LORMA COLLEGES CON TEMPLATE

NURSING CARE PLAN

RELATED NURSING EXPERIENCE
STUDENT NAME: Valdriz Joshua B.. ROTATION: 1ST ROTATION AREA:
YR LEVEL & SEC: BSN-III Jean Watson DATES: 14 15 16 21 22 23 28 CLINICAL INSTRUCTORS: Sir Randy B. Sandoval

PROBLEM: COPD exacerbations DIAGNOSIS: COPD

PRIORITIZATION: Relief of difficulty of breathing DATE: 09/10/20

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective Ineffective airway Within a minute of Assess the vital Assessing the vital Patients vital signs has
“The patient has a breathing related to nursing intervention signs of the patient. signs of the patient a little improvement
long history of increased product of patients difficulty of Assist the client in to know if there’s unlike before. Patient
cardiopulmonary secretions breathing will be proper positioning. changes. Proper knows the proper
problems with lessened Perform a proper positioning will position in order to
chronic productive breathing exercise. lessen the difficulty breath comfortably.
cough and had Apply bedside of breathing. Proper Patient has knowledge
been diagnosed a spirometry. Apply breathing exercise to do proper breathing
having COPD about chest x-ray. Apply will promote comfort. exercise. Patient knows
15 yrs ago.” 12 lead ECG. Bedside spirometry more about his
As verbalized by the Sputum GS-CS. Due to determine once conditions results of his
son of the patient. meds given. you breath it test. The patient is able
Objective distinguish if you to take medicine prior to
VS: BP: have a problem. the doctors order.
140/90mmHg ECG to detect if
RR: 35bpm, HR: there’s a problem in
145bpm, TEMP: your heart related to
37⁰C. ABG values breathing. Sputum
35% venturi mask culture if the sputum
pH 7.31, PaCO2 produces a
92mmHg, HCO3-46 microorganisms.
mEq/L, PaO2 Specific medications
52nmmHg, Sa O2 prior to the
82%, Hmg 13g%. condition.
 LORMA COLLEGES CON TEMPLATE
NURSING CARE PLAN
RELATED NURSING EXPERIENCE
STUDENT NAME: Valdriz Joshua B. ROTATION: 1ST ROTATION AREA:
YR LEVEL & SEC: BSN-III Jean Watson DATES: 14 15 16 21 22 23 28 CLINICAL INSTRUCTORS: Sir Randy B. Sandoval

PROBLEM: Confused and disoriented DIAGNOSIS: COPD

PRIORITIZATION: relief of confusion and disorientation DATE: 09/10/20

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective Disturbed processes within a minute of Explaining to the In order for the client The patient is able to
“When I got to see related to his nursing intervention client about his to have knowledge relieve confusion and
my father I realized disease the patient will able disease. Advised about his disease disorientation. The
that he was very to relief his confuse patient to perform and in order to not patient understands
confused and and disoriented. breathing exercise. get confused about what is happening to his
disoriented.” As Explain to the client his situation. Proper situation. The patient
stated by the the following breathing exercise is has knowledge to
patients son. implementation that a part in order to improve his condition.
Objective they will do to him. promote relaxing The patient is able to
Moderately Advised the client to condition to the keep relax.
overweight, barrel do some healthy life client. Build trust-
chest, cyanotic, practices. Provide a relationship to client
frequent weak quiet environment to and the nurse in
cough, gray yellow the client. Avoid order for the
sputum with each visitors. intervention to apply
cough, used successfully. In
accessory muscles, order for the client to
pursed lip breathing have more
3+ pitting edema of knowledge. Quiet
legs ankles and feet. environment to
Distended veins. make the client feel
safe.
.
 LORMA COLLEGES CON TEMPLATE
NURSING CARE PLAN
RELATED NURSING EXPERIENCE
STUDENT NAME: Valdriz Joshua B.. ROTATION: 1ST ROTATION AREA:
YR LEVEL & SEC: BSN-III Jean Watson DATES: 14 15 16 21 22 23 28 CLINICAL INSTRUCTORS: Sir Randy B. Sandoval

PROBLEM: Acute respiratory distress DIAGNOSIS: COPD

PRIORITIZATION: DATE: 09/10/20

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective Impaired gas Within an hour of Administer oxygen. Administer oxygen n The patients breathing
“I could not take a exchange related to nursing intervention Proper breathing order to promote is lessened unlike
deep breath.” As related to altered the patients exercise. Proper comfort breathing. before, the patient is
verbalized by the oxygen supply or breathing will be positioning of the Proper positioning of coping up well.
patient. obstruction of lessened. client. Provide the clients in order to
Objective airways by secretion adequate rest. Keep breath comfortably.
VS: BP: bronchospasm. the environment Adequate rest while
140/90mmHg quiet. Due meds doing the proper
RR: 35bpm, HR: given. positioning. Quiet
145bpm, TEMP: environment may
37⁰C. ABG values ease the condition of
35% venturi mask the patient. Specific
pH 7.31, PaCO2 medications given.
92mmHg, HCO3-46
mEq/L, PaO2
52nmmHg, Sa O2
82%, Hmg 13g%.