Nursing School Care Plan Design
Patient Information:
Patient Name | Age | Gender | Medical Record Number |
|---|
Javier Jacobs | 68 | Male | 1234567890 |
Date of Admission: July 15, 2050
Date of Plan: July 16, 2050
Assessment
Chief Complaint:
History of Present Illness (HPI):
Nursing Diagnosis
Impaired Gas Exchange related to COPD exacerbation, as evidenced by decreased oxygen saturation (92% on room air) and dyspnea.
Activity Intolerance related to fatigue and shortness of breath, as evidenced by the patient’s inability to complete basic activities without feeling exhausted.
Ineffective Health Maintenance related to non-adherence to prescribed treatment regimen for COPD management.
Goals
Goal | Expected Outcome | Target Date | Evaluation Criteria |
|---|
1. Improve gas exchange and oxygenation. | Patient's oxygen saturation will increase to ≥ 95% on room air. | July 18, 2050 | O2 Sat ≥ 95% on room air |
2. Enhance activity tolerance. | Patient will tolerate basic activities with minimal fatigue. | July 18, 2050 | Able to walk 20 feet without dyspnea |
3. Improve adherence to medication regimen. | Patient will verbalize understanding of medication regimen. | July 20, 2050 | Verbalizes medication routine correctly |
Interventions
Intervention | Rationale | Frequency | Person Responsible |
|---|
1. Administer supplemental oxygen via nasal cannula at 2L/min. | To improve oxygenation and alleviate shortness of breath. | As needed | Nurse |
2. Monitor vital signs, especially oxygen saturation and respiratory rate. | To assess effectiveness of interventions and detect early signs of deterioration. | Every 4 hours | Nurse |
3. Educate the patient on proper use of inhaler and adherence to medication. | To improve COPD management and prevent further exacerbations. | Once per shift | Nurse |
4. Encourage the patient to engage in light activities as tolerated. | To gradually increase activity tolerance and prevent deconditioning. | Twice per day | Nurse and Patient |
Evaluation
Goal | Expected Outcome | Status | Evaluation Date |
|---|
Improve gas exchange and oxygenation. | O2 Sat ≥ 95% on room air. | Met | July 18, 2050 |
Enhance activity tolerance. | Able to walk 20 feet without dyspnea. | Not Met | July 18, 2050 |
Improve adherence to medication regimen. | Patient verbalized understanding of the medication regimen. | Met | July 20, 2050 |
Discharge Plan
Discharge Date: July 22, 2050
Follow-up Appointment: July 25, 2050 with Dr. Alanis Durgan, Pulmonologist.
Discharge Instructions:
Continue prescribed medications as directed.
Use inhaler as needed for shortness of breath.
Schedule follow-up visit with pulmonologist.
Avoid exposure to triggers (e.g., smoke, allergens).
Report any new or worsening symptoms immediately.
Prepared by: [YOUR NAME]
Email: [YOUR EMAIL]
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