You are on page 1of 2

Patient Room Number _______ Age _____ M/F ___ CODE Status full code

__________
Primary Medical Diagnosis Reason for Admission
COPD Exacerbation, Hypotension
Secondary Medical Diagnoses List all that impact patients care
A-Fib
Nursing Care Plan for PRIORITY Physiological Nursing Diagnosis
Nursing Diagnosis in PES Format Patient Expected Outcome Individualized & Prioritized Nursing
(measurable and with time Interventions with Referenced
frame) Evidence/Rationale
P Ineffective airway clearance Client will demonstrate a 1.Assess respirations and breath sounds
reduction noting rate
Of congestion with breath And sounds (e.g. tachypnea, stridor, crackles
sounds or
More clear, noiseless Wheezes) indicative of respiration distress an
respirations, or
And improved oxygen exchange Accumulation of secretions
by
E r/t retained secretions/infection 2/18/16
Secondary to COPD
2. Treatment- administer medications (e.g.
Expectorants, anti-inflammatory,
bronchodilators,
S a.e.b. dyspnea and diminished Mucolytic agents, antibiotics,) to relax smooth
Adventitious breath sounds Respiratory musculature, reduce airway
edema,
AEB Mobilize secretions, decrease infection
Defining Characteristics Use Ackley Absence of cyanosis
text book did you pick the correct ABG/pulse oximetry results 3.Teach- Deep breathing, coughing exercises,
diagnosis? within
Client norms. Incentive spirometry, to maximize productive
Adventitious lung sounds Coughing and movement of secretions
decrease
By 40%

4.Discharge- Provide information about the


necessity
Of raising and expectorating secretions versu
Swallowing them. Report change in color and
Amount in the even that medical intervention
May be needed to prevent or treat infection