Rasmussen – Fort Myers School of Nursing Student Name: Ana Scaliante
Professional Nursing 2 Care-plan Date: 07/22/2020 Date of Care: 07/22/2020
Clients Admitting Dx: COPD Room # or Client Initials:
NURSING DIAGNOSES-
(Form #1)
MINIMUM OF 6 Diagnoses
Nursing Definition of Related to As Evidenced By Rationalization for
Diagnosis Diagnosis Prioritization
(in your own words)
Inability to clear secretions or Increased production of Changes in depth/rate of Monitoring ABGs, pulse oximetry,
1 obstructions from the secretion or Hyperplasia of respirations, use of and chest x-ray establishes a baseline
Ineffective airway respiratory tract to maintain bronchial walls. accessory muscles. for monitoring progression or
clearance clear airway. regression.
Excess or deficit in Altered oxygen supply Inability to move secretions Assessing and recording respiratory,
2 Impaired gas exchange oxygenation and/or carbon (obstruction of airways by and abnormal breathing. depth is useful in evaluating the
dioxide elimination at the secretion). degree of distress or chronicity of the
alveolar-capillary membrane. disease.
Inspiration and/or expiration Ineffective inspiration and Nasal flaring, Assessing respiratory status every 2-
3 that does not provide expiration occurring with wheezes/crackles, or 4 hours to indicate distress, shortness
Ineffective breathing adequate ventilation. chronic airflow constraints. presence of non-productive of breath, and changes in mental
pattern cough. status.
At increased risk for being Chronic disease process. Chronic Obstructive Monitoring breathing, cough, and
4 Risk for infection invaded by pathogenic Pulmonary disease. adequate fluid intake to promote
organism. mobilization of secretions to reduce
risk of developing pulmonary
infection.
Insufficient physiologic or Imbalanced between oxygen Dyspnea and shortness of Assess respiratory response to
5 physiological energy to supply and demand due to breath. activity because COPD patients can
Activity intolerance endure or complete required inefficient work of breathing. experience hypoxia during increased
or desired activity. activity and may need O2.
Absence or deficiency of Lack of Statement of
6 Deficient Knowledge cognitive information related information/unfamil concerns/misconception Decreases anxiety and understanding
to specific topic. ia rity with can lead to improved participation in
information the treatment plan.
resources
Professional Nursing 2 Care-plan Date: 07/22/2020 Date of Care: 07/22/2020
Clients Admitting Dx: COPD Room # or Client Initials:
NURSING DIAGNOSES-
(Form #1)
MINIMUM OF 6 Diagnoses
Nursing Definition of Related to As Evidenced By Rationalization for
Diagnosis Diagnosis Prioritization
(in your own words)
Inability to clear secretions or Increased production of Changes in depth/rate of Monitoring ABGs, pulse oximetry,
1 obstructions from the secretion or Hyperplasia of respirations, use of and chest x-ray establishes a baseline
Ineffective airway respiratory tract to maintain bronchial walls. accessory muscles. for monitoring progression or
clearance clear airway. regression.
Excess or deficit in Altered oxygen supply Inability to move secretions Assessing and recording respiratory,
2 Impaired gas exchange oxygenation and/or carbon (obstruction of airways by and abnormal breathing. depth is useful in evaluating the
dioxide elimination at the secretion). degree of distress or chronicity of the
alveolar-capillary membrane. disease.
Inspiration and/or expiration Ineffective inspiration and Nasal flaring, Assessing respiratory status every 2-
3 that does not provide expiration occurring with wheezes/crackles, or 4 hours to indicate distress, shortness
Ineffective breathing adequate ventilation. chronic airflow constraints. presence of non-productive of breath, and changes in mental
pattern cough. status.
At increased risk for being Chronic disease process. Chronic Obstructive Monitoring breathing, cough, and
4 Risk for infection invaded by pathogenic Pulmonary disease. adequate fluid intake to promote
organism. mobilization of secretions to reduce
risk of developing pulmonary
infection.
Insufficient physiologic or Imbalanced between oxygen Dyspnea and shortness of Assess respiratory response to
5 physiological energy to supply and demand due to breath. activity because COPD patients can
Activity intolerance endure or complete required inefficient work of breathing. experience hypoxia during increased
or desired activity. activity and may need O2.
Absence or deficiency of Lack of Statement of
6 Deficient Knowledge cognitive information related information/unfamil concerns/misconception Decreases anxiety and understanding
to specific topic. ia rity with can lead to improved participation in
information the treatment plan.
resources
