Nursing Care Plan
Pneumothorax, COPD, Emphysema, Malnutrition, Alzheimers, Dementia, Atrial Fibrillation
Nursing DX/Clinical Problem
Client Goals/Desired Outcomes/Objectives
Client verbalized statements indicative of confusion.
Client has a chest tube to treat a pneumothorax. Client has an increased AP diameter. Client was breathing through his mouth
and not his nose (which had a nasal cannula).
O2 saturation was in the 80’s while patient was mouth-breathing and in the
90’s while nasal breathing.
Client had an abnormal breathing pattern, restlessness, and visual
Problem: Impaired gas exchange
Client will demonstrate improved ventilation and adequate
oxygenation as evidenced by blood gas levels within normal parameters for this client
by 09:00, 2/23/09.
-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).
-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
Evaluation of this goal is set for 22:00, [Month] 23, [Year].
Reminders to breathe through his nose improved pulse oximetry measurements
of saturation. Some progress made towards
Client’s serum albumin is low and the BMI is 16.2. Assessment complete, continued
monitoring required. Help client eat
sorbet, administered nutritional supplements.
Intervention achieved today, continuation required.
Blood gas levels not drawn, this intervention not achieved, re-evaluation set for
22:00, [Month] 23, [Year].
Alveolar-capillary membrane changes and ventilation-perfusion imbalance
Client will maintain clear lung fields and remain free
of signs of respiratory distress by 12:30,
-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
Client’s lung fields were
clear to auscultation and client was calm and free of signs of respiratory distress
by 12:30, [Month] 17, [Year].
Monitored client’s respiratory
rate, depth, effort, behavioral and mental status.
Monitored client’s pulse oximetry and cued client to breathe through nose
when SaO2 dropped below 90%.
Positioned client in the semi-Fowler’s
position to facilitate breathing. Client’s
SaO2 and calm demeanor indicative of no respiratory distress, interventions successful.
Pulse oximetry below 90%, barrel chest, restlessness,
confusion, visual disturbances (hallucinations), abnormal breathing pattern.
*I = Implementation. Check those interventions/actions/orders
that were implemented.
Nursing Care Plan
Medical Diagnoses: Pneumothorax, COPD,
Emphysema, Malnutrition, Alzheimers, Dementia, Atrial Fibrillation
Client not hungry, turns away from food, spits it out,
expressed confusion regarding where he was
Client has developed urinary incontinence, hyperactive
bowel sounds upon auscultation, change in bowel pattern, unable to pass stool, and
no BM within the past 7 days, and
has a serum K+ and Ca+ level that are
Client will maintain passage of soft, formed stool every
1-3 days without straining by 12:00, [Month] 19, [Year].
-Promote regular consistent toileting each day based on the client's
triggering meal. Safeguard the client's visual and auditory privacy when toileting
Evaluation of this goal is set for 17:00, [Month] 23, [Year].
No progress made.
Evaluation of this intervention is set for 17:00, [Month] 23, [Year]. Intervention
unsuccessful to date. Further evaluation
Inadequate toileting, insufficient physical activity,
mental confusion, calcium carbonate supplements, and electrolyte imbalance.
Client will have a bowel movement
within 6 hour shift on [Month] 17, [Year].
-Assess client’s bowel hx, determine date of last bowel
-Palpate for abdominal distention, auscultated for bowel
sounds. In clients with constipation,
the abdomen is often distended and tender, bowel sounds are present
(Hinrichs, et al, 2001)
-Provide laxatives, stool softeners
and enema as ordered
-When giving soap suds enema, measure
the amount of fluid given and the amount expelled.
Enema fluid can be retained and damage epithelium
(Hinrichs, Huseboe, & Tang, 2001)
Client did not have a bowel
movement. Goal not achieved.
Further assessment required to facilitate achievement of the goal.
Assessed client’s bowel movement
history, palpated for abdominal distention (none present), and auscultated bowel
sounds (hyperactive). No tenderness
noted. Provided laxative, stool softener
and enema as ordered. Measured amount
instilled, estimated amount expelled.
Interventions achieved but were unsuccessful.
Further assessment required to reevaluate interventions utilized and whether
they meet the underlying issue.
Patient self-assessment of
pain rated an 8 on a scale 0f 0-8, generalized pallor, self-report of nausea r/t
pain quality, restlessness, and distractibility.
AHRQ. (2005). National Guideline Clearinghouse.
Retrieved [Month] 20, [Year], from Prevention of constipation in the older adult
Celli, B. R., & MacNee, W. (2004). ATS/ERS Task
Force: Standards for the diagnosis and treatment of patients with COPD: a summary
of the ATS/ERS position paper. European Respiratory Journal , 23 (6),
Hinrichs, M., Huseboe, J., & Tang, J. H. (2001).
Research-based protocol. Management of constipation. Journal of Geronological Nursing
, 27 (2), 17.
Schols, A. M., Soeters, P. B., & Mostert, R. et
al. (1995). Physiologic effects of nutritional support and anabolic steroids in
patients with chronic obstructive pulmonary disease. A placebo-controlled randomized
trial. American Journal of Respiratory Critical Care Medicine , 152
Simmons, P., & Simmons, M. (2004). Informed Nursing
Practice: The Administration of Oxygen to Patients with COPD. MedSurg Nursing
, 13 (2), 82-85.
Speelberg, B., & Van Beers, F. et al. (2003). Artificial
ventilation in the semi-recumbent position imrpoves oxygenation and gas exchange.
Chest , 124 (4), 203S.