ACUTE AND

CHRONIC COPD

ASSESSMENT DIAGNOSIS

Assess patient’s exposure to risk factors. Impaired gas exchange due to chronic inhalation of toxins.
Assess the patient’s past and present medical Ineffective airway clearance related to bronchoconstriction,
history. increased mucus production, ineffective cough, and other
Assess the signs and symptoms of COPD and complications.
Ineffective breathing pattern related to shortness of breath,
their severity.
mucus, bronchoconstriction, and airway irritants.
Assess the patient’s knowledge of the disease.
Self-care deficit related to fatigue.
Assess the patient’s vital signs.
Activity intolerance related to hypoxemia and ineffective breathing
Assess breath sounds and pattern.
patterns.

PLANNING
Improvement in gas exchange.
Improvement in breathing pattern.
Independence in self-care activities.
Improvement in activity intolerance.
Ventilation/oxygenation adequate to meet self-care needs.
Nutritional intake meeting caloric needs.
Infection treated/prevented.

IMPLEMENTATION
To achieve airway clearance
To improve breathing pattern
To improve activity intolerance
To monitor and manage potential complications

EVALUATION
Identifies the hazards of cigarette smoking.
Identifies resources for smoking cessation.
Enrolls in smoking cessation program.
Minimizes or eliminates exposures.
Is free of infection.
Practices breathing techniques.
Performs activities with less shortness of breath.
 PULMONARY
EMBOLISM
DIAGNOSIS
ASSESSEMENT Ineffective peripheral tissue
perfusion related to obstructed
Health history. Health history is assessed to pulmonary artery.
determine any previous cardiovascular disease. Risk for shock related to
Family history. History of any cardiovascular increased workload of the right
ventricle.
disease in the family may predispose the patient
Acute pain related to pleuritic
to PE.
origin.
Medication record. There are certain
medications that can increase the risk for PE.
Physical exam. Extremities are evaluated for
warmth, redness, and inflammation.

PLANNING
Develop a care plan tailored to the patient's needs and the
severity of the pulmonary embolism.
Consider the use of anticoagulant medications, oxygen
therapy, and other supportive measures.
Determine if the patient needs hospitalization or can be
managed on an outpatient basis.

IMPLEMENTATION
Administer prescribed medications, such as anticoagulants, to
prevent further clot formation.
Provide supportive care, such as oxygen therapy to improve
oxygenation.
Monitor the patient closely for any changes in their condition.

EVALUATION

Continuously assess the patient's response to treatment.

Adjust the care plan as needed based on changes in symptoms, vital
signs, and diagnostic test results.
Consider long-term management strategies and prevention measures.
ACUTE RESPIRATORY DISTRESS
ASSESSMENT
Hypoxemia
Abnormal breathing pattern
Abnormal arterial blood gases
Restlessness
Cyanosis
Dyspnea
Cough
Use of accessory muscles

DIAGNOSIS PLANNING

Ineffective Airway Develop a comprehensive care

plan that addresses the
Clearance underlying cause of ARDS and
Ineffective Breathing focuses on supportive measures
for respiratory distress.
Pattern Consider the use of mechanical
Impaired Gas Exchange ventilation with low tidal volumes
Anxiety to minimize further lung injury.
Plan for appropriate fluid
management, nutritional
IMPLEMENTATION support, and medications to
address the underlying
condition (e.g., antibiotics for
Identify and treat cause of
infection).
the Acute respiratory
distress syndrome
Administer oxygen as
prescribed.
EVALUATION
Position client in high
fowler’s position. Continuously assess the
Restrict fluid intake as patient's response to
prescribed. interventions, monitoring
Provide respiratory improvements in oxygenation
treatment as prescribed. and respiratory status.
Administer diuretics, Evaluate for any complications
anticoagulants or or side effects of treatments.
corticosteroids as Adjust the care plan based on
prescribed. ongoing assessment and changes in
the patient's condition, considering
Prepare the client for the potential need for escalation or
intubation and mechanical de-escalation of interventions.
ventilation using PEEP.
 COMMUNITY
ACQUIRED
PNEUMONIA

