NURSING CARE PLAN

ASSESSMENT Subjective: Nahihirapan ako huminga as verbalized by the patient. Objective: Use of accessory muscle. Abnormal breath sounds. V/S taken as follows: T: 37.3 P: 110 R: 40 BP: 110/80 DIAGNOSIS Ineffective airway clearance related to increased production of secretions.

SCIENTIFIC ANALYSIS
Bronchial asthma is a chronic Inflammatory disease of the airways, associated with recurrent, reversible airway obstruction with intermittent episodes of wheezing and dyspnea. Bronchial hypersensitivity is caused by various stimuli, which innervate the vagus nerve and beta adrenergic receptor cells of the airways, leading to bronchial smooth muscle constriction, hypersecretion of mucus, and mucosal edema.

PLANNING
After 3 days of nursing interventions, the patient will demonstrate behaviors to improve airway clearance.

INTERVENTION
Independent: Auscultate breath sounds. Note adventitious breath sounds like wheezes, crackles and rhonchi. Elevate head of the bed, have patient lean on overbed table or sit on edge of the bed. Keep environmental pollution to a minimum like dust, smoke and feather pillows, according to individual situation. Encourage or assist with abdominal or pursed lip breathing exercises. Assist with measures to Improve effectiveness of cough effort.

RATIONALE
Some degree of Bronchospasm is present with obstructions in airway and may or may not be manifested in adventitious breath sounds. Elevation of the bed facilitates respiratory function by use of gravity. Precipitators of allergic type of respiratory reactions that can trigger or exacerbate onset of acute episode. Provides patient with some means to cope with or control dyspnea and reduce air tapping. Coughing is most effective in an upright position after chest percussion.

EVALUATION After 3 days of nursing interventions, the patient was able to demonstrate behaviors to improve airway clearance.

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Medical Diagnosis: Bronchial Asthma Problem: Fatigue RT Physical Exertion to Maintain Adequate Ventilation Assessment Subjective: Luya kay ako lawas ug wala koy kusog as verbalized by patient. Objective: wheezing upon inspiration and expiration dyspnea coughing small amount of white sputum tachypnea, prolonged expiration tachycardia chest Nursing Diagnosis Fatigue r/t physical exertion to maintain adequate ventilation AEB use of accessory muscles to breathe Scientific Explanation Fluid accumulation in the lungs makes it difficult to breathe. The fluid inside prohibits the lungs to expand thus it is harder to breathe. The client, to have adequate ventilation makes use of his accessory muscles to breathe to have sufficient air. With too much use of the accessory muscles, Planning Interventions Rationale
1. To gain patients trust 2. For baseline data. 3. Temperature and level of humidity are known to affect exhaustion. 4. Promotes sense of control and improves selfesteem.

Evaluation Patient will verbalize understand on health teachings given and report improved sense of energy. Patient will perform ADLs within clients ability and participates in desired activities. Patient will be able to identify basis of fatigue and be able to cope

1. Establish Choose: rapport Patient will 2. Monitor and verbalize record vital understand on signs. health 3. Provide teachings environment given and conducive to report relief of improved fatigue. sense of energy. 4. Assist client to

Patient will perform ADLs within clients ability and participates in desired activities. Patient will be able to identify basis of fatigue and

identify appropriate coping behaviors.

5. Encourage 5. Helps patient to counteract restrict activity effects of and rest in increased bed as much metabolism. as possible. 6. Increased 6. Avoid topics irritability of that irritate or the CNS may

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tightness restlessness Altered loc weakness feeling of be able to tiredness may cope up with be present the problem. resulting to fatigue which is experienced by the client.
upset patient. Discuss ways to respond to these feelings. cause patient to be easily excited, agitated and prone to emotional outbursts. 7. Education may provide motivation to increase activity level even though patient may feel too weak initially. 8. Prevents excessive fatigue. 9. Indicates physiological levels of tolerance. 10. Increases confidence level/selfesteem and tolerance level.

up with the problem.

7. Discuss with the patient the need for activity. Plan schedule with patient and identify activities that lead to fatigue. 8. Alternate activity with rest periods. 9. Monitor VS before and after activity. 10. Increase patient participation in ADLs as tolerated.

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Medical Diagnosis: Bronchial Asthma Problem: Ineffective Breathing Pattern RT Presence of Secretions Assessment Subjective: Ubo ako ng ubo at hindi makahinga ng maayos., as verbalized by the client. Objective: wheezing upon inspiration and expiration dyspnea coughing small amout of white sputum tachypnea, Nursing Diagnosis Ineffective breathing pattern r/t presence of secretions AEB productive cough and dyspnea Scientific Explanation Presence of secretions in the bronchi will result into a blockage of air that will enter the body and thus producing insufficient air needed by the body. And inability to maintain clear airway. This obstruction is further heightened by bronchospasm due to the contraction of the smooth muscles in the Planning Choose: Patient will demonstrate pursed-lip breathing and diaphragmatic breathing. Patient will manifest signs of decreased respiratory effort AEB absence of dyspnea Patient will verbalize understanding of causative factors and demonstrate Interventions Establish rapport. assess pt.s condition VS monitor and record Auscultate breath sounds and assess airway pattern Elevate head of the bed and change position of the pt. every 2 hours. Encourage deep breathing and coughing exercises. Demonstrate diaphragmatic and pursed-lip Rationale To gain pt.s trust. To obtain baseline data Serve to track important changes to check for the presence of adventitiou s breath sounds To minimize difficulty in breathing To Evaluation Patient will demonstrate pursed-lip breathing and diaphragmatic breathing. Patient will manifest signs of decreased respiratory effort AEB absence of dyspnea Patient will verbalize understanding of causative factors and demonstrate behaviors that

