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

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

O2 Sat= 97.9%

Ineffective Breathing Pattern related to

bronchospasm, decreased lung

expansion

The physiologic changes in lung ventilation that occur during an acute asthma attack impair

both lung expansion and emptying. Anxiety

caused by hypoxia and dyspnea compounds the

problem by increasing the respiratory rate.

PATHOPHYSIOLOGYWhen a trigger such as

inhalation of an allergen or irritant occurs, an

acute or early response develops in the

hyperreactive airways predisposed to bronchospasm.

Sensitized mast cells in the bronchial mucosa release inflammatory

mediators such as histamine,

prostaglandins and leukotrienes. These mediators stimulate

The client will be able to establish an effective

respiratory pattern so as to provide adequate

ventilation as manifested by stabilizing respiratory

rate, decreasing chest tightness, slight to no

nasal flaring and decreasing usage of

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

INDEPENDENT:

1. Frequently assess respiratory rate, pattern, and breath sounds. Note

manifestations of ineffective breathing.

2. Monitor vital signs and laboratory results.

3.Assist with self-care activities.

4. Provide rest periods between scheduled

activities and treatments.

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

(with head and arms supported on the

overbed table) position

Early identification of ineffective respirations

allow timely initiation of interventions.

Tachypnea, tachycardia, an elevated blood pressure, and increasing hypoxemia and hypercapnia are signs of compromised respiratory status.

This conserves energy and reduces fatigue.

Scheduled rest is important to prevent

fatigue and reduce oxygen demands. .

These positions reduce the work of breathing

and increases lung expansion, especially the

basilar areas.

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. However, wheezes can still be auscultated from all lung fields and there is still usage of accessory muscles and nasal flaring.

pH= 7.501pCO2= 29.8 mmHg

Impression: Respiratory Alkalosis without

compensation

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. 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

to facilitate breathing and lung expansion.

6. Teach and assist to use techniques to control

breathing pattern:a. Pursed-lip breathingb. Abdominal breathingc. Relaxation technique including visualization, meditation and others.

.

DEPENDENT:

7. Administer 2 liters per minute of oxygen as

ordered.

8. Administer nebulizers treatments as ordered:

Combivent 1 nebuleDuavent 1 nebule

(with 15 minutes interval in between)

9. Administer anti-inflammatory agents as

ordered:Hydrocortisone 200 mg

IVTT

Pursed- lip breathing helps keep airways open by maintaining positive

pressure, and abdominal breathing improves lung

expansion. Relaxation techniques reduce

anxiety and its effect on the respiratory rate.

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

reduce bronchial hyperresponsiveness.

pp. 1106,1111-1112.