CARE PLAN OF ALBERR CLARKE

Running head: CARE PLAN OF ALBERR CLARKE
CARE PLAN OF ALBERR CLARKE
Name of the Student
Name of the University
Author Note

CARE PLAN OF ALBERR CLARKE
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Background of the case study
The case scenario centres round a 72 years old man named Albert, who had been
admitted in to the emergency respiratory ward with exacerbated symptoms of the COPD. He
was presented in the respiratory department with acute respiratory distressed, increased
sputum production and fever. After the diagnosis he was confirmed with community acquired
pneumonia He looked fatigued when he was being brought in to the emergency department,
but was oriented to both time and space. This paper aims to provide a care plan for Albert
Clarke by the use of the five sequential the nursing process namely assessment, diagnosis,
planning, implementation and evaluation. This will be followed by a proper implementation
and an evaluation plan.
Discussion
The two nursing diagnosis that has been selected for constructing a care plan is
ineffective airway clearance and impaired gas exchange.
Care plan
Assessment
Ineffective airway clearance is mainly caused due to the narrowing of the airways due to the
accumulation of the mucus and the continuous bronchospasms, which reduces the capacity of
the small bronchi and can cause difficulty in breathing, infection and stasis of the secretions.
Ineffective airway clearance can be brought about by monitoring the breath sounds
and the respiration, noting the rates and the sounds like tachypnoea, crackles stridor and
wheezes. Presence of infection can be indicated by the presence of acute infection. It can also
necessary to auscultate the breathing sound to detect the presence of any wheezing or
crackles. The grade of breathlessness scale is a scale that is used to measure the degree of

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breathless. The scale uses 0-10 scale for the assessment of the severity (Ko et al., 2017). The
urgency of this assessment lies in the fact, that severe dyspnoea might indicate towards the
occurrence pulmonary embolus.
Impaired gaseous exchange in COPD can be caused if the formation of the
inspissited plug due to the excessive mucous formation can obstruct the airways and impair
the pulmonary ventilation and the gaseous exchange. The symptoms are mainly evidenced by
abnormal breathing, restlessness, inability to remove the secretions. It can be assessed by
recording the respiratory rate depth (Ko et al., 2017). The use of the accessory muscle needs
to be noted including the pursed lip breathing and the inability to make any sorts of
conversation. It is necessary to monitor and assess the skin and the colour of the mucous
membrane, as cyanosis might develop due to lack of oxygen, which might lead to severe
hypoxemia. Normally agitation and restlessness and anxiety are some of the common
manifestations of the hypoxia, although Albert Clarke is oriented to time and space and has
not shown any signs of confusion.
Diagnosis
Ineffective airway clearance can be exhibited by the continuous formation of the
sputum plugs. There should be provisions for a bronchodilator reversibility test where both
the spirometer and a bronchodilator is combined together, to get the tests done. An arterial
blood gas test is required for measuring the levels of oxygen and the carbon-di-oxide that is
present in the blood (Burkhardt & Pankow, 2014). The levels of alpha-1 antitrypsin needs to
be checked , which is a protein , which actually helps the lungs to protect from any kind of
inflammation caused due to the entry of the obnoxious substances.
Impaired gaseous exchange can be evidenced by faint breath sounds due to the
decreased airflow or the areas of consolidation. Presence of wheezing can indicate

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bronchospasms (Kaufman, 2013). The doctors might hear scattered moist crackles indicating
towards interstitial fluids or cardiac decompensation. A decrease of the vibratory tremors
might indicate towards the collection of the fluid or trapping of air. A pulse oximetry reading
is necessary as a value less than 92 % might require oxygen titration.
Planning
A proper plan of care needs to be designed for Albert Clarke, after the assessment
along with the appointment of the desired multidisciplinary team that is required. The nursing
goals for an impaired gaseous exchange should include clearance of the secretion and the
gases from the lungs. It is necessary to keep the patient alert (Kaufman, 2013). The goal
should be to maintain a balanced and standard depth rate and the respiratory pattern of the
patient. The goal for an effective airway clearance would be to maintain the patency of the
airways with clear breath sounds (Fried, Vaz Fragoso & Rabow, 2012). Albert should be able
to cough properly and will be able to expectorate the secretions.
Implementation
Ineffective airway clearance
There should be a continuous monitoring of the respirations and the breath sounds, the
inspiratory and the expiratory ratio, auscultation of the sounds of breathing and noting for the
presence and the severity of the dyspnoea process. It is necessary to observe and monitor the
signs and the symptoms. Therapeutic approaches like positioning the head midline with
flexion in order to maintain an open airway (Kaufman, 2013). It is necessary to inspect the
mouth, neck and the position of the trachea for any presence of obstruction. Albert should be
encouraged to carry out pursed lip breathing (Chaves et al., 2016). The nursing intervention
should also include assisting the patients to assume a comfort level, by elevating the level of
the head of the bed allowing the patient to sit at the edge of the bed. Albert should be