if you are going to address copd for your care plan you begin by following the nursing process. the nursing process is a way of problem solving. the first step is assessment. since this is a mock patient, you need to go to a resource on copd and list out the signs and symptoms of copd. understand that copd is a very general diagnosis and actually includes four medical conditions:
- chronic obstructive asthma
- chronic obstructive bronchitis
- chronic bronchitis with emphysema
so, you need to make a list of all the signs and symptoms of those conditions. they will be your objective data for this care plan. those signs and symptoms will ultimately become the aeb items in your nursing diagnostic statement as well as the things you will develop your goals/outcomes and nursing interventions for.
didn't your instructor give you direction on how many goals/outcomes you needed? at the minimum i would think you need at least one long term and one short term goal/outcome. the long term goal can relate back to the underlying definition of the nursing diagnosis itself. the short term goals are what you expect to happen as a result of the successful application of your nursing interventions.
when you finally decide upon a diagnosis to use you should verify its validity by checking a nursing diagnosis reference. diagnosing is nothing more than a decision or opinion you make after the process of examination or investigation of the facts. the facts, in the case of care planning, are the patient's signs and symptoms that you discovered during your assessment process. nanda has very conveniently supplied us with a taxonomy (a big word meaning a classification--an arrangement or ordering of the nursing diagnoses into some kind of logical groupings). they have given us descriptions of each diagnosis and provided the symptoms (nanda calls them defining characteristics) for each as well as related factors (etiologies). you need to refer to this information to assist you in making sure you have diagnosed someone with the correct nursing diagnosis, particularly when you are new at doing this. ultimately, a nursing diagnosis is a label that identifies the patient's problem.
here is information on ineffective airway clearance
for you to look at in case you don't have a nursing diagnosis reference of your own. [color=#3366ff]ineffective airway clearance
make sure you have the correct signs and symptoms (aeb items) attached to the nursing diagnostic statement. for example. ineffective airway clearance r/t retained secretions aeb dyspnea, rhonchi and wheezes in all lung fields, ineffective coughing and restlessness.
this should not be your only nursing diagnosis for a copd patient. based on the symptoms there are a number of other nursing diagnoses that you should also have.
you can find more information on writing care plans and determining nursing diagnoses on these two sticky threads: