Nursing Care Plan Sample: Chronic Obstructive Pulmonary Disease

Model Answer

Patient Scenario

Mr K, a 71-year-old former factory worker, was admitted via the emergency department with worsening breathlessness, increased sputum purulence and a productive cough over four days. He has a 15-year history of COPD (GOLD stage 3), a 40 pack-year smoking history (quit six years ago), and uses a combination inhaler with home oxygen at 1 L/min overnight. On admission his respiratory rate was 26 breaths per minute, oxygen saturation 86% on air, heart rate 108 bpm, blood pressure 138/84 mmHg and temperature 37.8°C. He was using accessory muscles to breathe, able to speak only in short sentences, and appeared anxious. Arterial blood gas showed a mild respiratory acidosis with compensation. Mr K lives with his wife, is normally independent with activities of daily living, and expresses fear of “not getting his breath back this time”.

A collateral history from Mr K’s wife indicated that his sputum had changed from clear to green over the preceding four days, alongside worsening breathlessness on minimal exertion, such as walking to the bathroom, and disturbed sleep from coughing. He had increased his rescue inhaler use to little effect and had not yet started the rescue pack of oral steroids and antibiotics kept at home, as he was unsure when it was appropriate to do so. He has no known drug allergies, is up to date with influenza and pneumococcal vaccination, and holds a personalised COPD self-management plan from his respiratory clinic, though he admits to sometimes finding it “hard to know when things are bad enough” to act on. This gap in confident self-management is directly relevant to discharge planning and is addressed within the anxiety and education-focused elements of this care plan.

Mr K’s regular medications on admission included a long-acting muscarinic antagonist/long-acting beta agonist combination inhaler, a short-acting beta agonist rescue inhaler, and home oxygen at 1 L/min overnight for documented nocturnal desaturation. On auscultation, breath sounds were reduced globally with widespread expiratory wheeze and occasional coarse crackles at the right base, consistent with both chronic airflow limitation and a likely infective component. There was no peripheral oedema, jugular venous distension or cyanosis, providing reassurance against acute cor pulmonale at this stage, though this was flagged for ongoing monitoring given his disease severity.

Mr K’s pulse oximetry readings were interpreted with caution given his skin tone and peripheral perfusion, and a paired arterial blood gas sample was taken to corroborate the saturation reading and to establish his baseline PaCO2 and pH prior to commencing oxygen therapy, in line with best practice for patients at risk of hypercapnia. His Alert-Confusion-Verbal-Pain-Unresponsive (ACVPU) score was recorded as Alert, providing an important safety baseline against which any later reduction in consciousness, a recognised early warning sign of worsening hypercapnia, could be promptly identified.

A brief cognitive check confirmed Mr K remained orientated to time, place and person, and his usual baseline cognition, as reported by his wife, was noted for comparison should any confusion later emerge as a sign of deterioration.

Assessment

A structured Airway, Breathing, Circulation, Disability, Exposure (A–E) assessment was undertaken on arrival, supported by the ADPIE nursing process and the Roper-Logan-Tierney activities of living model for the ongoing plan of care (NMC, 2018).

Airway: patent, able to talk in short phrases. Breathing: respiratory rate 26, use of accessory muscles, bilateral expiratory wheeze on auscultation, oxygen saturation 86% on air, improving to 91% on 28% controlled oxygen via Venturi mask. Circulation: tachycardic at 108 bpm, blood pressure within normal limits, capillary refill under two seconds. Disability: alert, Glasgow Coma Scale 15/15, visibly anxious. Exposure: temperature 37.8°C, sputum green/purulent in colour, no peripheral oedema noted. NEWS2 score calculated at 6, prompting hourly observations and urgent medical review in line with escalation policy (Royal College of Physicians, 2017).

Further assessment identified fatigue on minimal exertion, disrupted sleep due to breathlessness, reduced appetite, and situational anxiety consistent with dyspnoea-related distress commonly reported in COPD exacerbations (NICE NG115, 2019).

A Malnutrition Universal Screening Tool (MUST) score of 1 was recorded, reflecting reduced appetite over recent days, prompting food-chart monitoring and dietitian referral if intake remained poor. Pressure area assessment using the Waterlow tool placed Mr K at moderate risk, given reduced mobility during the acute phase and his raised body mass index, and two-hourly repositioning was commenced accordingly. A falls risk assessment scored him as moderate risk owing to fatigue and breathlessness on exertion, and mobility aids were made available at the bedside. Smoking status was confirmed as an ex-smoker of six years, and this was documented clearly to avoid unnecessary repeated smoking-cessation advice, while still ensuring the electronic record reflected his full history accurately for future clinical decision-making.

Nursing Diagnoses

1. Impaired gas exchange related to airflow limitation and infective exacerbation, evidenced by oxygen saturation of 86% on air and respiratory rate of 26 (actual problem, high priority).

