Republic of the Philippines

Cebu Normal University

Osmeña Blvd. Cebu City, 6000 Philippines

College of Nursing
Center of Excellence (COE) | Level IV Re-Accredited (AACCUP)
Telephone No.: (032) 254 4837
Email: cn@cnu.edu.ph/secretary@cnunursing.org
Website: www.cnu.edu.ph

Theory-based (Betty Neuman)

NURSING CARE PLAN
Assessment 3 points Goals 2 points Interventions 4 points Bibliography
Diagnosis 3 points Theoretical Basis 2 points Evaluation 1 point 15 points

Name of Student: Lopez, Fritzie Vanbelle U,._______________

Client’s Initials:__P.F._____________________________________ Stressor Classification: (Please check)
Age:__74__Gender: _M___Civil Status:_Married_Religion:_N/A_ __/___ Physiological (body structure and functions)
Allergies: __none___________________________________________ ______ Psychological (mental processes and emotion)
Diet:__DAT________________________________________________ ______ Socio-cultural (relationships, social expectations)
Date of Admission:___November 8, 2020___________________ ______ Spiritual (influence of spiritual beliefs)
Diagnosis/Impression:__Chronic Bronchitis____________________ ______ Developmental (developmental processes over the lifespan)
NURSING DIAGNOSIS NURSING GOALS NURSING OUTCOME
Assessment Diagnosis Mutual Planning Interventions Actual Evaluation
(Goal attainable within the shift) (with Rationale & Source)
Subjective: SHORT TERM GOAL PRIMARY INTERVENTIONS Nursing Goals were
 “Maglisod kog ginhawa Impaired gas exchange related After 8 hours, the patient will Promotive: almost met;
mam”, as verbalized by the to obstruction of airways as be able to: I: Assess and record respiratory rate, depth. Note the use
of accessory muscles, pursed-lip breathing, inability to
patient. evidenced by dyspnea,  maintain optimal gas patient’s RR
speak or converse.
wheezing, restlessness, exchange as evidenced R: Useful in evaluating the degree of respiratory distress
reduced, but only to
 As per wife, patient decreased oxygen saturation, by usual mental status, or chronicity of the disease process. 26cpm (still not
experiences shortness of and increased PCO2 unlabored respirations S: [ CITATION Mat195 \l 13321 ] within the desired
breath whenever he walks at 12-20 per minute, normal range); O2
more than 10 feet and oximetry results within I: Assess and routinely monitor skin and mucous sat raised to 95%;
membrane color. SOB still present,
usually has cough that gets normal range, blood
R: Cyanosis may be peripheral (noted in nail beds) or
worse in the morning with gases within normal central (noted around lips/or earlobes). Duskiness and
and patient agrees to
a gray colored sputum. range, and baseline HR central cyanosis indicate advanced hypoxemia.
 History of smoking 30 Theoretical basis: for patient. S: [ CITATION Mat195 \l 13321 ]
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 sticks of cigarettes/day Gas is exchanged between the
alveoli and the pulmonary
capillaries via diffusion.
Objective: Diffusion of oxygen and
 dyspnea carbon dioxide occurs
 wheezing passively, according to their
concentration differences
 restlessness
 coughing across the alveolar-capillary
 nail clubbing barrier. These concentration
 ABG values: differences must be
pH = 7.236 maintained by ventilation
PO2 = 4.7 (airflow) of the alveoli and
perfusion (blood flow) of the
PCO2 = 8
pulmonary capillaries.
 vital signs:
T = 37.1 ͦC
[ CITATION Gil17 \l 13321 ]
PR = 85 bpm
Chronic bronchitis is the
RR = 31 cpm
widespread inflammation of
BP = 130/80 mmHg
airways with narrowing or
02 Sat = 94%
blocking of airways and
PS = 1/10 (upon
increased production of
inhalation)
mucoid sputum with marked
cyanosis.
The quantity and viscosity of
sputum can obstruct the
airway and impair pulmonary
ventilation and gas exchange.
[ CITATION Mat195 \l 13321 ]
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 maintain clear lung
I: Monitor changes in the level of consciousness and
fields and remain free
mental status.
of signs of respiratory R: Restlessness, agitation, and anxiety are common
distress. manifestations of hypoxia. Worsening ABGs accompanied
 verbalize by confusion/ somnolence are indicative of cerebral
understanding of dysfunction due to hypoxemia.
S: [ CITATION Mat195 \l 13321 ]
oxygen and other
therapeutic I: Monitor oxygen saturation continuously, using pulse
interventions. oximeter.
R: Pulse oximetry is a useful tool to detect changes in
oxygenation. An oxygen saturation of <90% (normal: 95%
LONG TERM GOAL to 100%) or a partial pressure of oxygen of <80 (normal:
80 to 100) indicates significant oxygenation problems.
After 3-5 days, the patient
S: [ CITATION Doe16 \l 13321 ]
will:
 demonstrate improved I: Monitor arterial blood gasses values as ordered.
ventilation and R: As the patient’s condition progresses, Pa02 usually
adequate oxygenation decreases. For patient’s with chronic carbon dioxide
of tissues by ABGs retention may have chronically compensated respiratory
acidosis with a low normal pH and a PaCo2 higher than 50
within patient’s normal
mm Hg.
range and be free of
S: [ CITATION Doe16 \l 13321 ]
symptoms of
respiratory distress. Preventive:
 participate in treatment I: Assess the patient’s ability to cough out secretions. Take
regimen within the note of the quantity, color, and consistency of the sputum.
level of R: Retained secretions weaken gas exchange.
S: [ CITATION Gil17 \l 13321 ]
ability/situation.
I: Evaluate the level of activity tolerance. Limit patient’s
activity or encourage bed or chair rest during the acute
phase.
R: During severe, acute or refractory respiratory distress,
the patient may be totally unable to perform basic self-care
activities because of hypoxemia and dyspnea. Rest
interspersed with care activities remains an important part
of the treatment regimen.
S: [ CITATION Gil17 \l 13321 ]
I: Evaluate sleep patterns, note reports of difficulties and
whether patient feels well rested. Provide quiet
environment, group care or monitoring activities to allow
 periods of uninterrupted sleep; limit stimulants such as
caffeine; encourage position of comfort
R: Multiple external stimuli and the presence of dyspnea
may prevent relaxation and inhibit sleep.
S: [ CITATION Gil17 \l 13321 ]

