Nursing School Care Plan Design

Patient Information:

Patient Name	Age	Gender	Medical Record Number
Javier Jacobs	68	Male	1234567890

Date of Admission: July 15, 2050
Date of Plan: July 16, 2050

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Assessment

Chief Complaint:

• "Shortness of breath and fatigue."

History of Present Illness (HPI):

• Patient is a 68-year-old male with a history of hypertension and chronic obstructive pulmonary disease (COPD). Complains of worsening shortness of breath and increased fatigue over the past week. Reports occasional chest tightness and difficulty sleeping.

Nursing Diagnosis

1. Impaired Gas Exchange related to COPD exacerbation, as evidenced by decreased oxygen saturation (92% on room air) and dyspnea.

2. Activity Intolerance related to fatigue and shortness of breath, as evidenced by the patient’s inability to complete basic activities without feeling exhausted.

3. Ineffective Health Maintenance related to non-adherence to prescribed treatment regimen for COPD management.

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Goals

Goal	Expected Outcome	Target Date	Evaluation Criteria
1. Improve gas exchange and oxygenation.	Patient's oxygen saturation will increase to ≥ 95% on room air.	July 18, 2050	O2 Sat ≥ 95% on room air
2. Enhance activity tolerance.	Patient will tolerate basic activities with minimal fatigue.	July 18, 2050	Able to walk 20 feet without dyspnea
3. Improve adherence to medication regimen.	Patient will verbalize understanding of medication regimen.	July 20, 2050	Verbalizes medication routine correctly

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Interventions

Intervention	Rationale	Frequency	Person Responsible
1. Administer supplemental oxygen via nasal cannula at 2L/min.	To improve oxygenation and alleviate shortness of breath.	As needed	Nurse
2. Monitor vital signs, especially oxygen saturation and respiratory rate.	To assess effectiveness of interventions and detect early signs of deterioration.	Every 4 hours	Nurse
3. Educate the patient on proper use of inhaler and adherence to medication.	To improve COPD management and prevent further exacerbations.	Once per shift	Nurse
4. Encourage the patient to engage in light activities as tolerated.	To gradually increase activity tolerance and prevent deconditioning.	Twice per day	Nurse and Patient

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Evaluation

Goal	Expected Outcome	Status	Evaluation Date
Improve gas exchange and oxygenation.	O2 Sat ≥ 95% on room air.	Met	July 18, 2050
Enhance activity tolerance.	Able to walk 20 feet without dyspnea.	Not Met	July 18, 2050
Improve adherence to medication regimen.	Patient verbalized understanding of the medication regimen.	Met	July 20, 2050

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Discharge Plan

Discharge Date: July 22, 2050
Follow-up Appointment: July 25, 2050 with Dr. Alanis Durgan, Pulmonologist.

Discharge Instructions:

• Continue prescribed medications as directed.

• Use inhaler as needed for shortness of breath.

• Schedule follow-up visit with pulmonologist.

• Avoid exposure to triggers (e.g., smoke, allergens).

• Report any new or worsening symptoms immediately.

Prepared by: [YOUR NAME]
Email: [YOUR EMAIL]

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