2. Ineffective breathing pattern related to increased work of breathing, evidenced by accessory muscle use and speaking in short sentences (actual problem, high priority).

3. Anxiety related to breathlessness and fear of deterioration, evidenced by Mr K’s verbalised fear and observable distress (actual problem, medium priority).

These diagnoses were prioritised on immediate physiological risk first, following the A–E structure of the initial assessment, before addressing the psychosocial dimension of anxiety. However, the plan recognises that unmanaged anxiety can itself worsen dyspnoea through increased respiratory rate and muscle tension, creating a vicious cycle recognised in the COPD literature, so the anxiety-focused intervention was commenced alongside the physiological interventions rather than deferred until they were resolved (British Thoracic Society, 2017; NICE NG115, 2019).

The Care Plan

The table below sets a SMART goal against each nursing diagnosis, with interventions drawn from British Thoracic Society oxygen guidance and NICE guidance on COPD exacerbation, and a stated rationale grounded in the underlying pathophysiology of airflow limitation and the risk of hypercapnic respiratory failure. Evaluation criteria are deliberately measurable, so that Mr K’s progress can be tracked objectively across shifts rather than relying on subjective impressions of “looking better”, consistent with the NMC requirement for clear, accountable record-keeping (NMC, 2018).

Evaluation and Review

Evaluation was undertaken at each set of observations and formally reviewed at 24 and 48 hours, comparing NEWS2 trends, oxygen saturation, arterial blood gas results and Mr K’s self-reported breathlessness against the goals set. Where oxygen saturation failed to reach target despite optimised therapy, the plan specified escalation for consideration of non-invasive ventilation rather than simply increasing inspired oxygen. Discharge planning incorporated smoking-relapse prevention advice, pulmonary rehabilitation referral, and review of his home oxygen and inhaler technique by the respiratory nurse specialist, supporting a safe transition home and reducing readmission risk (NMC, 2018).

By 24 hours, Mr K’s oxygen saturation had stabilised at 90% on 28% Venturi oxygen, his respiratory rate had fallen to 19 breaths per minute, and repeat arterial blood gas showed an improving pH with stable PaCO2, indicating the impaired gas exchange and ineffective breathing pattern goals were on track. He successfully demonstrated pursed-lip breathing during a period of exertion-related breathlessness and reported his anxiety score had fallen from 8/10 to 4/10 on a simple numerical scale, suggesting the combined physiological and psychological interventions were effective. Sputum culture confirmed a bacterial exacerbation sensitive to the prescribed antibiotic, supporting continuation of the current regimen. A respiratory physiotherapy review on day two recommended continued incentive spirometry and graded mobilisation, both incorporated into the ongoing plan. At the day-three multidisciplinary discharge meeting, attended by the respiratory nurse specialist, physiotherapist and Mr K and his wife, a structured discharge pathway was agreed comprising early supported discharge follow-up within 24 hours, review of inhaler technique, referral to pulmonary rehabilitation once the acute episode had settled, and a written update to his self-management plan clarifying the specific triggers for starting his rescue pack independently in future. This directly addressed the gap in confident self-management identified on admission and aimed to reduce the likelihood of a similarly late presentation at the next exacerbation (NICE NG115, 2019; NMC, 2018).

This case also illustrates the value of viewing COPD exacerbation care through both a biomedical and a psychosocial lens simultaneously, rather than sequentially. Mr K’s admission was driven by a straightforward infective trigger, but his delay in starting his rescue medication at home, and his description of finding it “hard to know when things are bad enough” to act, point to a gap in confidence rather than a gap in knowledge alone; he held a written self-management plan yet did not feel able to use it under pressure. Addressing this through structured, rehearsed decision rules during his admission, rather than simply re-issuing the same written plan at discharge, reflects an evidence-informed understanding that health literacy and self-efficacy are distinct constructs, both of which nursing intervention can influence (NICE NG115, 2019; NMC, 2018). This nuance is easy to overlook in a task-focused account of oxygen therapy and nebulisers, but it is central to reducing his risk of a similarly late presentation at his next exacerbation.

References

British Thoracic Society (2017) BTS Guideline for Oxygen Use in Adults in Healthcare and Emergency Settings. London: BTS.
National Institute for Health and Care Excellence (2019) Chronic Obstructive Pulmonary Disease in Over 16s: Diagnosis and Management (NG115). London: NICE.
Nursing and Midwifery Council (2018) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. London: NMC.
Roper, N., Logan, W.W. and Tierney, A.J. (2000) The Roper-Logan-Tierney Model of Nursing: Based on Activities of Living. Edinburgh: Churchill Livingstone.
Royal College of Physicians (2017) National Early Warning Score (NEWS) 2. London: RCP.