NURSING CARE PLAN
Name of Patient:
Age:
Clustered Cues Nursing Diagnosis
04/20/10 11:00 am
Ineffective Breathing
Client refrains from Pattern related to
talking because he finds
it hard to breathe while
doing so.
Client simply points out
objects he wants and
makes signs because he
finds it difficult to
breath.
Complains of tight
feeling in the chest
RR=37 breaths/minute
With rapid and shallow
respirations
Uses accessory muscles
to aid in breathing
Exhibits nasal flaring
ABG Results 04/20/10
HCO3= 23.2 mmol/L
O2 Sat= 97.9%
Attending Physician:
Impression/Diagnosis:
Rationale Outcome Criteria Interventions Rationale Evaluation
INDEPENDENT: 04/20/10 3:00 p.m
The physiologic changes The client will be able to
in lung ventilation that establish an effective 1. Frequently assess Early identification of GOAL PARTIALLY MET.
bronchospasm, occur during an acute respiratory pattern so as respiratory rate, pattern, ineffective respirations The client manifested
decreased lung asthma attack impair to provide adequate and breath sounds. Note allow timely initiation of decreasing respiratory
expansion both lung expansion and ventilation as manifested manifestations of interventions. rate, RR=22
emptying. Anxiety by stabilizing respiratory ineffective breathing. breaths/minute and
caused by hypoxia and rate, decreasing chest appeared less strained
dyspnea compounds the tightness, slight to no 2. Monitor vital signs and Tachypnea, tachycardia, and distressed upon
problem by increasing nasal flaring and laboratory results. an elevated blood breathing. However,
the respiratory rate. decreasing usage of pressure, and increasing wheezes can still be
accessory muscles by hypoxemia and auscultated from all lung
PATHOPHYSIOLOGY 04/20/10 3:00 p.m. hypercapnia are signs of fields and there is still
When a trigger such as compromised respiratory usage of accessory
inhalation of an allergen status. muscles and nasal
or irritant occurs, an flaring.
acute or early response 3.Assist with self-care This conserves energy
develops in the activities. and reduces fatigue.
hyperreactive airways
predisposed to 4. Provide rest periods Scheduled rest is
bronchospasm. between scheduled important to prevent
Sensitized mast cells in activities and fatigue and reduce
the bronchial mucosa treatments. oxygen demands. .
release inflammatory
mediators such as 5. Place in Fowler’s, High These positions reduce
histamine, Fowler’s or orthopneic the work of breathing
prostaglandins and (with head and arms and increases lung
leukotrienes. These supported on the expansion, especially the
mediators stimulate overbed table) position basilar areas.
 pH= 7.501 parasympathetic to facilitate breathing
pCO2= 29.8 mmHg receptors and bronchial and lung expansion.
Impression: Respiratory smooth muscle to
Alkalosis without produce 6. Teach and assist to use Pursed- lip breathing
compensation bronchoconstriction. techniques to control helps keep airways open
They also increase breathing pattern: by maintaining positive
capillary permeability, a. Pursed-lip breathing pressure, and abdominal
leading to mucosal b. Abdominal breathing breathing improves lung
edema, and stimulate c. Relaxation technique expansion. Relaxation
mucus production. including visualization, techniques reduce
The attack is prolonged meditation and others. anxiety and its effect on
by the late response the respiratory rate.
phase, which develops 4
to 12 hours after .
exposure to the trigger.
Inflammatory cells such DEPENDENT:
as basophils and
eosinophils are 7. Administer 2 liters per Supplemental oxygen
activated, which damage minute of oxygen as reduces hypoxemia.
airway epithelium, ordered.
produce musocsal
edema, impair 8. Administer nebulizers Adrenergic stimulants
mucociliary clearance, treatments as ordered: affect receptors on
and produce ro prolong Combivent 1 nebule smooth muscle cells of
bronchoconstriction. The Duavent 1 nebule the respiratory tract,
degree of hyperreactivity (with 15 minutes interval causing smooth muscle
depends on the extent of in between) relaxation and
inflammation, and bronchodilation.
mucous secretion
narrow the airway. These are used to
Airway resistance 9. Administer anti- suppress airway
increases, limiting inflammatory agents as inflammation and reduce
airflow and increasing ordered: asthma symptoms. It
work of breathing. Hydrocortisone 200 mg blocks late response to
IVTT inhaled allergens and
Source: reduce bronchial
LeMone, P. ,et.al. 2004. hyperresponsiveness.
Medical-Surgical
Nursing: Critical Thinking
in Client Care 3rd Edition
pp. 1106,1111-1112.