NURSING CARE PLAN

Name of Patient: Attending Physician: Age: Impression/Diagnosis:

Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Interventions Rationale Evaluation04/20/10 11:00 am

Client refrains from talking because he finds it hard to breathe while doing so.

Client simply points out objects he wants and makes signs because he finds it difficult to breath.

Complains of tight feeling in the chest

RR=37 breaths/minute

With rapid and shallow respirations

Uses accessory muscles to aid in breathing

Exhibits nasal flaring Faint breath sounds with expiratory wheezes (on

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. Both

inspiratory and expiratory volume are

affected decreasing the oxygen available at the alveolus for the process of respiration. Narrowed air passages increase the

work of breathing, increasing the metabolic rate and tissue demand

for oxygen.

PATHOPHYSIOLOGYWhen a trigger such as

inhalation of an allergen or irritant occurs, an

acute or early response develops in the

hyperreactive airways

The client will be able to maintain a patent airway

as manifested by effective expectoration

of secretions and decreasing signs and

symptoms of bronchospasm (dyspnea,

tachypnea, use of accessory muscles,

cough) and clearing of breath sounds (wheezes)

by 04/20/10 3:00 p.m.

INDEPENDENT:

1. Frequently assess respiratory status at

least every 1 to 2 hours: respiratory rate and

depth, chest movement or excursion and breath

sounds.

2. Monitor skin color and temperature and level of

consciousness.

3. Assess arterial blood gas results.

ABG Results 04/20/10HCO3= 23.2 mmol/L

O2 Sat= 97.9%pH= 7.501

pCO2= 29.8 mmHgImpression: Respiratory

Alkalosis without compensation

4. Assess cough effort and sputum for color,

Respiratory status can change rapidly during an acute asthma attack and

its treatment.

Cyanosis, cool clammy skin and changes in level of consciousness indicate

worsening hypoxia.

These values provide information about gas

exchange and the adequacy of alveolar ventilation. A fall in

oxygen saturation levels is an early indicator of

impaired gas exchange.

Ineffective cough may also signal impending

04/20/10 3:00 p.m

GOAL PARTIALLY MET.The client manifested decreasing respiratory rate, RR=22 breaths/minute and appeared less strained and distressed upon breathing. The client was also able to cough out effective purulent sputum approximately 60 cc in amount. However, wheezes can still be auscultated from all lung fields and there is still usage of accessory muscles and nasal flaring.

all lung fields)

Coughs out purulent sputum.

predisposed to bronchospasm.

Sensitized mast cells in the bronchial mucosa release inflammatory

mediators such as histamine,

prostaglandins and leukotrienes. These mediators stimulate

parasympathetic receptors and bronchial

smooth muscle to produce

bronchoconstriction. They also increase

capillary permeability, leading to mucosal

edema, and stimulate mucus production.

The attack is prolonged by the late response

phase, which develops 4 to 12 hours after

exposure to the trigger. Inflammatory cells such

as basophils and eosinophils are

activated, which damage airway epithelium, produce musocsal

edema, impair mucociliary clearance,

and produce ro prolong bronchoconstriction. The degree of hyperreactivity depends on the extent of

inflammation, and mucous secretion

narrow the airway.

consistency and amount.

5. Place in Fowler’s, High Fowler’s or orthopneic

(with head and arms supported on the

overbed table) position to facilitate breathing and lung expansion.

6. Initiate or assist with chest physiotherapy, including percussion,

coughing exercises and postural drainage.

7. Encourage to increase fluid intake to 2.5-3.0

liters per day.

DEPENDENT:

8. Administer 2 liters per minute of oxygen as

ordered.

9. Administer nebulizers treatments as ordered:

Combivent 1 nebuleDuavent 1 nebule

(with 15 minutes interval in between)

10. Administer anti-inflammatory agents as

ordered:Hydrocortisone 200 mg

IVTT

respiratory failure.

These positions reduce the work of breathing

and increases lung expansion, especially the

basilar areas.

These facilitate the movement of secretions

and airway clearance.

Increasing fluids help keep secretions thin.

Supplemental oxygen reduces hypoxemia.

Adrenergic stimulants affect receptors on

smooth muscle cells of the respiratory tract,

causing smooth muscle relaxation and

bronchodilation.

These are used to suppress airway

inflammation and reduce asthma symptoms. It

blocks late response to inhaled allergens and

Airway resistance increases, limiting

airflow and increasing work of breathing.

Source: LeMone, P. ,et.al. 2004. Medical-Surgical Nursing: Critical Thinking in Client Care 3rd Edition pp. 1106,1111-1112.

reduce bronchial hyperresponsiveness.