CARE PLAN

Assessment
CC: chest
discomfort and
SOB
DX: COPD;
Morphine-induced
respiratory
depression
Past Surgeries/
Medical History:
Atrial Fibrillation,
pacemaker, HTN,
Congestive Heart
Failure,
Gastroesophageal
Reflux Disease,
Closed Fracture of
Left Humerus, hx
of back surgery, hx
of Left
Intertrochanteric
hip fracture surgery
Subjective Data:
84 yr old patient
states I need an
ash tray where my
ash tray? Pt states

NANDA Nursing
DX
1. Impaired Gas
exchange r/t
ventilationperfusion
inequality as
evidenced by
diminished breath
sounds bilateral
lobes, O2 sat
below 90%,
expiratory
wheezes,
occasional
tachycardia
114bpm, and
intermittent
confusion.

Plan/ Goal

Interventions

Evaluation

1. Patient will experience

improved ventilation and
adequate perfusion of tissues
within 8hrs AEB audible breath
sounds with decreased
expiratory wheezing, O2 sat
maintained above or at 90%,
Heart rate decreased to 60100bpm, improved neurological
status noted by less confusion
and more orientation to person,
place and thing.

1. (A) Assess VS B/P, P, R, T every

2hrs and PRN as needed.
(Ignatavicius & Workman 2013)

1.Goal partially met AEB

breath sounds more
audible less diminished
bilateral lobes, occasional
expiratory wheezes
remain present, O2 sat at
2100 91%, HR- 91, R18, intermittent confusion
remains pt. oriented X1
to person. Will Continue
POC and reevaluate upon
discharge.

(B) Assess Respiratory Status

noting rate, rhythm, depth and ease
Q2hrs and PRN as needed. (Ackley
& Ladwig 2014)
(C) Assess O2 Sat continuously
every shift. Encourage and teach
the use of incentive spirometer
Q2hrs while awake and PRN
(Ignatavicius & Workman 2013)
(D) Administer Oxygen via NC at
2L/min continuously as ordered by
physician. (Ignatavicius &
Workman 2013)
(E) Assess Neurological Status
Q4hrs and PRN noting PERRLA,
alertness and orientation status.
(Ignatavicius & Workman 2013)

2. Ineffective tissue 2. Patient will have improved

perfusion r/t
tissue perfusion throughout
altered hemoglobin body within 8hrs AEB oxygen

2. (A) Assess Cardiovascular and

Respiratory status Q2hrs and PRN
noting heart rate, rhythm, and

2. Goal partially met

AEB heart rate remained
irregular ranging between
88-114bpm, EKG

I smoked for over

34years. Pt denies
any pain or
difficulty breathing
at this time. Pt rates
pain on scale 0-10 a
0. Pt states Ive
had several falls
Inquired as to what
happens to cause
falls. Pt stated I
get weak and dizzy
and fall, I dont
know. Pt keeps
talking to
imaginary person
on wall calling
them Linda. Saying
Linda wheres my
ashtray? Linda is
patients daughters
name.

for oxygen and

impaired transport
of oxygen AEB
abnormal EKG
rhythm
occasionally no Pwaves before QRS
waves, irregular
fluctuating heart
rate, decreased O2
sat below 90%,
Low Blood counts
Hemoglobin- 9.7,
Hematocrit- 29.3,
RBC- 3.24

Objective Data:
Pt admitted from
ER to ICU due to
morphine-induced
respiratory
depression. Patient
alert, confused at
times, mild
hallucinations,

3. Ineffective
breathing pattern
r/t compromised
cardiac and
pulmonary
function and
decreased lung
expansion AEB O2
sat fluctuating

sat remaining above 90%,

increase in Hemoglobin (13-18)
normal range, Hematocrit (3644) normal range, more
stabilization/normalization in
EKG waves more P-waves
before QRS. And capillary refill
less than 3 sec.

quality, assess capillary refill and

note respiratory rate, sound and
quality. (Ackley & Ladwig 2014)
(B) Monitor Chest x-ray, EKG, and
ABGs and CBC as ordered per
physician. (Ackley & Ladwig
2014)
(C) Administer IV fluids D5W in
0.45% NaCL continuously at
75cc/hr per physicians order

remained abnormal
occasional no P waves
noted before QRS,
Hemoglobin-9.7,
Hematocrit-29.3, RBC3.24, and O2 sat at 2100
91%, and capillary refill
<3sec. Will continue
current POC and revise
and reevaluate as needed.

