Assessment Subjective: “Di, po ako makahinga ng maayos.” As verbalized by the patient.

Objective: • Difficulty breathing • PR: 134 bpm • Chest tightness • Productive cough • Restlessness

Nursing Diagnosis Ineffective airway clearance related to increase production of secretion secondary to bronchospasm, evidenced by difficulty breathing

Inference Air pollution ↓ Inflammation ↓ Swelling of the membranes (mucosal edema) ↓ Reducing the airway diameter ↓ Bronchospasm ↓ ↑ mucus production ↓ DOB/cough

Planning After 1 hour of nursing intervention the patient will be able to: Improve/ maintain airway clearance as evidenced by absence of respiratory distress

Intervention  Assess pt.’s condition  VS monitor and record  Auscultate breath sounds and assess airway pattern

Rationale  To obtain baseline data  Serve to track important changes  To check for the presence of adventitious breath sounds  To minimize difficulty in breathing  To maximize effort for expectoration.  To decrease air trapping and for efficient breathing.  To prevent fatigue.  To prevent situations that will aggravate

Evaluation Goal met. The patient was able to exhibit improved airway clearance by the absence of respiratory distress.

Reference: Brunner and Suddarth’s textbook of MedicalSurgical Nursing V1 10th edition

 Elevate head of the bed and change position of the patient every 2 hours.  Encourage deep breathing and coughing exercises  Demonstrate Diaphragmatic and pursed-lip breathing  Encourage increase in fluid intake  Encourage opportunities for

rest and limit physical activities. Collaborative:  Reinforce low salt, low fat diet as ordered  Administer medication as prescribed by the doctor: Salbutalmol 1neb Prednisone 30mg

the condition

 To mobilize secretions.

 Bronchodilator and Antihypertensive

Assessment Subjective: “di ko po kasi alam, bigla nalang po akong ina-atake”, as verbalized by the patient. Objective: • Inaccurate followthrough of instruction • Unable to mention other factors that triggers an attack of asthma

Nursing Diagnosis Knowledge deficit related to complexity of therapeutic regimen

Inference Inability to perceive the factors that may trigger the attack of asthma and techniques/ management used during an episode of DOB.

Planning After 8 hours of nursing intervention the patient will be able to: • Verbalize understanding about the disease process • Demonstrate appropriate breathing techniques during activityinduced shortness of breath or coughing episodes • Identify factors that may trigger attacks.

Intervention  After acute episode resolves, help the client identify triggers that may cause or contribute to attacks.  Discuss and demonstrate proactive strategies the patient can use when confronted with an environment al irritant.  Teach the patient how to use a metereddose inhaler. Discuss the potential

Rationale  To help the client know what factors can cause attack


Reference: MedicalSurgical Care Planning 4th edition of Nancy M. Holloway, RN, MSN

Goal met. The patient was able to: • Verbalize understandi ng about the disease process • Demonstrate appropriate  To breathing implement techniques an assertive, during nonactivityaggressive induced type strategy shortness of for dealing breath or with coughing potentially episodes hazardous • Identify situations factors that may trigger  To attacks understand how to use the metered dose inhaler effectively

adverse effects of medications  Demonstrate strategies to be used during coughing episode  Demonstrate and have the patient practice relaxation and stress reduction exercise  Teach the patient the symptoms of an attack  To reduce forceful exhalation

 To help reduce the frequency of attacks

 To ensure that the patient knows the symptoms and steps to take should an attack occur

Assessment Subjective: “Di na nga rin ako maka pagtrabaho, kahit gawaing bahay mejo limitado na rin kasi baka atakihin ulit ako”, as verbalized by the patient. Objective: • Fatigue

Nursing Diagnosis Risk for activity Intolerance r/t decrease oxygenation

Inference ↑ in activity ↓ ↑ cardiac rate ↓ ↑ respiratory ↓ Vasoconstriction/ Bronchospasm ↓ Ineffective tissue perfusion ↓ Hypoxemia ↓ Fatigue

Planning After 8 hours of nursing intervention the patient will participate willingly in necessary/ desired activities such as deep breathing exercises.

Intervention  Monitor VS.  Assess motor function.  Note contributing factors to fatigue.  Evaluate degree of deficit.  Ascertain ability to stand and move about.  Assess emotional or psychological factors  Plan care with rest periods between activities  Increase

Rationale  To have a baseline data  To identify causative factors.  To identify precipitating factors.  To identify severity.  To identify necessity of assistive devices.  Stress and/or depression may increase the effects of illness.  To reduce fatigue

Evaluation Goal met. Patient participated willingly in necessary/ desired activities such as deep breathing exercises.

