Student Name: Arenas, Junior
Date: Oct 7th, 2023
Miami Dade College
Medical Campus
Benjamín León School of Nursing
CARE PLAN
Medical Diagnosis:
COPD
Subjective Data:
Exacerbation of chronic obstructive pulmonary disease (COPD)
- Productive cough
- History of smoking 2 packs a day for 50 years
- Two exacerbations in the last year
Objective Data:
- O2 saturations: 94% on 2 L/min of oxygen per nasal cannula
- IV infusion of potassium chloride in 5% dextrose and normal saline at 100
mL/hr - Resting appearance
- Barrel chest
- Clubbed fingers
Priority Nursing Diagnosis:
Problem: Impaired Gas Exchange Etiology (related factor): Chronic obstructive
pulmonary disease (COPD) and decreased oxygen saturations Symptoms
(defining characteristics): - O2 saturations at 94% on 2 L/min of oxygen per
nasal cannula - Barrel chest - Clubbed fingers
Expected Outcome:
Maintain oxygen saturations above 92% - Demonstrate effective coughing and
clearing of airway secretions - Demonstrate improved respiratory status, with
decreased shortness of breath and increased activity tolerance Please note that
this information is generated based on the given scenario, and for an accurate
diagnosis and care plan, it is essential to consult a healthcare professional.
Nursing Actions:
*Must include assessment, interventions, and patient teaching, accompanied
by rationale for doing each.
Action
1. Monitor oxygen saturation levels
using pulse oximetry every 4
hours.
2. Nursing Intervention:
Administer supplemental oxygen
as prescribed to maintain
oxygen saturation above 92%
3. Assist the patient in
maintaining an upright position
or positioning him in
high Fowler's position
4. Nursing Intervention: Encourage
and assist with effective
coughing and deep breathing
exercises
5. Educate the patient on smoking
cessation strategies and provide
smoking cessation resources
Rationale
1. Regular monitoring of oxygen
saturation levels helps assess
the effectiveness of interventions
and identifies any changes in
respiratory status (Ackley,
Ladwig, & Makic, 2020)
2. Supplemental oxygen helps
improve oxygenation and tissue
perfusion, promoting optimal
gas exchange in patients with
impaired gas exchange (Ackley
et al., 2020)
3. An upright or high Fowler's
position promotes lung
expansion and improved
ventilation by reducing the
pressure on the diaphragm and
maximizing thoracic space
(Ackley et al., 2020).
4. Effective coughing and deep
breathing exercises help clear
airway secretions, prevent
atelectasis, and promote optimal
gas exchange (Ackley et al.,
2020)
5. Smoking cessation is crucial in
managing COPD and preventing
further decline in lung function.
Education and resources help
empower the patient to make
positive lifestyle changes (Ackley
et al., 2020)
References: Ackley, B. J., Ladwig, G.
B., & Makic, M. B. F. (2020). Nursing
Diagnosis Handbook: An EvidenceBased Guide to Planning Care (12th
ed.). Elsevier.