Nursing Care plan Of A Patient

Running head: NURSING CARE PLAN
NURSING CARE PLAN
Name of the Student
Name of the University
Author Note

NURSING CARE PLAN1
Introduction of the case person
The case study is about Albert, which is a 72 years old man, who has been admitted in
to the hospital after an acute exacerbation of the Chronic Obstructive Pulmonary disease
(COPD). He has been admitted to the respiratory ward with symptoms of shortness of breath,
productive cough with an increased production of sputum and a temperature of about 39
degree Celsius. He has also been diagnosed with community acquired pneumonia. When
Albert has appeared in the emergency ward, he appeared tired, but is oriented to time and
space and is able to follow command. He felt extremely tired and breathless. This assignment
will give an account of the care plan for Albert Clarke, by using the five sequential process of
nursing along with the interventions related to two specific nursing diagnosis that has been
chosen for the patient. This paper will provide all the assessment information along with the
justifications, followed by the planning, implementation and evaluation of the interventions
taken.
Body
The two nursing diagnosis that has been chosen to develop a person centred care plan
is –
Ineffective breathing pattern and ineffective airway clearance
Care plan
Assessment
Ineffective breathing pattern is mainly caused by the ineffective aeration due to the
faulty respiratory mechanics of the chest wall and the lungs due to the trapping of air,
ineffective diaphragmatic movement, and obstruction of the airways.

NURSING CARE PLAN2
Ineffective breathing pattern can be assessed by assessing the respiratory status of the
patient every 2 to 4 hours. The breath sounds needs to be auscultated every 2-4 hours, as
occurrence of tachypnea and any changes in the mental status can be assessed. Arterial blood
gas levels can be checked to find out the occurrence of the alkalosis (Casanova, et al., 2017).
In order to assess the ineffective airway clearance, it is necessary to monitor the
breath sounds and the respirations, noting rates and the sounds (tachypnea, stridor, crackles,
and wheezes). Presence of tachypnea can there indicating acute infection. It can also be
helpful to detect shallow and rapid expiration. The breath sounds needs to be auscultated to
note the presence of any adventitious breathing sounds like the presence of crackles or
wheezing (Chaves et al., 2018). The degree of the dyspnoea should be measured by using the
0-10 scale or by using the American Thoracic society’s “Grade of the breathlessness scale’
for rating the difficulty in breathing. This assessment is important because the rapid onset of
the dyspnoea might report the presence of pulmonary embolus (Chaves et al., 2018).
Diagnosis
Ineffective breathing pattern can be evidenced by shortness of breath with the use of
the accessory muscles, oxygen saturation of about 85 % and abnormal arterial blood gas
values. A spirometry test can be done for conforming the COPD diagnosis. In this case study,
it can be seen that the oxygen saturation level of the patient is as low as 83 % (Casanova, et
al., 2017). Ineffective clearance of the airways can be evidenced by the presence of thick
sputum. A bronchodilator reversibility test combines the use of a bronchodilator along with
the use of a spirometer (Casanova, et al., 2017). The arterial blood gas tests will be able to
measure the oxygen levels and carbon dioxide present in the blood. Again a doctor might
check the levels of alpha-1 antitrypsin. This is a protein that actually helps to protect the
lungs from any kind of inflammation caused by the irritants like the he smoking and
pollution.

NURSING CARE PLAN3
Planning
After the diagnosis, a proper plan of care should be chalked out by the nurses. The dosages of
the medicines should be calculated as prescribed by the doctors. The nursing goals would be
to restore the normal breathing pattern in Albert, to improve the oxygen saturation in Albert,
to provide relief from chest congestion and promote breathing by clearing the airways.
Implementation
Ineffective airway clearance
Therapeutic interventions like the positioning of the head midline with flexion for the
maintenance of an open airway. Albert should be assisted to maintain a comfortable position,
like elevation of the head of the bed, as elevation of the head improves the respiratory
function by using the gravity. However, the patient who is in severe distress will always try to
seek the position that makes the breathing easier (Lima et al., 2018). Any environmental
pollution should be reduced to minimum. Purse lip breathing exercise can be instated for the
improvement of the effectiveness of the cough efforts. The fluid intake for Albert needs to be
increased to 3000mL per day within the cardiac tolerance level (Hernández et al., 2018).
Provision of warm and tepid liquids the helps in decreasing the viscosity of the secretions,
facilitating expectoration. Again use of warm liquids can also decrease the incidence of
bronchospasms. It will also be helpful in increasing gastric distension and the presence of any
pressure of the diaphragm. The patient needs to be repositioned after every 2 hours. This is
due to the fact the movement helps in clearing of the airway (Hernández et al., 2018). In case
Albert finds difficulty with the increasing secretion of the sputum, it is necessary to suction
the secretions. Suctioning of the secretions are necessary for the oxygenation.
Ineffective breathing pattern