ASSESSMENT DIAGNOSIS
Assess respiratory symptoms. Symptoms of Ineffective airway clearance
fever, chills, or night sweats in a patient should
be reported immediately to the nurse as these related to copious
can be signs of bacterial pneumonia.
Assess clinical manifestations. Respiratory
tracheobronchial secretions.
assessment should further identify clinical Activity intolerance related to
manifestations such as pleuritic pain,
bradycardia, tachypnea, and fatigue, use of impaired respiratory
accessory muscles for breathing, coughing, and
purulent sputum.
function.
Physical assessment. Assess the changes in Risk for deficient fluid
temperature and pulse; amount, odor, and color
of secretions; frequency and severity of cough; volume related to fever and a
degree of tachypnea or shortness of breath; and
changes in the chest x-ray findings.
rapid respiratory rate.
Assessment in elderly patients. Assess elderly
patients for altered mental status, dehydration,
unusual behavior, excessive fatigue, and
concomitant heart failure. IMPLEMENTATION
To improve airway patency
PLANNING To promote rest and conserve
Improve airway patency. energy
Rest to conserve energy. To promote fluid intake
Maintenance of proper fluid To maintain nutrition
volume. To promote patient’s
Maintenance of adequate nutrition. knowledge
Understanding of treatment
protocol and preventive measures.
Absence of complications.
EVALUATION
Demonstrates improved airway
patency.
Rests and conserves energy by limiting
activities and remaining in bed while
symptomatic and then slowly
increasing activities.
Maintains adequate hydration.
Consumes adequate dietary intake.
States explanation for management
strategies.
Complies with management strategies.
Exhibits no complications.
Complies with treatment protocol and
prevention strategies.
 VENTILATOR ACQUIRED
PNEUMONIA

DIAGNOSIS
ASSESSMENT
Impaired gas exchange
Changes in rate, depth
Ineffective airway
of respirations
Abnormal breath clearance
sounds (rhonchi, Ineffective breathing
bronchial lung sounds, pattern
egophony) Knowledge
Use of accessory deficit/Deficient
muscles knowledge
Dyspnea, tachypnea Activity intolerance
Cough, effective or Risk for infection
ineffective; Risk for nutritional
with/without sputum imbalance: less than
production body requirements
Cyanosis
Decreased breath
sounds over affected
lung areas
Ineffective cough PLANNING
Purulent sputum
Hypoxemia Implement evidence-based
Infiltrates seen on practices to prevent VAP.
chest x-ray film Patient will demonstrate
Reduced vital capacity improved ventilation and
oxygenation of tissues by ABGs
within the patient’s acceptable
range and absence of symptoms
of respiratory distress.
IMPLEMENTATION Patient will maintain optimal gas
exchange.
Maintaining Patent Airway
Patient will participate in actions
Clearance
to maximize oxygenation.
Improving Gas Exchange
Monitor ventilator-associated
Promoting Effective
events and outcome measures.
Breathing Pattern and Breathing
Reduce ventilator-associated
Exercises
events (VAE).
Administering Medications and
Make evidence-based
Pharmacological Support determinations about the care of
Initiating Measures for Infection ventilated patients.
Control & Management
Managing Acute Pain &
Discomfort EVALUATION
Promoting Rest and Improving
Tolerance to Activity Demonstrated improved
Maintaining Normal Body ventilation.
Thermoregulation Maintained optimal gas
Promoting Optimal Nutrition & exchange
Fluid Balance Participated in actions to
Providing Patient Education &
maximize oxygenation
Health Teachings
Demonstrated behaviors
Monitoring Potential
Complications of Pneumonia achieved airway clearance
Maintained patent airway
 COVID
ASSESSMENT DIAGNOSIS
Travel history
Physical examination Infection related to
Possible exposure to failure to avoid pathogen
the virus that causes
secondary to exposure to
COVID-19
The patient’s level of COVID-19
knowledge about the Deficient knowledge
transmission of
COVID-19
related to unfamiliarity
Fever with disease transmission
Impaired breathing information .
pattern related to
shortness of breath
Hyperthermia related to
Anxiety associated increase in metabolic rate
with the unknown
etiology of the
disease

