Name of Patient: H Age/Sex: 27/F Ward: Sta.

Rosa Bed #: 2B Chief Complaint: shortness of breath

Diagnosis: Asthma Physician: Dr. Davis

Date/ Cues Nee Nursing Diagnosis Patient Nursing Interventions Impleme Evaluation
Time d Outcome n
tation
Sep. S: Ineffective airway clearance related to At the end of 1. Encourage deep breathing and 4 “Goals are met”
7, “Mag lisod S excessive mucus as evidenced by the 8-hour shift, coughing exercises After 8 hours of duty,
2020 kog ginhawa” A abnormal breathing pattern and thick the patient will R: This technique can help the patient was able
At as verbalized F yellowish sputum be able to increase sputum clearance and to regain normal
2:00 by the patient E enhance her decrease cough spasms. breathing pattern and
pm T airway 2. Monitor respiratory patterns 1 demonstrated
O: Y clearance and including rate, depth, effort and effective coughing.
Wheezing / demonstrate breath sounds.
upon P behaviors that R: To indicate respiratory distress
inspiration R Rationale: would improve and/or accumulation of secretion
and expiration O The airways are cleared by mucociliary breathing 3. Encourage increase in fluid 3
Pallor on the T action and coughing. Failure of two pattern and intake
patient’s lips E mechanisms may lead to sputum elimination of R: To prevent fatigue
Sputum is C retention in the post-operative state or secretions. 4. Reinforce low salt, low fat diet 2
yellowish in T acute-on-chronic bronchitis, with as ordered.
color I respiratory failure. Similarly, in asthmatics R: To mobilize secretions
VS: O sputum plugging may occur, even in mild 5. Monitor peaked expiratory flow 7
T: 38.7 ℃ N asthma. rates and forced expiratory
RR: 45 cpm volume as taken by the
PR: 100bpm respiratory therapist.
R: The severity of the exacerbation
can be measured objectively by Jennifer D. Condiman
monitoring these values.  St. N
6. Institute respiratory therapy 8
treatments (e.g., nebulizer) as
needed
R: A variety of respiratory therapy
Reference: treatments may be used to open
Suppl, E. (1998). Rationale of airway constricted airways and liquefy
clearance. Retrieved from secretions.
https://pubmed.ncbi.nlm.nih.gov/2679608/ 7. Position head appropriate for 6
 condition such as fowler’s
position
R: To open or maintain open
airway in at rest or compromised
individual 5
8. Encourage opportunities for
rest and limit physical activities.
R: To prevent situations that will
aggravate the condition
9. Note changes in SpO2, tidal 9
volume, and changes in arterial
blood gas values as
appropriate.
R: Evaluates the status of
oxygenation, ventilation, and acide
base balance.
10. Refer to physician or 10
consultants for any unusualities
R: Consultants may be helpful in
ensuring that proper treatments are
met.

Reference: Carpenito-Moyet, L. J.
(2006). Handbook of nursing diagnosis.
Lippincott Williams & Wilkins. Retrieved
from https://nurseslabs.com/asthma-
nursing-care-plans/

References:

Carpenito-Moyet, L. J. (2006). Handbook of nursing diagnosis. Lippincott Williams & Wilkins. Retrieved from https://nurseslabs.com/asthma-nursing-care-plans/

NANDA International Nursing Diagnoses: Definitions and Classification 2018-2020, Eleventh Edition. Retrieved from https://nanda.org/nanda-i-publications/nanda-
international-nursing-diagnoses-definitions-and-classification-2018-2020/

Suppl, E. (1998). Rationale of airway clearance. Retrieved from https://pubmed.ncbi.nlm.nih.gov/2679608/

Clustering of Cues
Sexuality
Patient H Female, 27 yrs old
Activity/ Exercise Self-Perception Elimination/Exchange
Pallor on the patient’s lips The patient verbalized “Maglisod Sputum is yellowish in color
VS T: 38.7 ℃ kog ginhawa” Wheezing upon inspiration and
RR: 45 cpm expiration
PR: 100bpm