NURSING CARE PLAN COPD (COMPLETED) GRADED A; PT PRESENTED AT ED WITH C/O SOB AND DYPSNEA

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NURSING CARE PLAN COPD (COMPLETED) GRADED A; PT PRESENTED AT ED WITH C/O SOB AND DYPSNEA Assessment (Supporting data) Nursing Diagnosis (NANDA diagnostic statement) Goals & Expected O... utcomes (Realistic, timed, measurable) Nursing Interventions (Strategies or actions for care) Rationale for interventions Evaluation (Client’s response to nursing actions & progress toward achieving goals & outcomes) Subjective: Pt presented at ED with C/O SOB and dypsnea Objective: Pt was hypoxemic at admission; spoke in short sentences; used acc. muscles when breathing Ineffective airway clearance r/t secretions in bronchi and obstructed airway aeb hypoxemia and dypsnea Pt will maintain a patent airway at all times Pt will demonstrate improved ventilation and adequate oxygenation within normal parameters for her as evidenced by blood gas levels before d/c Pt will maintain clear lung fields and remain free of signs of respiratory distress throughout hospital stay Pt will Demonstrate effective coughing techniques after teaching session ✓Monitor resp. rate, depth, and effort, use of accessory muscles, nasal flaring, and abnml breathing patterns. ↑ respiratory rate, use of accessory muscles, nasal flaring, and abdominal breathing may indicate hypoxia. ✓Auscultate breath sounds Q1- 2 °. Presence of crackles, wheezes may signify airway obstruction, leading to or exacerbating existing hypoxia. ✓Observe sputum, noting color, odor, and volume. Normal sputum is clear or gray and minimal; abnormal sputum is green, yellow, or bloody; malodorous; and often copious. Pt’s airway remained open Pt’s lungs remained free of new onset wheezes Pt demo’d effective coughing techniques for student nurse [Show More]

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