Nursing Care Plans

This contains 5 bronchial asthma nursing care plans.

1. Ineffective Airway Clearance

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 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.

Assessment

Patient may manifest

Difficulty breathing

Changes in depth and rate of respiration

Use of respiratory accessory muscles

Persistent ineffective cough with or without sputum production

Wheezing upon inspiration and expiration

Dyspnea

Coughing

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

May be related to

Increased production or retainment of pulmonary secretions

Bronchospasms

Decreased energy

Fatigue

Planning

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.

Nursing Interventions Rationale

Keep the patient adequately hydrated.
Teach and encourage the use of diaphragmatic
breathing and coughing exercises.
Instruct patient to avoid bronchial irritants such Bronchial irritants cause bronchoconstriction
as cigarette smoke, aerosols, extremes of
temperature, and fumes.
Teach early signs of infection that are to be
reported to the clinician immediately.
Assist and prepare patient for postural drainage.
Systemic hydration keeps secretion moist and
easier to expectorate.
These techniques help to improve ventilation
and mobilize secretions without causing
breathlessness and fatigue.
and increased mucus production, which then
interfere with airway clearance.
Minor respiratory infections that are of no
consequence to the person with normal lungs
can produce fatal disturbances in the lungs of an
asthmatic person. Early recognition is crucial.
Uses gravity to help raise secretions so they can
be more easily expectorated.
Nursing Interventions Rationale
This ensures adequate delivery of medications
Administer nebulization as ordered.
to the airways.
Antibiotics may be prescribed to treat the
Administer medications as ordered.
infection.

2. Ineffective Breathing Pattern

Presence of secretions in the bronchi will result into a blockage of air that will enter the body and
thus producing insufficient air needed by the body. And inability to maintain clear airway. This
obstruction is further heightened by bronchospasm due to the contraction of the smooth muscles
in the bronchi. This is caused by parasympathetic stimulation of the muscarinic m2 receptors as
well as by chemical mediators released in response to the presence of allergens.

Assessment

Patient may manifest:

wheezing upon inspiration and expiration

dyspnea

coughing

tachypnea

tachycardia

chest tightness

suprasternal retraction

restlessness

anxiety

cyanosis

loss of consciousness

Nursing Diagnosis

Ineffective breathing pattern r/t presence of secretions AEB productive cough and
dyspnea

Planning
 Patient will demonstrate pursed-lip breathing and diaphragmatic breathing.

Patient will manifest signs of decreased respiratory effort AEB absence of dyspnea

Patient will verbalize understanding of causative factors and demonstrate behaviors that
would improve breathing pattern

Nursing Interventions Rationale

Assess patients respiratory rate, depth, and
To obtain baseline data
rhythm. Obtain pulse oximetry.
Increase in respiratory rate could mean
Monitor and record vital signs.
worsening condition.
Auscultate breath sounds and assess airway to check for the presence of adventitious breath
pattern sounds
Elevate head of the bed and change position of
To minimize difficulty in breathing
the pt. every 2 hours.
Encourage deep breathing and coughing
To maximize effort for expectoration.
exercises.
Demonstrate diaphragmatic and pursed-lip To decrease air trapping and for efficient
breathing. breathing.
Encourage increase in fluid intake To prevent fatigue.
Encourage opportunities for rest and limit To prevent situations that will aggravate the
physical activities. condition
Reinforce low salt, low fat diet as ordered. To mobilize secretions.

3. Impaired Gas Exchange

Bronchial asthma is a condition wherein the airway diameter is highly reduced. This is due to
severe bronchospasm, mucosal edema and mucus plug formation. There is a rise in airway
resistance which leads to decreased amount of air that enters upon inspiration as well as
expiration. Thus, ventilation is impaired. In bronchial asthma, perfusion is not directly affected.
However, the balance between ventilation and perfusion (V/Q ratio) is lost because despite the
adequate perfusion (capillary circulation), not much gas is available to diffuse from the alveoli to
the capillaries. Conversely, the gases in the capillaries do diffuse to the alveoli but since
expiration is impaired, such gases fail to be ventilated out. Thus, gas exchange is impaired.

Assessment

Patient may manifest:

wheezing upon inspiration and expiration

dyspnea

coughing, sputum is yellow and sticky

tachypnea, prolonged expiration

 tachycardia

chest tightness

suprasternal retraction

restlessness

anxiety

cyanosis

Altered loc

Changes in ABGs

Nursing Diagnosis

Impaired gas exchange RT ventilation perfusion imbalance AEB dyspnea, tachypnea, and
tachycardia

May be related to

altered delivery of inspired O2 or air trapping

Planning

Patient will improve gas exchange AEB absence of respiratory distress

Patient will demonstrate improved ventilation and adequate oxygenation of tissues by

ABGs within clients normal limits and absence of symptoms of respiratory distress.

