s.

asthma
Assessment

Diagnosis

Planning

Implementation

Evaluation

Objective
-severe
bronchospas
m
breathlessness
-persistent
wheezing
-cough
-High
respiratory
rate
(greater
than 30
breaths
per
minute)
-O2
saturation
of less
than 90%
-Poor
Capillary
refill
- Presence of
secretions

Impaired
gas
exchange r/t
decrease in
oxygen
supply due
to
the
constriction
and
narrowing
of
the
airways as
manifested
by wheezes
upon
auscultation

Long Term:
After 12 hours of
nursing intervention
the patient will be
able to breathe
effectively.

Independent:
- Elevate head of bead to
ensure effective breathing.

After
the
nursing
interventions the
patient will be
able to

Short Term:
After 1 hour of
nursing intervention
the patient will be
able to decrease
respiratory
rate
within the normal
range.

- Assist patient to change or

wear loose clothing since
tight clothing will further
increase constriction of the
airways
- Advise patient to rest
- Perform back tap to loosen
secretions
Dependent:
- Administer O2 via face
mask 4-6 L/min
-Administer
Bronchodilators as ordered

- Verbalize that
he/she
can
breathe properly
- Increase in o2
saturation
- Decrease RR
within
the
normal range
- Absence of
wheezing sound
in the lungs
Less
removal
secretions.

or
of