JAYCEE M.

SABILE

Name: Patient X
Dx: Chronic obstructive Disease in exacerbation (copd)

SOAPIE

S=Ø

O= “ Received pt. lying on bed in semi fowlers position awake and

conscious with # 9 iL PNSS regulated @ 50 cc level locating @ left
arm. Patient is also attached to an oxygen via ventori mask @ 50%
F1O2 and V/S are = BP=140/80,PR=94,RR=32, and oxygen sat. of
95% with NGT and GCS score of = 10

A= Ineffective Airway clearance r/t chronic obstructive disease

(COPD)

P= After 3-4 hours of Nursing interventions, the pt. will maintain

airway patency

I= -Monitored V/S Q1
-Position head midline with flexion appropriate for age/ condition to
open or maintain open airway in at rest
-Suction naso/oral prn to clear airway when secretions are
blocking airway
-Elevate head of the bed/change position every 2 hrs. prn.
-Keep environment allergen free.
-Monitor for signs and symptoms of congestive heart failure .
-Provided supplemental humidification, if needed.
-Observed for signs and symptoms of infections

E= Partially met: the patient is able to attain/progress toward desired

outcome
JAYCEE M. SABILE

Name: Patient X
Dx: COPD in exacerbation

S=Ø

O= Received pt. lying on bed with IVF # 12 PNSS 1L +20 meqs

KCL@ 30 gtts/min with good back flow,patent on left arm on
NIPPV/BIPAP with parameters of IPAP -12,EPAP-14,Oxygen 10 LPM
with NGT in place in nuren diet, 100 Kcal/d in 6% feeding q4 with
initial vital signs of BP=150/90, PR= 91, RR=37, Oxygen sat.= 95%
with initial GCS of 15/15 with IFC

A= Ineffective Breathing Patterns r/t disease process

P= After 3-4 Hrs. of NI., the pt. will establish a normal respiratory
pattern aeb absence of cyanosis

I= -Monitored V/S and recorded q1

-Administered oxygen at lowest concentration indicated
-Monitor pulse oximetry as indicated to verify maintenance on
oxygen saturation.
-Maintained calm attitude whiledealing with patient
-Encourage position of comfort

E= Goal partially met. Patient establish a effective respiratory pattern

as evidenced by absence of cyanosis.