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Bronchospasm and bronchoconstriction, increased mucous secretion and airway edema narrow the airways and impair airflow during acute attack of asthma. When a trigger such as inhalation of an allergen or irritant occurs, an acute or early response develops in the hyperreactive airways.
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Ineffective Airway Clearance related to bronchospasm
Bronchospasm and bronchoconstriction, increased mucous secretion and airway edema narrow the airways and impair airflow during acute attack of asthma. When a trigger such as inhalation of an allergen or irritant occurs, an acute or early response develops in the hyperreactive airways.
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Bronchospasm and bronchoconstriction, increased mucous secretion and airway edema narrow the airways and impair airflow during acute attack of asthma. When a trigger such as inhalation of an allergen or irritant occurs, an acute or early response develops in the hyperreactive airways.
Copyright:
Attribution Non-Commercial (BY-NC)
Formati disponibili
Scarica in formato DOC, PDF, TXT o leggi online su Scribd
Age: Impression/Diagnosis: Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Interventions Rationale Evaluation 04/20/10 11:00 am INDEPENDENT: 04/20/10 3:00 p.m Ineffective Airway Bronchospasm and The client will be Client refrains from Clearance related to bronchoconstriction, able to maintain a 1. Frequently assess Respiratory status GOAL PARTIALLY talking because he bronchospasm increased mucous patent airway as respiratory status at can change rapidly MET. finds it hard to secretion and manifested by least every 1 to 2 during an acute The client breathe while doing airway edema effective hours: respiratory asthma attack and manifested so. narrow the airways expectoration of rate and depth, its treatment. decreasing and impair airflow secretions and chest movement or respiratory rate, Client simply points during acute attack decreasing signs excursion and RR=22 out objects he of asthma. Both and symptoms of breath sounds. breaths/minute and wants and makes inspiratory and bronchospasm appeared less signs because he expiratory volume (dyspnea, 2. Monitor skin color Cyanosis, cool strained and finds it difficult to are affected tachypnea, use of and temperature clammy skin and distressed upon breath. decreasing the accessory muscles, and level of changes in level of breathing. The oxygen available at cough) and clearing consciousness. consciousness client was also able Complains of tight the alveolus for the of breath sounds indicate worsening to cough out feeling in the chest process of (wheezes) by hypoxia. effective purulent respiration. 04/20/10 3:00 p.m. 3. Assess arterial sputum RR=37 Narrowed air blood gas results. These values approximately 60 cc breaths/minute passages increase ABG Results provide information in amount. the work of 04/20/10 about gas exchange However, wheezes With rapid and breathing, HCO3= 23.2 mmol/L and the adequacy of can still be shallow respirations increasing the O2 Sat= 97.9% alveolar ventilation. auscultated from all metabolic rate and pH= 7.501 A fall in oxygen lung fields and there Uses accessory tissue demand for pCO2= 29.8 mmHg saturation levels is is still usage of muscles to aid in oxygen. Impression: an early indicator of accessory muscles breathing Respiratory impaired gas and nasal flaring. PATHOPHYSIOLOGY Alkalosis without exchange. Exhibits nasal When a trigger such compensation flaring as inhalation of an allergen or irritant 4. Assess cough Faint breath sounds occurs, an acute or effort and sputum Ineffective cough with expiratory early response for color, may also signal wheezes (on all lung develops in the consistency and impending fields) hyperreactive amount. respiratory failure. airways predisposed Coughs out purulent to bronchospasm. 5. Place in Fowler’s, These positions sputum. Sensitized mast High Fowler’s or reduce the work of cells in the orthopneic (with breathing and bronchial mucosa head and arms increases lung release supported on the expansion, inflammatory overbed table) especially the mediators such as position to facilitate basilar areas. histamine, breathing and lung prostaglandins and expansion. leukotrienes. These