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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.