SECONDARY INTERVENTIONS
Curative
I: Position patient with head of bed elevated, in a semi-
Fowler’s position (head of bed at 45 degrees when supine)
as tolerated.
R: Upright position or semi-Fowler’s position allows
increased thoracic capacity, full descent of diaphragm, and
increased lung expansion preventing the abdominal
contents from crowding.
S: [ CITATION Gil17 \l 13321 ]

I: Maintain an oxygen administration device as ordered,

attempting to maintain oxygen saturation at 90% or
greater.
R: Supplemental oxygen may be required to maintain
PaO2  at an acceptable level.
S: [ CITATION Gil17 \l 13321 ]

I: Do chest physiotherapy.
R: Chest percussion helps loosen and mobilize secretions
in smaller airways that cannot be removed by coughing or
suctioning.
S: (Wayne, 2017)

I: Help patient deep breathe and perform controlled

coughing. Have patient inhale deeply, hold breath for
several seconds, and cough two to three times with mouth
open while tightening the upper abdominal muscles as
tolerated.
R: This technique can help increase sputum clearance and
decrease cough spasms. Controlled coughing uses the
diaphragmatic muscles, making the cough more forceful
and effective.
S: [ CITATION Gil17 \l 13321 ]

I: Administer medications as prescribed.

R: It depends on the etiological factors of the problem
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 (e.g., antibiotics for pneumonia, bronchodilators for
COPD, anticoagulants and thrombolytics for pulmonary
embolus, analgesics for thoracic pain).
S: [ CITATION Doe16 \l 13321 ]

TERTIARY INTERVENTIONS
Rehabilitative
I: Provide reassurance and reduce anxiety.
R: Anxiety increases dyspnea, respiratory rate, and work
of breathing.
S: [ CITATION Gil17 \l 13321 ]

I: Pace activities and schedule rest periods to prevent

fatigue. Assist with ADLs.
R: Activities will increase oxygen consumption and
should be planned so the patient does not become hypoxic.
S: [ CITATION Doe16 \l 13321 ]

I: Instruct family in complications of disease and

importance of maintaining medical regimen, including
when to call physician.
R: Knowledge of the family about the disease is very
important to prevent further complications.
S: [ CITATION Gil17 \l 13321 ]

Bibliography
Doenges, M. E., Moorhouse, M., & Murr, A. C. (2013). Nurse's Pocket Guide (13th ed.). Philadelphia: F.A. Davis Company.

Vera, M. (2019, September 28). 7 Chronic Obstructive Pulmonary Disease (COPD) Nursing Care Plans. Retrieved from Nurseslabs: https://nurseslabs.com/chronic-obstructive-pulmonary-
disease-copd-nursing-care-plans/2/

Wayne, G. (2017, September 4). Impaired Gas Exchange Nursing Care Plan. Retrieved from Nurseslabs: https://nurseslabs.com/impaired-gas-exchange/

Cebu Normal University Document

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