Medical Diagnosis: Bronchial Asthma Problem: Ineffective Airway Clearance RT Bronchial Constriction and Increased Mucus Production Assessment

Subjective:(none) Objective: wheezing upon inspiration and expiration dyspnea coughing, sputum is yellow and sticky tachypnea, prolonged expiration tachycardia chest tightness suprasternal retraction restlessness anxiety cyanosis loss of consciousness Nursing Diagnosis Ineffective airway clearance RT bronchoconstriction, increased mucus production, and respiratory infection AEB wheezing, dyspnea, and cough Scientific Explanation The presence of a foreign microorganism triggers the B lymphocyte to produce antibodies that are specific to that antigen. These antibodies then attach to mast cells in the lungs. The mast cells with the antibody attaches to the antigen and begins to degranulate. This degranulation causes the release of certain chemical mediators, namely, histamine, bradykinin, prostaglandin, and leukotriene. These chemical mediators cause bronchospasm leading to bronchoconstriction, increased vascular permeability leading to fluid leakage from the lung vasculature and increased mucus Planning Choose: Patient will maintain/improve airway clearance AEB absence of signs of respiratory distress Patient will verbalize understanding that allergens like dust, fumes, animal dander, pollen, and extremes of temperature and humidity are irritants or factors that can contribute to ineffective airway clearance and should be avoided. Patient will demonstrate behaviors that would prevent the recurrence of the problem Interventions 1. Adequately hydrate the pt. 2. Teach and encourage the use of diaphragmatic breathing and coughing exercises. 3. Instruct pt to avoid bronchial irritants such as cigarette smoke, aerosols, extremes of temperature, and fumes. 4. Teach early signs of infection that are to be reported to the clinician immediately. Increases sputum production Change in color of sputum Increased Rationale 1. Systemic hydration keeps secretion moist and easier to expectorate. 2. These techniques help to improve ventilation and mobilize secretions without causing breathlessness and fatigue. 3. Bronchial irritants cause bronchoconstrict ion and increased mucus production, which then interfere with airway clearance. 4. Minor respiratory infections that are of no consequence to the person with normal lungs can produce fatal Evaluation Short Term: The pt shall be free from any signs of respiratory distress

Long Term: The patient shall have demonstrated behaviors and understood causative factors to prevent recurrence of problem.

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production. These lead to swelling of the bronchi, mucus buildup that plugs the airway and decreased bronchial diameter. This causes an increased airway resistance and a constricted pathway for air. Air cannot pass effectively and this manifests as a whistling sound. Coughing is a way to expel the obstruction (mucus plug) while dyspnea is a manifestation of the increased airway resistance.

thickness of sputum Increased SOB, tightness of chest, or fatigue Increased coughing Fever or chills

disturbances in the lungs of an asthmatic person. Early recognition is crucial. 5. Uses gravity to help raise secretions so they can be more easily expectorated.

5. If indicated, perform postural drainage with percussion and vibration in the morning and at night as prescribed. 6. Assist in administering nebulizer, as indicated. 7. Administer ATX as prescribed.

6. This ensures adequate delivery of medications to the airways.

7. Antibiotics may be prescribed to treat the infection.

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