Nursing Care Plan

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Medical Diagnoses: Impaired gas exchange, Alveolar-capillary membrane changes, ventilation-perfusion imbalance


Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale


Daughter reported patient exhibited “mood swings” and periods of “confusion.”  Client expressed she didn’t want to move “anymore than she has to.”

Hx of DM II, CAD



Temp:  101.0

Basilar rales bilaterally

Elevated BP (145/86)

Elevated HR (110)

Client is in atrial fibrillation w/ rapid ventricular response

EKG findings of inferior infarction and left axis deviation

Decreased urine output (0 ml/10 hours)

Elevated potassium level of 5.3

Elevated BUN (41)

Elevated Creatinine (1.73)

2x3, 1 inch depth stage II ulceration on coccyx

Unstageable ulceration on right heal

Presence of multiple tears on upper extremities

Client is NPO

Elevated blood glucose (185)

Yellow sputum production



Impaired gas exchange

Long Term:

Client will demonstrate improved ventilation and adequate oxygenation as evidenced by blood gas levels within normal parameters for this client by 09:00, [date].

-Assess nutritional status including serum albumin level and body mass index. Weight loss in a client with COPD ha a negative effect on the course of the disease; resulting in a loss of muscle mass and in the respiratory muscles which can lead to respiratory failure  (Celli & MacNee, 2004, pg).

-Help the client eat small frequent meals and use dietary supplements as necessary.  Having a BMI less than 21 has been associated with earlier mortality in patients with COPD  (Schols et. al, 1995)
-monitor patient’s blood gas levels


Alveolar-capillary membrane changes, ventilation-perfusion imbalance


Short Term:

Client will maintain clear lung fields and remain free of signs of respiratory distress by 12:30, today.

-Monitor respiratory rate, depth and effort.

-Monitor client’s behavior and mental status for the onset of restlessness.  Changes in a client’s mental status can be an early sign of impaired gas exchange  (Simmons & Simmons, 2004).

-Monitor client’s oxygen saturation continuously by pulse oximetry.  The goal of inpatient therapy for the client with COPD is to maintain the oxygen saturation greater than 90% and PaO2 at or above 80 mm Hg to maintain cellular oxygen  (Celli & MacNee, 2004)

-Position client in the semi-Fowler’s position.  Research indicates that the 45 degree position facilitates breathing and reduces the risk of pneumonia (Speelberg & Van Beers, 2003).

-Remind the client to breathe through his nose and not his mouth



Altered BP outside of acceptable parameters, oliguria (0 ml/10 hr), dysrhythmias, altered respiratory rate (24), decreased Hgb (10.2), decreased albumin (2.0), bilateral lobar rales, 90% oxygenation status on room air

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