OUR LADY OF FATIMA UNIVERSITY
College of Nursing
NURSING CARE PLAN
ASSESSMENT
SUBJECTIVE DATA:
The patient has smoking
history
No relief from over-the-
counter drugs for cough
Interview:
I: “How many stick of
cigarettes that you
consumed every day?”
Pt.: “I usually smoke 1-2
packs of cigarettes for 40
years”
I: “Even if you are already
have difficulty of breathing,
you still smoke?”
Pt.: “yes, I continue to
smoke” as verbalized by the
patient
NAME: SECTION: GROUP #
COURSE: DATE:
SCHEDULE:
Diagnosis: Chronic Obstructive Pulmonary Disease Patient’s Initials: HW
DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Impaired Adjustment as SHORT TERM GOAL: INDEPENDENT INTERVENTION: INDEPENDENT INTERVENTION: After 1 hour of nursing
evidenced by failure to 1 Establish rapport with the 1. Client involvement in intervention the patient was
After 1 hour of nursing
take actions that would patient decision making is an able to:
intervention the
prevent further integral part of care
patient will be able to:
complications delivery (Weber & 1. Identify harmful
1.Undestandand the Kelly 2018, Health contents of cigarette
common content of a Assessment in Nursing 2. Verbalize interest to
cigarette stick 6th edition) start a healthy
a. How it 2. The health belief lifestyle
affects the 2.Provide presentation about model proposes that a
body? harmful content of cigarettes person's health-
related behavior After 2 days of nursing
b. Example of
3. Explain possible depends on the intervention the patient was
complications
due to further complications of continuous person's perception of able to:
use of cigarette smoking four critical areas: the
a. Provide video severity of a potential 1. Cope up stress with
2.Identify stress
presentation illness, the person's stress coping
situations leading to
b. Provide time for susceptibility to that technique
cause of using
question and answer illness, and the
cigarette 2. Continue practicing
portion benefits of taking a
3. Increase Interest to changes on his
c. Allow patient to preventive action. (
commit in a new lifestyle
express concerns (n.d.). Retrieved
healthy lifestyle October 14, 2020,
from
LONG TERM GOAL: http://currentnursing.
After 2 days of nursing com/nursing_theory/
intervention the health_belief_model.
patient will be able to: html)
3. Imogene King’s theory
1. Verbalize interest to
of goal attainment has
start a healthy lifestyle
4.Provide stories of successful resulted in the
2. Develop ability to patient who completely development of a goal-
assume responsibility committed to lifestyle change oriented record that MCALIM2020
for personal needs a. Present videos of has been used by
documentation of health care
3. Initiate lifestyle
patients who survived practitioners.(George
changes that permits
COPD 2008, Nursing
adaptation for the
Theories: The Base for
current patient’s
Professional Nursing
situation
Practice 5th Edition)

4. Nursing intervention
are autonomous
actions based on
5. Explain lifestyle changes that scientific rationale
the patient should follow to where the patient is
avoid further complications. the beneficence
(Potter and Perry
2005, Fundamentals
of Nursing)
COLLABORATIVE
INTERVENTION:
5. Ida Jean Orlando and
COLLABORATIVE Ernestine Wiedenbach
INTERVENTION: both focused on
6. Counsel the patient with responding to a
psychologist for proper stress validated need of
coping technique without any patient.The concept of
involvement of abusive validating what the
substances client wants or needs,
as well as identifying
what capabilities the
client has, is an
important concept in
collaborative practice.
(George 2008, Nursing
Theories: The Base for
Professional Nursing
Practice 5th Edition)

MCALIM2020