Nursing Care Plan Help

[mollybee06]

I need help writing goals and interventions for a patient that didn't experience any major issues throughout the shift.

They were admitted for COPD exacerbation and were most likely going to be discharged the next day. Only thing I can think of was when I was ambulating with them I was concerned about their respirations, O2 sat and if they were feeling weak. We had a wheelchair follow behind, they used the walker and they were on 2L O2. Took respirations and O2 sats before, during and after ambulating. They had some dyspnea and O2 dropped from 98 to 89 after 200 ft, we rested in the hallway and checked O2 again and it was up to 93, we continued back to room. After sitting and resting for about 5 min, respirations became less labored and O2 went up to 95.

My question is, would Impaired gas exchange be the appropriate NDX? What would be some goals to include in this particular case?

I'm having such a hard time writing these careplans. My instructor says I'm all over the place and basically try to squeeze 8 different careplans into one. Any help would be appreciated!

[Banana nut, BSN, RN, EMT-B]

Hi there! You have a bunch of stuff to work with so you will be able to make a great NDX and intervention list from this data. What kind of COPD do they have? do they have a breathing patter issue or a VQ mismatch? depending on the pathology behind hypoxia will determine the NDX. Intervention can include everything you did while caring for the Pt.

1. Administer 02 via NC @ 2LPM while ambulating.

2. Education on IS

3. Place Pt. in High fowlers if c/o orthopnea

4. Monitor SPO2%

5. Administer Rx per MD order

Here are just a few there are TONS more you can pick from. The goal is to pick a NDX and make sure your interventions can directly relate to it. You would not use an intervention such as assess pupil response when concerned with a VQ mismatch.

Good luck!