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NURSING CARE PLAN: INEFFECTIVE AIRWAY

Name of Patient: Cell Phone


Age: 74 years old
Chief Complaint: Difficulty of Breathing
Diagnosis: Bronchial Asthma, in acute exacerbation t/c CAP

NURSING ANALYSIS/HEALTH GOAL AND NURSING


CUES RATIONALE EVALUATION
DIAGNOSIS IMPLICATION OBJECTIVES INTERVENTIONS

INTERACTION Ineffective IMMEDIATE CAUSE GOAL


The client’s relative airway Asthma After 8 hours of
verbalized clearance shift, the client will
“Hinihingal siya” related to INTERMEDIATE be able to maintain
The client asthma CAUSE airway clearance
verbalized Diffuse airway and effective gas
“Nahihirapan ako inflammation exchange
huminga”
ROOT CAUSE OBJECTIVES
OBSERVATION Exposure to indoor
• Difficulty of and outdoor (1) The client will a. Position head Open or maintain EFFECTIVENESS
breathing allergens maintain adequate, midline with flexion open airway in (1) Was the client
• Difficulty in patent airway appropriate for at-rest or maintain adequate,
vocalizing HEALTH age/condition compromised patent airway
• Pale and IMPLICATION individual _yes __no why?
weak Substances such as (Nurse’s Pocket
• Restlessne hydrocarbons and Guide by (2) Was the client able
ss oxidants emitted by Doenges, to promote systemic
• Cough cars and factories Moorhouse and fluid hydration
interfere with Geissler-Murr, 9th _yes __no why?
MEASUREMENT oxygenation by edition, page 70)
Temperature: directly damaging (3) Was the client was
37.2° C the lungs. Carbon To take able to be provided
Respiratory Rate: monoxide inhibits b. Elevate head of advantage of with oxygen therapy?
16 breaths per oxygen attachment the bed/change gravity _yes __no why?
minute onto hemoglobin. position every 2 decreasing
Blood Pressure: Because they are hours and as pressure on the (4) Was the client able
130/70 mmHg respiratory irritants, necessary diaphragm and to be monitor
pollutants caused enhancing regarding to his
increased mucus drainage respiratory
NURSING ANALYSIS/HEALTH GOAL AND NURSING
CUES RATIONALE EVALUATION
DIAGNOSIS IMPLICATION OBJECTIVES INTERVENTIONS
production and may of/ventilation to functioning?
contribute to different lung _yes __no why?
bronchitis and segments
asthma. Workers in (pulmonary EFFICIENCY
industrial plants or in toilet) Was the interventions
certain occupation (Nurse’s Pocket done within the time
may be exposed to Guide by frame?
strong Doenges, _yes __no why?
concentrations of Moorhouse and
specific pollutants Geissler-Murr, 9th APPROPRIATENESS
and harmful dust. edition, page 70) Were the interventions
These workers may suitable to the client?
be prone to Adequate fluid _yes __no why?
development of intake enhances
breathing problems. (2) Encourage and a. Increase fluid liquefaction of ACCESSIBILITY
(Fundamentals of teach the client the intake to at least pulmonary Were the interventions
Nursing by Craven importance of 2000mL/day within secretions and acceptable to the
and Hirnle, 4th edition adequate hydration level of cardiac facilitates client?
page 813) tolerance expectoration of _yes __no why?
mucus
(Fundamentals ADEQUACY
of Nursing by Were the interventions
Kozier, 7th edition adequate to meet the
page 1327) client’s needs?
_yes __no why?
Deep breathing
promotes
b. Encourage to take oxygenation
several deep before controlled
breaths coughing
(Fundamentals
of Nursing by
Kozier, 7th edition
page 1327)

Controlled
coughing is
c. Encourage to take accomplished by
a deep breath, hold closure of the
for 2 seconds, and glottis and the
NURSING ANALYSIS/HEALTH GOAL AND NURSING
CUES RATIONALE EVALUATION
DIAGNOSIS IMPLICATION OBJECTIVES INTERVENTIONS
cough two or three explosive
times in succession expulsion of air
from the lungs by
the work of
abdominal and
chest muscles
(Fundamentals
of Nursing by
Kozier, 7th edition
page 1327)

A variety of
respiratory
therapy
d. Provide treatments may
supplemental be used to open
humidification, if constricted
needed airways and
liquefy
secretions
(Fundamentals
of Nursing by
Kozier, 7th edition
page 1328)

Oxygen demand
is greater during
(3) Provide oxygen a. Instruct the client febrile illness
therapy about importance of and physical
leaving oxygen stress. At low
delivery device on PO2 level in the
atmosphere,
oxygen
saturation falls
rapidly; therefore
oxygen should
be maintained ,
especially during
activity
A variety of
NURSING ANALYSIS/HEALTH GOAL AND NURSING
CUES RATIONALE EVALUATION
DIAGNOSIS IMPLICATION OBJECTIVES INTERVENTIONS
respiratory
therapy
treatments may
be used to open
constricted
airways and
liquefy
secretions
(Fundamentals
of Nursing by
Kozier, 7th edition
page 1328)

Too much or too


little can be
b. Periodically check detrimental,
oxygen delivery especially during
device to ensure activity
that the prescribed A variety of
concentration is respiratory
being delivered therapy
treatments may
be used to open
constricted
airways and
liquefy
secretions
(Fundamentals
of Nursing by
Kozier, 7th edition
page 1328)

To ascertain
status and note
(4) Respiratory a. Auscultate breath progress
monitoring sounds and assess (Nurse’s Pocket
air movement Guide by
Doenges,
Moorhouse and
Geissler-Murr, 9th
NURSING ANALYSIS/HEALTH GOAL AND NURSING
CUES RATIONALE EVALUATION
DIAGNOSIS IMPLICATION OBJECTIVES INTERVENTIONS
edition, page 71)

Provide basis for


evaluating
adequacy of
b. Monitor rate, ventilation
rhythm, depth, and (Fundamentals
effort of respirations of Nursing by
Kozier, 7th edition
page 1327)