ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

In 1 hour (short Independent:

After 1 hour of
Subjective: Ineffective term) of nursing Assess the client’s vital signs as Increased BP, RR, and HR
“asthmatic” as breathing intervention, the needed while in distress. occur during the initial hypoxia nursing
what the patient pattern client will be able and hypercapnia. And when it interventions
wrote on the to: becomes severe, BP and HR
paper. drops and respiratory failure the client
1. Establish may result. maintained
a normal,
Objective: effective optimal
- Cough respiratory Assess for the respiratory rate Changes in the respiratory rate breathing
- dyspnea pattern as and rhythm. and rhythm may indicate an
- Abnormal evidenced early sign of impending pattern, as
rise and by the respiratory distress evidenced by
fall of chest absence
- Adventitiou of the Assess the client’s level Anxiety may result from the relaxed
s breath signs and of anxiety struggle of not being able to breathing,
sounds symptoms breathe properly.
of normal
specifically
growing hypoxia, Assess breath sounds and Adventitious sounds may respiratory
sounds with the adventitious breath sounds such indicate a worsening condition
rate or pattern,
- Excessive arterial as wheezing or additional developing
sputum blood complications such as and absence
- Alterations gases pneumonia. Wheezing happens
of dyspnea.
in (ABGs) as a result of bronchospasm.
respiratory within the Diminishing wheezing and
pattern client’s indistinct breath sounds are
- Difficulty in normal or suggestive findings and
verbalizing acceptabl indicate impending respiratory
- Wide eyed e ranges. failure.
look
- Restlessne 2. Client will
ss maintain
 optimal Assess the relationship of Reactive airways allow air to
Vital signs: breathing inspiration to expiration move into the lungs more easily
BP: 140/80bmp pattern, than out of the lungs. If the
TEMP: 37’c as client is gasping for air,
RR: 25 breaths evidenced instruction for effective
per min by relaxed breathing is needed.
PR: 93bpm breathing,
normal Assess for dyspnea (Flaring of These indicate respiratory
respiratory nostrils chest retractions, and distress. Once the movement
rate or use of accessory muscle) of air into and out of the lungs
pattern, becomes challenging, the
and breathing pattern changes.
absence
of
dyspnea.
Assess for fatigue Fatigue may indicate distress,
leading to respiratory failure.

Maintain head elevated This promotes maximum lung

expansion and assists in
breathing.

Oxygen saturation is a term

Monitor oxygen saturation
referring to the fraction of
oxygen-saturated hemoglobin
relative to the total hemoglobin
in the blood. Normal oxygen
saturation levels are
considered 95-100%
Dependent:
Monitor peaked expiratory flow
rates and forced expiratory
volume as taken by the
respiratory therapist.
Monitor arterial blood gases
(ABG)
The severity of the
exacerbation can be measured
objectively by monitoring these
values. The peak expiratory
flow rate is the maximum flow
rate that can be generated
during a forced expiratory
maneuver with fully inflated
lungs. It is measured in liters
per second and requires
maximal effort. When done with
good effort, it correlates well
with forced expiratory volume in
1 second (FEV1) measured by
spirometry and provides a
simple, reproducible measure
of airway obstruction.
During a mild to moderate
asthma attack, clients may
develop respiratory alkalosis.
Hypoxemia leads to increased
respiratory rate and depth, and
carbon dioxide is blown off. An
ominous finding is a respiratory
acidosis, which usually
indicates that respiratory failure
is pending and that mechanical
ventilation may be necessary.
Collaborative:

Short-acting beta-2-adrenergic Short-acting beta2-agonists are

agonist. bronchodilators. They relax the
muscles lining the airways that
carry air to the lungs; treatment
 Albuterol (Proventil,
of choice for acute
Ventolin). exacerbation of asthma.
 Levalbuterol
(Xopenex).
 Terbutaline (Brethine).

Inhaled Corticosteroids.

 Budesonide (Pulmicort) Corticosteroids reduce

. inflammation in the airways that
carry air to the lungs and
 Fluticasone (Flovent). reduce the mucus made by the
 Beclomethasone(Vanc bronchial tubes. Inhaled
steroids should be given after
enase). beta-2-adrenergic agonist.
 Mometasone
(Asmanex Twisthaler).