Introduction
Chronic obstructive pulmonary disease (COPD) affects around one in twenty Australians aged 45 and over and remains one of the leading causes of potentially preventable hospitalisation nationally (Australian Institute of Health and Welfare [AIHW], 2024). This assignment develops a structured nursing care plan for a 68-year-old man admitted to a regional Victorian medical ward with an infective exacerbation of COPD. The plan is organised through the eight phases of the Clinical Reasoning Cycle (Levett-Jones, 2018), illustrated in Figure 1, and is framed by the Registered Nurse Standards for Practice (Nursing and Midwifery Board of Australia [NMBA], 2016) and the person-centred practice framework of McCormack and McCance (2017). Three prioritised nursing diagnoses are presented with goals, interventions, rationales and evaluation criteria, followed by medication considerations, patient education and a smoking cessation strategy grounded in Australian guidelines and services.
Patient Scenario: Considering the Situation
Mr Kevin Ward (a pseudonym, used in accordance with confidentiality obligations) is a 68-year-old retired boilermaker who lives with his wife Margaret in their own home in Geelong, Victoria. COPD was diagnosed nine years ago, and his history also includes hypertension, gastro-oesophageal reflux disease and osteoarthritis. He has smoked 20 cigarettes a day since the age of 18, with two brief unsupported quit attempts. Usual medications are tiotropium, salbutamol as required, perindopril and pantoprazole. He missed this year’s influenza vaccination. At baseline he walks more slowly than others his age on flat ground (modified Medical Research Council [mMRC] dyspnoea grade 3), yet he still plays social lawn bowls, the activity he most wants to keep.
Mr Ward presented to the emergency department after four days of worsening breathlessness, increased sputum volume with a change to green-yellow purulence, fever and poor sleep. The first phase of the Clinical Reasoning Cycle asks the nurse to situate these facts within a bigger picture: an older man with severe airflow limitation, very heavy smoking exposure, incomplete vaccination and an infective trigger, whose personal priority is to return home independent and get back to his bowls club (Levett-Jones, 2018).
Assessment Data: Collecting Cues
A comprehensive admission assessment was completed in line with NMBA Standard 4, which requires comprehensive and systematic assessment (NMBA, 2016). The cues collected are summarised in Table 1.
Table 1: Admission assessment data for Mr Ward
| Parameter | Finding on admission | Reference range or target |
|---|---|---|
| Respiratory rate | 28 breaths per minute, accessory muscle use | 12-20 breaths per minute |
| Oxygen saturation | 86% on room air | Target 88-92% in COPD |
| Heart rate | 104 beats per minute, regular | 60-100 beats per minute |
| Blood pressure | 152/88 mmHg | Below 140/90 mmHg |
| Temperature | 38.1 °C | 36.5-37.5 °C |
| Arterial blood gas (room air) | pH 7.36; PaCO2 49 mmHg; PaO2 54 mmHg | pH 7.35-7.45; PaCO2 35-45; PaO2 80-100 |
| Breath sounds | Widespread expiratory wheeze; coarse right basal crackles | Vesicular, no adventitious sounds |
| Sputum | Increased volume, green-yellow, thick | Clear or white, minimal |
| Dyspnoea (mMRC) | Grade 4 (baseline grade 3) | Grade 0-1 |
| Spirometry (post-bronchodilator, recent clinic review) | FEV1 42% predicted; FEV1/FVC 0.48 | FEV1/FVC 0.70 or above |
| Inflammatory markers | White cells 13.2 × 109/L; C-reactive protein 68 mg/L | 4.0-11.0; below 5 |
| Weight and height | 58 kg; 1.68 m | See calculation below |
Two worked calculations sharpen the risk profile. Smoking exposure: pack-years = (cigarettes per day ÷ 20) × years smoked = (20 ÷ 20) × 50 = 50 pack-years, a very heavy cumulative exposure. Nutritional status: body mass index = weight ÷ height² = 58 ÷ (1.68 × 1.68) = 58 ÷ 2.82 = 20.6 kg/m². This value sits near the lower boundary of the healthy range, and Margaret reports unintentional loss of 4 kg over six months; a Malnutrition Screening Tool score of 2 therefore triggered dietitian referral.
Processing Information and Identifying Problems
Processing these cues means clustering them and relating them to pathophysiology. Hypoxaemia, tachypnoea and accessory muscle use indicate acute-on-chronic respiratory compromise, while the PaCO2 of 49 mmHg with a compensated pH marks Mr Ward as a chronic carbon dioxide retainer in whom uncontrolled oxygen therapy could precipitate hypercapnic respiratory failure; Australian and New Zealand guidance therefore sets a saturation target of 88-92% for this group (Beasley et al., 2015). Fever, purulent sputum and raised inflammatory markers point to a bacterial infective exacerbation, the most common precipitant (Yang et al., 2022), and spirometry confirms severe, grade 3 airflow limitation (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2024). Underneath, loss of elastic recoil and dynamic hyperinflation raise the work of breathing, fatigue the respiratory muscles and weaken the cough needed to clear the very secretions now accumulating (Brown et al., 2020). The salient predicted risk is progression to type 2 respiratory failure, so vigilance is mandated by the Recognising and Responding to Acute Deterioration standard (Australian Commission on Safety and Quality in Health Care [ACSQHC], 2021).
