Scenario: A female patient 38 years, history of asthma in your ward unit was brought into hospital gasping for

air with nose flaring,

restless and wheezing sounds during Auscultation. She definitely has a problem breathing. She will undergo various tests to determine
her medical diagnosis. Vital sign upon admission T 37.5, PR-120, RR 30, BP 120/90, O2 sat 90 % (Oxygen saturation).

Name: Mrs Jona Ko

Age: 38 years old

Date: July 10, 2021

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

(Adriano) (Castro, De (Andallaza, Capitle) (de Leon, Balubar) (de Leon, Balubar) (Tigyab, Cruz)
Guzman)

Subjective: Ineffective SHORT TERM: INDEPENDENT: INDEPENDENT: Goal met:

breathing pattern 1. Monitor vital 1. To have a
“I was cleaning my related to tightened 1. After 2 hours signs noting baseline data After 2 hours of
room for almost an airway as of nursing changes in and to nursing intervention,
hour when I manifested by interventions determine if patient/client RR 20
Respiratory
suddenly forgot to gasping for air the patients the client’s bpm, and the O2 sat at
with nose flaring Rate, Pulse vital signs are
put on my mask, should Rate, and 95%, the patient was
and wheezing back to
which I do every sound, with O2 sat maintain Oxygen normal able to establish a
time I clean my level of 90%, and normal Saturation. 2. To promote normal and effective
room because I am respiratory rate of breathing 2. Assist the client physiological breathing pattern. In
aware that I have 30 bpm. pattern, to maintain and addition, the client
asthma. I then felt including rate comfortable psychological demonstrated adequate
like I couldn’t depth of position, to ease of coping mechanisms
breathe and my respiration facilitate maximal and was able to
usual breathing from 30 bpm breathing by inspiration. communicate his
pattern became to 20 bpm. elevating the (NANDA pg. awareness of the
head of the bed 169)
unusual as I 2. Patient report appropriate coping
and/or have the 3. To assist the
panicked.” feeling rested client sit up in a client in behaviors.
after chair, as “taking
Objective: scheduled rest appropriate control” of
periods (NANDA pg. the situation,
● Gasping for 169) especially
3. Patients
air 3. Direct client in when the
maintain
● Restless breathing condition is
normal vital
● Nose efforts as associated
signs PR from needed. with anxiety
flaring
120 bpm to Encourage and air
● Wheezing 100 bpm and slower and hunger
sounds normal deeper (NANDA pg.
during oxygen respirations and 110)
auscultation saturation use of the 4. Changes in
pursed-lip the
from 90% to
V/S taken as technique respiratory
97% (NANDA pg. rate and
follows: 110) rhythm may
● T: 37.5 LONG TERM: 4. Monitor client’s indicate an
● P: 120 breathing. early sign of
1. Breath sounds Noting its rate, impending
● R: 30
are clear in depth, and respiratory
● Bp:
auscultation pattern. distress.
120/90 (NANDA pg. (NANDA pg.
with little or
● O2 sat: 109) 109)
no evidence
90% 5. Auscultate 5. Abnormal
of wheezing
chest, breath sounds
describing are indicative
2. The patient presence, of numerous
will be able to absence, and problems and
verbalize character of must be
breath sounds. evaluated
understanding
(NANDA pg. further
of causative 110) (NANDA pg.
factors and 6. Refer patient 110)
demonstrate for chest x-ray 6. To
appropriate (NANDA pg. determine/hel
coping 110) p in obtaining
behaviors. the medical
diagnosis
(NANDA pg.
110)

DEPENDENT:
DEPENDENT: 1. to diagnose
1. Assist the client the
with various presence/seve
tests as ordered rity of lung
diseases.
by the doctor.
HEALTH
TEACHING:
HEALTH TEACHING:
1. Encourage 1. Extra activity
frequent rest can worsen
periods and shortness of
teach the patient breath.
to pace activity Ensure the
2. Teach/demonstr patient rests
ate to the between
strenuous
patient how to 2. Pursed lip
do the purse-lip breathing
breathing. improves
breathing
patterns by
moving old
air out of the
lungs and
allowing for
new air to
enter the
lungs.