Reference: Brunner and Suddarth’s textbook of Medical-Surgical Nursing V1 10th edition

 Minimizes

activity/exerc ise gradually such as assisting the patient in doing PROM to active or full range of motions.  Provide adequate rest periods.  Assist client indoing self careneeds  Elevate arm and hand  Place knees and hips in extended position

muscle atrophy, promotes circulation, helps to prevent contractures

 To replenish energy.  To promote independence and increase activity tolerance  Promotes venous  Maintains functional position

Assessment Subjective: “Tulungan niyo po ako, maawa po kayo sa akin, ayoko pa po mamatay.” As verbalized by the patient. Objective: • Trembling • Extraneous movement • PR: 134 bpm

Nursing Diagnosis Anxiety related to perceived threat of death evidenced by fearful expression

Inference Anxiety is commonly viewed along a continuum of mild (to moderate) severe. With mild anxiety, the patient is coherent enough to vocalize and discuss what’s distressing him.



Rationale  To establish the priorities of care  To let the patient gain trust with his nurse and able to express feelings  To decrease the anxiety of the patient

Evaluation After 8 hour of nursing intervention the patient was be able to: • Minimize or prevent the escalation of the his anxiety • Identify healthy ways to deal with and express anxiety • Appear relaxed and report anxiety is reduced to a manageable level

Reference: MedicalSurgical Care Planning 4th edition of Nancy M. Holloway, RN, MSN

After 8 hour of  Assess the nursing level of intervention the anxiety of the patient will be able patient to:  Establish • Minimize or rapport with prevent the the patient, escalation of conveying the his anxiety empathy and • Identify unconditional healthy ways positive to deal with regard and express  Encourage anxiety the patient to • Appear talk about the relaxed and fears report anxiety associated is reduced to a with the manageable stressful level feelings  Discuss the patient’s perception about death, misconceptio ns and fears related to dying

 To express self and explore patient’s concern

Assessment Subjective: “Nahihilo at masakit po ulo ko”, as verbalized by the patient.

Nursing Diagnosis


Planning After 4 hours of nursing intervention patient will demonstrate adequate tissue perfusion AEB blood pressure, pulse rate and rhythm within normal parameters for patient

Intervention  Monitor VS at least q 1-2 hrs and prn  Encourage patient to decrease intake of caffeine, cola and chocolates  Observe for complaints of blurred vision, tinnitus or confusion.  Monitor I&O status  Monitor for sudden onset of chest pain.  Monitor ECG for changes in rate, rhythm, dysrhythmias and conduction defects.  Observe extremities for swelling, erythema, tenderness and pain. Observe for decreased perip heral pulses, pallor,

Rationale  to monitor baseline data  Caffeine is a cardiac stimulant and may adversely affect cardiac function.  May indicate cyanide toxicity from increasing intracranial pressure .  I&O will give an indication of fluid balance or imbalance, thus allowing for changes in treatment regimen when required  May indicate dissecting aortic aneurysm.  Decreased perfusion may result in dysrhythmias caused by decrease in oxygen.  Bedrest promotes venous statis which

Evaluation Goal partially met. After 4 hours of nursing intervention the patients blood pressure decrease from 240/110 mmHg to 160/100 mmHg

Ineffective tissue Stress perfusion: ↓ Cardiopulmonary Adrenal medulla related to ↓ hypertension and Norepinephrine/ decreased epinephrine cardiac output as ↓ manifested by Fight/Flight Objective: increased response blood pressure of ↓ • PR: 134 240/110 mmHg Vasoconstriction bpm ↓ • BP: 240/110 ↑ blood pressure • Shortness of breath • Restlessness • Fatigue

Reference: Brunner and Suddarth’s textbook of MedicalSurgical Nursing V1 10th edition

coldness and cyanosis.  Instruct client in signs/symptoms to report to physician such as headache upon rising, increased blood pressure, chest pain, shortness of breath, increased heart rate, visual changes, edema, muscle cramps and nausea and vomiting Collaborative: Administer medication as prescribed by the doctor:  Catapres 75mg  Amlodopine 5mg

can increase the risk of thrombo embolus formation. If treatment is too rapid and aggressive in decreasing the blood pressure, tissue perfusion will be impaired and ischemia can result.  Promotes knowledge and compliance with treatment. Promotes prompt detection and facilitates prompt intervention

 Anti-hypertensive drugs

Sign up to vote on this title
UsefulNot useful