Synthesising the processed cues, three nursing diagnoses were prioritised:
- Impaired gas exchange related to ventilation-perfusion mismatch and alveolar hypoventilation secondary to an infective exacerbation of COPD, as evidenced by oxygen saturation of 86% on room air, respiratory rate of 28 and borderline hypercapnia.
- Ineffective airway clearance related to increased purulent secretions, airway inflammation and fatigue, as evidenced by coarse right basal crackles, a weak moist cough and difficulty expectorating.
- Activity intolerance related to dyspnoea, fatigue and deconditioning, as evidenced by severe breathlessness on minimal exertion (Borg 7 out of 10 walking to the bathroom) and mMRC grade 4 on admission.
The ordering follows an airway and breathing first logic: gas exchange is the immediate threat, secretion clearance addresses its reversible cause, and activity intolerance shapes recovery. Malnutrition risk, anxiety, tobacco dependence and suboptimal inhaler technique are addressed through referral and education.
Nursing Care Plan: Establishing Goals and Taking Action
Goals were negotiated with Mr Ward and Margaret at the bedside, treating planning as a shared process built on the patient’s own values and priorities (McCormack & McCance, 2017). Each goal is specific, measurable and time-framed, and each intervention is paired with a rationale and evaluation criterion, reflecting NMBA Standards 5, 6 and 7 (NMBA, 2016). Table 2 presents the numbered care plan.
Table 2: Prioritised nursing care plan for Mr Ward
| Nursing diagnosis | Goal | Interventions | Rationale | Evaluation |
|---|---|---|---|---|
| 1. Impaired gas exchange related to ventilation-perfusion mismatch and alveolar hypoventilation, evidenced by SpO2 86% on room air, respiratory rate 28 and PaCO2 49 mmHg. | Mr Ward will maintain SpO2 of 88-92% with a respiratory rate below 24 within 48 hours, without rising carbon dioxide. | 1. Administer oxygen via 28% Venturi mask, titrated to SpO2 88-92%. 2. Nurse in high Fowler’s or forward-lean position. 3. Administer salbutamol and ipratropium as charted, assessing response. 4. Monitor respirations, saturation, work of breathing and conscious state hourly, escalating via the track-and-trigger chart. | 1. Controlled titration prevents oxygen-induced hypercapnia in chronic retainers (Beasley et al., 2015). 2. Upright positioning maximises diaphragmatic excursion and lowers the work of breathing (Brown et al., 2020). 3. Bronchodilators reverse the treatable component of airflow limitation (Yang et al., 2022). 4. New drowsiness may signal carbon dioxide narcosis and requires rapid escalation (ACSQHC, 2021). | SpO2 held at 89-91%, weaned to 2 L nasal prongs, with respiratory rate 20-22 by day 2; repeat blood gas stable. Goal met. |
| 2. Ineffective airway clearance related to increased purulent secretions and fatigue, evidenced by coarse basal crackles and a weak, ineffective cough. | Mr Ward will clear secretions effectively, with reducing sputum purulence and improving breath sounds, within 72 hours. | 1. Teach and supervise the active cycle of breathing technique with huff coughing every four hours while awake. 2. Encourage oral fluids of 1.5-2 litres daily unless contraindicated. 3. Collect a sputum specimen, then administer antibiotics as charted. 4. Refer to ward physiotherapy for airway clearance and early mobilisation. | 1. The active cycle of breathing mobilises secretions with less fatigue than repeated forced coughing (Brown et al., 2020). 2. Hydration reduces sputum viscosity. 3. Purulence indicates bacterial infection for which antibiotics shorten the exacerbation (Yang et al., 2022). 4. Physiotherapy consolidates technique and links clearance with mobility. | By day 3, sputum white and reducing, crackles resolving, afebrile since day 2. Goal met. |
| 3. Activity intolerance related to dyspnoea, fatigue and deconditioning, evidenced by Borg 7 of 10 walking to the bathroom and mMRC grade 4 on admission. | Mr Ward will walk to the bathroom with standby assistance reporting Borg 4 or less by day 4, and will accept a pulmonary rehabilitation referral before discharge. | 1. Structure care to alternate activity with planned rest. 2. Teach pursed-lip breathing for use during exertion. 3. Progress graded mobilisation with physiotherapy, scoring Borg before and after each walk. 4. Refer to pulmonary rehabilitation, explicitly linking the program to his goal of returning to lawn bowls. | 1. Energy conservation lowers oxygen demand during recovery. 2. Pursed-lip breathing slows expiration, limits dynamic hyperinflation and eases dyspnoea (Brown et al., 2020). 3. Objective scoring makes progress visible and guards against overexertion. 4. Rehabilitation improves exercise capacity and reduces readmission (McCarthy et al., 2015); anchoring it to a valued activity supports engagement (McCormack & McCance, 2017). | Day 4: walked 30 metres with standby assistance, Borg 4; rehabilitation referral accepted. Goal met. |
Medication Considerations
Mr Ward’s acute prescriptions follow COPD-X recommendations for exacerbation management, and administration was governed by the Medication Safety standard of the National Safety and Quality Health Service Standards (ACSQHC, 2021; Yang et al., 2022). Continuity matters as much as the acute chart: perindopril and pantoprazole continue, prednisolone is taken with food because of his reflux disease, and repeated salbutamol dosing warrants heart rate and potassium monitoring given his hypertension. All listed agents are subsidised through the Pharmaceutical Benefits Scheme, directly relevant to adherence in a pensioner household. Table 3 outlines the key nursing considerations.