IMPLEMENTATION PLANNING
Monitor vital signs, particularly
temperature and respiratory rate, as Establishing goals, interventions
fever and dyspnea are common Assessing altered skin integrity
symptoms of COVID19 risks, fatigue, impaired comfort,
Assess for signs and symptoms of gas exchange, nutritional
anxiety, and provide care in a calm needs, and nausea
and reassuring manner Preventing the spread of
Administer prescribed medications, coronavirus infection to the
and monitor for effect patient’s family members,
Provide quiet time, and decrease community, and healthcare
environmental stimulation providers
Explain all tests and procedures to the Providing more information
patient using clear, simple
about COVID-19 and its
explanations
management to the patient – in
Help the patient identify factors that
a Pew Research Center poll
increase anxiety
released June 29, 2020, only 64
percent of adults said the CDC
EVALUATION “mostly gets the facts about the
COVID-19 is a disease caused by the SARS- outbreak right”
CoV-2 virus 123. The virus is part of the Reducing fever
coronavirus family, which also includes Restoring normal respiratory
viruses that cause the common cold, severe patterns
acute respiratory syndrome (SARS), and Easing anxiety, which is
Middle East respiratory syndrome (MERS) 1. relatively common in COVID-19
The virus spreads mainly through respiratory patients
droplets when an infected person talks,
coughs, or sneezes 14. It can also spread by
touching a surface contaminated with the
virus and then touching one’s mouth, nose, or
eyes
 PNEUMOTHORAX

ASSESSMENT
DIAGNOSIS
Tracheal alignment. Ineffective airway clearance related to
Expansion of the chest.
intrapulmonary pressure
Breath sounds.
Altered gas exchange related to defective
Percussion of the chest
Thoracic CT gas flow
Chest X-Ray PLANNING Pain related to the reduction of lung
ABG’s expansion
Thoracentesis Maintaining airway patency and Risk for impaired skin integrity related
Hb adequate ventilation to air leakage
Assessing and managing pain Acute pain related to the positive
effectively
Providing wound care and pressure in the pleural space
monitoring for signs of infection Ineffective breathing pattern related to
Preventing and monitoring for respiratory distress
potential complications Ineffective peripheral tissue perfusion
Providing information about the
related to severe hypoxemia
disease process/prognosis and
treatment regimen Anxiety related to difficulty in breathing
Providing supplemental oxygen Risk for infection
therapy Risk for decreased cardiac output
Monitoring vital signs and lung
sounds
Administering prescribed
medications for pain relief
Providing chest physiotherapy and
exercises to maintain adequate
ventilation
Instructing patient on proper
breathing techniques
Advising patient to avoid smoking,
avoid excessive alcohol consumption

IMPLEMENTATION

EVALUATION

Maintained airway
patency
Monitored vital
signs and lung sound
Provided wound
care
Promoted clean
environment
Instructed proper
breathing excercises
CARDIOVASCULAR
DISEASES

ACUTE ISCHEMIC
DISEASE

HEAR FAILURE

CORONARY ARTERY
DISEASE

CARDIOMYOPATHY

ARRYTHMIAS

NORMAL ECG
TRACING

DIFFERENT ECG
TRACING
 ACUTE ISCHEMIC DISEASE

ASSESSMENT DIAGNOSIS PLANNING

Change in level of Acute Pain: r/t ischemia, Improve mobility.

secondary to peripheral Avoidance of shoulder pain.
consciousness or
arterial disease Achievement of self-care.
responsiveness.
Impaired Physical
Presence or absence of Relief of sensory and
Mobility: r/t hemiparesis,
voluntary or involuntary perceptual deprivation.
loss of balance and
movements of Prevention of aspiration.
coordination, spasticity,
extremities. Continence of bowel and
and brain injury.
Stiffness or flaccidity of bladder.
Self-Care Deficits: r/t
the neck. stroke sequelae Transient Improved thought
Ischemic Attack processes.
Eye opening,
Sexual dysfunction Achieving a form of
comparative size of
related to neurologic communication.
pupils, and pupillary
deficits or fear of failure. Maintaining skin integrity.
reaction to light.
Risk for impaired skin Restore family functioning.
Color of the face and
integrity related to Improve sexual function.
extremities; temperature Absence of complications.
hemiparesis or hemiplegia
and moisture of the skin.
and decreased mobility.
Ability to speak. Disturbed thought
Presence of bleeding. processes related to brain
Maintenance of blood damage.
pressure.

