340 Care Plan JKushner 02/03/2019

 PLU School of Nursing Care Plan Form
STUDENT NAME: John Smith DATE: 10/18/19 WEEK #: 6

Patient Age/Decade: 70 Gender: M Medical/Admitting Diagnosis: Lung mass, COPD

episodes of increased
dyspnea.

Rationale- Diaphragmatic
or abdominal and pursed
lip breathing can be
helpful in managing
dyspneic episodes. These
techniques delay airway
compression and reduce
air trapping (Ignatavicius,
Workman, Rebar, 2018,
p.578).

Ignatavicius, D.,
Workman, M., and Rebar,
C. (2018). Medical-
surgical nursing concepts
for interprofessional
collaborative care (9th
ed.). Elsevier: St Louis,
MO.

N340 Care Plan JKushner 02/03/2019