Nursing Care Plan

In Partial Fulfillment of the Requirement in NCM 207 – RLE

PRE - CLINICAL ROTATION

Submitted to:
JOHANNA ZEHENDER, RN

Submitted by:
GWYNETH ROCHEL PAQUIDING, StN
BSN – 2I – GROUP 4

September 9, 2021
 CLUSTERED DATA NURSING DIAGNOSIS PRIORITY

Activity and Exercise Pattern

 Persistent cough for 3 months
 Cough disturbing her sleep and making her tired during
the day
 Cough is troublesome when going out to the playground
and on jogging
 25% drop in peak flow after completion of a 6 min Ineffective airway clearance High priority - 1
vigorous exercise upon Spirometry
 RR: 18 cpm
 Chest is clear
 Chest x-ray is normal
 No abnormalities in the nose, pharynx, cardiovascular, and
respiratory system
Health Perception and Health Management Pattern.
 Initial course of amoxicillin made no difference
 Appendectomy 3 years ago
 Tonsillectomy during childhood
 Maintenance of oral contraceptives

Cognition and Perception Pattern

 No abnormalities in nervous system
 SPC Nursing Department
NURSING CARE PLAN

Name of Patient: Patient X Age: 26 Ward: _________________ Bed#: ____

Chief Complaint: Persistent cough for 3 months Diagnosis: Bronchial Asthma Physician: Doctor Z
Date/ Cues Need Nursing Patient Nursing Implementation Evaluation
Time Diagnosis Outcome Interventions
September Subjective: Activity - Ineffective airway After 5 days, a. Assess for 1 The goal
6, 2021 Exercise clearance related Patient will fatigue was partially
@ 9:00 pm - Cough is to Bronchial comfortably met.
disturbing her Asthma as maintain R: Patient’s
sleep and evidenced by a stable sleep was Patient did
making her 25% drop in peak condition disrupted by not complain
tired during flow after with the constant about
the day completion of a 6 absence of coughing thus, disturbed
min vigorous persistent prone to fatigue sleeping, but
- Cough is exercise coughing. which may still has
troublesome cause some
when going R: A peak flow respiratory reoccurring
out to the that scores 20- failure coughing
playground 50% lower than episodes
and on jogging the normal b. Assess during
percentage acts breath sounds 3 vigorous
- Took as an early and adventitious activities
Amoxicillin as warning sign for sounds such as upon
an initial an asthma wheezes and periodically
course and attack. This stridor. monitored
she said it indicates an peak flows
made no implementation R: Adventitious
difference of an immediate breath sounds
action plan to be are an indication
Objective: taken care of. of a more
(Asthma UK, severe
- Persistent 2020) complication
cough for 3 such as
months pneumonia
7
- 25% drop in c. Plan for
peak flow after periods of rest
completion of between
a 6 min activities.
vigorous
exercise upon R: An increase
Spirometry oxygen
requirement
- RR: 18cpm during activities
due to
- Chest is respiratory
clear distress may
lead to fatigue
- Chest x-ray 2
is normal d. Maintain head
of bed elevated.
- No
abnormalities R: Promotes
in nose, expansion of
pharynx, lungs that
cardiovascular assists
, respiratory or breathing
nervous pattern which
system will aid patient to
sleep at night
- Recurrent 4
episodes of e. Asses history
Bronchitis of allergic
between 3 to 6 reactions
years of age
R: To be able to
- Appendix control the
removed 3 possible triggers
years ago that cause
asthma attacks
- Tonsils to the patient
removed as a 5
child f. Administer
medication as
- Takes up oral ordered by
contraceptives physician:
Short-acting
beta-2-
adrenergic
agonist.
Albuterol
(Proventil,
Ventolin).
Levalbuterol
(Xopenex).
Terbutaline
(Brethine).

R: Beta2-
agonists are
bronchodilators
that relaxes the
muscle linings of
airway during
acute
exacerbation of
asthma

g. Inhaled 6
Corticosteroids.
Budesonide
(Pulmicort).
Fluticasone
(Flovent).
Beclomethason
e (Vancenase).
Mometasone
(Asmanex
Twisthaler).

R: Given after
the beta-2-
Adrenegic
agonist to
reduce
inflammation in
airway and
reduce mucus
build up in the
bronchial tubes
8
h. Assess
respiratory
status

R: Periodically
monitoring
respiratory
status through
peak
flow/Spirometry
will identify
further lung
complications
that needs to be
assessed. It
also helps
measure the
severity of
asthma and
indicates the
current degree
of asthma
control. 9

i. Assess the
client’s vital
signs as needed
while in distress.

R: An increase
in BP, RR and
HR would be an
indicative of the
initial hypoxia
and
hypercapnia. BP
and HR might
drop and may
result to a
respiratory
failure. 10

j. General
anesthesia

R: In a life
threatening
continuation of
bronchospasm,
general
anesthesia is
used when there
is dynamic
hyperinflation
 and hypercapnia
that cannot be
corrected by
increasing
minute
ventilation 11

k. Heliox (a
helium-oxygen
mixture)

R: The use of
helium (a less
dense gas than
nitrogen) causes
decrease airway
resistance thus
lessens the
work of
breathing

References:

Asthma UK. (2020, November). Peak flow. Retrieved from Asthma UK: https://www.asthma.org.uk/advice/manage-your-
asthma/peak-flow/
Belleza, M. (2021, February 20). Asthma. Retrieved from Nurselabs: https://nurseslabs.com/asthma/
Martin, P. (2020, January 9). 8 Asthma Nursing Care Plans. Retrieved from Nurse Labs: https://nurseslabs.com/asthma-nursing-
care-plans/