(D) Assess O2 Saturation

continuously and administer O2 via
NC @ 2L/min as ordered per
physician. (Ignatavicius &
Workman 2013)
(E) Encourage and Teach Patient
how to cough and deep breathe
Q2hrs and PRN as needed
(Ignatavicius & Workman 2013)
3. Patient will have a more
effective breathing pattern
within 8hrs AEB O2 saturation
above 90% at all times during
hospital stay, breath sounds
more audible during
auscultation, resp rate
remaining within normal range
of 12-20 per/min, decrease or

3. (A) Monitor Respiratory status

noting rate, rhythm, effort, O2
saturation, Q2hrs and PRN (Ackley
& Ladwig 2014)
(B) Keep head of bed elevated to at
least 45 degree angle at all times Q
shift. (Ackley & Ladwig 2014)

3. Goal partially met

AEB O2 sat at 2100 91%,
breath sounds slightly
more audible still
diminished some in
middle lobes, resp-18,
occasional expiratory
wheezes remain.
Continue POC until
hospital discharge and

PERRL noted,
Patient weak
limited ROM all
extremities, skin
dry, cool and
appropriate for age
and race, irregular
apical pulse heart
rate and rhythm at
88-114 bpm,
pacemaker noted to
upper chest wall,
capillary refill 4
sec, Oxygen via NC
infusing at 2L/min,
lung sounds slightly
diminished on
auscultation
bilaterally,
occasional
expiratory wheezes
noted, dry cough,
no sputum noted,
bowel sounds
active X4 quads,
Foley urinary
catheter in place
draining clear dark
yellow urine 175
cc, posterior tibial
and pedal pulses
palpable bilaterally,
lower extremities

between 87-92%,
Resp rate 22,
diminished breath
sounds bilaterally
to middle lobes,
occasional
expiratory wheezes

absence in expiratory wheezes.

(C) Administer Oxygen via NC

continuously at 2L/Min per
physicians order (Ignatavicius &
Workman 2013)

reevaluate as needed

(D) Encourage and teach incentive

spirometer and cough deep
breathing exercises Q2hrs and PRN
(Ignatavicius & Workman 2013)
(E) Administer Nebulizer
treatments DuoNeb 0.5-2.5mg/3ml
1 amp QID per physicians order

4. Activity
Intolerance r/t
imbalance between
oxygen supply and
demand AEB SOB
noted when
maneuvering pt. to
change diaper after
BM episode, O2
sat dropped to 87%
while turning in
bed, use of
accessory muscles
to catch breath
after maneuver,
fluctuation of resp.
rate from 17-22,
increase in HR
114, abnormal

4. Patient will demonstrate

increase tolerance to activity
within 8hrs AEB O2 sat
remaining above 90% during
activity/movement, respirations
remain within normal range 1220/min during activity, HR
remaining between normal rates
60-100 with movement/activity.

4. (A) Teach and assist patient with

controlled breathing techniques
during movement and activity
including pursed lip breathing, and
inspiratory muscle use Q2hrs and
PRN. (Ackley & Ladwig 2014)
(B) Make sure Oxygen remains on
and infusing at 2L/min via NC at
all times per physician orders
(Ignatavicius & Workman 2013)
(C) Assist and Teach patient about
ROM exercises of unaffected
extremities Q4hrs and change
position using log-rolling technique
Q2hrs (Ackley & Ladwig 2014)
(D) Evaluate CBC and CMP noting

4. Goal not met AEB O2

continuing to fluctuate
between 87-92%,
respirations at 2100
18/min, HR continuing to
be abnormal in rhythm
and fluctuate between 88114 bpm, EKG remains
abnormal. Continue
current POC for 48hrs
and re-evaluate

coo and dry to

touch, SCD devices
noted bilaterally to
legs. IV 22G
infusing to right
inner wrist at
75ml/hr. IV fluids:
(5% Dextrose/
0.45% NaCl).
Dressings noted to
left arm and Left
hip area. Both
dressings clean, dry
and intact.