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prolonged expiration chest tightness restlessness bronchi. This is caused by parasympathetic stimulation of the muscarinic2 receptors as well as by chemical mediators released in response to the presence of allergen. behaviors that would improve breathing pattern breathing. maximize Encourage effort for increase in fluid expectorat intake ion. Encourage opportunities To for rest and decrease limit physical air activities. trapping Reinforce low and for salt, low fat diet efficient as ordered. breathing. To prevent fatigue. To prevent situations that will aggravate the condition To mobilize secretions would improve breathing pattern

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Medical Diagnosis: Bronchial Asthma Problem: Impaired Gas Exchange RT Ventilation Perfusion Imbalance Assessment Subjective: (none) Objective: wheezing upon inspiration and expiration dyspnea coughing small amout of white sputum tachypnea, prolonged expiration tachycardia chest tightness restlessness Altered loc Nursing Diagnosis Impaired gas exchange RT ventilation perfusion imbalance AEB dyspnea, tachypnea, and tachycardia Scientific Explanation
Bronchial asthma is a condition wherein the airways diameter is highly reduced. This is due to severe bronchospasm, mucosal edema and mucus plug formation. There is a rise in airway resistance which leads to decreased amount of air that enters upon inspiration as well as expiration. Thus, ventilation is impaired. In bronchial

Planning Choose: Patient will improve gas exchange AEB absence of respiratory distress Patient will demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within clients normal limits and absence of symptoms of respiratory distress. Patient will

Interventions Establish rapport. assess pt.s condition VS monitor and record Auscultate breath sounds and assess airway pattern Elevate head of the bed and change position of the pt. every 2 hours. Encourage deep breathing and coughing exercises. Demonstrate diaphragmati

Rationale To gain pt.s trust. To obtain baseline data Serve to track important changes to check for the presence of adventitious breath sounds To minimize difficulty in breathing To maximize effort for expectoratio

Evaluation Patient will improve gas exchange AEB absence of respiratory distress Patient will demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within clients normal limits and absence of symptoms of respiratory distress. Patient will verbalize

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asthma, perfusion is not directly affected. However, the balance between ventilation and perfusion (V/Q ratio) is lost because despite the adequate perfusion (capillary circulation), not much gas is available to diffuse from the alveoli to the capillaries. Conversely, the gases in the capillaries do diffuse to the alveoli but since expiration is impaired, such gases fail to be ventilated out. Thus, gas exchange is impaired.

verbalize understand of causative factors and appropriate interventions (deep breathing, cough exercises, etc)

c and pursed-lip breathing. Encourage increase in fluid intake Encourage opportunities for rest and limit physical activities. Reinforce low salt, low fat diet as ordered.

n. To decrease air trapping and for efficient breathing. To prevent fatigue. To prevent situations that will aggravate the condition To mobilize secretions.

understand of causative factors and appropriate interventions (deep breathing, cough exercises, etc)

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Medical Diagnosis: Bronchial Asthma Problem: Risk for Activity Intolerance RT Decreased Oxygenation Assessment Subjective: (none) Objective: Immobility Weakness Nursing Diagnosis Risk for Activity Intolerance r/t decrease oxygenation Scientific Explanation Inadequate oxygen in the circulation can develop weakness in our muscles. Muscles need oxygen to move and to do its function. If the patient cannot tolerate any activities because of the low oxygenation caused by the ventilationperfusion imbalance caused by the pathological minimized lung expansion. Planning Choose: Patient will participate willingly in necessary/ desired activities such as deep breathing exercises. Patient will perform ADLs within clients ability and participates in desired activities. Patient will be able to increase activity tolerance AEB Interventions 1. Monitor VS. 2. Assess motor function. 3. Note contributing factors to fatigue. 4. Evaluate degree of deficit. 5. Ascertain ability to stand and move about. 6. Assess emotional or psychological factors 7. Plan care with rest periods between Rationale 1. For baseline data. 2. To identify causative factors. 3. To identify precipitating factors. 4. To identify severity. 5. To identify necessity of assistive devices. 6. Stress and/or depression may increase the effects of illness. 7. To reduce Evaluation Patient will participate willingly in necessary/ desired activities such as deep breathing exercises. Patient will perform ADLs within clients ability and participates in desired activities. Patient will be able to increase activity tolerance AEB attendance of

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attendance of self-care needs. Patient will be able to gradually increase activity within level of ability activities 8. Increase activity/exerc ise gradually such as assisting the patient in doing PROM to active or full range of motions. 9. Provide adequate rest periods. 10. Assist client in doing selfcare needs 11. Elevate arm and hand 12. Place knees and hips in extended position fatigue 8. Minimizes muscle atrophy, promotes circulation, helps to prevent contractures 9. To replenish energy. 10. To promote independen ce and increase activity tolerance 11. Promotes venous 12. Maintains functional position self-care needs. Patient will be able to gradually increase activity within level of ability