Patient Information.

65-year-old male experiencing shortness of

breath with exertion due to COPD exacerbation. Patient has a
history of COPD and Hypertension. Patients ABG results show
respiratory acidosis. Pt wants to feel better and is willing to work
towards this goal.

Priority 1 Priority 2 Priority 3

Nursing Diagnosis: Ineffective Nursing Diagnosis: Impaired
Nursing Diagnosis: Ineffective
Breathing Pattern related to Gas Exchange related to COPD
Airway Clearance related to
COPD exacerbation as evidenced by ABG results
wheezing heard during
auscultation of lung sounds

Outcome: Maintain effective Outcome: Maintain clear Outcome: ABG results return
breathing pattern while airways with normal breath to normal levels before patient
performing activities by the sounds both at rest and when is discharged.
end of the day. performing any ADLs.

Nursing Interventions:
Auscultate lungs sounds during
head-to-toe assessment and
also before and after any
breathing treatments.
Nursing Interventions:
Administer proper medications
and nebulizer treatments and
then document the patient’s
response.
Nursing Interventions:
Monitor respiratory effort,
depth and rate as ordered to
ensure patient is getting
appropriate air movement.

Monitor patients SPO2 as
ordered to ensure adequate
saturation.
Provide supplemental oxygen
as ordered and document the
patients response.
Evaluation: Patient was able to
maintain a normal breathing
pattern while at rest, but while
attempting to perform ADLs
the patient becomes short of
breath and has a drop in SPO2.
Patient will continue to be
monitored and treated to meet
this goal.
Collaborate with other Monitor arterial blood gas
healthcare professionals as levels as ordered to determine
appropriate to provide the patients’ current respiratory
patient with the best possible status.
care and outcome.
Make sure to schedule care
Eliminate any barriers to activities that also allow the
airway clearance such as patient to get enough rest.
improper positioning.
Evaluation: Patients ABGs have
returned to normal levels.
Evaluation: Patient has
maintained clear airways as
evidenced by clear lung sounds
upon auscultation of the lungs
during assessment.