IMPLEMENTATION EVALUATION
Prevent flexion Promoted a hearth
Positioning healthy lifestyle
Prevent adduction Provided
Prevent edema symptom relief
Full range of motion Prevented
Prevent venous stasis secondary
Regain balance myocardial
Personal hygiene infarction
Manage sensory difficulties Increased
Visit a speech therapist functional capacity
Voiding pattern and longevity
Be consistent in patient’s
activities
Assess skin
 HEART FAILURE

ASSESSMENT DIAGNOSIS
Intervention Evaluation Causes Signs and Activity Intolerance r/t fatigue
Symptoms secondary to cardiac insufficiency
Taking the complete history of symptoms, Excess fluid volume r/t cardiac failure
onset and duration of symptoms, and the Disturbed sleep pattern r/t nocturnal
response of the symptom to rest.
dyspnea
Assessing the neurological status of the
Impaired Gas Exchange r/t increased
patient. Auscultating the heart sound,
rhythm and measuring the blood preload and afterload Anxiety r/t
pressure. dyspnea/fear of death Knowledge
Assessing for any peripheral edema. deficit r/t disease process
Assessing the signs and symptoms such as
dyspnea, shortness of breath, fatigue, and
edema.
Assessing for sleep disturbances, especially PLANNING
sleep suddenly interrupted by shortness of
The patient will exhibit optimal cardiac output,
breath.
indicated by vital signs within acceptable ranges,
Exploring the patient’s understanding of
absence/control of dysrhythmias, and absence of
HF, self management strategies, and the heart failure symptoms.
ability and willingness to adhere to those The patient will engage in activities that reduce
strategies. cardiac workload. The patient will actively
participate in desired activities and meet their own
self-care needs.
The patient will maintain stable fluid volume, with
balanced intake and output, clear/clearing breath
IMPLEMENTATION sounds, vital signs within acceptable range, stable
weight, and absence of edema.
The patient will verbalize understanding of
Initiating Interventions for individual dietary and fluid restrictions.
Decrease in Cardiac Output The patient will prioritize maintaining skin
Monitoring Diagnostic integrity.
Procedures and Laboratory The patient will effectively manage pain.
Studies Administering The patient will identify strategies to reduce
anxiety.
Medication and Providing The patient will exhibit improved concentration.
Pharmacological Interventions The patient will actively participate in their
Maintaining or Improving treatment regimen based on their abilities and
Respiratory Function situation.
Managing Fluid Volume and
Electrolyte Imbalance
Providing Perioperative Nursing
Care Managing
Acute Pain and Discomfort
Promoting Adequate Tissue
EVALUATION
Perfusion and Managing
Decreased Cardiac Tissue Demonstration of
Perfusion tolerance for increased
Promoting Optimal Nutritional activity.
Balance and Adherence to
Maintenance of fluid
LowSodium Diet
Maintaining Skin Integrity & balance. Less anxiety.
Preventing Pressure Ulcers Decides soundly
Managing Decreased Tolerance to regarding care and
Activity and Fatigue Reducing
treatment.
Anxiety, Fear and Improving
Coping Initiating Health Teaching Adherence to self-care
and Patient Education regimen.
 CORONARY ARTERY DISEASE