Table 3: Medication considerations during the admission
| Medication and order | Class and purpose | Key nursing considerations |
|---|---|---|
| Oxygen, 28% Venturi mask, weaning to nasal prongs | Therapeutic gas; corrects hypoxaemia | Titrate strictly to SpO2 88-92%; observe for new drowsiness or morning headache suggesting carbon dioxide retention (Beasley et al., 2015). |
| Salbutamol 5 mg nebulised, then 4-8 puffs via spacer as required | Short-acting beta-2 agonist; bronchodilation | Monitor heart rate, tremor and potassium with frequent dosing; significant given existing hypertension and tachycardia. |
| Ipratropium bromide 500 micrograms nebulised, four times daily | Short-acting muscarinic antagonist; bronchodilation | Anticipate dry mouth; direct the mist away from the eyes to avoid precipitating glaucoma symptoms. |
| Prednisolone 50 mg orally each morning for five days | Systemic corticosteroid; reduces airway inflammation | Give with food due to reflux disease; monitor blood glucose, mood and sleep; no taper is required after a five-day course (Yang et al., 2022). |
| Amoxicillin 500 mg orally every eight hours for five days | Aminopenicillin antibiotic; treats bacterial exacerbation | Confirm allergy status before the first dose; collect sputum first; educate to complete the course. |
| Tiotropium 18 micrograms inhaled daily (usual maintenance) | Long-acting muscarinic antagonist; maintenance bronchodilation | Withheld while regular ipratropium is charted to avoid additive anticholinergic effects, then resumed at discharge with a teach-back technique check. |
Patient Education and Smoking Cessation
Education was staged across the admission and checked by teach-back, an approach suited to variable health literacy (ACSQHC, 2021). Priorities were inhaler technique, recognising early exacerbation signs, and the written COPD action plan promoted by Lung Foundation Australia (2023), so that Mr Ward knows when to step up bronchodilators, commence standby therapy or call 000. Vaccination catch-up followed the Australian immunisation handbook, including annual influenza and pneumococcal protection (Department of Health and Aged Care, 2023), and a general practitioner review within seven days of discharge was booked before he left.
Smoking cessation is the single most effective intervention to slow the decline in lung function, so the admission was treated as a teachable moment rather than an occasion for blame (Yang et al., 2022). Following the five As of Ask, Advise, Assess, Assist and Arrange (Royal Australian College of General Practitioners [RACGP], 2021), the nurse assessed dependence, commenced combination nicotine replacement therapy (patch plus gum) for inpatient withdrawal, and obtained consent for a Quitline (13 7848) callback referral. Margaret joined the conversation at his request, and relapse was framed as a normal part of quitting rather than failure (RACGP, 2021). The pulmonary rehabilitation referral through a local Barwon Health program complements cessation by rebuilding exercise tolerance toward his bowls goal (McCarthy et al., 2015).
Evaluating Outcomes and Reflecting
Evaluation against the stated criteria showed all three goals met, as recorded in Table 2: oxygenation stabilised within the prescribed target by day 2, sputum cleared and fever resolved by day 3, and by day 4 Mr Ward walked 30 metres with a Borg score of 4. He was discharged on day 5 with a completed action plan, nicotine replacement supplies and Quitline follow-up, a dietitian plan targeting his weight loss, a rehabilitation referral and a booked general practitioner review.
The final phase asks what should be learned. First, nutrition risk was only formally screened on the ward although the weight loss history was available at triage; earlier screening would have engaged the dietitian a day sooner. Second, raising cessation on day 1, while symptoms were vivid, appeared to strengthen Mr Ward’s resolve, suggesting timing is itself an intervention. Reflection of this kind converts one admission into transferable learning, the mechanism by which nurses develop expert pattern recognition (Levett-Jones, 2018), and completes the evaluation obligations of NMBA Standard 7 (NMBA, 2016).
Conclusion
This care plan demonstrates how the Clinical Reasoning Cycle converts scattered clinical data into prioritised, defensible nursing action for a patient living with severe COPD. Systematic cue collection identified impaired gas exchange, ineffective airway clearance and activity intolerance as the admission priorities, while negotiated goals kept Mr Ward’s ambition to return to independent life and lawn bowls at the centre of care. The plan is anchored in the Australian practice environment, from COPD-X and the 88-92% oxygen target to the National Safety and Quality Health Service Standards, the Pharmaceutical Benefits Scheme, Quitline and Lung Foundation Australia. A care plan written this way is not paperwork; it is clinical reasoning made visible, auditable and person-centred.
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