Nursing Care Plan
Student(s) Name: Date:
Medical Diagnosis: exacerbation of chronic obstructive pulmonary disease (COPD)
| Assessment Data | Nursing Diagnosis and Related Goals | Nursing Interventions and Rationale | Evaluation |
| Subjective
“I can’t… I can’t breathe.”
Objective
exacerbation of chronic obstructive pulmonary disease (COPD) due to left lower lobe pneumonia
three-day history of increasingly productive cough, difficulty breathing and fever
medical history includes COPD, osteoarthritis, gastroesophageal reflux disease (GERD) and atrial fibrillation (Afib)
alert oriented X3 Nasal cannula 2L/min SPO2 85% Resp 26 HR 79 BP 138/87 Temp 36.9 |
Nursing Diagnosis
Ineffective breathing pattern related to COPD diagnosis as evidenced by productive cough, difficulty breathing and fever.
Goals: short-term goal. The patient will be given teaching on how to properly take inhalers and medications as well as the importance of a healthy lifestyle and smoking cessation when it comes with COPD. She will receive this teaching 2 days prior to discharge date, in the meantime medication education will be reinforced each time medication is administered.
long-term goal. Further exacerbation will be prevented by monitoring closely the vitals signs, especially SPO2 and respiratory rate. Making sure SPO2 stays between 88-92. In this way she will not experience any COPD exacerbation within 5 months after discharge date. |
Nursing Interventions
1. Educate patient on impact of smoking. 2. Develop breathing exercises for client. 3. Monitor vital signs. 4. Educate on how to properly take medications. 5. Encourage healthy lifestyle.
Rationale
– Cigarette smoking is a major cause of COPD. – Will help strengthen breathing muscles and assist in getting m ore oxygen as well as breathing with less effort. – This will allow to quickly notice any decline in health. – After discussing the important of a healthy lifestyle and smoking cessation, encourage patient to apply changes to life. For example by setting a plan. |
Goal 1 – NOT MET – discharge date has not been set yet and therefore goal cannot yet be considered met.
Goal 2 – NOT MET – not enough time has passed to consider this goal has met |
References
Mayo Foundation for Medical Education and Research. (2020, April 15). COPD. Mayo Clinic. Retrieved March 22, 2023, from https://www.mayoclinic.org/diseases-conditions/copd/symptoms-causes/syc-20353679
WebMD. (n.d.). Breathing exercises for COPD patients. WebMD. Retrieved March 22, 2023, from https://www.webmd.com/lung/copd/copd-and-exercise-breathing-and-exercise-programs-for-copd#:~:text=When%20you%20do%20this%20for,and%20breathe%20with%20less%20effort.