EKG readings.

5. Ineffective
Health
Vital Signs:
Maintenance r/t
1630= B/P 150/99, deficient
T- 97.3, P-88, R-17, knowledge
O2 sat- 87- 90%,
regarding care of
2005= B/P 150/90, chronic lung
T- 96.8, P-114, Rdisease COPD
22, O2 sat-92%
AEB patient keep
2100= B/P 139/85, asking wheres
T-96.3, P-91, R-18, my ashtray? , pt.
O2 sat- 91%
has smoked for
over 34 years
Hospital Meds:
Aspirin 81mg QD
PO
D5W-0.45% NaCL
Bag 1000 ml
Continuous IV

blood count, glucose level, albumin

and protein numbers and consult
with dietician as needed to improve
nutrition which may help increase
inspiratory muscle function and
decrease dyspnea (Ackley &
Ladwig 2014)
(E) Consult with PT, OT to evaluate
and treat patient with strengthening,
and endurance exercises per
physicians order (Ackley &
Ladwig 2014)
5. Patient and family will
demonstrate understanding of
health care maintenance
regimen concerning COPD by
disharge AEB verbalization of
knowledge about the body
destruction COPD causes,
identify reasons and desire for
smoke cessation, demonstrate
breathing techniques that will
increase tissue perfusion,
willingness to seek support
from COPD groups/resources.

5. Goal not met AEB

5. (A) Assess patient and familys
patient continuing to ask
feelings, values, and reasons for not for ashtray and
following COPD health
intermittent confusion,
maintenance. (Ackley & Ladwig
unable to teach patient
2014)
proper breathing
techniques due to
(B) Help patient and Family learn
confusion alternating
about medication/modalities that
with sleep, and Pt in ICU
help with smoking cessation.
family only present
Identifying oral medication as well during a specified time
as nicotine patches. (Ackley &
frame. Revise and
Ladwig 2014)
Reevaluate POC.
(C) Teach Patient and Family about
the pathophysiology of COPD and
how it affects tissue perfusion, as
well as heart and lung functions.
(D) Teach patient and family about

Ferrous Sulfate
325mg QD PO,
Heparin Sodium Inj
subq 5000u Q8hr 1
ml dose, HCTZ
12.5 mg PO QD
Lisinopril 20mg PO
QD, PiperacillinTazobactum inj
3.375GM Q8hrs in
NACl 0.9% 100ml
IVPB, Simvastatin
20 mg PO at hs,
Sotalol HCL 80 mg
PO BID,
Vancomycin HCL
Inj 1GM IV once
daily, Duoneb 0.52.5mg/3ml via
nebulizer PO, PRN
meds: Benadryl PO
Q4hrs PRN, Norco
5-325mg PO Q6hr
PRN, Zofran 4 mg
PO Q8hr PRN
Home Meds:
Lisinopril 20mg
PO QD, Sotalol
80mg PO BID,
Zocor 20 mg PO @
hs, Xarelto 20 mg
PO QD, Norco

breathing techniques (pursed-lip

breathing, cough and deep
breathing exercises) and allow
return demonstration. (Ignatavicius
& Workman 2013)
(E) Teach patient about prescribed
medication for COPD and how they
work to increase lung capacity and
function. Also help patient find
local support groups/information
related to COPD. (Ackley &
Ladwig 2014)

5/325mg PO PRN,
Miralax 17GM PO
QD, Aspirin 81mg
PO QD, MOM
30ml PO Q12hr
PRN, Duoneb via
neb PRN SOB,
Citalopram 20mg
PO @hs
Diagnostic Studies:
6/9/14 Chest x-ray
small pleural
effusion left side
Glucose 130H
RBC 3.24L
Hemoglobin 9.7L
Hematocrit 29.3L
K+ 3.4L
BUN 20H

Reference:
Ackley, B., & Ladwig, G. (2014). Nursing Diagnosis Handbook: An Evidenced-Based Guide to Planning Care.
Maryland Heights, MO: Mosby, INC
Ignatavicius, D., & Workman, M. (2013). Medical-Surgical Nursing: Patient-Centered Collaborative Care. 7th ed. St. Louis, MO: Saunders, INC