Nursing Care Plan

Assessment Diagnosis Nursing Outcome Nursing Intervention Rationale Evaluation

Subjective data Ineffective Airway Clearance The patient will be able to Assess the patient’s vital signs and To assist in creating and The patient shall maintain
“I am having a bad asthma r/t asthma as evidence by maintain airway patency characteristics of respirations at accurate diagnosis and airway patency and improved
attack. My chest feels very shortness of breath, and improved airway least 4 hours. Assess breath monitor effectiveness of airway clearance as evidenced
tight and I cannot catch my high-pitched wheeze, SpO2 clearance as evidenced by sounds via auscultation. medical treatment. Wheeze is by being able to expectorate
breath.’’ as verbalized by level of 86 % and respiratory being able to expectorate one of the important signs of phlegm effectively, respiratory
the patient rate of 34 phlegm effectively, asthma. rates between 12-20 bpm,
respiratory rates between oxygen saturation within the
12-20 bpm, oxygen Encourage coughing. Suction To help clear thick phlegm target range and verbalize ease
Objective data saturation within the secretions as needed. that the patient is unable to of breathing.
● Dyspnea with target range and verbalize expectorate.
audible ease of breathing.
high-pitched Administer supplemental oxygen, To increase the oxygen level
wheezing as prescribed. Discontinue if SpO2 and achieve an SpO2 value
level is above the target range or within the target range.
● Difficulty speaking as ordered by the physician.
● Abnormal breath
sounds, inspiratory Administer the prescribed asthma Bronchodilators:To dilate or
and expiratory medications (e.g bronchodilators, relax the muscles on the
wheezing steroids or combination airways.
inhalers/nebulizers). Steroids:To reduce the
V/S taken as follows: inflammation in the lungs.
● R-34 bpm
● BP-142/96 mmHg Elevate the head of the bed and Head elevation and proper
● O2-86 % assist the patient to assume positioning help improve the
semi-Fowler’s position. expansion of the lungs,
enabling the patient to
breathe more effectively.