The free nursing care plan example below includes the following conditions: Ineffective Gas Exchange, Ineffective Airway Clearance, Pneumonia, COPD, Emphysema, & Common Cold.
What are nursing care plans? How do you develop a nursing care plan? What nursing care plan book do you recommend helping you develop a nursing care plan?
This care plan is listed to give an example of how a Nurse (LPN or RN) may plan to treat a patient with those conditions.
Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. Do not treat a patient based on this care plan.
Care Plans are often developed in different formats. The formatting isn’t always important, and care plan formatting may vary among different nursing schools or medical jobs. Some hospitals may have the information displayed in digital format, or use pre-made templates. The most important part of the care plan is the content, as that is the foundation on which you will base your care.
Nursing Care Plan for: Ineffective Gas Exchange, Ineffective Airway Clearance, Pneumonia, COPD, Emphysema, & Common Cold
If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, scroll down to view this completed care plan.
Scenario: |
| A 63 year old female presents to the ER with complaints of shortness of breath on excretion and atypical chest pain. Pt states she has felt bad since Monday and today is Friday. Pt states she has been coughing up greenish to brownish sputum that is thick. During history collection from pt, pt becomes short of breath and has to stop talking to catch her breath. Vital Signs: BP 120/80, HR 80, O2 Sat 87% on room air, Temp. 101.6. On assessment, patients skin feels hot to touch despite the patient stating she feels chilled. Lab and Diagnostic work shows: WBC 30,000 and chest x-ray preliminary results show possible bilateral lower lobe pneumonia. |
Nursing Diagnosis: |
| Ineffective gas exchange related to thick secretions as evidence by O2 saturation of 87% on room air, complaints of shortness of breath, and coughing up greenish to brown sputum. |
Subjective Data: |
| Complaints of shortness of breath on excretion and atypical chest pain, has felt bad since Monday, states she is coughing up greenish to brownish sputum that is thick, pt feels chilled |
Objective Data: |
| Vital Signs: BP 120/80, HR 80, O2 Sat 87% on room air, Temp. 101.6, Skin feels hot on assessment, WBC 30,0000, chest x-ray shows possible bilaterally lower lobe pneumonia. |
Nursing Outcomes: |
| -Pt’s O2 Saturation will be between 90-100% as evidence by nursing documentation during hospitalization.-Pt will have clear sputum as evidence by nursing documentation by discharge.
-Pt will verbalize 5 benefits of the pneumococcal vaccine within 48 hours. |
Nursing Interventions: |
| -Pt will be place on 2L O2 by nasal cannula per MD order for O2 saturation of less than 90%.-The nurse will demonstrate and verbalize how to use the incentive spirometer for effective oxygenation and airway clearance.
-The nurse will verbalize 5 benefits of the pneumococcal vaccine to the patient within 24 hours. |