Patient will verbalize understand of causative factors and appropriate interventions (deep
breathing, cough exercises, etc)

Nursing Interventions Rationale

Assess vital signs, noting respiratory rate,
depth, and rhythm.
VS monitor and record
Auscultate breath sounds and assess airway
pattern
Elevate head of the bed and change position of
the pt. every 2 hours.
Encourage deep breathing and coughing
exercises.
Demonstrate diaphragmatic and pursed-lip
To obtain baseline data
Serve to track important changes
to check for the presence of adventitious breath
sounds
To minimize difficulty in breathing and promote
maximum lung expansion.
To maximize effort for expectoration.
To decrease air trapping and for efficient
Nursing Interventions Rationale
breathing. breathing.
Encourage increase in fluid intake To prevent fatigue.
Encourage opportunities for rest and limit To prevent situations that will aggravate the
physical activities. condition
Reinforce low salt, low fat diet as ordered. To mobilize secretions.

4. Fatigue

Fluid accumulation in the lungs makes it difficult to breathe. The fluid inside prohibits the lungs
to expand thus it is harder to breathe. The client, to have adequate ventilation makes use of his
accessory muscles to breathe to have sufficient air. With too much use of the accessory muscles,
feeling of tiredness may be present resulting to fatigue which is experienced by the client

Assessment

Patient may manifest:

Generalized weakness

Verbalization of overwhelming lack of energy

Inability to maintain usual routines

Tired

Lethargic

Compromised concentration

Decreased performance

Nursing Diagnosis

Fatigue r/t physical exertion to maintain adequate ventilation AEB use of accessory
muscles to breathe

Planning

Patient will verbalize understand on health teachings given and report improved sense of
energy.

Patient will perform ADLs within clients ability and participates in desired activities.

Patient will be able to identify basis of fatigue and be able to cope up with the problem.
Nursing Interventions
Establish rapport
Monitor and record vital signs.
Provide environment conducive to relief of
fatigue.
Assist client to identify appropriate coping
behaviors.
Encourage patient to restrict activity and rest in
bed as much as possible.
Avoid topics that irritate or upset patient.
Discuss ways to respond to these feelings.
Discuss with the patient the need for activity.
Plan schedule with patient and identify
activities that lead to fatigue.
Alternate activity with rest periods.
Monitor VS before and after activity.
Increase patient participation in ADLs as
tolerated.
Rationale
To gain patients trust
For baseline data.
Temperature and level of humidity are known to
affect exhaustion.
Promotes sense of control and improves self-
esteem.
Helps counteract effects of increased
metabolism.
Increased irritability of the CNS may cause
patient to be easily excited, agitated and prone
to emotional outbursts.
Education may provide motivation to increase
activity level even though patient may feel too
weak initially.
Prevents excessive fatigue.
Indicates physiological levels of tolerance.
Increases confidence level and/or self-esteem
and tolerance level

5. Risk for Activity Intolerance

Inadequate oxygen in the circulation can develop weakness in our muscles. Muscles need oxygen
to move and to do its function. If the patient cannot tolerate any activities because of the low
oxygenation caused by the ventilation-perfusion imbalance caused by the pathological
minimized lung expansion.

Assessment

Not applicable. Presence of signs and symptoms will establish an actual nursing
diagnosis.

Nursing Diagnosis

Risk for Activity Intolerance r/t decrease oxygenation

Planning

Patient will participate willingly in necessary/ desired activities such as deep breathing
exercises.

Patient will perform ADLs within clients ability and participates in desired activities.

Patient will be able to increase activity tolerance AEB attendance of self-care needs.

Patient will be able to gradually increase activity within level of ability

Nursing Interventions Rationale
Monitor VS. For baseline data.
Assess motor function. To identify causative factors.
Note contributing factors to fatigue. To identify precipitating factors.
Evaluate degree of deficit. To identify severity.
Ascertain ability to stand and move about. To identify necessity of assistive devices.
Stress and/or depression may increase the
Assess emotional or psychological factors
effects of illness.
Plan care with rest periods between activities To reduce fatigue
Increase activity/exercise gradually such as
Minimizes muscle atrophy, promotes
assisting the patient in doing PROM to active or
circulation, helps to prevent contractures
full range of motions.
Provide adequate rest periods. To replenish energy.
To promote independence and increase activity
Assist client in doing self care needs
tolerance
Elevate arm and hand Promotes venous
Place knees and hips in extended position Maintains functional

Other Possible Nursing Care Plans

Anxietymay be related to perceived threat of death, possibly evidenced by

apprehension, fearful expression, and extraneous movements.

Risk for contaminationrisk factors may include presence of atmospheric pollutants,

environmental contaminants in the home.