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nursing care plan


Mr. W is an 83-year-old man who was brought to the hospital from a long-term care facility by paramedics after reporting severe dyspnea and shortness of breath. He has been experiencing cold-like symptoms for the past 2 days. He has a productive cough with thick greenish sputum.

When Mr. W awoke in the nursing home, it was found that he had difficulty breathing even after using his albuterol (Proventil) metered-dose inhaler (MDI). He appears very anxious and is in respiratory distress.

His history includes chronic obstructive pulmonary disease related to smoking 2 packs of cigarettes per day since he was 15 years old. He also has a history of HTN and coronary artery disease. He had bypass surgery 15 years ago. Mr. W is a widower, his wife died 8 years ago. Mr. W has 2 grown children and several grandchildren who visit him weekly. His past occupation was a construction worker.

Initial vital signs:

Blood pressure 154/92 mm Hg

Heart rate . 118 bpm

O2 saturation . 88% on 1 L/min oxygen by nasal cannula

Respiratory rate . 38 breaths per minute

Temperature . 100.9 F (38.3 C)

In the ED, Mr. W undergoes a chest xray and admission labs are obtained including an electrolyte panel, CBC, and arterial blood gas. A sputum sample is sent to the lab for gram stain and culture and sensitivity.


CBC . WBC 12000 mm3

HGB . 11.6 g/dL

HCT . 35.2 %


Glucose . 122 mg/dL

Potassium . 4.1 mEq/L

Sodium . 135 mEq/L


PH 7.32

PaC02 . 55.4 mm Hg

Pa02 51.2 mm Hg

HC03 . 38 mEq/L

Chest Xray – results show abnormal air collections within the lung, lung hyperinflation, and lobular consolidation.


Pt is awake but drowsy. Auscultation of lungs notes bilateral crackles and decreased breath sounds. Pt reports pain of 3 out of 10 when he takes a deep breath.


Proventil (Albuterol)



Appropriate antibiotic for probable pneumonia/lung infection

Anti-hypertensive medication


Students must use the care plan template and it must be submitted to the drop box for grading.

Each section of the care plan must be completed.

There must be 3 Nursing diagnoses (2 physical and 1 psychosocial). Nursing diagnoses must be NANDA approved.

If you have any questions or concerns, please contact an instructor.

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