Clinical Care Plan #_1_
Medical Diagnosis
COPD with acute exacerbation
Subjective Data “I feel like I can’t catch my breath.”
Objective Data 99.2 86 17 156/70 95% (O2 2 Lpm via NC) Patient denies pain or discomfort at present.
Barrel chested. Orthopnea.
Nursing Diagnosis
Activity Intolerance related to fatigue, dyspnea, and an imbalance between oxygen supply and
demand as evidenced by orthopnea and weakness.
Short Term Goal #1 Patient will maintain O2 saturation at 92% or greater for next 3 days.
m
er as
co
Intervention 1. Maintain 02 at 2 LPM via NC prn per HCP orders.
eH w
2. Encourage patient to cough at bedtime, mealtimes, and when awakening.
o.
rs e
(0700,0800,1200)
ou urc
3. Teach patient to do pursed lip breathing with activities. Teach when patient
has less dyspnea between 0800 and 1500.
o
Rationale 1. The patient with COPD may need an oxygen flow of 2-4 L/min via NC or up to
aC s
40% via Venturi mask. (Ignatavicius, 563)
vi y re
2. Coughing effectively can improve gas exchange by helping increase airflow in
the larger airways. (Ignatavicius, 563)
ed d
3. Diaphragmatic or abdominal and pursed-lipped breathing may be helpful for
ar stu
managing dyspneic episodes. (Ignatavicius, 562)
is
Evaluation Goal not met.
Th
Short Term Goal #2 Patient will remain free of pulmonary edema for next 3 days.
sh
Intervention 1. Administer Lasix 40mg PO daily as ordered by HCP. (0900)
2. Weigh patient daily at same time with same clothes/bed linen. (0700)
3. Provide patient with low-sodium meals (avoid salty foods and adding table
This study source was downloaded by 100000831887191 from CourseHero.com on 10-16-2021 03:48:42 GMT -05:00
https://www.coursehero.com/file/32967789/COPD-care-plan-52418docx/
Medical Diagnosis
COPD with acute exacerbation
Subjective Data “I feel like I can’t catch my breath.”
Objective Data 99.2 86 17 156/70 95% (O2 2 Lpm via NC) Patient denies pain or discomfort at present.
Barrel chested. Orthopnea.
Nursing Diagnosis
Activity Intolerance related to fatigue, dyspnea, and an imbalance between oxygen supply and
demand as evidenced by orthopnea and weakness.
Short Term Goal #1 Patient will maintain O2 saturation at 92% or greater for next 3 days.
m
er as
co
Intervention 1. Maintain 02 at 2 LPM via NC prn per HCP orders.
eH w
2. Encourage patient to cough at bedtime, mealtimes, and when awakening.
o.
rs e
(0700,0800,1200)
ou urc
3. Teach patient to do pursed lip breathing with activities. Teach when patient
has less dyspnea between 0800 and 1500.
o
Rationale 1. The patient with COPD may need an oxygen flow of 2-4 L/min via NC or up to
aC s
40% via Venturi mask. (Ignatavicius, 563)
vi y re
2. Coughing effectively can improve gas exchange by helping increase airflow in
the larger airways. (Ignatavicius, 563)
ed d
3. Diaphragmatic or abdominal and pursed-lipped breathing may be helpful for
ar stu
managing dyspneic episodes. (Ignatavicius, 562)
is
Evaluation Goal not met.
Th
Short Term Goal #2 Patient will remain free of pulmonary edema for next 3 days.
sh
Intervention 1. Administer Lasix 40mg PO daily as ordered by HCP. (0900)
2. Weigh patient daily at same time with same clothes/bed linen. (0700)
3. Provide patient with low-sodium meals (avoid salty foods and adding table
This study source was downloaded by 100000831887191 from CourseHero.com on 10-16-2021 03:48:42 GMT -05:00
https://www.coursehero.com/file/32967789/COPD-care-plan-52418docx/
