NCP (NURSING CARE PLAN)

Name of Patient: _Disney Princess Scott Age: __33_ Sex: __F_ Room: __ ___Date: _________________
Admitting Diagnosis: ___COPD_______________________________ Attending Physician: _________________________Diet: __DAT____________
SCIENTIFIC
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
EXPLANATION
Subjective data: Acute pain related to In some cases, After 8 hrs. of nursing -Establish a therapeutic nurse- -building rapport makes Goal met.
Reports having a “chest discomfort associated individuals with intervention, the patient patient relationship the patient feel After 8 hrs. of nursing
cold” for 2 weeks. with respiratory respiratory will; comfortable intervention, the
Shortness of breath condition conditions may have -educate on breathing - reduce pain during patient;
techniques breathing
upon exertion. to exert more effort Maintain clear airways
-administer prescribed -help relieve asthma,
Experiencing pain in to breathe, such as for effective breathing COPD and other lung improved oxygenation,
bronchodilators or
lungs. in cases of severe expectorants condition symptoms reduced fever, alleviate
asthma or chronic Improve gas exchange -administer pain medication as -improved sense of the pain, and
Objective data: obstructive and oxygenation prescribed to alleviate chest overall well-being and decreased respiratory
Elevated temperature pulmonary disease pain or discomfort decrease intensity of pain distress
Productive cough (COPD). This Prevent infection and -Monitor Vs and saturation -check the level of
Rapid, labored increased respiratory promote recovery regularly physical functioning
respirations effort can strain the -maintain a calm and -help the patient increase
muscles involved in Alleviate or control pain reassuring environment to relaxation and decreases
reduce respiratory distress anxiety
breathing and lead to
-Collaborate with the -Collaboration ensures
a sense of that the assessment is
healthcare provider for
discomfort and pain. possible medication comprehensive and that
interventions for anxiety if all relevant factors are
necessary considered before
-arrange for follow-up deciding on treatment.
appointments and provide -to check the patient’s
discharge instructions for progress since the last
home care appointment

Bibliography: __________________________________________________________________________________________________________________________

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Name and Signature of Student Name and Signature of Clinical Instructor