ASSESSMENT DIAGNOSIS
Chest pain or discomfort Decreased cardiac output r/t the
Shortness of breath disease process of coronary artery
Tachycardia disease (CAD) as evidenced by fatigue
and inability to do ADLs as normal
Hypertension
Acute pain r/t myocardial ischemia as
Tachypnea evidenced by chest pain Anxiety r/t
Palpitations Nausea the diagnosis of CAD as evidenced by
(especially in women) verbalization of fear and
Dizziness Sweating apprehension
Restlessness Ineffective tissue perfusion r/t
decreased cardiac output as evidenced
by decreased peripheral pulses and
cool extremities
Risk for decreased cardiac output r/t
the disease process of CAD as
evidenced by history of myocardial
infarction

PLANNING
Maintain adequate cardiac output
by administering medications as
ordered, monitoring vital signs, IMPLEMENTATION
and assessing for signs of heart
failure. Promote perfusion
Reduce pain by administering Manage the symptom
nitroglycerin as ordered,
Cardiac Rehabilitation Lower
monitoring vital signs, and
assessing for signs of heart
the Risk:
failure. Preventive Measures Provide
Decrease anxiety by providing Safety
emotional support, encouraging
the patient to express feelings,
and teaching relaxation
techniques.
Improve tissue perfusion by
administering medications as
EVALUATION
ordered, monitoring vital signs,
and assessing for signs of heart Maintained adequate
failure. cardiac output
Reduced pain by
administering
nitroglycerin as
ordered
Decreased anxiety
Improved tissue
perfusion
 CARDIOMYOPATHY

ASSESSMENT DIAGNOSIS
Vital Signs Decreased Cardiac Output
Calculation of pulse pressure and Impaired Gas Exchange
identification of pulsus paradoxus Activity Intolerance
Current weight and any weight gain Excess Fluid Volume
or loss Ineffective Tissue Perfusio
Detection of Palpation of the point n Deficient Knowledge Acute
of maximal impulse, often shifted Pain Fatigue
to the left
Cardiac auscultation for a systolic
murmur and S3 and S4 heart sound
Pulmonary auscultation for
crackles Measurement of jugular
vein distension
Assessment of edema and it’s
severity

IMPLEMENTATION
Improving cardiac output and
peripheral blood flow
PLANNING Increasing activity tolerance and
Improving Gas exchange
Stopping the disease from Reducing Anxiety Decreasing the
getting worse Sense of Powerlessness
Managing any conditions Promoting Home, Community-
that cause or contribute to Based and Transitional Care
the disease Educating patient about Self
Reducing complications Care Continuing and
and the risk of sudden Transitional Care
cardiac arrest (SCA)
Controlling symptoms so
that you can live as
normally as possible

EVALUATION
Maintains or improves cardiac
function
Maintains or increases activity
tolerance
Is less anxious Decreases sense of
powerlessness
Effectively manages selfcare
program
 ARRYTHMIAS

ASSESSMENT DIAGNOSIS
Heart Rate Rhythm Impaired cardiac output
Blood Pressure Altered associated with inadequate
Electrical Conduction ventricular filling or
Reduced Myocardial altered heart rate
Contractility Anxiety associated with
the fear of the unknown
outcome of altered health
state Lack of knowledge
about the arrhythmia and
PLANNING it’s treatmen

Decreasing the occurrence of the

arrhythmia (by decreasing
contributory factors)
To maintain cardiac output
Verbalizing reduction in anxiety
Verbalizing an understanding about
the arrhythmia Test used to
diagnose the problem and it’s
treatment
Developing or maintaining IMPLEMENTATION
selfmanagement skills
Monitoring and managing the
arrhythmia to Maintain Cardiac
Output Reducing Anxiety
Educating Patients about Self-
Care Continuing and
Transitional Care

EVALUATION
Maintain Cardiac output
Experiences Reduced
Anxiety Express
understanding of the
arrhythmia and it’s
treatment
NORMAL ECG
TRAINING A normal ECG is a
recording of the electrical
activity of the heart at a
standard speed and
frequency.
A normal ECG shows a
regular rhythm of P
waves, QRS complexes,
and T waves.
A normal ECG has a heart
rate of 60-100/min in an
adult at rest, and a lower
rate with age.
A normal ECG has
segments of specific
durations.
A normal ECG is
diagnosed by excluding
any abnormality.
 DIFFERENT
ECG TRACING