NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVA

LUATION
Subjective:Nahihirapan akohuminga asverbalized by thepatient.
Objective:

Use ofaccessorymuscle.

Abnormalbreathsounds.

V/S taken asfollows:T: 37.3P: 82R: 25BP: 110/80

Ineffectiveairwayclearancerelated toincreasedproduction ofsecretions.
Bronchial asthma isa chronicinflammatorydisease of theairways, associatedwith
recurrent,reversible airwayobstruction withintermittentepisodes ofwheezing anddyspnea.
Bronchialhypersensitivity iscaused by variousstimuli, whichinnervate the vagusnerve and
betaadrenergic receptorcells of the airways,leading to bronchialsmooth
muscleconstriction,hypersecretion ofmucus, andmucosal edema.
After 3 days ofnursinginterventions,the patient willdemonstratebehaviors toimprove
airwayclearance.
Independent:

Auscultate breathsounds. Noteadventitiousbreath soundslike wheezes,crackles andrhonchi.

Elevate head ofthe bed, havepatient lean onoverbed table orsit on edge of thebed.

Keepenvironmentalpollution to aminimum likedust, smoke andfeather pillows,according

toindividualsituation.

Encourage orassist withabdominal orpursed lipbreathingexercises.

Assist withmeasures toimproveeffectiveness ofcough effort.

Some degree ofbronchospasmis present withobstructions inairway and mayor may not bemanifested
inadventitiousbreath sounds.

Elevation of thebed facilitatesrespiratoryfunction by useof gravity.

Precipitators ofallergic type ofrespiratoryreactions thatcan trigger orexacerbateonset of

acuteepisode.

Provides patientwith somemeans to copewith or controldyspnea andreduce airtapping.

Coughing ismost effectivein an uprightposition afterchestpercussion.

After 3 days ofnursinginterventions,the patient wasable todemonstratebehaviors toimprove
airwayclearance.

cont intervention
Increased fluidintake to 3000 ml/ day. Providewarm or tepidliquids.
Collaborative:

Administerbronchodilatorsas prescribed.

cont rationale
Hydration helpsdecrease theviscosity ofsecretions,facilitatingexpectoration.Using warmliquids
maydecreasebronchospasm.

To reduce theviscosity ofsecretions.