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Asthma Nanda Diagnoses, Goals and Interventions

1. Ineffective airway clearance related to bronchospasms and inability to remove airway secretions effectively. Goal: The patient showed the ability to maintain effective airway clearance, with the expected outcomes:

There is expulsion of secretion Lungs sound clear on auscultation Demonstrate effective coughing and increased air exchange

Intervention: 1. Airway management:


Monitor the chest wall retraction Monitor respirations (rate, depth and quality) Place client in semi fowler position Monitor Arterial Blood Gas

2. Clear the airway:


Listen to lung sounds Encourage the patient to drink clear fluids Monitor oxygen delivery Evaluation of lung sounds Effective coughing techniques

2. Ineffective breathing pattern related to bronchoconstriction of the airway, respiratory muscle fatigue. Goal: Assess patient's respiratory status, with the result criteria:

Achieve respiratory rate within normal limits Patient not using accessory muscles for breathing No complaints of pain upon inspiration and expiration Patient will express relief of (improvement in) feelings of shortness of breath

Intervention: 1. Airway management:


Monitor the use of additional respiratory muscles (chest wall retraction) Monitor vital signs; respiration, pulse, blood pressure, temperature Position the patient in semi fowler position

2. Oxygen Therapy:

Provide oxygen as recommended Give supplemental oxygen through a nasal canulla or oxygen mask o The flow of 1-6 liters / minute oxygen concentration produces 24-44% o The flow of 5-8 liters / minute oxygen concentration produces 40-60% o The flow of 8-12 liters / min oxygen concentration produces 60-80% o The flow of 8-12 liters / min oxygen concentration producing 90%

3. Collaboration for bronchodilator therapy.

3. Impaired gas exchange related to bronchospasm, damage to the alveoli and hypoxemia. Goal: Effective gas exchange, with expected outcomes:

Free from symptoms of respiratory failure, cyanosis and hypoxemia. Arterial blood gas analysis results within normal limits.

Intervention: 1. Airway management:


Position the patient in semi fowler position Auscultation of breath sounds Monitor patient's fluid balance for intake and output (1-3L) per 24hr Monitor respiration rate Clear the airway of secretions Teach the client the correct usage of the inhaler

2. Acid-base management:

Monitor blood gas analysis Monitor electrolyte levels Monitor oxygen saturation Collaboration of medication to maintain the acid-base balance (sodium bicarbonate) Monitor hemodynamic status

4. Activity intolerance related to imbalance of oxygen being supplied to the body Goal: The patient showed a tolerant state of activity, with the expected outcome:

No shortness of breath on exertion Ability to participate in activities

Intervention: 1. Energy management:


Determine the causes of fatigue Monitor respiratory (respiration, dyspnea, pallor) Assist clients with ADL (activities for daily living) Recommend the increased intake of nutrients

2. Monitor response of breathing during activities, assess abnormal response in respiration, blood pressure and pulse.

5. Knowledge deficit related to lack of information. Goal: Increase patient knowledge about asthma. The expected outcomes:

Help client to identify asthma triggers and how to avoid them Educate client on how to handle an asthmatic episode Educate family members about asthma; extra inhalers should be available

Intervention: 1. Assess for known triggers of asthma attacks in clients. 2. Assess the patient's condition before teaching session, do not provide health education while patients are in the state of an attack. 3. Education:

Define asthma, its causes, signs and symptoms Explain the pathophysiology of the condition Identify the genetic and environmental factors that predispose the client to an asthmatic episode: allergens, stress, excessive cold weather activity Explain how to address an asthma attack at home Evaluate what has been delivered by clients ability to verbalize and demonstrate their understanding of information given.

6. Anxiety related to change in health status Goal: The client can control anxiety and increase coping mechanisms. Expected outcomes:

Clients facial expression becomes relaxed Vital signs are within normal limits

Intervention: 1. Lower levels of anxiety:


Listen to client and show empathy Instruct the family on how to assist the client during an asthma attack

2. Teach coping mechanisms if stress cannot be avoided:


Respiratory control by the ability to take deep breaths (relaxation) Create a relaxed atmosphere

7. Imbalanced nutrition: less than body requirements related to inadequate intake of nutrients. Goal: Improve nutritional status, with expected outcomes:

Increased oral input

Intervention: 1. Environmental Management:


Provide a relaxed dining atmosphere Limit visitors during meal times

2. Manage clients nutrition:


Assess the client's food preferences and diet recommended Monitor oral intake, if not enough add parenteral nutrition Work in collaboration with the nutritionist